State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Summary and Conclusions


Policy makers, practitioners, and advocates have long been concerned about quality issues in Texas nursing homes, with little agreement about the best way to address these. Over the last several years, the state has implemented a number of regulatory and other changes--including a major overall of the Medicaid reimbursement system--designed to address some key quality issues. Texas was one of the first states in the nation to implement (in 1999) a web-based quality reporting system. Some believe that these initiatives have focused on marginal issues and/or have involved the investment of too few resources to be effective. For example, a number of consumer groups believe that legislation requiring higher staffing would be the most effective action, while others believe that higher Medicaid reimbursement rates are essential. Some believe that the enforcement of quality regulations has been too lax, while others believe the opposite to be true.

In 2000, the legislature mandated and funded an annual statewide assessment of nursing home quality issues. This annual empirical research effort provides Texas policy-makers with far better information about the scope of problems and progress towards goals than is available in other states. Research to date has revealed a somewhat higher level of customer satisfaction with care than some had expected but also confirmed serious issues in a number of areas such as restraint use.

In 2001, the legislature again debated proposed approaches to address nursing home quality issues. While advocates of substantially higher payment rates and new staffing requirements were not successful, the legislature was responsive to a proposal, first suggested by providers, to try a different approach to harnessing state expertise to help providers improve quality. Some providers had long argued that surveyors focused solely on noting deficiencies, but did little to help homes actually understand what they might do to optimize quality. They proposed a program--initially modeled on one in Florida--in which state long term care experts in nursing, pharmacy, and nutrition would provide consultative technical assistance to homes, focusing first on those where the greatest problems appeared to exist. This initiative, called the "Quality Monitor Program," found support among some consumer advocates (at least initially) and key legislators long involved in nursing home reform efforts because it appeared to have the potential for providing additional state presence, focused on quality, in homes across the state. When the legislation passed, however, it was accompanied by a budget bill that funded the new program (and some smaller initiatives) by transferring 82 FTE from the survey, thus reducing resources available to regulatory enforcement by approximately 22 percent. For this reason, some consumer representatives and other stakeholders have come to view the new Quality Monitor Program's potential effect on quality with considerable skepticism, given the simultaneous reduction in resources available for regulatory enforcement.

When the legislature mandated the new Quality Monitor Program, DHS program implementers had few sources of information to guide them in developing details of a program that met the legislative mandate and also might reasonably be expected to have a positive effect on quality. There have been no formal evaluations of the one long-standing state technical assistance program (i.e. that in Washington State); further, the Texas legislature mandated that the new Quality Monitors operate separate from the surveyors, in contrast to the Washington State program where those providing technical assistance also serve as surveyors. Given this situation, DHS staff focused on designing the new Quality Monitor Program to complement other state quality improvement efforts.

In contrast to a number of other quality improvement initiatives that states have implemented over the years, the new Texas Quality Monitor Program has a clearly identified, objective, and measurable goal; a rational program logic model; and an evaluation plan. The program's success in terms of actually affecting quality depends on the degree to which sustained behavioral changes can be stimulated principally by educational efforts. In part this will depend on provider acceptance of the value of the types of changes the program envisions--namely greater conformity with selected, specific evidence-based best practices. At the time of our site visit, as the program was just getting started, program goals and the best practice protocols were not well understood by most of those we interviewed. In addition, knowledgeable staff at the provider organizations raised some issues about the degree to which local practitioners might fully embrace DHS' best practice concepts.

Finally, most of the providers interviewed had expected a different sort of technical assistance than the Quality Monitors provide. Quality monitors are specifically trained not to instruct nursing facilities regarding specific solutions to specific problems with individual residents or issues; rather, they are to brainstorm with them, allowing facilities to "own" the system solutions. Recognizing the potential limitations of the program model (i.e., its dependence on education to effect sustained change), senior management was beginning to explore the idea of linking with the QIOs to provide more "hands-on" assistance for facilities.

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