Defining and Achieving Quality

Defining and Achieving Defining and Achieving QualityQuality

Michigan’s Long-Term Care ConferenceMichigan’s Long-Term Care ConferenceTroy HiltonTroy Hilton

March 23, 2006March 23, 2006

Alison Hirschel, Esq., Michigan Poverty Alison Hirschel, Esq., Michigan Poverty Law ProgramLaw Program

Pam McNab, MI Dep’t Community HealthPam McNab, MI Dep’t Community HealthRoAnne Chaney, MPA, MI Disability Rights RoAnne Chaney, MPA, MI Disability Rights

CoalitionCoalition

Defining and Achieving QualityDefining and Achieving Quality

What is quality in long-term care?What is quality in long-term care?

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


Facility-based qualityFacility-based quality

How does the law define quality?How does the law define quality?

– The federal Nursing Home Reform Law (“OBRA The federal Nursing Home Reform Law (“OBRA ‘87”) defines quality of life requirements: “A ‘87”) defines quality of life requirements: “A nursing facility must provide services and nursing facility must provide services and activities to attain or maintain the highest activities to attain or maintain the highest practicable physical, mental, and psychosocial practicable physical, mental, and psychosocial well-being of each resident.”well-being of each resident.”


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


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

Defining and Achieving QualityDefining and Achieving Quality Rights to self-determination and person Rights to self-determination and person centered planning are more limited in adult centered planning are more limited in adult foster care and homes for the aged. foster care and homes for the aged.

More limited oversight by the state and More limited oversight by the state and likelihood of less frequent contact with likelihood of less frequent contact with advocates in these facilities. advocates in these facilities.

In unlicensed assisted living, there are no In unlicensed assisted living, there are no person centered planning requirements person centered planning requirements outside of the contract, no state oversight, outside of the contract, no state oversight, and no access for advocates.and no access for advocates.


Person-Centered planning in long term Person-Centered planning in long term care facilities is often compromised by:care facilities is often compromised by:

unwillingness to recognize resident’s capacityunwillingness to recognize resident’s capacitydeference to family and other “responsible parties,” deference to family and other “responsible parties,” medical and administrative staff and facility medical and administrative staff and facility routine and convenienceroutine and conveniencealleged concerns about the safety and health of alleged concerns about the safety and health of other residents and staffother residents and stafffacility concerns about possible citations in facility concerns about possible citations in regulated facilities.regulated facilities.


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


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


CMS’s quality indicators focus on medical CMS’s quality indicators focus on medical outcomes, not quality of life concerns. outcomes, not quality of life concerns.

Although the issues addressed are Although the issues addressed are important, quality indicators give an important, quality indicators give an imperfect view of quality of care:imperfect view of quality of care:– based on facility’s own unverified reports;based on facility’s own unverified reports;– may not reflect current situation in facility; andmay not reflect current situation in facility; and– do not permit facility to explain apparent do not permit facility to explain apparent

problem areas.problem areas.


CMS Nursing Home Quality InitiativeCMS Nursing Home Quality Initiative

– Limited in scopeLimited in scope– Purely voluntaryPurely voluntary– Clinical concerns rather than quality of life and Clinical concerns rather than quality of life and

person centered planning issues.person centered planning issues.


State quality initiatives in the past had State quality initiatives in the past had limited or no impact on quality of life and limited or no impact on quality of life and person centered planningperson centered planning

– Nursing home quality incentive programNursing home quality incentive program– Quality Assurance Assessment ProgramQuality Assurance Assessment Program

New initiatives show more promise.New initiatives show more promise.


Culture change models across the country Culture change models across the country show real promise for emphasis on person show real promise for emphasis on person centered planning and quality defined from centered planning and quality defined from a consumer perspective:a consumer perspective:

– Eden AlternativeEden Alternative– GreenhousesGreenhouses– Pioneer NetworkPioneer Network– OthersOthers


Advocates for residents are increasingly Advocates for residents are increasingly skilled at advocating for quality from a skilled at advocating for quality from a consumer’s perspective:consumer’s perspective:

– Long Term Care Ombudsman ProgramLong Term Care Ombudsman Program– Michigan Protection and Advocacy ServiceMichigan Protection and Advocacy Service– In the future, the Independent Advocate at the In the future, the Independent Advocate at the

SPEs can also assume this role.SPEs can also assume this role.


Continuing challenge to balance:Continuing challenge to balance:

– state and federal requirements and state and federal requirements and appropriate concerns about ensuring facilities appropriate concerns about ensuring facilities meet minimal standards;meet minimal standards;

– reality that facilities serve multiple clients and reality that facilities serve multiple clients and have to accommodate them all; andhave to accommodate them all; and

– individual perceptions of quality and individual individual perceptions of quality and individual rights to control life, services and supports.rights to control life, services and supports.


MDS data and quality indicatorsMDS data and quality indicators

– Home Care (Handout # 1)Home Care (Handout # 1)

Quality Assurance SurveysQuality Assurance Surveys

– CMS MIChoice waiver protocolsCMS MIChoice waiver protocols


CMS Quality Framework CMS Quality Framework (Handout # 2)(Handout # 2)

CMS Quality FrameworkCMS Quality FrameworkFocusFocus Desired OutcomeDesired Outcome

Participant AccessParticipant Access Individuals have access to home and community-based Individuals have access to home and community-based services and supports in their communities.services and supports in their communities.

Participant-Centered Participant-Centered Service Planning and Service Planning and DeliveryDelivery

Services and supports are planned and effectively implemented Services and supports are planned and effectively implemented in accordance with each participant’s unique needs, expressed in accordance with each participant’s unique needs, expressed preferences and decisions concerning his/her life in the preferences and decisions concerning his/her life in the communitycommunity

Provider Capacity and Provider Capacity and CapabilitiesCapabilities

There are sufficient HCBS providers and they possess and There are sufficient HCBS providers and they possess and demonstrate the capability to effectively serve participants.demonstrate the capability to effectively serve participants.

Participant SafeguardsParticipant Safeguards Participants are safe and secure in their homes and Participants are safe and secure in their homes and communities, taking into account their informed and expressed communities, taking into account their informed and expressed choices.choices.

Participant Rights and Participant Rights and ResponsibilitiesResponsibilities

Participants receive support to exercise their rights and in Participants receive support to exercise their rights and in accepting personal responsibilities.accepting personal responsibilities.

Participant Outcomes Participant Outcomes and Satisfactionand Satisfaction

Participants are satisfied with their services and achieve Participants are satisfied with their services and achieve desired outcomes.desired outcomes.

System PerformanceSystem Performance The system supports participants efficiently and effectively and The system supports participants efficiently and effectively and constantly strives to improve quality.constantly strives to improve quality.


New toolsNew tools

– Participant Experience Survey: measures Participant Experience Survey: measures experiences of consumersexperiences of consumers

– Participant Outcomes and Status Participant Outcomes and Status MeasurementMeasurement ( (POSM): measures desired POSM): measures desired quality of life vs. actual quality of life quality of life vs. actual quality of life (Handout # 3)(Handout # 3)


The Quality Management Collaborative The Quality Management Collaborative (Handout #4)(Handout #4)

– Membership: Consumers and providersMembership: Consumers and providers

– Why did the collaboration form?Why did the collaboration form?

– Tensions:Tensions:Independent Living model vs Professional expertiseIndependent Living model vs Professional expertiseChoice and Risk vs. Assuring Health and WelfareChoice and Risk vs. Assuring Health and Welfare

– What has the collaboration accomplished? What has the collaboration accomplished? (Handout #5)(Handout #5)


The future of quality collaboration:The future of quality collaboration:

– Local level – Single Points of EntryLocal level – Single Points of Entry

– Small groupsSmall groups

– Consumer and advocates value to QIConsumer and advocates value to QI

– Listening skills and identifying issuesListening skills and identifying issues

Documents

Defining and Achieving Quality