Phillips 1 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.

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

Charles Phillips, Ph.D., M.P.H.Health Policy and ManagementSchool of Rural Public HealthTexas A&M 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 die

“Annie Hall”

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EINSTEIN’S EINSTEIN’S FIRST LAW OF FIRST LAW OF

NURSING FACILITY NURSING FACILITY MOTIONMOTION

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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 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

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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 CNA’s 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 CAN’T AND WON’T DO IT ALONE!

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EINSTEIN’S 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 penny

and Bubbes took the children

for a walk in the park --when it was safe.

When pickles were a treat.