Strategies for Improving the Quality of Long-Term Care

Presented byJoshua M. Wiener, PhD, Marc Freiman, Ph.D., and David Brown, M.A.

RTI International

RTI International is a trade name of Research Triangle Institute

701 13th Street, NW ■ Suite 750 ■ Washington, DC 20005Phone 202-728-2094 e-mail jwiener@rti.orgFax 202-728-2094

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Introduction

Concerns about quality for 30 years or longer

Quality of care and quality of life

Omnibus Budget Reconciliation Act of 1987

Some improvements, but poor quality care continues (IOM, GAO)

A lot known about nursing homes, very little about home care and residential care facilities

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Strategies for Improvement

Mandatory external pressure:Strengthen inspections and enforcementMany workforce initiatives (e.g., staffing ratios)

Voluntary external incentives:Provide information to consumersChange Medicare and Medicaid reimbursement

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Strategies (cont.)

Voluntary provider strategies:Change organizational culture

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Strengthen Inspections and Enforcement

Inspections are the main quality strategy of federal and state governments and other countries

Options include: Increasing funding for inspectionToughening enforcementTargeting poor facilitiesReducing predictability of surveyStrengthening federal oversight

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Inspections and Enforcement (cont.)

Inspections focus on structure and paperwork

Inconsistent application of rules

Rules may stifle innovation

Strict regulation may “poison” provider-state relations

Focus on minimum standards

Hard to make sanctions apply to management and not residents

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Strengthen Caregiver Workforce

LTC provided by people, not machines

Increase staffing in nursing homes:No staffing ratios in federal regulationsStudies find better quality with more staffingOpponents say management of staff is more

importantCosts could be high

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Strengthen Workforce (cont.)

Staff training: Increase training requirementsWhat is right level? Training on what?Who will pay?Will this exacerbate the staffing shortage?

Wages and benefits: Increase wages and provide fringe benefitsCosts would be significantLimited research on effect of wages on turnover

and quality

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Provide Consumers with More Information about Quality

Addresses market failure

Nursing Home and Home Health Compare, state Web sites

Little research on effectiveness

Can consumers interpret information?

Provider response?

Depends on imperfect regulatory data

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Change Medicare and Medicaid Reimbursement

75 percent of nursing home residents depend on Medicare and Medicaid, but responses to incentives are up to providers

Federal and state governments control level and type of reimbursement

Complex relationship between costs and quality

Pay-for-performance

Could cost more

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Change Organizational Culture

Eden, Wellspring, Pioneers, Green House

Regulatory barriers

Does greater medical need undercut rationale?

Do they require more staff?

Does it work?

Are effects the result of a charismatic leader?

What public policy levers?

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Conclusions

Know a lot about nursing homes, but not residential care and home care

Quality of care rather than quality of life

Shared federal-state responsibility

Regulation uneven across providers

Many options require additional resources

Existing research provides little guidance regarding relative effectiveness of different strategies