RTI International is a trade name of Research Triangle Institute

1. Strategies for Improving the Quality of Long-Term CarePresented byJoshua M. Wiener, PhD, Marc Freiman, Ph.D., and David Brown, M.A. RTI International 701 13th Street, NW ■ Suite 750 ■ Washington, DC 20005 Phone 202-728-2094 Fax 202-728-2094 e-mail jwiener@rti.org RTI International is a trade name of Research Triangle Institute

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