Discussion Topic
Before starting this forum, please read Chapter 12.
In this forum, I would like you to identify at least one Quality initiative, that is either one System-Wide Quality Program or one Government Program in your area. You can share your thoughts on this initiative, that is pros, cons etc. Feel free to use outside research for this discussion.
At least 275 words
Course Materials (Available in the Content area of the course): Pratt. J. Long-Term Care- Managing Across the Continuum. 4th edition. Jones and Bartlett ISBN: 978-1-284-05459-0.
Long-Term Care: Managing Across the Continuum, Fourth Edition
John R. Pratt
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.
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.
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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
6
102(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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John R. Pratt
Advancing Excellence in America’s Nursing Homes – a coalition of 1
4
national
provider organizations that care for 6
5
0,000 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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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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John R. Pratt
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System-Wide Quality Programs – include both government and private programs.
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.
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
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
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.
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.
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.
Chapter 11
Long-Term Care
Reimbursement
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
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
and
in 1965
Has evolved since then
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
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
Supplemental Security Income program
Department of Veterans Affairs
Older Americans Act
Others
Out-of-pocket payments
Private long-term care insurance
Public/private partnership programs
Managed care
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
• Impact on long-term care
• Types of MCO/provider arrangements
• Making the transition to managed care
• Managed care’s tarnished image
• 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
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
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.
Learning Objectives
Learning Objectives (continued)
Current Reimbursement Options
Medicare
Medicaid
Medicaid (continued)
Other Public Funding Sources
Private Reimbursement Sources
Public/Private Partnerships
Managed Care
Trends in Reimbursement
Financing Reform
Summary
