In most study states, facility participation in technical assistance programs is mandatory. Participation in the technical assistance programs in Maine and Missouri, however, is voluntary. About 45 percent of nursing facilities received on-site consultation from Missouri's technical assistance program. Detailed facility statistics are not available for the Maine program since they track interventions by resident rather than by facility, but it is believed that a majority of the state's 126 nursing facilities have participated.
Voluntary programs allow facilities that do not want technical assistance to opt out and not receive this assistance. This runs the obvious danger that the facilities most in need of help may not receive it. Study discussants suggested that facilities with the worst quality do not participate, in part because they either do not understand the program or do not have the systems in place to benefit from it. This is certainly a plausible result of voluntary participation. The state survey agency in Missouri did not contradict this position, but was not troubled by such a possibility, arguing that the problems at the facilities with the most severe quality issues should most properly be addressed through the enforcement process rather than through TA.
On the other hand, even for states with mandatory technical assistance programs, it is likely that some facilities do not benefit from the programs--either because they are not willing or able to use advice received during the technical assistance visit to make changes to care processes. Some discussants believe that high staff turnover has resulted in facility staff actually having less contact with technical assistant staff. It is not clear that focusing on poor performing facilities would maximize the impact of technical assistance programs, given that these facilities may be too overwhelmed by the tasks involved in providing basic care to be able to undertake new quality improvement initiatives.