CULTURE, COSTS, AND QUALITY: THE FUTURE OF LONG-TERM CARE

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CULTURE, COSTS, AND QUALITY THE FUTURE OF
LONG-TERM CARE

• Charles Phillips, Ph.D., M.P.H.
• Health Policy and Management
• School of Rural Public Health
• Texas AM University System Health Science Center

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QUALITY AND COSTS IN NURSING FACILITIES
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Relationships are like sharks, if they stop
moving forward they dieAnnie Hall
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EINSTEINS FIRST LAW OF NURSING FACILITY MOTION
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When a facility is not moving forward , it is
moving backward. Facilities are never standing
still.
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The Quality of Care in Facilities is Constantly
Changing. THE ONLY ISSUE IS, IN WHAT
DIRECTION?
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COMPLEXITIES IN NF QUALITY

• Diversity of Residents
• Short-stay
• Long-stay
• With dementia
• End-stage
• Nature of the institution
• Health care facility
• Residence

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COMPLEXITIES IN NF QUALITY

• MOST BASIC COMPLEXITY
• It is a calling, and
• It is a business

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QUALITY AND COSTS

• Costs cant be discussed separately from quality
• Cost and quality are assumed to move up or down
  together
• Evidence indicates that the relationship is more
  complex
• There are examples of higher quality facilities
  with lower costs

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STUDYING COST AND QUALITY

• Two Studies Cleveland and New York City
• Looked at cost reports and found facilities with
  lower than expected costs
• Looked at MDS data and surveyed ombudsmen and
  advocates to find higher quality facilities
• 6 NYC facilities and 5 Cleveland
• Interviewed staff

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CONTROLLING COST AND ENHANCING QUALITY

• EXAMPLES
• Nobody Eats Vegetables
• Turning Around Turnover
• Drug Review
• Single Task Workers part-time workers

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CONTROLLING COST AND ENHANCING QUALITY

• EXAMPLES
• Toileting and activities cross-training
• Even CNAs get older
• Using Technology

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CONTROLLING COST AND ENHANCING QUALITY

• STRATEGIES
• Single gatekeeper
• Departmental responsibility
• All staff (with payback)
• Working to a budget
• Working to no budget

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COST AND QUALITY(PRINCIPLES)

• Facility must make a conscious choice of an
  expense control strategy -- leadership
• Information about costs and quality are key
  elements of success
• Facilities must think of revenue enhancement as
  the flipside of expense control
• Evaluating effects of changes is crucial

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COST AND QUALITY

• MORE GENERAL PRINCIPLES
• There is no magic bullet, pat answer, or
  formulaic answer!
• Must recognize better quality does not always
  cost more
• The will is more important than the way

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QUALITY, CULTURE, AND INNOVATION
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TRADITIONAL QUALITY INTERVENTIONS

• CLINICALLY-FOCUSED
• EXTERNALLY IMPOSED
• VULNERABLE POPULATION
• MAJOR PAYOR
• INDUSTRY INACTION
• CLASSIC EXAMPLE MDS, regs on restraints and
  antipsychotics

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PROBLEMS WITH TRADITIONAL INTERVENTIONS

• Burden rather than challenge
• Fail to be holistic
• Ignore quality of life issues

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QUALITY OF LIFE(Abt)

• Dimensions of Quality of Life
• DIGNITY
• PRIVACY
• INTERACTIONS WITH STAFF
• FACILITY ENVIRONMENT
• FACILITY OPERATIONS
• RELATIONSHIPS

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CULTURAL INTERVENTIONS

• Self-initiated by facility
• Focus on changing beliefs and traditional
  practices
• Emphasis on resident preferences and autonomy
• Emphasis on changing authority relationships
  among staff

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THE EDEN ALTERNATIVE

• Core problems are loneliness, boredom,
  helplessness
• Caring, as well as treatment, is needed
• Empowerment, animals, and plants are core of
  intervention.

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EFFECTS OF EDEN

• Results reported by Thomas
• New York Study
• Texas study of outcomes
• Texas study of psychosocial wellbeing

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Relationship Between QoL and QoC
QUALITY OF LIFE
Quality of care
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THE WELLSPRING MODEL

• Clinical modules
• Care resource teams
• Technical assistance
• Resident-focused care
• Empowerment of CNAs
• The Alliance

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EFFECTS OF WELLSPRING

• COMMONWEALTH STUDY
• No outcome differences
• Lower turnover
• Fewer deficiencies
• Variations in implementation

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LESSONS FROM CULTURAL INNOVATIONS

• There are no formula
• Change process is usually poorly understood
• Integration of new and old structures difficult
• Implementation varies by facility

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IMPLICATIONS FOR STATES

• THERE IS NO MAGIC BULLET FOR QUALITY CHANGE!
• INNOVATIONS MUST BE BOTH CLINICAL AND CULTURAL!
• MANY PATHS LEAD TO THE SAME DESTINATION!
• INNOVATION IS NOT AND EVENT, BUT A PROCESS!
• THE INDUSTRY CANT AND WONT DO IT ALONE!

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EINSTEINS SECOND LAW OF NURSING FACILITY
DYNAMICS
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Quality improvement, expense control, and
cultural change are like dieting
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Laura P.In 1923 when pickles were a pennyand
Bubbes took the children for a walk in the park
--when it was safe.When pickles were a treat.