Defining and Achieving Quality

1. Defining and Achieving Quality Michigan’s Long-Term Care Conference Troy Hilton March 23, 2006 Alison Hirschel, Esq., Michigan Poverty Law Program Pam McNab, MI Dep’t Community Health RoAnne Chaney, MPA, MI Disability Rights Coalition

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

3. Defining and Achieving Quality • Facility-based quality • How does the law define quality? • The federal Nursing Home Reform Law (“OBRA ‘87”) defines quality of life requirements: “A nursing facility must provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.”

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

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

6. Defining and Achieving Quality • Rights to self-determination and person centered planning are more limited in adult foster care and homes for the aged. • More limited oversight by the state and likelihood of less frequent contact with advocates in these facilities. • In unlicensed assisted living, there are no person centered planning requirements outside of the contract, no state oversight, and no access for advocates.

7. Defining and Achieving Quality • Person-Centered planning in long term care facilities is often compromised by: • unwillingness to recognize resident’s capacity • deference to family and other “responsible parties,” medical and administrative staff and facility routine and convenience • alleged concerns about the safety and health of other residents and staff • facility concerns about possible citations in regulated facilities.

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

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

10. Defining and Achieving Quality • CMS’s quality indicators focus on medical outcomes, not quality of life concerns. • Although the issues addressed are important, quality indicators give an imperfect view of quality of care: • based on facility’s own unverified reports; • may not reflect current situation in facility; and • do not permit facility to explain apparent problem areas.

11. Defining and Achieving Quality • CMS Nursing Home Quality Initiative • Limited in scope • Purely voluntary • Clinical concerns rather than quality of life and person centered planning issues.

12. Defining and Achieving Quality • State quality initiatives in the past had limited or no impact on quality of life and person centered planning • Nursing home quality incentive program • Quality Assurance Assessment Program • New initiatives show more promise.

13. Defining and Achieving Quality • Culture change models across the country show real promise for emphasis on person centered planning and quality defined from a consumer perspective: • Eden Alternative • Greenhouses • Pioneer Network • Others

14. Defining and Achieving Quality • Advocates for residents are increasingly skilled at advocating for quality from a consumer’s perspective: • Long Term Care Ombudsman Program • Michigan Protection and Advocacy Service • In the future, the Independent Advocate at the SPEs can also assume this role.

15. Defining and Achieving Quality • Continuing challenge to balance: • state and federal requirements and appropriate concerns about ensuring facilities meet minimal standards; • reality that facilities serve multiple clients and have to accommodate them all; and • individual perceptions of quality and individual rights to control life, services and supports.

16. Defining and Achieving Quality • MDS data and quality indicators • Home Care (Handout # 1) • Quality Assurance Surveys • CMS MIChoice waiver protocols

17. Defining and Achieving Quality • CMS Quality Framework (Handout # 2)

18. CMS Quality Framework

19. Defining and Achieving Quality • New tools • Participant Experience Survey: measures experiences of consumers • Participant Outcomes and Status Measurement (POSM): measures desired quality of life vs. actual quality of life (Handout # 3)

21. Defining and Achieving Quality • The Quality Management Collaborative (Handout #4) • Membership: Consumers and providers • Why did the collaboration form? • Tensions: • Independent Living model vs Professional expertise • Choice and Risk vs. Assuring Health and Welfare • What has the collaboration accomplished? (Handout #5)

22. Defining and Achieving Quality • The future of quality collaboration: • Local level – Single Points of Entry • Small groups • Consumer and advocates value to QI • Listening skills and identifying issues