# Presentation: 035519

## 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 A&M University System Health Science** **Center*

**Notes:**
Culture, Costs, and Quality:  The Future of Long Term Care, a presentation by Charles Phillips of the Department of Health Policy and management, School of Rural Public Health, Texas A&M University System Health Science Center. Presented at the AHRQ-NGA meeting, State Long Term Care Systems: Reducing Cost, Quality and Access, held in Indianapolis, IN May 6-8, 2002.

## QUALITY AND COSTS IN NURSING FACILITIES

**Notes:**
I will discuss 2 or 3 studies on cost and quality in nursing homes.  
First, I’ll take a look at the relationship between cost and quality -- the new wave in quality improvement. We’re talking about quality, but also new innovations with the promise to affect lives of people in long term care.

## Relationships are like sharks, if they stop moving forward they die“Annie Hall”

**Notes:**
Relationships are like sharks, if they stop moving forward they die.“Annie Hall”

## EINSTEIN’S FIRST LAW OF NURSING FACILITY MOTION

**Notes:**
To talk about results from looking into long term care issues, we start with deep thinking about important issues.  Einstein’s first law of nursing facility motion – (the accountant Louis Einstein, last known to be working for Anderson). Einstein’s First law says...

## When a facility is not moving forward , it is moving backward.  Facilities are never standing still.

**Notes:**

1-When a facility is not moving forward it is moving backwards. It is never in a condition of stasis.  If we are not continually pushing facilities to move forward, then they have lost a decade.

## The Quality of Care in Facilities is Constantly Changing.  THE ONLY ISSUE IS, “IN WHAT DIRECTION?”

**Notes:**
“Sharks” is a variant of Einstein’s first law. 

## COMPLEXITIES IN NF QUALITY

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

**Notes:**
What is quality for short stay residents? Leaving is quality.  Long stay residents live in a different world.  The last thing they want is a roommate who is not capable.  Discussing the quality of someone’s death is different from discussing getting them out.  A good nursing home must deal with all variations.  The core is contradictory – it is a health care facility but also a place where people live.  It is not a hospital. Care is one of the things that happens there but what residents are doing is living.

## COMPLEXITIES IN NF QUALITY

- MOST BASIC COMPLEXITY
**“****It is a calling, and **
**It is a business”**

**Notes:**
A nursing home is a calling AND a business.  They can’t care for anyone if they are bankrupt.  If they are put out of business, they can’t make money, but they can make money by providing horrific care.

## QUALITY AND COSTS

- Costs can’t 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

**Notes:**
Also important is the relationship between cost and quality.  Reimbursement committees and quality committees or CFO and quality of care orientation in the clinical side can’t get together.  The relationships are more complex.

## 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

**Notes:**
Studies of homes in Cleveland and New York found facilities with lower than expected costs.  These facilities had characteristics such as size and costs that were lower than average considering their characteristics. We looked at facilities with good quality indicators, and we looked also to ombudsman and advocates to identify quality facilities.  We examined facilities that had above average quality.  We found higher quality facilities very diverse in terms of race, ethnic diversity and size. 

## CONTROLLING COST AND ENHANCING QUALITY

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

**Notes:**
We looked at what they had done. We talked to the dietician.  No one was eating the vegetables when they were served separately.  The dietician put together entrees that included vegetables but incorporated them into the main meal.  She decreased waste and increased nutrition.  Next we looked at a drug review. We looked for less expensive drug combinations and reduced pharmacy costs.  Staff turnover was reduced by giving extra pay for extra attendance and extra shifts.  Staff received a bonus for being there and providing services. Others found different ways of using staff such as part time or single use or they might create a new position for certified persons who are ready to retire so as to maintain certified and also to facilitate cross-training.

## CONTROLLING COST AND ENHANCING QUALITY

- EXAMPLES
- “Toileting and activities – cross-training”
- “Even CNA’s get older”
- “Using Technology”

**Notes:**
For cross-training, staff don’t have to be a CNA. Anyone can get coffee, open yogurt or carry a tray – include everyone with responsibility for the residents.  This policy also released CNA’s to care for higher maintenance clients. This also fosters a continual daily recognition that everyone in the facility is responsible for the residents. 

## CONTROLLING COST AND ENHANCING QUALITY

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

**Notes:**
Strategies for interventions. Sometimes there is an elaborate structure with meetings, sometimes just one person keeps everything in their head. All have staff suggestion boxes and departmental administrators.  Each have very different sorts of strategies that got them to exactly the same place - to a category where they provided higher quality at lower cost, something that supposedly can’t be done.

## 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

**Notes:**
On general principles, each facility must make a conscious choice and commitment. You must think of revenue enhancement when you think of cost control. We found very little evaluation function for any innovations.  Policy makers might demand systematic evaluations of innovations as facilities may not do so on their own.

## 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”

**Notes:**
Another general principle is that there is not magic bullet or easy answer. But we do recognize that better quality does not always cost more to obtain. 

## QUALITY, CULTURE, AND INNOVATION

**Notes:**
Cost and quality are inextricably intertwined, and this must be addressed in the process of innovation associated with quality.

## TRADITIONAL QUALITY INTERVENTIONS

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

**Notes:**
Quality innovations are also externally focused. Facilities think the State regulators will make them do it.  This is a traditional responsibility that must be changed. Everyone is responsible for quality.

## PROBLEMS WITH TRADITIONAL INTERVENTIONS

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

**Notes:**
Quality interventions have problems, and can be a burden rather than a challenge.  Some facilities fail to be holistic and ignore quality of life.  As we conducted our research, we found more regulation of processes and less concern with quality of life.  

## QUALITY OF LIFE(Abt)

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

**Notes:**
Dimensions of quality of life.

## 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

**Notes:**
Cultural interventions can be self-initiated by a facility. Nursing homes are structured as an authority structure like hospitals which are organized like the army.  We need new ideas for organizations.

## THE EDEN ALTERNATIVE

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

**Notes:**
The Eden alternative is a very appealing model.  It focuses on the home as a place where people live.  Key problems are loneliness, boredom and helplessness.  Caring and treatment are needed.  An empowerment process is developed with staff.  A homelike environment – plants and pets –makes the residence look like a home with health care people running around. 

## EFFECTS OF EDEN

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

**Notes:**
Results have not been replicated outside the Eden Alternative.  Innovative models can stagnate and lead, for example,  to situations where a resident is tied to chair next to a fish tank.  At the core of this image is a fundamental truth that we need to talk about places where people live but have been turned into a place where the objects, a fish tank, becomes the innovation rather than the way life carries on.

## Relationship Between QoL and QoC

- 						QUALITY
- 					 	OF LIFE

- Quality of care

**Notes:**
Eden does not recognize that quality of care is part of quality of life. A dog is not good if you have a decubitous ulcer.

## THE WELLSPRING MODEL

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

**Notes:**
The Wellspring model recognizes that quality of care is part of quality of life. It includes training of staff, from aides and administrators, led through modules. They receive training on skin, skin team, and data requirements are filtered through staff. Large scale organizations can skip something.  Wellspring has a team to evaluate, assist, and enhance clinical skills. Turnover in facilities leads to people who don’t know how to care for elders. Facilities need a continual process of education. The first model is assessment that teach nurses how to assess.  This is an empowerment process for CNA’s who then set their own schedule and plan of action.  CNA’s are part of the care team.  Communication between and among staff is part and parcel of Wellspring.  Teach others to observe and report.  All persons in facility are responsible for residents. 

## EFFECTS OF WELLSPRING

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

**Notes:**
The Wellspring model didn’t find outcome differences but did find process differences.  There is lower turnover in Wellspring facilities. There are fewer deficiencies during surveys and no change in costs. There is no incremental cost for innovation.  Training is focused and content in new setting.  The difference is in implementation.

## 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

**Notes:**
There is no magic bullet, no laying on of hands for healing.  Innovation in both clinical and cultural. Innovation is not an event but a process.  We are not throwing bread on water and letting it sink, we must remain involved in the process. Industry will not do it alone, there must be regulations.

## 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 CAN’T AND WON’T DO IT ALONE!

**Notes:**
Innovations have to cover both cultural and clinical aspects of care. There is not single or best way to devise better innovations and doing something is better than searching for the perfect solution. You have to treat innovation as a process, not an event. 

## EINSTEIN’S SECOND LAW OF NURSING FACILITY DYNAMICS

**Notes:**
Einstein’s second law of nursing facility dynamics. 

## Quality improvement, expense control, and cultural change are like dieting

**Notes:**
You must commit yourself to a diet and stick to it. There are lots of different paths to the same destination  and many paths will be successful. But you cannot try them all, you have to make a choice and follow through. 

## Slide 30

**Notes:**
This is a Memory quilt 

## Slide 31

**Notes:**
This is one panel from the quilt: Sophie and her brother making music.

## Slide 32

**Notes:**
Another quilt square – This is Bubbes and the pickle vendor. 

## Laura P.“In 1923 when pickles were a pennyand Bubbes took the children for a walk in the park --when it was safe.When pickles were a treat.

**Notes:**
This quote from Laura P. shows a way to help residents to live the life they want to live.“In 1923 when pickles were a pennyand Bubbes took the children for a walk in the park --when it was safe.When pickles were a treat.