Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

CHAPTER TWELVE: LONG-TERM CARE QUALITY

CHAPTER HIGHLIGHTS

Defining Quality

 Means different things to different people and different things in different

situations.

 Includes both technical care and the management of the interpersonal exchanges

between residents and providers.

 Includes three generally accepted measurement types: structure, process, and

outcomes:

 Structure – organizational makeup.

 Process – how care is delivered.

 Outcomes – results of care.

 Quality of life refers to the total living experience, which results in overall

satisfaction with one’s life.

Total Quality Management/Continuous Quality Improvement

 Has been used extensively in business and industry for years.

 An organized quality program based on concept that those delivering the care

want to do a good job and know how.

Quality Initiatives – growing emphasis on measuring and improving quality in long-

term care.

 System-Wide Quality Programs – include both government and private programs.

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 Government Programs – have historically consisted mostly of regulating quality,

but have recently included quality information initiatives.

History of Government Quality Regulations

 Quality Assurance – an early method of quality management that identified

quality issues and set minimum standards to be met for the issues.

 Quality Assurance and Performance Improvement (QAPI) program as proscribed

by Section 6102(c) of the Affordable Care Act

 Minimum Data Set (MDS) for Long-Term Care – a means of structuring the

assessment of nursing facility residents.

 OASIS – an assessment tool for home health care, called the Outcomes and

Assessment Information Set (OASIS).

 Quality Improvement Organizations – CMS-contracted organizations that

review medical care and help beneficiaries with complaints about the quality of

care and to implement improvements in the quality of care available throughout

the spectrum of care.

 Pay-for-Performance – involves identifying procedures for which providers will

not be reimbursed as CMS identifies them as not necessary or resulting from poor

quality.

Public Information Quality Initiatives

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 Nursing Home Compare – designed to identify certain quality measures and to

show how individual facilities compared to the preset standard and to each

other. The information is available on the CMS website.

 “Five-Star” Ratings – a rating system based on the quality and safety

information on Nursing Home Compare to help beneficiaries, their families,

and caregivers compare nursing homes more easily.

Quality-Related Research – government agencies that fund and publish quality

research.

 AHRQ – Agency for Healthcare Research and Quality funds quality-related

research.

 National Library of Medicine – collects materials and provides information

and research services in all areas of biomedicine and health care

Private Quality Programs – nongovernment programs focusing on quality in health

care.

 Quality First – a voluntary initiative created by several leading long-term care

professional organizations and designed to improve the quality of nursing home

care and other long term care services.

 AHCA/NCAL Quality Award: a criteria-based program that recognizes a

commitment to performance excellence by member facilities.

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

 Advancing Excellence in America’s Nursing Homes – a coalition of 14 national

provider organizations that care for 650,000 elderly and disabled patients

annually.

 Alliance for Quality Nursing Home Care – a coalition of 14 national provider

organizations that care for 650,000 elderly and disabled patients annually.

 American Health Quality Association – a charitable, educational, not-for-profit

national membership association dedicated to health care quality through

community-based independent quality evaluation and improvement programs.

 National Quality Forum – a private, not-for-profit membership organization

created to develop and implement a national strategy for health care quality

measurement and reporting.

 Accreditation Organizations – organizations that require a strong emphasis on

quality improvement in the provider organizations they accredit.

 Private Foundations – foundations (e.g., the Robert Wood Johnson Foundation

and the Henry. J Kaiser Family foundation) that provide funding for quality-

related research and project implementation.

 College and University Research Institutes – many colleges and universities

maintain research institutes or other organizational divisions addressing quality of

care.

 Other Organizations – There are many other organizations, associations, and

coalitions working to improve long-term care

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

Provider-Administered Quality Improvement Programs – programs used by long-

term and other health care providers to ensure quality of care within their organizations.

Developing a Quality Improvement Program – includes several important

elements, including:

 Top-Level Support – must have support from the very top levels of

administration.

 Mission Based – should be an integral part of the mission of the organization.

 Defining the Customers – the organization will need to define who its

customers are, those residents or other individuals served by the organization.

 Measurement – defining and monitoring certain key indicators (e.g., the

number of residents with physical restraints, number of medication errors, or

infection rates).

 Evaluation – evaluating how well the organization is doing.

 Improvement – making changes in procedures based on the information

gleaned.

 Ongoing Measurement and Evaluation – a continuous process.

Quality Teams – quality improvement usually involves teams consisting of staff

closely involved with the area being evaluated.

Technology – an increasingly valuable resource in measuring and maintaining

quality.

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Long-Term Care: Managing Across the Continuum, Fourth Edition John R. Pratt

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Chapter 11 Long-Term Care

Reimbursement

Learning Objectives

1. Understand how long-term care services are reimbursed

2. Identify and define public sources of reimbursement

3. Identify and define private sources of reimbursement

Learning Objectives (continued)

4. Understand how managed care works and its impact on long-term care

5. Understand the trends affecting long-term care reimbursement

Long-Term Care System Development

Little government involvement until welfare (Social Security) in 1935

Major involvement with Medicare and Medicaid in 1965

Has evolved since then

Current Reimbursement Options Government (public) sources:

• Medicare • Medicaid • Other

Private sources: • Out-of-pocket payments • Private long-term care insurance • Managed care organizations

Public/private partnerships

Medicare

Title XVIII of the Social Security Act Covers elderly and some disabled No means test Covers (with some limitations):

• Skilled nursing in nursing facilities and subacute care

• Home health care • Hospice

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Medicaid Title XIX of the Social Security Act Covers “medically indigent” Funded partly by federal and partly by state

governments Run by the states under federal guidelines Covers (depending on the state’s program):

• Nursing care facilities • Assisted living • Home health care

Medicaid (continued)

State efforts to reduce costs: • Divert funds to less expensive forms

of care (community-based) • “Spend-down” requirements • May be greatly expanded by the

Affordable Care Act

Other Public Funding Sources

Supplemental Security Income program Department of Veterans Affairs Older Americans Act Others

Private Reimbursement Sources

Out-of-pocket payments Private long-term care insurance Public/private partnership programs Managed care

Public/Private Partnerships

Robert Wood Johnson Foundation demonstration projects

Provide incentives for consumers to provide some long-term care coverage in return for asset protection

2006 legislation to create nationwide program

Managed Care

• Impact on long-term care • Types of MCO/provider arrangements • Making the transition to managed care • Managed care’s tarnished image

Trends in Reimbursement

• Growth of private managed care • Growth of public managed care • Prospective payment • Emphasis on community-based care • Incentives for purchase of private • LTC insurance • Liability costs and tort reform

Financing Reform

Much talk, not much action until 2010 • Passing of the ACA

Long-term care is not a high priority • Hard to define • Would be very expensive

Summary

Long-term care provider organizations are

reimbursed by a combination of public and

private organizations and agencies.

Reimbursement is fragmented and varies by

type of provider.

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