Strategies for Improving the Quality of Long-Term Care Presented by Joshua M. Wiener, PhD, Marc Freiman, Ph.D., and David Brown, M.A. RTI International RTI International is a trade name of Research Triangle Institute th Street, NW ■ Suite 750 ■ Washington, DC Phone

2 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

3 Strategies for Improvement Mandatory external pressure: Strengthen inspections and enforcement Many workforce initiatives (e.g., staffing ratios) Voluntary external incentives: Provide information to consumers Change Medicare and Medicaid reimbursement

4 Strategies (cont.) Voluntary provider strategies: Change organizational culture

5 Strengthen Inspections and Enforcement Inspections are the main quality strategy of federal and state governments and other countries Options include: Increasing funding for inspection Toughening enforcement Targeting poor facilities Reducing predictability of survey Strengthening federal oversight

6 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

7 Strengthen Caregiver Workforce LTC provided by people, not machines Increase staffing in nursing homes: No staffing ratios in federal regulations Studies find better quality with more staffing Opponents say management of staff is more important Costs could be high

8 Strengthen Workforce (cont.) Staff training: Increase training requirements What is right level? Training on what? Who will pay? Will this exacerbate the staffing shortage? Wages and benefits: Increase wages and provide fringe benefits Costs would be significant Limited research on effect of wages on turnover and quality

9 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

10 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

11 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?

12 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