State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Sustainability and Lessons Learned


Currently, funding for Florida's quality improvement programs comes from general revenue and licensure fees with some federal funding. AHCA staff noted that there is general support for quality initiatives among members of the legislature. Other state agency officials offered that there has been a focus on seniors, primarily because of the large elderly population, and that the governor and the legislature are committed to seniors' issues. State agency staff also noted that the programs are up for review every year and that the funding for the both the Medicaid Up and Out program and for the Consumer Satisfaction survey have been cut, and that continued support may be tied to demonstration of positive outcomes in the future.

We asked providers, state program administrators, and consumer representatives we spoke with in Florida for lessons they have learned and any recommendations they wished to offer other states considering quality improvement programs. Nearly all we spoke to would recommend the Quality Monitor program, which was generally characterized as having a positive impact on facility quality of care. Quality Monitors have been able to establish a more collaborative, less adversarial relationship with nursing facilities than is typical for surveyors, and this relationship allows providers the opportunity to have an open dialogue with TA staff about problems and issues in resident's care, to obtain information on good clinical care practices, and to receive feedback on how they can improve their care processes. Some stakeholders felt the intervention should be targeted either to the smaller free-standing facilities with no corporate support, or to facilities that were having more problems. Most providers said they wanted to see the program continue, remain confidential and separate from survey. They especially wanted the content of the visits not to be shared with surveyors or to be available for litigation. Most said they would prefer that the QM staff not overlap with survey staff--they should be kept entirely separate. However, some providers said that surveyors and Quality Monitors should be trained to provide consistent guidance, and felt that TA staff with past survey experience were most valuable in helping them interpret applicable regulations. All agreed that Quality Monitors needed to be well qualified and experienced in long-term care.

Discussants also had recommendations on several of the other quality improvement programs Florida has initiated. Consumer advocates supported the public reporting website as important for consumer decision-making. They believed that the algorithm for ranking facilities is good, but they don't like the fact that every facility gets a star regardless of how low its quality rating is, and would prefer a numeric ranking. Provider representatives recommended that the website resolve problems associated with the reporting of 45 months of survey and deficiency information by showing current performance alongside historical performance. They also thought that regular updating was critical for accurate representation of facilities.

Regarding the Gold Seal program, participants thought it important to ensure that there is a well-defined consumer advocate position on the selection panel and that the panel performs an on-site inspection of any facility being considered for an award. They also stated that the awards should be reserved for facilities that were truly doing something special for residents and not merely meeting minimum criteria. Provider representatives noted that there is a need for rewards beyond public recognition that make the Gold Seal worth pursuing and that in order to have an impact, it had to be more attainable for more facilities.

Finally, numerous stakeholders reported that the risk management program has real potential for prevention, managing losses and minimizing litigation and that it was helping facilities focus on how best to prevent adverse incidents.

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