State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Role of the Federal Government in Quality Improvement


Marilyn Rantz believes that the Federal Government should support and expand programs like QIPMO into other states. The partnership between the university and the Department of Health and Senior Services could serve as a model for other states. She also believes that the partnership could be expanded to include the state QIO as well as the state survey agency and an academic institution with a strong clinical focus on gerontology. Together these groups may be able to bring about the necessary changes in facility practices to achieve the desired level of quality. The current involvement of the QIOs in providing technical assistance to nursing facilities concerns Dr Rantz as she fears that CMS' interest in this initiative will not be sustained and that in a few years they may change their focus and direct their efforts and funding elsewhere.

Dr. Rantz would like to see the "Show-Me" Quality Indicator Reports made available to all states and made a formal request to CMS that the CHSRA QIs be expanded to include "Show-Me" reports. She also shared information on the "Show-Me" Reports with the QIOs as an option to include in their programs.

Provider representatives that we spoke with were harsh in their criticism of the Federal Government. The relationship between the state and federal agency was described as being "hostile" and "out of hand," and providers urged the Federal Government to "get off the state's back." Providers were especially upset by a belief that a deficiency-free survey by the state is an indicator of a survey that was not done correctly. There is a belief that a deficiency-free survey by the state often triggers a federal survey. Provider groups encourage the Federal Government to reward good nursing homes with less frequent surveys and to focus resources on poor performing facilities. Their presence in good homes causes a diversion of resources, taking time away from resident care. There was also support for an "outcomes-based survey" and a need to make "penalties consistent" by considering the amount of evidence when making decisions about deficiencies.

Providers also identified inadequate reimbursement as a major cause of poor quality care. Higher reimbursement would eliminate a lot of quality problems, provider representatives contend. The potential reduction in Medicare funding could cause bankruptcy for many Missouri nursing homes.

In addition, the CMS quality indicators, which will be posted on the Nursing Home Compare web site, were criticized for being "too complicated." Because these quality indicators use multivariate risk adjustment techniques, facilities cannot track their scores back to particular residents, thus making it difficult to use for quality improvement purposes.

Lastly, state survey agency staff cited a need for improvements to the CMS Long Term Care Enforcement System, which tracks complaints, particularly for facilities with multiple complaints.

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