Comparative Perspectives on Long Term Care Quality Regulation

1. Comparative Perspectives on Long Term Care Quality Regulation Comparative Health Care Systems Class 4/2/2013 Vincent Mor, Ph.D. Florence Pirce Grant University Professor Brown University

2. Purpose • Provide a conceptual framework for understanding and comparing regulatory and quality assurance systems pertaining to Long Term Care across the developed and developing world • Review several “case studies” following a prescribed format selected on the basis of socio-political spectrum Comparative Health Care Systems Class 4/2/2013

3. Background • Historically caring for elderly was a family responsibility • Purchasing help to care for elderly was the province of the wealthy • Like hiring servants, it was assumed that the employer was discerning and controlled the care provided by the hired help • Residential arrangements were initially informal – placing older family members to be cared for in someone else’s home • Religious and mutual aide societies emerged to provide care for members and care of the elderly was among earliest services • State sponsored care homes largely serving the destitute and those without families emerged from the tradition of poor houses. Comparative Health Care Systems Class 4/2/2013

4. Background • As societal aging accelerates, geographic and social mobility increases, elderly left behind need care solutions • Supply of governmental and sectarian care home solutions become inadequate • Government grapples with long term care policy agenda • Almost all industrialized and industrializing countries introduced policies to stimulate supply of care homes • This often implies providing incentives to the private sector to meet the anticipated demand • Inevitably this entails subsidizing or paying for long term care for the poor or those who become poor due to high needs • The Challenge is to devise regulatory control systems to assure the quality of care provided by the private sector Comparative Health Care Systems Class 4/2/2013

5. Background • Cambridge University Press Book of Quality Measurement Systems included a chapter on Long Term Care written by and highlighting interRAI countries: Finland, Canada, Switzerland and US • Positive reception so series editor at London School of Economics asked for special book on long term care quality • Specially commissioned chapters on the regulatory structure of long term care (residential or home) • Outline agreed to and writing reviewed with feedback and comments by Mor and co-editors Comparative Health Care Systems Class 4/2/2013

6. Austria Australia Canada China England Finland Germany Japan The Netherlands New Zealand South Korea Spain Switzerland USA 14 countries

7. Demographics

8. Case Study Question #1 • What is the regulatory structure for long term care? • Which Ministry (Department)? • How do different related Ministries coordinate • How much is in law and how much is included administrative rules? • What is the relationship between the Central Government and Regional/Local government? How centralized are the means of regulatory authority and oversight? Comparative Health Care Systems Class 4/2/2013

9. Case Study Question #2 • Does the Regulatory Structure differ for residential vs. community based services? • For whom are community and residential services coordinated and connected? • Is there case management that helps clients move between the two services? • Which agency (if any) is responsible for this kind of triage. Comparative Health Care Systems Class 4/2/2013

10. Case Study Question #3 • Does the regulatory apparatus vary by region of the country? • Are Regions, States, Provinces the basis for implementing regulations? • Do Regions, etc. add their own regulations, standards and requirements? • Is there a way to measure variation in the stringency of regulatory enforcement? Comparative Health Care Systems Class 4/2/2013

11. Case Study Question #4 • Does the regulatory apparatus vary by who is paying? • Are publicly funded services regulated differently way than those that are purchased privately? • Are there different regulations applicable to differently funded individuals? Comparative Health Care Systems Class 4/2/2013

12. Case Study Question #5, #6, #7 • What is the application, inspection and certification (licensure) system for long term care services? • Is there a routine monitoring and/or repeat inspection system for the long term care services? • Are systematic data about patients and/or care processes collected and used to guide the inspection process? • How is enforcement excercised and how is it documented? Comparative Health Care Systems Class 4/2/2013

13. Case Study Question #8, #9, #10 • Is there a way to give “voice” to the consumers’ (clients’/patients’) preferences? e.g. satisfaction with care and with the caregivers of the services received? • Is there public reporting of inspection results to the public and prospective users of the long term care services? Comparative Health Care Systems Class 4/2/2013

14. Financing of LTC

15. Components of a Regulatory Control System • Certification standards and the standard setting process, including how providers apply, are reviewed, inspected and determined to meet specified criteria • Ongoing monitoring of compliance with standards; oversight and inspection & complaint investigation • Enforcement of the regulations in the form of fines, prohibition on new admission and final de-certification or revocation of licensure • Publicly reporting quality monitoring results to help consumers and their advocates select providers ; using market forces to stimulate competition Comparative Health Care Systems Class 4/2/2013

16. Regulatory Dimensions • Governing the physical space, minimal professional resources and available services • Governing the educational achievement and minimum training standards for people caring for long term care clients • Governing the processes of care provided • Governing the outcomes clients experience Comparative Health Care Systems Class 4/2/2013

17. Inter-relationship between Regulatory Control & Purchasing Standards • Licensing and minimal quality standards apply to the provider • Government or purchaser’s role can be passive or more active • As “purchaser” Government can set higher standards OR “steer” patients to facilities with superior quality since regulations set minimum standards • Even in the absence of “market” forces purchaser can make a market – however, rarely done Comparative Health Care Systems Class 4/2/2013

18. Comparative Regulatory Perspectives • Standards setting and Inspection Indepedence • Reliance on “professionalism” and training of provider staff • Reliance on Measurement of Residents’ Care Processes and Outcomes • Public Reporting to Stimulate Market Forces • Not necessarily independent; a matter of relative emphasis and compatability with cultural norms Comparative Health Care Systems Class 4/2/2013

19. Categories of Regulatory Approach • Professionalism Based Regulatory System • Inspection Based Regulatory System • Empirical Data & Reporting Regulatory System • Developing Country Approach Comparative Health Care Systems Class 4/2/2013

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21. Regulatory Structure • Centralized • National Authority • Limited Local Discretion • Decentralized • Local Government rules OR • Inspection teams Comparative Health Care Systems Class 4/2/2013

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26. Regulatory Functions • Licensure • Structural Standards • Professional Standards • Professional Associations • Minimum Care Process Standards • Resident/Client Outcome Status Measurement • Routine Inspections • Random Unannounced Inspections • Data Driven Inspections • Sanctions and Warnings • Legal Appeals Process • Complaint collection and Monitoring • Public Reporting Comparative Health Care Systems Class 4/2/2013

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29. Exemplars of Inspection Variation • All US states have adopted Federal quality standards • State officials and staff conduct inspections in accordance with the Federal standards • Considerable inter-state variation in the frequency and severity of “deficiencies” (departures) from established standards as perceived by inspectors • Although many other countries have similar national to regional or local delegation of inspection and monitoring functions, few other countries make this kind of data available Comparative Health Care Systems Class 4/2/2013

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31. Summary • Quality Regulation in the form of Quality Assurance and Protection of the Public is a fundamental Government function • Considerable cross-national variation in the philosophical underpinnings of the long term care regulatory system • Variation likely due to; • perception of government • “Trust” in non-governmental institutions • Historical Idiosyncracies • Range of regulatory functions and “tools” is broad • How well (strigently) applied may not be related to the regulatory approach countries have developed. Comparative Health Care Systems Class 4/2/2013