Embed Size (px)
Citation preview
This article was downloaded by: [Case Western Reserve University]On: 16 October 2014, At: 14:43Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK
Home Health Care Services QuarterlyPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/whhc20
Assuring Quality Care: Exploring Strategies of MedicaidE&D Waiver ProvidersNancy Brossoie MS , Karen A. Roberto PhD , Pamela B. Teaster PhD & Anne P. Glass PhDPublished online: 04 Oct 2008.
To cite this article: Nancy Brossoie MS , Karen A. Roberto PhD , Pamela B. Teaster PhD & Anne P. Glass PhD (2006) AssuringQuality Care: Exploring Strategies of Medicaid E&D Waiver Providers, Home Health Care Services Quarterly, 24:4, 81-101, DOI:10.1300/J027v24n04_05
To link to this article: http://dx.doi.org/10.1300/J027v24n04_05
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) containedin the publications on our platform. However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon andshould be independently verified with primary sources of information. Taylor and Francis shall not be liable forany losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use ofthe Content.
This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Assuring Quality Care:Exploring Strategies of Medicaid
E&D Waiver Providers
Nancy Brossoie, MSKaren A. Roberto, PhDPamela B. Teaster, PhD
Anne P. Glass, PhD
ABSTRACT. Implementing quality assurance (QA) programs inunregulated non-institutional settings remains a challenge for home- andcommunity-based service providers. A sample of 65 Elderly andDisabled (E&D) Waiver providers were presented with eight problemscenarios commonly found in homecare services. Each of the respon-dents was able to identify strategies they would use to recognize and ad-dress each problem. Findings suggest providers currently use multiplemechanisms as part of their overall QA program. Discussion focuses onthe strengths of using multiple approaches and on increasing providerawareness of complementary QA strategies and reducing the reliance onstaff report as a major QA strategy. [Article copies available for a fee fromThe Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address:
This project was supported by a subcontract to the Virginia Department of MedicalAssistance Services under a “Real Choice Systems Change” grant (Grant No.P-91599/3) from the Centers for Medicare and Medicaid Services. However, thecontents herein do not necessarily represent the policy of the U.S. Department of Healthand Human Services, and you should not infer endorsement by the Federal Government.
This article contains and/or is based, in whole or in part, upon data accessed fromthe Virginia Department of Medical Assistance Services (DMAS). DMAS retains allrights of ownership to said data. No copies or reproductions, electronic or otherwise, inwhole or in part, of the following materials may be made without the expressed writtenpermission of DMAS.
Home Health Care Services Quarterly, Vol. 24(4) 2005Available online at http://www.haworthpress.com/web/HHC
2005 by The Haworth Press, Inc. All rights reserved.doi:10.1300/J027v24n04_05 81
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
<[email protected]> Website: <http://www.HaworthPress.com>© 2005 by The Haworth Press, Inc. All rights reserved.]
KEYWORDS. Quality assurance, home- and community-based care,Elderly & Disabled Waiver
Medicaid home- and community-based service (HCBS) waiver pro-grams are designed to enable individuals with serious health problemsto remain living at home while receiving necessary medical care andpersonal assistance. Each year, the popularity of HCBS programs in-creases. Nationally, enrollment in HCBS waiver programs nearly tri-pled from 1991 to 1999, while during that same period waivers thatserved older adults doubled to 377,083 recipients. In response to that in-crease, the total Medicaid HCBS expenditures allocated in the federalbudget increased from $1.6 billion in 1991 to $14.4 billion in 2001(U.S. General Accounting Office, 2003). With the baby boom genera-tion coming of age, HCBS programs will continue to play an importantrole in the healthcare system. As the demand for HCBS services rises,providers face increased challenges in assuring that quality services areprovided within the unsupervised setting of the home.
The Health Care Finance Administration first authorized home-basedpersonal care services nationwide in 1975. Positive public response tothe program led to the passage of the Omnibus Budget Reconciliation Act(1981) and the Social Security Act (1982), which provided for the estab-lishment of home- and community-based services and the developmentof 1915(c) waiver programs within state HCBS programs (Harrington,LeBlanc, Wood, Satten, & Tonner, 2002). Since the initiation of waiverprograms, services have targeted the needs of specific at-risk populations,such as older adults and persons with disabilities.
For more than a decade, scholarly literature has addressed the contin-uing need for quality assurance in HCBS (Bass, Noelker, & McCarthy,1999; Harrington et al., 2002; Hughes, 1995; R. L. Kane, 1999; Kane,Kane, Illston, & Eustis, 1994; Smith, Cotter, & Rossiter, 1996; Weineret al., 2002), yet little research is available that examines quality assess-ment (QA) mechanisms implemented by providers (Kane et al., 1997).The focus of this study is to examine QA strategies currently em-ployed by local agencies providing Elderly & Disabled (E&D) Waiverservices.
82 HOME HEALTH CARE SERVICES QUARTERLY
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
QUALITY ASSURANCEIN COMMUNITY-BASED SERVICES
In 1966, Donabedian pioneered the development of quality assurancesystems across healthcare settings using a model based on three compo-nents: structure, process, and outcome. Structure refers to the healthsystem’s infrastructure, resources, and staff. Process refers to how thesystem utilizes resources and how staff members operate within thesystem. Outcome refers to the results of the care provided. To ensurequality service delivery, Donabedian advocated for the developmentof measures that captured the efficiency and effectiveness of eachcomponent.
Identifying dimensions of quality care existing within each compo-nent also helps providers recognize stakeholders within the healthcaresetting. Stakeholders who hold a vested interest in service provision in-clude the funding source, the agency providing services, professionaland nonprofessional staff, clients, family members, and other commu-nity members. Because there are many stakeholders involved in the de-livery of HCBS programs, QA strategies ultimately must recognize andaddress the needs of each group. For example, methods for addressingquality issues about an agency might include consumer surveys, retro-spective chart reviews, audits, and complaint mechanisms. Strategiesfor evaluating quality in staffing might focus on recruitment, orienta-tion, training and staff development, supervision, and performanceevaluation (Kane et al., 1997). Service quality outcomes can be mea-sured by periodically assessing client health status and tracking perfor-mance outcomes (e.g., number of days clients are kept out of the nursinghome).
In 1980, Donabedian advocated for the inclusion of a fourth compo-nent to his quality model: a survey of client satisfaction with services. Theintegration of consumer input into the QA process lends an important per-spective of the services delivered and provides a new lens through whichservice delivery can be viewed and evaluated.
Principles of Continuous Quality Improvement (CQI) have emergedin healthcare settings as a formal method of incorporating communica-tion into the QA process (IOM, 1996) and complement Donabedian’smodel. Through continuous and ongoing communication among stake-holders, staff members are able to analyze and adjust routine practicesin an effort to meet the needs of the client and maintain quality servicedelivery (IOM, 1996; Kane et al., 1997). This system of analysis im-proves the chances of identifying potential successes as well as targets
Brossoie et al. 83
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
failures before they occur and before it is too late to intervene to preventproblems.
Quality improvement (QI) programs and QA mechanisms based onDonabedian’s model and CQI are not new to the U.S. healthcare sys-tem; however, implementation has not been firmly established acrossHCBS programming (Kane et al., 1997). Although the benefits of de-veloping comprehensive QI/QA strategies were introduced a decadeago (Hughes, 1995), few studies have since been published about theirdevelopment (Applebaum, Mollica, & Tilly, 1997-98). Even the Insti-tute of Medicine’s (IOM) (2001) report, Improving the Quality ofLong-Term Care, includes only one page on the quality of HCBS pro-grams, as compared to 22 pages of QA analysis on nursing home care.Nevertheless, state agencies and local providers continue to identify theneed to assure quality in the homecare setting (Applebaum et al.,1997-98).
In 2003, the U.S. General Accounting Office (GAO) published a re-port for Congress on the quality of Medicaid HCBS waivers, with a fo-cus on programs accessed by older adults. The agency was charged withexamining state trends in establishing Medicaid HCBS waivers, federaloversight of the state waivers, and the quality assurance practices of theCenters for Medicare and Medicaid Services (CMS) and state agenciesoverseeing the waiver programs.
The GAO findings were congruent with earlier writings. Limited fed-eral and state oversight existed on how waiver services were providedand the quality of services delivered from 1991 to 2001. Even thoughmandated by federal law, CMS conducted limited reviews of statewaiver programs during that time. Few states were in compliance withreporting their annual waiver program outcomes to CMS. As a result,limited information is available on the condition, quality, and growth ofHCBS waiver programs nationwide.
The GAO recommended that CMS play a more proactive role in reg-ulating and ensuring state quality assurance activities. Suggestions in-cluded identifying a QA system for all HCBS providers, developing amethodology for reviewing state waiver programs, allocating adequatefunding to conduct ongoing state reviews, and requiring states to imple-ment a QA program at the initiation of each state waiver program.
In a rebuttal to the GAO report and recommendations, the U.S.Department of Health and Human Services (HHS) responded that theresponsibility of QA remains not with CMS, but with the state, reinforc-ing the concept that “Federal statutes convey respect for state authorityand competence in the administration of HCBS programs” (GAO,
84 HOME HEALTH CARE SERVICES QUARTERLY
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
2003, page 61). The HHS comment makes two assumptions: states arebest suited to develop and oversee programs that enhance and promotethe well-being of their recipients, and states will automatically incorpo-rate quality components into the development of programs because theyknow they must be accountable for program results.
In addition, HHS disagreed with the GAO call for quality by statingthat services provided through HCBS waivers are fundamentally differ-ent than those provided within an institutional setting and cannot bemonitored and regulated using traditional quality assurance techniquesand approaches. This perspective recognizes the fundamental difficultyin evaluating quality in the homecare setting. The purpose of home-careservices is two-fold: therapeutic and compensatory. Both functions arebased on different perspectives of care and make different assumptionsabout oversight and who should direct it (R. A. Kane, 1999; Kane et al.,1997).
The therapeutic focus represents a medical approach to personal wel-fare, with medical staff directing the client’s plan of care. The goal is totreat the medical condition and to restore health as quickly and effi-ciently as possible, with the health of the client as the primary focus. Inassessing the quality of care in a therapeutic model, quality correlateswith the success of the medical intervention.
The compensatory focus represents a biopsychosocial approach topatient welfare. The goal is to provide services that promote self-reliancewhile specifically meeting the physical needs and personal preferencesof the individual. Services are provided to compensate for loss in func-tioning and independence, and to assist in maintaining high levels offunctioning while delaying institutionalization. Patient autonomy andself-determination direct the services in the compensatory model andtake precedence over medical necessity for as long as possible. Conse-quently, HCBS programs require QA strategies that address both thera-peutic and compensatory models of care.
In 2004, in response to the GAO recommendations, CMS promul-gated the HCBS Quality Framework (CMS, 2004) as a guide to incorpo-rate quality activities into service delivery at the state and providerlevel. The framework identifies seven focus areas highlighting differentaspects of service delivery that affect the quality of services receivedby the client. The seven dimensions include participant access, partici-pant-centered service planning and delivery, provider capacity andcapabilities, participant safeguards, participant rights and responsibili-ties, participant outcomes and satisfaction, and system performance.Throughout the framework, desired outcomes in service delivery are
Brossoie et al. 85
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
identified (e.g., client participation in planning services, freedom ofchoice of provider, client satisfaction) and reinforce quality across theservice delivery spectrum.
The development of the HCBS Quality Framework (CMS, 2004) in-dicates significant and positive changes in the recognition of QA as im-portant to HCBS services. Evidenced by the content of the framework,CMS recognizes that (1) quality assurance is important to service deliv-ery from the moment services are initiated through discharge, (2) statesbenefit from guidance on how to design and implement waiver pro-grams, (3) a quality framework provides methods for evaluating thestrengths and challenges of the programs at the state and local levels,and (4) the health and safety of the client is enhanced through the en-forcement of quality guidelines on care. The HCBS Quality Framework(CMS, 2004) is a foundation for QI/QA programs for state systems andlocal providers and supports development of QA strategies to addressthe challenges of providing care.
QUALITY ASSURANCE STRATEGIES
Kane and colleagues (1997) investigated the use of QA strategies im-plemented by local providers working in home-care settings. They de-veloped a series of seven scenarios demonstrating common conflicts orproblems between clients and the aides providing care, the agency, orfamily members. The scenarios included a clash existing between theclient and the worker, an unreliable worker, a client’s health deteriorat-ing despite care, a client preferring a different schedule for when theworker visits, a worker with poor skills, a client with unstable mentalhealth, and a worker having unpleasant encounters with a client’s fam-ily. Agency administrators were asked to indicate how common theyfound each of the problems within their agency, how likely they were torecognize the existence of the problems, how their agency would recog-nize the problems, and what action they would take in response to theproblems.
Responses were obtained from “best practice” agencies that repre-sented medical (therapeutic) and social (compensatory) models ofhome care. The findings indicated that participants representing bothmodels relied heavily on their paraprofessional staff to report qualityproblems more often than relying on formal agency QA programs.Formal QA programs were identified by respondents as retrospectiveaudits, feedback from current and discharged clients, supervision and
86 HOME HEALTH CARE SERVICES QUARTERLY
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
performance evaluation of staff, complaint mechanisms, care confer-ences, staff feedback, and training and orientation of staff. The currentexploratory study adapts Kane and colleagues’ (1997) scenarios toidentify QA strategies employed by providers under Virginia’s E&DWaiver program.
METHODS
This exploratory study was part of a larger project, conducted underthe federal Real Choice Systems Change Grant Initiative. One goal ofthe project was to focus on quality assurance strategies employed byagencies providing services under the Commonwealth of Virginia’sDepartment of Medicaid Services (DMAS) E&D Waiver program.Virginia’s E&D Waiver recipients represent a fragile and vulnerablepopulation who meet the criteria for nursing facility placement. To helpdelay and prevent admission into institutional care, E&D Waiver ser-vices are designed to provide a variety of home- and community-basedservices, including personal care, respite care, adult day healthcare, andthe personal emergency response system. The E&D Waiver serves ap-proximately 10,000 Virginians annually, the most recipients of any ofVirginia’s HCBS waivers (DMAS, 2003).
Sample
In 2002, agencies that provided the E&D Waiver services of personalcare, adult day services, and respite care were identified as potential re-spondents to a survey that included a focus on QA strategies. BecauseVirginia’s population is located among concentrated urban areas as wellas remote rural areas, a stratified sample of E&D Waiver providers wasselected to represent the diversity and care needs associated with differ-ent geographical areas. DMAS provided the researchers with contactinformation for 340 potential agencies. Upon review, some of the agen-cies did not offer the specific services covered by the E&D Waiver.Their names were deleted from the contact list. A letter describingthe purpose of the project and the selection process for participationwas mailed to each of the 282 remaining providers one month prior toselection.
Our method for selecting participants for the study was systematic.To ensure equal representation, providers were categorized by the stateplanning district in which they provided services. Then, within each
Brossoie et al. 87
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
planning district, providers were grouped according to the services theyprovided. Due to resource constraints, our sampling goal was to contactparticipants from one-half of the agencies within each category. Thiswas achieved by contacting every other agency listed as potential par-ticipants. If the category had only one or two providers listed, weover-sampled and contacted each agency within that group.
Agencies chosen for participation were contacted by telephone. Ini-tially, 160 agencies agreed to complete the survey. Two large multi-sitecorporate agencies were initially contacted to participate in the study.However, since their local agency representatives could not providestudy-specific responses for any of the six locations chosen for inclu-sion, they were not included and we randomly selected other agencieswithin the category to take their place. Unlike Kane’s earlier study(Kane et al., 1997), our participants represented only social (compensa-tory) models of care and were not limited to “best practices” agencies.The professional roles of the 70 agency representatives from whom wereceived useable data included administrators, administrative supportstaff, registered nurses, supervisors, and agency owners. Of those re-spondents, 65 provided responses to variables that were central to thisstudy.
Agency representatives chose one of two formats to receive the sur-vey: email attachment or hard copy delivered by the U.S. Postal Ser-vice; they were about evenly split in their choices. No difference inresponses was detected by the method chosen by participants. Aboutone-third (37%) of the questionnaires were returned via email, and 63%were returned by FAX or U.S. mail. The final response rate for com-pleted surveys was 44%, with 70 of the 160 agencies responding.
Measures
The survey included questions that profiled the number of clientsserved in the past 30 days, length of time in business, and number ofstaff. Respondents were also asked to list the QA strategies their agencyhad in place to recognize issues and concerns. In order to assess pro-vider perceptions of problems, how they identified them, and the man-ner in which they were resolved, we presented respondents with eightproblem scenarios commonly found in homecare services. We utilizedthe problem scenarios developed by Kane and colleagues (1997) withone exception. We expanded the original scenario “worker with poorskills,” to represent two separate problems: a worker with a poor workethic and a worker with poor technical skills. This separation provided
88 HOME HEALTH CARE SERVICES QUARTERLY
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
agencies an opportunity to address two very distinct qualities in aworker: poor performance due to an unwillingness to work versus notperforming adequately due to possessing poor direct care skills. Theother six scenarios remained consistent with the Kane study and fo-cused on client-oriented and worker-oriented problems: a client/workerclash; an unreliable worker; a client deteriorates despite care; a clientprefers a different schedule for when the aide visits; a client has unstablemental health; and a worker has unpleasant encounters with a client’sfamily member. Like the original study, agency respondents were askedto indicate how common they found each problem (“very common,”“somewhat common,” “somewhat uncommon,” and “very uncom-mon”), and how likely they were to recognize the existence of the prob-lem (“likely to recognize,” “somewhat likely to recognize,” and“unlikely to recognize”). Using an open-ended response format, re-spondents were asked to comment on how their agency would recog-nize the problem, and what action would likely be taken in response tothe problem.
FINDINGS
Respondents indicated that their agency had been providing E&DWaiver services for an average of 10.25 years (S.D. = 5.62), with arange of 1 to 20 years in operation. Two-thirds of the agencies had 50 orfewer employees, and 43.3% reported having no current job openings.Of the remaining agencies, 31.7% had part-time openings only, 18.3%had both full- and part-time openings, and 6.7% had full-time openingsonly.
Thirty percent of the agencies had served 10 or fewer clients in themost recent month, while 11% of the agencies reported serving morethan 100 clients. Sixty-nine percent of the agencies currently had no cli-ents on a waiting list for services; but, none of the agencies reported thatthey did not maintain a list. For those agencies that did report maintain-ing a client waiting list, the maximum number of clients at any giventime was ten, with the longest waiting time being seven months, asreported by one agency.
Sixty-five respondents (86.2%) indicated that they incorporatedformal QA mechanisms in their business practices. QA practicescited included on-site supervision (94.7%), formal complaint mecha-nisms (86.0%), active chart audits (82.5%), client satisfaction sur-veys (81.4%), retrospective chart reviews (80.7%), family caregiver
Brossoie et al. 89
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
satisfaction surveys (72.9%), performance outcome measures (52.6%),and formal QI teams (35.1%). This degree of participation is noteworthywhen considering that 30% of the agencies are small businesses, havingserved 10 or fewer clients in the month preceding data collection.
Frequencies of Problem Scenarios
Findings suggest that the problem scenarios presented are neitherextremely rare nor exceedingly common. When the two “common” re-sponses (very common and somewhat common) were combined and thetwo “uncommon” responses (somewhat uncommon and very uncom-mon) were combined, the findings suggest that the majority of agenciesfound each scenario to be uncommon (Table 1). Closer examination re-veals that less than 10% of respondents ever selected the choice “verycommon.” For two scenarios (a worker has poor technical skills; aworker has unpleasant encounters with a client’s family member), thechoice “very common” was never selected. In seven of the eight scenar-ios, over 50% of the respondents selected either “somewhat common”or “somewhat uncommon” as their response. Over 50% of the respon-dents indicated the scenario “poor technical skills of staff” as “veryuncommon.”
Likelihood of Identifying Problem Scenarios
Across all eight scenarios, at least 79% of the respondents indicatedthat their agency would be likely to recognize the problem (Table 2). Infive scenarios (a client/worker clash; an unreliable worker; a client dete-
90 HOME HEALTH CARE SERVICES QUARTERLY
TABLE 1. Responses to Problem Scenarios (N = 65)
Problem Scenario Agency Response (%)
VeryCommon
SomewhatCommon
SomewhatUncommon
VeryUncommon
Client deteriorates despite care 9.2 32.3 46.2 12.3Client prefers different schedule 6.2 36.9 46.2 12.3Clients unstable mental health 4.6 40.0 33.8 21.5Unpleasant family 0 26.2 50.8 23.1Unreliable worker 7.7 38.5 35.4 18.5Poor work ethic of staff 4.6 21.5 30.8 43.1Poor technical skills of staff 0 10.8 33.8 55.4Client/ worker clash 1.5 21.5 46.2 30.8
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
riorates despite care; a worker has poor technical skills; a client hasunstable mental health), none of the respondents reported their agencywould be unlikely to recognize the problem.
Strategies Used to Recognize Problems
Regardless of whether the scenario problem was a client-orientedproblem or a worker-oriented problem, over 50% of the time, the pri-mary informants of the problems were direct care staff, the client or cli-ent’s family, or supervisory staff (Tables 3 and 4). In four of the eightscenarios presented, the clients and their families were the main infor-mants of the problem: a client/worker clash, a client prefers differentschedule, an unreliable worker, a worker with a poor work ethic. Inthree scenarios, direct care staff members were the main informants: aclient deteriorates despite care, a client has unstable mental health, and aworker has unpleasant encounters with a client’s family. In only onescenario, “a worker with poor technical skills,” the direct care supervi-sor was the main source of information.
Additional methods by which agencies became aware of problemsincluded their own formal QA strategies, such as satisfaction surveys,complaint mechanisms, retrospective chart reviews, and other QAmechanisms. However, in each scenario the formal QA mechanismidentified the problem in less than 10% of the responses. Other sourcesof information included outside reports generated by the client’s visit tothe emergency room and routine medical appointments. None of therespondents reported using a performance outcome measure as a means
Brossoie et al. 91
TABLE 2. Likelihood of Identifying Problem Scenarios
Problem Scenario Agency Response (%)
TotalResponses
Likely toRecognize
SomewhatLikely
Unlikely toRecognize
Client deteriorates despite care 64 90.6 9.4 0Client prefers different schedule 63 79.4 19.0 1.6Clients unstable mental health 64 89.1 10.9 0Unpleasant family 62 91.9 6.5 1.6Unreliable worker 64 93.8 6.3 0Poor work ethic of staff 64 84.4 14.1 15.6Poor technical skills of staff 64 81.3 18.8 0Client/worker clash 65 87.7 12.3 0
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
to identify the problems presented in the scenarios, despite the fact thatover half (53.3%) of the respondents reported their collection.
QA Strategies that Address Problems
The aggregate responses fit into 30 distinct categories for both cli-ent-oriented and worker-oriented problems (Tables 5 and 6). Perhapsnot surprisingly, no single QA strategy was selected for meeting theneeds of all eight problem scenarios. Resolving issues by discussing theproblem with the employee, the client, and their family members wasthe preferred method of resolution in three of the scenarios: an unreli-able worker (42.1%), a worker with a poor work ethic (28.1%), and aworker who has an unpleasant encounter with a client’s family (19.3%).In situations where there was a client/worker clash, agencies wereprepared to replace the aide (54.2%), counsel them (6.8%), monitortheir performance (6.8%), or retrain them (1.7%). Over three-fourths
92 HOME HEALTH CARE SERVICES QUARTERLY
TABLE 3. Strategies Used to Recognize Client Problems
Strategy Used to RecognizeProblems
Problem Scenario (%)
ClientDeterioratesDespite Care
Client PrefersDifferentSchedule
Client’sUnstableMentalHealth
UnpleasantFamily
Client/clients family 23.5 79.6 28.8 30.8Direct care staff 62.7 13.0 73.1 71.2Supervisor 35.3 13.0 30.8 23.1Records/documentation 19.6 1.9 13.5 0Client/family satisfaction surveys 0 1.9 0 0Complaint mechanisms 0 1.9 1.9 5.8Other QA mechanisms 2.0 0 1.9 0Routine medical visit 7.8 0 7.7 1.9Result of emergency medical visit 2.0 0 0 0Staff scheduling 0 3.7 0 0Report 1.9 0 0 1.9Call or drive-by, service calls,check in calls
0 0 3.8 0
Total agencies responding 51 54 52 52
Note: Percentages do not total 100% for each problem scenario because agencies identify morethan one strategy. Percentage = number of agencies who gave an answer to scenario problem/number of agencies responding to scenario problem.
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
(78.2%) of the responding agencies reported that they would provideadditional training for a worker with poor technical skills. If a clientpreferred to have the aide come on a different schedule, 87.7% of theagencies reported that they would accommodate his or her wishesif possible. When the client’s health was deteriorating despite care, agen-cies would consider meeting with the client’s family and doctor(25.0%), referring the client to an outside agency (17.9%), discussingthe situation with the client, the employee, and the family (16.1%), con-sulting the client’s doctor (12.5%), altering the plan of care (12.5%),and holding a care conference (7.1%) to develop a suitable plan of care.
Support of Donabedian’s Framework
The analysis of the data provided us insight into the utilization of QAstrategies among E&D Waiver provider agencies. The different types of
Brossoie et al. 93
TABLE 4. Strategies Used to Recognize Worker Problems
Strategy Used to RecognizeProblems
Problem Scenario (%)
UnreliableWorker
Poor WorkEthic of
Staff
PoorTechnicalSkills of
Staff
Client/WorkerClash
Client/clients family 54.7 51.9 24.1 58.5Direct care staff 24.5 32.7 18.5 45.3Supervisor 20.8 44.2 66.7 13.2Records/documentation 3.8 9.6 11.1 1.9Client/family satisfaction Surveys 1.9 3.8 1.9 1.9Complaint mechanisms 3.8 9.6 3.7 0Other QA mechanisms 0 5.8 3.7 1.9Routine medical visit 1.9 1.9 3.7 0Staff scheduling 1.9 0 0 0Report 0 0 0 1.9Competency testing 0 0 3.7 0Call or drive-by, service calls,check in calls
3.8 5.8 0 0
Orientation 0 0 1.9 0Other, not clear 1.9 1.9 0 0
Total agencies responding 53 52 54 53
Note: Percentages do not total 100% for each problem scenario because agencies identify morethan one strategy. Percentage = number of agencies who gave an answer to scenario problem/number of agencies responding to scenario problem.
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
94 HOME HEALTH CARE SERVICES QUARTERLY
TABLE 5. QA Strategies That Address Client Problems
Agency Action Problem Scenario (%)
ClientDeterioratesDespit Care
Client PrefersDifferentSchedule
Client'sUnstableMentalHealth
UnpleasantFamily
Discuss with employee 3.6 0 1.8 5.3
Discuss with employee & client 1.8 1.8 1.8 0
Discuss with employee & family 1.8 3.5 3.6 1.8
Discuss with employee, client,and family
16.1 3.5 10.9 19.3
Discuss with client 0 1.8 0 1.8
Discuss with family 7.1 7.0 10.9 33.3
Accommodate wishes if possible 0 87.7 0 0
Training 3.6 0 5.5 7.0
Decrease caseload untilimprovement/ plan
0 0 0 v1.8
Consult/discuss with Dr. 12.5 0 10.9 0
Consult/discuss with Dr. andfamily
25.0 0 18.2 0
Care conference/interdisciplinarymtg.
7.1 0 20.0 5.3
Refer/admit to outside agency 17.9 3.5 16.4 5.3
Document 0 0 1.8 0
Check documentation/scheduling 0 0 1.8 0
Follow up/monitor/closersupervision
7.1 0 1.8 1.8
Investigate, handled bysupervisory staff
5.4 1.8 5.5 8.8
Review/alter care plan/extrahours
12.5 1.8 12.7 0
Clarify expectations 0 0 0 3.5
Counsel employee/support staff 1.8 0 3.6 12.3
Assess 5.4 0 9.1 0
Assess safety 3.6 3.5 5.5 3.5
Somewhat expected 5.4 0 0 0
Other 1.8 1.8 1.8 7.0
Total agencies responding 56 57 55 57
Note: Percentages do not total 100% for each problem scenario because agencies identified morethan one strategy.
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
strategies identified were consistent with Donabedian’s framework forquality assurance in healthcare. Collectively, they focused more on theprocess dimension than on structure or outcome.
Structure. The average respondent represented a small business, inoperation for over ten years, with staffing levels that have supportedagency operations. As expected in any business, job openings existed forfull and part-time work. However, this did not appear to affect the
Brossoie et al. 95
TABLE 6. QA Strategies That Address Worker Problems
Agency Action Problem Scenario (%)
UnreliableWorker
PoorTechnicalEthic ofStaffe
PoorClient/
Skills ofStaff
WorkerClash
Discuss with employee 42.1 28.1 12.7 22.0Discuss with employee & client 0 0 0 22.0Discuss with employee & family 0 0 0 0Discuss with employee, client, & family 0 0 0 6.8Discuss with family 0 0 0 5.1Warning/discipline 3.5 10.5 1.8 3.4Progressive disciplinary action 17.5 12.3 0 0Restaff case/replace aide 12.3 7.0 3.6 54.2Discharge employee 19.3 19.3 1.8 5.1Accommodate wishes if possible 0 0 0 1.7Training 1.8 14.0 72.2 1.7Decrease caseload until improvement/plan
8.8 14.0 16.4 0
Care conference/interdisciplinary mtg. 0 0 0 1.7Document 1.8 3.5 0 0Check documentation/scheduling 3.5 3.5 0 1.7Follow up/monitor/closer supervision 17.5 22.8 27.3 6.8Investigate, handled by supervisorystaff
1.8 1.8 0 0
Review/ alter care plan/extra hours 0 1.8 0 0Mentoring 0 1.8 1.8 0Counsel employee/support staff 24.6 26.3 5.5 6.8Assess 0 0 1.8 1.7Other 0 1.8 0 3.4Total agencies responding
Note: Percentages do not total 100% for each problem scenario because agencies identified morethan one strategy.
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
availability of client services, as 69% of the agencies reported not hav-ing client names on their waiting list for services.
Process. Most of the respondents indicated that they utilized a variety ofQA mechanisms to meet clients’ service delivery needs. However, wecould not identify a core group of QA mechanisms consistently usedacross all agencies. Most of the agencies in this study informally uti-lized a principle of CQI even if they did not indicate having a formalCQI program in place. Basic CQI practices were demonstrated by thedialog existing between staff, clients, and the clients’ family membersin identifying care needs. The input and feedback of each person in-volved promoted the quality of services provided to the recipient.
The agencies were very confident in the abilities of their staff to pro-vide quality care, with over 89% of respondents indicating that a workerwith poor technical skills was “somewhat uncommon” or “very uncom-mon.” However, over 15% of the agencies said they would be unlikelyto recognize the poor work ethic of staff, and other findings suggest thatadditional staff issues appeared more troublesome. Over 46.2% of therespondents indicated that an unreliable worker was “very common” or“somewhat common”; 26% indicated that a worker with a poor workethic was either “very common” or “somewhat common” in their agency;and 23.1% indicated that a client/worker clash was “very common” or“somewhat common.” Formal QA mechanisms (i.e., complaint mecha-nisms) identified some of these problems, but most agencies found outabout these specific staff problems through communication with clients,clients’ family members, and direct care staff.
Providing home-based services necessitates that agencies and directcare staff have some contact with their client’s family members. Ourstudy, like the Kane and colleagues’ (1997) study, found that agenciesrely heavily on staff to identify and report service delivery problems.For the scenario, “a worker has an unpleasant encounter with a client’sfamily,” 71% of the agencies recognized the problem through commu-nication with the direct care staff, over 30% reported finding outthrough direct contact with the client’s family, and 23.0% reportedsupervisors would recognize the problem. Only 5.8% of the agenciesreported using formal complaint mechanisms as an outlet for families toexpress their frustrations or discontent.
Outcome. As expected by the nature of the E&D Waiver program,agencies serve a frail and vulnerable population whose participation inservices is constantly changing. Approximately 43% of the agencies
96 HOME HEALTH CARE SERVICES QUARTERLY
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
reported at least one client was transferred to a nursing home in the mostrecent month. Thirty-eight percent indicated that at least one of their cli-ents died in the last month, and 6% of the agencies reported transferringa client to end-of-life care, including hospice. Despite the reality thatE&D Waiver clients are part of a fluid population moving in and out ofservices, 58.5% of respondents believed that the problem “client deteri-orates despite care,” was uncommon in their agency. These responsesrepresent a potential “disconnect” between what the providers perceivedthe status of their clients to be and the reality of their clients leavingservices.
Thirty-two agencies (52.6%) indicated that they used performanceoutcome measures as part of their QI program. The outcome measurescollected included 82 different objectives, representing three main cat-egories: agency operations, the client, and the client’s family. Almosthalf (46.9%) of the measures were considered operational (i.e., numberof clients served, cost per client, staffed hours). One-third (33.3%) ofthe measures focused on client benefits (i.e., maintaining the client athome) and one-fifth (19.8%) of the measures targeted family caregiverbenefits (i.e., reducing the stress level of the family, enabling caregiverto work). Twenty measures (24.4%) were written in quantifiable termsbut only four measures stated specific goals (i.e., three-fourths of recipi-ents will remain in services for three months). These responses indicatethat there are opportunities for improvement in educating providersabout the value and use of performance outcome measures as part of aformal QA program.
DISCUSSION
Every healthcare system is unique and requires the development of aQA system tailored to its needs (Kane, 1997). Our findings suggest thatE&D Waiver providers users QA mechanisms in their businesses, butnot all have a comprehensive quality assurance plan in place. The use offormal QA processes indicates a commitment to providing quality careand establishment as a conscientious healthcare provider. Although in-dividual QA mechanisms are effective in ensuring quality services forsome situations, no one method is effective for monitoring all of thecomponents of care provided. Satisfaction surveys are helpful in ad-dressing some issues, but due to their infrequency and lengthy process-ing time, they are not necessarily appropriate tools for addressingimmediate client issues. Retrospective chart audits provide insight into
Brossoie et al. 97
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
the continuity of care but fall short of identifying immediate client andstaff problems.
The importance of relying on more than one QA mechanism is bestdemonstrated by the following example. Most of the agencies in ourstudy utilize and support a basic communication component to meettheir QA needs and maintain the quality of their services. The findingssuggest that most providers have maintained a continuous dialogbetween staff, client, and family members. Continuous communica-tion could enable providers to respond to client needs quickly andefficiently.
However, relying heavily on direct care staff to communicate clientneeds and concerns may introduce bias or conflicting information. Thefindings indicate that almost one-half of the agencies are confrontedwith the problems of unreliable staff and one-fourth report staff with apoor work ethic. If the quality of care provided rests mainly on the in-tegrity, interest, and cooperation of staff to communicate client needsand concerns, both the QA process and the quality of care provided maybe compromised. Unreliable staff and those with a poor work ethic arenot likely candidates for employing positive communication techniques.If a staff person does not willingly participate in a dialog with the clientand his or her family members, he or she cannot be depended upon toadvocate for the client’s needs.
One solution to this potential problem is to develop well-publicizedand easily comprehensible formal complaint mechanisms at both theagency and state level. Clients and their family members need a mecha-nism whereby they can complain without fear of retribution from thestaff or agency and still get a timely response to their concerns. InVirginia, as in most states, the local long-term care Ombudsman han-dles complaints for recipients of long-term care services, if they cannotbe resolved within the agency. By building upon this current system ofreporting, E&D Waiver clients can be encouraged to utilize this servicewhen their aide or agency is unresponsive to their needs and requests.
QA programs that currently utilize a communication component canbe enhanced by the addition of other formal QA mechanisms in theirquality assurance program. Our data indicate that the majority of agen-cies reported utilizing at least one formal QA strategy: satisfactionsurveys, chart audits, performance outcome measures, complaint mech-anisms, and on-site supervision. By utilizing multiple QA mechanisms,agencies have the potential to uncover more of the problem scenariospresented. For example, a formal complaint mechanism was reported touncover a client/worker clash, a worker with a poor work ethic, and a
98 HOME HEALTH CARE SERVICES QUARTERLY
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
worker having an unpleasant encounter with a client’s family. By add-ing a consumer satisfaction survey to a QA program using a formalcomplaint mechanism, the existence of an unreliable worker, a clientpreferring a different schedule, and a worker with poor technical skillscould also be potentially identified. Developing a quality assurance planthat utilizes a variety of QA mechanisms increases the possibility ofidentifying problems before they become too large and unmanageable.
The findings also suggest however, that there is a gap between whatagencies understand a QA program to be and how to utilize it effec-tively. Despite reporting the use of formal QA mechanisms, few respon-dents mentioned using the mechanisms to identify the problems pre-sented. Less than 10% of the agencies reported using a complaintmechanism as a response to the problem scenarios presented. Fewerthan 4% utilized consumer satisfaction surveys, less than 20% identi-fied a chart audit, and no one identified outcome measures as a means toidentify the problems presented. This suggests that either formal QApractices are not used to their full potential, or they are only considereduseful in addressing operational issues and not direct care services.
The training and competency of staff providing services may alsoinfluence the quality of care provided. Unlicensed paraprofessionalworkers provide the majority of direct care services in Virginia’s E&DWaiver programs. State regulations mandate personal care aides to par-ticipate in a 40-hour certification training course on personal care skills.However, once aides have completed this one-time training beforeproviding care to recipients, the state does not require any additionalcertification. The nurse supervisor at each agency is responsible forevaluating the aide’s performance during monthly supervised sessions.If the nurse identifies any significant gaps in caregiving abilities, he orshe must provide or arrange for the necessary retraining of the aide(DMAS, 2002). Because professional licensing boards do not regulatethe work provided by paraprofessional staff, the QA process remains animportant piece in supporting nursing supervisors in ensuring qualityservice delivery.
QA programs should be recognized as an essential piece in the carecontinuum for quality services to Virginia’s citizens as well as otherstates in the nation. Virginia’s E&D Waiver providers have experiencedsuccess in implementing their QA programs. Most agencies report thatthey are able to identify problems, such as the eight problem scenariospresented in this study. To further improve QI/QA programs and en-hance the results, providers should be provided additional training inthe principles of QA and QI, identifying QA mechanisms, and develop-
Brossoie et al. 99
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
ing a comprehensive and effective quality improvement program thatmeets their agency’s needs. Future research can improve quality care inHCBS programs by focusing on the evaluation of QA programs. Re-search will also support the continued development of a theoreticalframework to guide the provision of continued and evolving quality care.
REFERENCES
Applebaum, R., Mollica, R., & Tilly, J. (1997-1998). Assuring homecare quality: Acase study of state strategies. Generations, 21, 57-63.
Bass, D. M., Noelker, L. S., & McCarthy, C. A. (1999). The influence of formal andinformal helpers on primary caregivers’ perceptions of quality care. Journal ofApplied Gerontology, 18, 177-200.
Centers for Medicare and Medicaid Services (2004, June). The quality matrix andframework. Retrieved May 11, 2005 from http://www.cms.hhs.gov/medicaid/waivers/frameworkmatrix.asp
Donabedian, A. (1966). Evaluating the quality of medical care. Millbank MemorialFund Quarterly/Health and Society, 4, 166-206.
Donabedian, A. (1980). Explorations in quality assessment and monitoring: The defi-nition of quality and approached to its assessment. Ann Arbor, MI.: Health Admin-istration Press.
U.S. General Accounting Office (2003, June). Long-term care: Federal Oversight ofgrowing Medicaid home and community-based waivers should be strengthened(Publication No. GAO-03-576). Retrieved May 11, 2005 from http://www.gao.gov/new.items/d03576.pdf
Harrington, C., LeBlanc, A. J., Wood, J., Satten, N. F., & Tonner, C. F. (2002). Met andunmet need for Medicaid home and community based services in the states. Journalof Applied Gerontology, 21, 484-510.
Hughes, S. L. (1995). Evaluation and quality assurance for in-home services. (Newdevelopments in home care services for the elderly: Innovations in policy, program,and practice). Journal of Gerontological Social Work, 24, 117-132.
Institute of Medicine (1996). Best at home: Assuring quality long-term care in homeand community-based settings. Washington, DC.: National Academy Press.
Institute of Medicine (2001). Improving the quality of long-term care. Washington, DC.:National Academy Press.
Kane, R. A. (1999). Goals of home care: Therapeutic, compensatory, or both? Journalof Aging and Health, 11, 299-321.
Kane, R. L. (1999). Examining the efficiency of home care. Journal of Aging andHealth, 11, 322-340.
Kane, R. A., Frytak, J., & Eustis, N. N. (1997). Agency approaches to common qualityproblems in home care: A scenario study. Home Health Care Services Quarterly,16, 21-40.
Kane, R. A., Kane, R. L., Illston, L. H., & Eustis, N. N. (1994). Perspectives in homecare quality. Health Care Financing Review, 16, 69-90.
100 HOME HEALTH CARE SERVICES QUARTERLY
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
Virginia Department of Medical Assistance Services (2002). Elderly and disabledwaiver services manual. Commonwealth of Virginia: Richmond, VA.
Virginia Department of Medical Assistance Services (2003). Statistical records ofthe Virginia Medicaid program and other indigent health care programs 2003edition. Retrieved March 7, 2004 from http://www.dmas.state.va.us/downloads/Stats_03/Chapter%2012/E&D-WVR-03.pdf
Weiner, J. M., Tilly, J., & Alechxih, L. M. B. (2002). Home and community-based ser-vices in seven states. Health Care Financing Review, 23, 89-114.
RECEIVED: 11/15/04REVISED: 06/09/05
ACCEPTED: 06/27/05
Brossoie et al. 101
Dow
nloa
ded
by [
Cas
e W
este
rn R
eser
ve U
nive
rsity
] at
14:
43 1
6 O
ctob
er 2
014
