Best at Home Assuring Quality Long-Term Care in Home and Community-Based Settings (1996) / Chapter Skim
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3 CURRENT QUALITY ASSURANCE AND IMPROVEMENT STRATEGIES
3 CURRENT QUALITY ASSURANCE AND IMPROVEMENT STRATEGIES
Pages 29-42
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From page 29... ...
This chapter introduces elements of quality to be assessed and improved, briefly describes different types of quality assurance or improvement programs, and offers some ofthe committee's ideas about the appropriateness, effectiveness, and adequacy of existing strategies in the home and community-based context. It is intended to provide a conceptual background for the issues and study questions posed in Chapter 4, but it does not purport to be an exhaustive review of this field.
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From page 30... ...
The Health Care Financing Administration (HCFA) is sponsoring work on the development of an outcomes-based quality improvement approach, which has the capability to examine specific patient-level outcomes, for use by Medicare home health agencies and the Medicare system (Peter Shaughnessy, University of Colorado, personal communication, September 22, 1995~.
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From page 31... ...
They attempt to define and maintain at least minimum standards for quality; often, they can serve as a catalyst for provider organizations to establish or enhance their own quality improvement efforts. External programs typically follow a variety of approaches to establish criteria, set quality standards (structure, process, and/or outcome)
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From page 32... ...
One indication of this can be seen in state licensure laws; in 1992, 39 states required compliance with their own licensure requirements in addition to federal requirements for Medicare-certifiedhome health agencies, 35 states applied such licensure requirements to non-Medicare-certified agencies, and 20 required individual providers of home care (home care aides, homemakers, personal care assistants) to obtain a license from the state (NAHC, 1993~.
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From page 33... ...
Agencies that receive accreditation through these organizations are deemed to have met, and in some places, to have exceeded the federal conditions for participation in the Medicare program. No similar accrediting organizations currently exist for residential care settings.
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From page 34... ...
Internal Quality Assurance Programs Internal quality assurance and improvement programs are developed and used by provider organizations of their own accord as a way to improve the systems and processes that help them realize the goal of providing excellent care that continues to improve over time (JCAHO, 1994~. Embodied in many of these internal programs are the principles of "total quality management" and "continuous quality improvement." The procedures followed by organizations
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From page 35... ...
Little if any progress has been made in adapting these approachesfully to providers such as home care agencies or to settings such as homes or residential care settings, although some providers (primarily Medicare-certified or privately accreditedhome care agencies~have developed and begun implementing elements that are critical to successful quality improvement efforts. Many agencies and residential care settings develop internal guidelines or standard operating procedures to guide the way in which services are to be provided by their organizations.
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From page 36... ...
In the broad area of home and community-based care, this is open a more difficult issue to come to terms with than it might be in the general area of inpatient and outpatient medical care rendered in traditional settings. For one thing, in this broader arena, the services stretch beyond well-known medical, nursing, or rehabilitation care to a variety of other personal assistance and social services that have not traditionally been the focus of organized quality assurance programs.
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From page 37... ...
Similarly, functional assessment is different for children, adults, and the elderly (NRC/TOM, 1994) , and this variation must be considered when developing appropriate outcomes measures to be used in quality improvement programs.
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From page 38... ...
A state-licensed residential care facility provides home care services, but it is not certified to receive reimbursement from Medicare or Medicaid. Therefore, whereas private pay residents can receive services directly from the residential care facility, Medicare and Medicaid beneficiaries must receive services from a Medicare-certified home health agency in order to have the costs reimbursed.
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From page 39... ...
noted barriers to the effectiveness of LTC ombudsmen working in B&C facilities, including limited access: It found that in most states ombudsmen are not a major presence in such facilities.3 As noted earlier, ombudsan involvement with home care consumers is extremely rare; given the likelihood of federal cuts to the ombudsman program, it is not expected to expand significantly. Sabatino (1992)
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From page 40... ...
For example, nursing staff interventions in a continuous quality improvement context at an Intermountain Health Care hospital dramatically lowered the rate of decubitus ulcers among inpatients (Susan Horn, Ph.D., Senior Scientist, Institute for Clinical Outcomes Research, personal communication, July 10, 19953. Consumer satisfaction surveys are a well-known adjunct to quality improvement efforts by provider organizations, but their record with respect to effectiveness is not conclusive.
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From page 41... ...
For example, given the infrequency of licensure and accreditation surveys, these programs on their own have little capacity to oversee how well care fits the needs of consumers who age in place or who have a change of status. Conversely, reliance solely on putative quality improvement efforts undertaken by provider groups or agencies with little formal training in quality measurement or little history of successful implementation of such programs would be foolhardy.
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From page 42... ...
42 BEST AT HOME SUMMARY This chapter has commented on the structure, process, and outcomes variables important to a full conceptualization of quality of care; it has also briefly discussed different~types of quality assurance or improvement programs that can be mounted externally by regulatory agencies or by private voluntary entities, as well as those that can be implemented by provider organizations themselves. Given the original legislation's emphasis on the appropriateness, effectiveness, and adequacy of existing quality-of-care strategies in the home and community-based context, the committee has also offered its ideas on how these aspects of quality improvement programs might be considered and assessed.
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