2. Phillips 1 CULTURE, COSTS, AND QUALITY: THE FUTURE OF LONG-TERM CARE Charles Phillips, Ph.D., M.P.H. Health Policy and Management School of Rural Public Health Texas A&M University System Health Science Center

3. Phillips 2 QUALITY AND COSTS IN NURSING FACILITIES

4. Phillips 3 Relationships are like sharks, if they stop moving forward they die “Annie Hall”

5. Phillips 4 EINSTEIN’S FIRST LAW OF NURSING FACILITY MOTION

6. Phillips 5 When a facility is not moving forward, it is moving backward. Facilities are never standing still.

7. Phillips 6 The Quality of Care in Facilities is Constantly Changing. THE ONLY ISSUE IS, “IN WHAT DIRECTION?”

8. Phillips 7 COMPLEXITIES IN NF QUALITY Diversity of Residents –Short-stay –Long-stay –With dementia –End-stage Nature of the institution –Health care facility –Residence

9. Phillips 8 COMPLEXITIES IN NF QUALITY MOST BASIC COMPLEXITY “It is a calling, and It is a business”

10. Phillips 9 QUALITY AND COSTS Costs can’t be discussed separately from quality Cost and quality are assumed to move up or down together Evidence indicates that the relationship is more complex There are examples of higher quality facilities with lower costs

11. Phillips 10 STUDYING COST AND QUALITY Two Studies – Cleveland and New York City Looked at cost reports and found facilities with lower than expected costs Looked at MDS data and surveyed ombudsmen and advocates to find higher quality facilities 6 NYC facilities and 5 Cleveland Interviewed staff

12. Phillips 11 CONTROLLING COST AND ENHANCING QUALITY EXAMPLES “Nobody Eats Vegetables ” “Turning Around Turnover” “Drug Review” “Single Task Workers –part-time workers”

13. Phillips 12 CONTROLLING COST AND ENHANCING QUALITY EXAMPLES “Toileting and activities – cross- training” “Even CNA’s get older” “Using Technology”

14. Phillips 13 CONTROLLING COST AND ENHANCING QUALITY STRATEGIES Single gatekeeper Departmental responsibility All staff (with payback) Working to a budget Working to no budget

15. Phillips 14 COST AND QUALITY (PRINCIPLES) Facility must make a conscious choice of an expense control strategy -- leadership Information about costs and quality are key elements of success Facilities must think of revenue enhancement as the “flipside” of expense control Evaluating effects of changes is crucial

16. Phillips 15 COST AND QUALITY MORE GENERAL PRINCIPLES “There is no magic bullet, pat answer, or formulaic answer!” “Must recognize better quality does not always cost more” “The will is more important than the way”

17. Phillips 16 QUALITY, CULTURE, AND INNOVATION

18. Phillips 17 TRADITIONAL QUALITY INTERVENTIONS CLINICALLY-FOCUSED EXTERNALLY IMPOSED –VULNERABLE POPULATION –MAJOR PAYOR –INDUSTRY INACTION CLASSIC EXAMPLE – MDS, regs on restraints and antipsychotics

19. Phillips 18 PROBLEMS WITH TRADITIONAL INTERVENTIONS Burden rather than challenge Fail to be holistic Ignore quality of life issues

20. Phillips 19 QUALITY OF LIFE (Abt) Dimensions of Quality of Life –DIGNITY –PRIVACY –INTERACTIONS WITH STAFF –FACILITY ENVIRONMENT –FACILITY OPERATIONS –RELATIONSHIPS

21. Phillips 20 CULTURAL INTERVENTIONS Self-initiated by facility Focus on changing beliefs and traditional practices Emphasis on resident preferences and autonomy Emphasis on changing authority relationships among staff

22. Phillips 21 THE EDEN ALTERNATIVE Core problems are loneliness, boredom, helplessness Caring, as well as treatment, is needed Empowerment, animals, and plants are core of intervention.

23. Phillips 22 EFFECTS OF EDEN Results reported by Thomas New York Study Texas study of outcomes Texas study of psychosocial wellbeing

24. Phillips 23 Relationship Between QoL and QoC QUALITY OF LIFE Quality of care

25. Phillips 24 THE WELLSPRING MODEL Clinical modules Care resource teams Technical assistance Resident-focused care Empowerment of CNAs The “Alliance”

26. Phillips 25 EFFECTS OF WELLSPRING COMMONWEALTH STUDY No outcome differences Lower turnover Fewer deficiencies Variations in implementation

27. Phillips 26 LESSONS FROM CULTURAL INNOVATIONS There are no formula Change process is usually poorly understood Integration of “new” and old structures difficult Implementation varies by facility

28. Phillips 27 IMPLICATIONS FOR STATES THERE IS NO MAGIC BULLET FOR QUALITY CHANGE! INNOVATIONS MUST BE BOTH CLINICAL AND CULTURAL! MANY PATHS LEAD TO THE SAME DESTINATION! INNOVATION IS NOT AND EVENT, BUT A PROCESS! THE INDUSTRY CAN’T AND WON’T DO IT ALONE!

29. Phillips 28 EINSTEIN’S SECOND LAW OF NURSING FACILITY DYNAMICS

30. Phillips 29 Quality improvement, expense control, and cultural change are like dieting

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34. Phillips 33 Laura P. “In 1923 when pickles were a penny and Bubbes took the children for a walk in the park -- when it was safe. When pickles were a treat.