1. Hawes - Texas A&M University System Health Science Center 1 Assuring Nursing Home Quality: Divining Effective Models of Regulation Catherine Hawes, Ph.D. School of Rural Public Health Texas A&M University System HSC for the AHRQ User Liaison Conference Indianapolis, IN: May 2002

2. Hawes 2 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

3. Hawes 3 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

4. Hawes 4 Early Results  Improvements in process quality  e.g., reduced use of physical restraints  Improvements in resident outcomes  Decreased use of hospital care

5. Hawes 5 However~Continuing Concerns About Nursing Home Quality  Representative Waxman’s report on abuse  Ombudsman reports  Research studies  CMS staffing study

6. Hawes 6 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

7. Hawes 7 Five Partial Explanations 1.An industry in disarray 2.Staffing issues 3.Poor support for ombudsmen 4.A flawed regulatory system  Flawed survey system  Weaknesses in enforcement 5.Reimbursement policy

8. Hawes 8 Single Biggest Problem Today To paraphrase James Carville…

9. Hawes 9 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

10. Hawes 10 Indicators of An “Effective” Regulatory System, cont.  Effective Survey System  Examples…  Qualified surveyors  Low % of NFs with no deficiencies  Low % of surveys with > 18 month interval

11. Hawes 11 State Variation on Survey StateOmbud. view % Surveys > 18 months % NF w/ Zero Deficiences Athorough0.0%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%

12. Hawes 12 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

13. Hawes 13 State Variation on Enforcement - 1999 State % NF cited harm or jeopardy Range of remedies Impose immediately A59.8%> 3Many B47.4%> 3Few C31.3%> 3Many D22.6%noNo E29.2%> 3No

14. Hawes 14 Additional Indicators  State communicates with public  State regularly communicates with providers, ombudsmen  State has and supports meaningful quality improvement program

15. Hawes 15 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

16. Hawes 16 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

17. Hawes 17 Description of State, cont.  Surveyors have Master’s 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

18. Hawes 18 State and Quality Improvement  QUANs ~ Masters-trained nurses for voluntary quality improvement  80% of facilities participate  Consultation~good clinical practice  Training on MDS and RAPs  How to implement new practices  Quarterly to monthly visits

19. Hawes 19 Genuine Partnership Among All Stakeholders  State survey agency  Providers  Ombudsman and aging network  Shared commitment  Support each other  Support good reimbursement  Support for CNAs

20. Hawes 20 Lessons from the 1990s  Regulation can improve quality  Especially if tied to clinical quality  Quality Coalition  Advocates + Providers  Regulation is necessary…but not sufficient  Quality improvement initiatives  Reimbursement policy, staffing

21. Hawes 21