Assuring Nursing Home Quality: Divining Effective Models of Regulation

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Assuring Nursing Home Quality Divining Effective
Models of Regulation

• Catherine Hawes, Ph.D.
• School of Rural Public Health
• Texas AM University System HSC
• for the AHRQ User Liaison Conference
• Indianapolis, IN May 2002

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Retirement Research Foundation

• Data from a study funded by Retirement Research
  Foundation
• Also data and advice from colleagues
• Zimmerman, Harrington, Edelman, Stegemann,
  Phillips
• Conclusions my own not necessarily those of RRF

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The OBRA-87 Reforms

• Resident focused/outcome oriented
• Addressed all three elements
• Standards, Inspection, Enforcement
• Elevated quality of life
• Established the RAI
• Assessment and care planning
• Data system for quality indicators

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Early Results

• Improvements in process quality
• e.g., reduced use of physical restraints
• Improvements in resident outcomes
• Decreased use of hospital care

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HoweverContinuing Concerns About Nursing Home
Quality

• Representative Waxmans report on abuse
• Ombudsman reports
• Research studies
• CMS staffing study

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Continuing Concerns About Nursing Home Quality

• Recent GAO reports
• Hearings by the US Senate Special Committee on
  Aging
• Quality problems
• Failures in the regulatory system

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Five Partial Explanations

• An industry in disarray
• Staffing issues
• Poor support for ombudsmen
• A flawed regulatory system
• Flawed survey system
• Weaknesses in enforcement
• Reimbursement policy

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Single Biggest Problem Today

• To paraphrase James Carville

"It's the staffing, stupid!"
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What Are Indicators of An Effective Regulatory
System?

• Ombudsman report
• Provider report
• Effective complaint investigation
• Outreach, intake, type of complaints,
  investigations, resolution, sanctions
• For allegations of abuse and neglect
• For general complaints

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Indicators of An Effective Regulatory System,
cont.

• Effective Survey System
• Examples
• Qualified surveyors
• Low of NFs with no deficiencies
• Low of surveys with gt 18 month interval

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State Variation on Survey
State Ombud. view Surveys gt 18 months NF w/ Zero Deficiences
A thorough 0.0 1.5
B thorough 0.0 7.2
C inadequate 8.6 4.2
D inadequate 0.0 27.4
E inadequate 33.5 41.8
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Effectiveness Indicators, cont.

• Comprehensive Enforcement
• Has a written guidelines for which remedies to
  impose
• Uses a range of remedies
• Uses sanctions for deficiencies not just
  failure to correct
• Cites deficiencies at appropriate level

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State Variation on Enforcement - 1999
State NF cited harm or jeopardy Range of remedies Impose immediately
A 59.8 gt 3 Many
B 47.4 gt 3 Few
C 31.3 gt 3 Many
D 22.6 no No
E 29.2 gt 3 No
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Additional Indicators

• State communicates with public
• State regularly communicates with providers,
  ombudsmen
• State has and supports meaningful quality
  improvement program

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State With Good System

• Quarterly meeting with advocates, ombudsmen,
  providers, public
• Outreach to public
• Billboards, radio and television public service
  on reporting abuse
• News releases on deficiencies
• Some states have web page w/ QI

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Description of State, cont.

• Toll-free hotline, 24 hours a day
• Written investigative protocols for investigating
  complaints
• Most experienced surveyors used to investigate
  complaints
• Few complaints about physical abuse, relative to
  other states

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Description of State, cont.

• Surveyors have Masters in nursing
• Aggressive citing all deficiencies seen
• Cite at appropriate level of scope and severity
• Use range of federal and state remedies
• Immediate imposition for deficiency

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State and Quality Improvement

• QUANs Masters-trained nurses for voluntary
  quality improvement
• 80 of facilities participate
• Consultationgood clinical practice
• Training on MDS and RAPs
• How to implement new practices
• Quarterly to monthly visits

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Genuine Partnership Among All Stakeholders

• State survey agency
• Providers
• Ombudsman and aging network
• Shared commitment
• Support each other
• Support good reimbursement
• Support for CNAs

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Lessons from the 1990s

• Regulation can improve quality
• Especially if tied to clinical quality
• Quality Coalition
• Advocates Providers
• Regulation is necessarybut not sufficient
• Quality improvement initiatives
• Reimbursement policy, staffing

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The End