PHI National Policy Recommendation: Quality Assurance (pdf)

Problem

Direct-care workers provide an estimated 70 to 80 percent of the hands‐on long‐term care and personal assistance services received by Americans with disabilities or living with chronic conditions. Because they spend the most time with consumers, these frontline caregivers are often in the best position to notice subtle changes in the consumer’s condition, which left unattended might develop into serious medical problems. Moreover, for many consumers, a stable caregiving relationship based on personalized service that respects the consumer’s individuality and preferences goes to the very heart of the definition of quality care.

The long-term care industry has long been characterized by a high degree of turnover among direct-care staff—the result of the poor quality of direct‐care jobs. This constant workforce churning disrupts critical caregiving relationships and undermines the quality of care suggesting that the most significant lever that policymakers may have over quality of care outcomes is the quality of direct-care jobs. Yet the quality assurance framework in long-term care does not include quality job measures.

Standard quality of care measures range from indicators of care outcomes (e.g., pressure sores and outcomes related to physical and psychosocial functions) to use‐of‐service measures (e.g., emergency room visits) to process‐of‐care measures (e.g., overuse of restraints). They sometimes incorporate incidence of complaints, violations, and deficiencies as well as measures of patient and family satisfaction. Given the critical importance of job quality to the quality of the services and supports that consumers receive, quality assurance mechanisms must be broadened to encompass measures that indicate basic workforce conditions related to direct-care staffing.

Furthermore, our country’s reimbursement rates for nursing‐home and community-based services are not structured to provide financial rewards or incentives for high productivity or superior performance with respect to staffing adequacy and stability. Of the $59 billion of Medicaid payments for institutional services, and an additional $42 billion for Medicaid homeand community‐based services, only a small fraction is leveraged to encourage providers to adopt human resource practices consistent with high‐quality service delivery. By creating financial rewards for basic job quality standards shown to be critical to quality care, reimbursement rates can be used to generate competitive pressures that push quality up and costs down.

Solutions

The most significant lever that policymakers have over the quality of care provided to long-term care consumers is the quality of jobs for direct‐care workers.

To ensure high-quality long‐term services and supports to older adults and people living with disabilities, PHI recommends that policymakers take the following actions:

• Support the development of national and state job quality/workforce indicators for direct‐care occupations and incorporate these measures into national and state provider quality standards. These indicators can create incentives for adequate and safe staffing and greater workforce stability through the inclusion of such measures as: staffing levels, turnover rates, and measures of compensation and worker preparedness.
• Make workforce an explicit part of CMS’s review processes by including greater oversight and guidance to states about the adequacy and quality of their direct‐care workforce in Home and Community‐Based Services waiver applications/renewals and
  Medicaid State Plan Amendments.
• Promote state contracting standards and reimbursement methods that reward providers for superior performance with regard to improving job quality.