Meeting the demographic challenges ahead: Toward culture change in an ageing New Zealand

There are several innovative service delivery models in the United States (US) relevant to long-term care policy development and implementation in New Zealand. An especially fruitful source of innovation has been the culture change movement, which originated in the US but has begun to spread to New Zealand and other OECD countries. The culture change philosophy requires that providers respond to the values, preferences, and needs of care recipients. It also requires devolving authority to direct care workers who know their clients best, in addition to transitioning from sterile 'clinical' settings to more homelike environments. New Zealand has a more favourable policy context for improving long-term care than the US. Thus, it is critical that it build upon these short term advantages to promote further dissemination of the culture change ethos, thereby placing caregivers in a better position to meet current care challenges, not to mention those posed by growth in the elderly population ahead

Is a Skilled Nursing Facility’s Rehospitalization Rate a Valid Quality Measure?

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/134892/1/hesr12603-sup-0001-AuthorMatrix.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/134892/2/hesr12603.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/134892/3/hesr12603_am.pd

Implications of Rhode Island’s Global Consumer Choice Compact Medicaid Waiver for Rebalancing Long-Term Care under the Affordable Care Act

Federal approval of Rhode Island’s Global Consumer Choice Compact Global Waiver in 2009 provided Rhode Island with greater flexibility to modify its Medicaid program. Because 96% of long-term care expenditures in Rhode Island were directed toward institutional settings, a primary goal was to facilitate the state’s efforts to shift the locus of long-term care to non-institutional settings. This study draws lessons from Rhode Island’s experience with the Global Waiver for the long-term care rebalancing provisions of the Patient Protection and Affordable Care Act of 2010. Data derive from 325 archival sources and 26 semi-structured interviews. Results suggest that prospectively documenting home- and community-based services (HCBS) capacity is necessary to ensure that sufficient resources are available to meet the complex care needs of an increasingly larger service clientele. Results also suggest that increased reimbursement is especially important for attracting participating providers; so too is maintaining sufficient numbers of state regulators for purposes of monitoring quality. Barring the adoption of even more substantial changes in federal policy than included in the Affordable Care Act the distribution of long-term care spending is likely to remain stagnant in laggard states such as Rhode Island given just how difficult it is to make more than marginal progress despite the provision of additional options and incentives that otherwise should promote rebalancing. Nursing home care continues to be a mandatory benefit while most HCBS remains optional. This leaves investments in HCBS especially vulnerable to the vagaries of state budget and political processes, which when combined with the absence of minimum standards and requirements to cover all geographic areas and target populations, suggest persistent unmet need, both within and across states

Implications of Rhode Island’s Global Consumer Choice Compact Medicaid Waiver for Block Granting Medicaid and Other Retrenchment

On January 16, 2009, the Federal government approved Rhode Island’s application for a Global Consumer Choice Compact Medicaid Waiver whereby the state became the first granted permission to operate its entire Medicaid program under the state plan and a single 1115 “research and demonstration” waiver. The Global Waiver has been implemented in the context of Republican proposals to turn Medicaid into a block grant which would give states substantially more flexibility administering the program in exchange for receiving an upfront allotment from the Federal government. Proponents have held up the Global Waiver as a successful example of what might be achieved nationally if all states received block grants to run their Medicaid programs. This study draws lessons from Rhode Island’s Global Waiver for the Medicaid block grant debate. Data derive from 325 archival sources and 26 semi-structured interviews. Results indicate that the Global Waiver is not a block grant but a capped federal match where the state is required to spend its own money before receiving the federal contribution. Moreover, the state did not receive unlimited discretion to administer Medicaid under the Global Waiver nor achieved nearly as much savings as has been claimed. Indeed, most savings obtained by Rhode Island during this time period derive not from efficiencies stemming from the Global Waiver but from increased federal spending and from measures the state could have implemented independently of the waiver. The generosity of the Global Waiver is in marked contrast to most block grant proposals which would substantially reduce the level of federal fiscal support. In the near future, turning Medicaid into a block grant is not going to occur in light of President Obama’s reelection. Identifying the implications of RI’s experience for Medicaid retrenchment and the block grant debate is important, however, as some states eschew expanding the program under the Affordable Care Act and as proponents continue to propose block grant approach to Medicaid reform, both in future budget proposals and presidential party platforms

Implications of Rhode Island’s Global Consumer Choice Compact Medicaid Waiver for Designing and Implementing State Health Reform

Provisions in the Medicaid statute permit states to apply for waivers from traditional program requirements. On January 16, 2009, the federal government approved Rhode Island\u27s Global Consumer Choice Compact Waiver. In exchange for a cap on combined federal and state spending of $12.075 billion through 2013, Rhode Island received greater flexibility to adopt certain Medicaid program changes. This study analyzes the design and implementation of the Global Waiver to draw general lessons for health reform at the state-level, a key concern given ongoing state discretion to improve their health care systems under the Patient Protection and Affordable Care Act. Data derive from 325 archival sources and 26 semi-structured interviews. The Global Waiver would not have happened without political and ideological alignment between Rhode Island’s Republican Governor and the Bush administration and the fractured nature of the waiver’s opposition across provider and advocacy groups. The waiver was motivated largely by ongoing fiscal and programmatic pressures. Development was dominated by state officials, working over a short time period characterized by growing budgetary uncertainty. Dissatisfaction in the level of outside input contributed to distrust among stakeholder groups. Subsequent legislative constraints together with insufficient administrative personnel and antiquated information systems hampered implementation. So too did remaining divisions among those overseeing, advocating, and serving different beneficiary communities. Specific lessons include: ensuring sufficient levels of stakeholder input and transparency throughout the program design, approval, and implementation process; devoting adequate personnel and informational resources to program administration, including coordination across disparate elements of the state bureaucracy; and carefully considering the breadth and timing of the reform strategy pursued; factors that promote adoption, for example, may, in turn, impede implementation

Association of the Resident Assessment Instrument (RAI) with Changes in Function, Cognition, and Psychosocial Status

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111069/1/j.1532-5415.1997.tb02971.x.pd

Inter-rater reliability of nursing home quality indicators in the U.S

BACKGROUND: In the US, Quality Indicators (QI's) profiling and comparing the performance of hospitals, health plans, nursing homes and physicians are routinely published for consumer review. We report the results of the largest study of inter-rater reliability done on nursing home assessments which generate the data used to derive publicly reported nursing home quality indicators. METHODS: We sampled nursing homes in 6 states, selecting up to 30 residents per facility who were observed and assessed by research nurses on 100 clinical assessment elements contained in the Minimum Data Set (MDS) and compared these with the most recent assessment in the record done by facility nurses. Kappa statistics were generated for all data items and derived for 22 QI's over the entire sample and for each facility. Finally, facilities with many QI's with poor Kappa levels were compared to those with many QI's with excellent Kappa levels on selected characteristics. RESULTS: A total of 462 facilities in 6 states were approached and 219 agreed to participate, yielding a response rate of 47.4%. A total of 5758 residents were included in the inter-rater reliability analyses, around 27.5 per facility. Patients resembled the traditional nursing home resident, only 43.9% were continent of urine and only 25.2% were rated as likely to be discharged within the next 30 days. Results of resident level comparative analyses reveal high inter-rater reliability levels (most items >.75). Using the research nurses as the "gold standard", we compared composite quality indicators based on their ratings with those based on facility nurses. All but two QI's have adequate Kappa levels and 4 QI's have average Kappa values in excess of .80. We found that 16% of participating facilities performed poorly (Kappa <.4) on more than 6 of the 22 QI's while 18% of facilities performed well (Kappa >.75) on 12 or more QI's. No facility characteristics were related to reliability of the data on which Qis are based. CONCLUSION: While a few QI's being used for public reporting have limited reliability as measured in US nursing homes today, the vast majority of QI's are measured reliably across the majority of nursing facilities. Although information about the average facility is reliable, how the public can identify those facilities whose data can be trusted and whose cannot remains a challenge