Budgetary issues emerged as having a significant impact on the department's current programs and plans for future quality improvement programs. Iowa had experienced a 4.6 percent cut in last year's budget, plus additional cuts that amount to about 4.6 percent for this year. Despite the Governor's support for long-term care issues (he introduced a bill that would have allowed the state to shift resources so that budget cuts would not need to be as large) the general assembly rejected this proposal. Due to the budget cuts and expanded responsibilities (DIA recently assumed the responsibility for regulating assisted living programs), the concern for DIA has been to maintain current QI programs, as it is currently not feasible to implement new programs.
Provider group representatives expressed their desire for a consultative component to the survey process. They appreciate the recognition programs and awards, but identify the lack of "someone they could call for help," as a problem. Other than higher reimbursement, some type of technical assistance is what facilities want most from the state. Dr. Tooman noted that he has interest in implementing a technical assistance program, but the lack of available state funding in combination with additional DIA responsibilities make such an undertaking not feasible at this time. Funding remains a difficult issue.
Another significant influence on quality improvement programs in Iowa comes from the media. The State's major newspaper, the Des Moines Register, has focused a great deal of attention on long-term care issues, raising public awareness of quality in nursing homes and assisted living programs. The Nursing Home Report Cards are a major source of information for these articles and attention has been given to homes that receive awards, but are later cited for major deficiencies. During the site visit, the Register began a major series on assisted living programs. The attention generated from previous articles on these programs reportedly led to the change in oversight responsibility from the Department of Elder Affairs to DIA.
Finally, Dr. Tooman's background as a former facility chief executive officer and administrator and his sensitivity to facility issues appear to have contributed to the direction that DIA has taken in developing and implementing its quality improvement programs. DIA has made an effort to recognize facilities doing exemplary work, to improve relations between providers and surveyors, and to encourage facilities to engage in continuous quality improvement.