Defining and Achieving Quality

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Defining and Achieving Quality

• Michigans Long-Term Care Conference
• Troy Hilton
• March 23, 2006
• Alison Hirschel, Esq., Michigan Poverty Law
  Program
• Pam McNab, MI Dept Community Health
• RoAnne Chaney, MPA, MI Disability Rights Coalition

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Defining and Achieving Quality

• What is quality in long-term care?
• Task Force definition Quality is defined and
  measured by the person receiving supports, and
  not through surrogates (payers, regulators,
  caregivers, families, professionals and/or
  advocates). The elements of quality are
  meaningful relationships, continuity of community
  involvement in the person's life, personal
  well-being, performance measures, customer
  satisfaction measures, the dignity of risk
  taking, and the freedom to choose or refuse
  available options.

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Defining and Achieving Quality

• Facility-based quality
• How does the law define quality?
• The federal Nursing Home Reform Law (OBRA
  87) defines quality of life requirements A
  nursing facility must provide services and
  activities to attain or maintain the highest
  practicable physical, mental, and psychosocial
  well-being of each resident.

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Defining and Achieving Quality

• Federal law also gives residents qualified rights
  to be fully informed, to make decisions about
  medical care, and to participate in on-going care
  planning. Facilities can be cited for these
  violations as well as violations of quality of
  care and other standards and requirements.

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Defining and Achieving Quality

• Federal law requires reasonable accommodation of
  individual needs and preferences in nursing
  facilities including choices about daily
  activities such as schedules, meals, activities,
  and medical care. Although the law does not use
  the term person centered planning, this
  provision supports PCP.

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Defining and Achieving Quality

• Rights to self-determination and person centered
  planning are more limited in adult foster care
  and homes for the aged.
• More limited oversight by the state and
  likelihood of less frequent contact with
  advocates in these facilities.
• In unlicensed assisted living, there are no
  person centered planning requirements outside of
  the contract, no state oversight, and no access
  for advocates.

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Defining and Achieving Quality

• Person-Centered planning in long term care
  facilities is often compromised by
• unwillingness to recognize residents capacity
• deference to family and other responsible
  parties, medical and administrative staff and
  facility routine and convenience
• alleged concerns about the safety and health of
  other residents and staff
• facility concerns about possible citations in
  regulated facilities.

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Defining and Achieving Quality

• Nursing homes and nursing home surveyors often
  focus more on quality of care and other
  technical standards in the law instead of quality
  of life requirements, thus often defeating or
  overlooking person centered planning.

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Defining and Achieving Quality

• Most apparent conflicts between personal choices
  and usual protocols or quality of care
  requirements can be resolved if the facility
  simply documents the residents preference and
  how the facility is accommodating that
  preference.

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Defining and Achieving Quality

• CMSs quality indicators focus on medical
  outcomes, not quality of life concerns.
• Although the issues addressed are important,
  quality indicators give an imperfect view of
  quality of care
• based on facilitys own unverified reports
• may not reflect current situation in facility
  and
• do not permit facility to explain apparent
  problem areas.

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Defining and Achieving Quality

• CMS Nursing Home Quality Initiative
• Limited in scope
• Purely voluntary
• Clinical concerns rather than quality of life and
  person centered planning issues.

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Defining and Achieving Quality

• State quality initiatives in the past had limited
  or no impact on quality of life and person
  centered planning
• Nursing home quality incentive program
• Quality Assurance Assessment Program
• New initiatives show more promise.

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Defining and Achieving Quality

• Culture change models across the country show
  real promise for emphasis on person centered
  planning and quality defined from a consumer
  perspective
• Eden Alternative
• Greenhouses
• Pioneer Network
• Others

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Defining and Achieving Quality

• Advocates for residents are increasingly skilled
  at advocating for quality from a consumers
  perspective
• Long Term Care Ombudsman Program
• Michigan Protection and Advocacy Service
• In the future, the Independent Advocate at the
  SPEs can also assume this role.

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Defining and Achieving Quality

• Continuing challenge to balance
• state and federal requirements and appropriate
  concerns about ensuring facilities meet minimal
  standards
• reality that facilities serve multiple clients
  and have to accommodate them all and
• individual perceptions of quality and individual
  rights to control life, services and supports.

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Defining and Achieving Quality

• MDS data and quality indicators
• Home Care (Handout 1)
• Quality Assurance Surveys
• CMS MIChoice waiver protocols

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Defining and Achieving Quality

• CMS Quality Framework (Handout 2)

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CMS Quality Framework
Focus Desired Outcome
Participant Access Individuals have access to home and community-based services and supports in their communities.
Participant-Centered Service Planning and Delivery Services and supports are planned and effectively implemented in accordance with each participants unique needs, expressed preferences and decisions concerning his/her life in the community
Provider Capacity and Capabilities There are sufficient HCBS providers and they possess and demonstrate the capability to effectively serve participants.
Participant Safeguards Participants are safe and secure in their homes and communities, taking into account their informed and expressed choices.
Participant Rights and Responsibilities Participants receive support to exercise their rights and in accepting personal responsibilities.
Participant Outcomes and Satisfaction Participants are satisfied with their services and achieve desired outcomes.
System Performance The system supports participants efficiently and effectively and constantly strives to improve quality.
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Defining and Achieving Quality

• New tools
• Participant Experience Survey measures
  experiences of consumers
• Participant Outcomes and Status Measurement
  (POSM) measures desired quality of life vs.
  actual quality of life (Handout 3)

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Defining and Achieving Quality

• The Quality Management Collaborative (Handout 4)
• Membership Consumers and providers
• Why did the collaboration form?
• Tensions
• Independent Living model vs Professional
  expertise
• Choice and Risk vs. Assuring Health and Welfare
• What has the collaboration accomplished? (Handout
  5)

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Defining and Achieving Quality

• The future of quality collaboration
• Local level Single Points of Entry
• Small groups
• Consumer and advocates value to QI
• Listening skills and identifying issues