In Focus

FIVE STEPS TO IN-HOME QUALITY CARE

By ROBERT APPLEBAUM

Subscribe to Aging Today

In talking with care managers, administrators, funders, regulators and policy makers, I am always impressed by their commitment to quality services. Ironically, despite this universal interest in quality, in most instances these same respondents do not feel that their programs are as good as they can be. Many of them describe a scenario in which they are committed to quality, but others in their organizations do not share their view. Often care managers report being limited in realizing their goals for better quality by agency administrative staff and service providers.

Furthermore, providers who assert their commitment to quality have told me at times that they wonder why care managers do not share their vision. Why is it that agreeing on a common concept of quality is so difficult? And why is it so hard for care-management agencies to develop a working model of quality assurance and care?

 

THREE CRITICAL FACTORS
Systems addressing quality care fail to achieve their goals for three critical reasons. First and foremost, quality is compromised because agencies do not keep a clear enough focus on their consumers. Those of us in the field of aging also experience being consumers every day. We know that good quality exists when a service or product does what we want it to do. If providers have no mechanism for consumer input, high quality seldom is possible. Because care-management programs serve older consumers who experience chronic disability, many assume that consumer input is difficult to ascertain and less important than moving ahead with care.

The second quality challenge results from a lack of agreement at care-management organizations about their major goals. When one unit makes its objectives more important than the goals of the overall agency, quality is compromised. One example occurs when the fiscal office of a care-management agency decides that getting the lowest unit price for purchased services is its most important objective, regardless of service quality. This decision may result in consumers receiving sub-par services and care managers spending more time monitoring services. The common goal of all units of a care-management oranization should be providing cost-effective, high-quality in-home services.

The third factor is an organization's quality-management approach. Efforts to assuring quality care long have been based on a model oriented toward inspections. The dominant strategy of this method relies on an annual inspection, which focuses primarily on measuring proxies of quality, such as the number of training hours employees complete, the thoroughness of paperwork and an accounting of expenditures. This approach has two major flaws: It largely ignores consumers of care and, regardless of how good an inspection process is, an annual monitoring visit cannot succeed in developing ongoing quality in a program. The unsuccessful efforts in the United States to regulate nursing homes using this model provide considerable evidence for the failure of this approach.

 

ACTION STEPS
In response to these challenges, I propose five action steps to enable care-management agencies to achieve quality care.

Agency staff must be committed to changing practices when necessary. Most people and organizations have mixed feelings about feedback. On the one hand, they would like to know how they are performing; on the other, they generally like to hear words of praise. Unless there is a strong determination to improving practice by considering both positive and negative feedback, efforts to ensure quality will fail. This commitment must be shared across an agency. Many agencies set up a dichotomy by separating the staff that delivers services from those responsible for quality, but all staff need to be responsible for quality care.

Listening to consumers is integral to any quality strategy. There are many reasons why it is difficult to get older people, especially those with disability or chronic illness, to provide feedback to a healthcare program. Providers truly devoted to delivering quality care must create a mechanism to hear the voices of consumers. Listening to individuals takes a strong commitment from an organization, as well as a willingness to allocate resources to this task.

Develop a good system for processing information. Almost all care-management agencies have a horror story to tell about their management-information system. Although most organizations have developed a workable way to pay the bills, many are unable to do even the most basic information processing. Some of the blame for nonworking information systems can be applied to consultants and information-system companies, but blame must also be applied to the many organizations that have failed to do the hard work of figuring out what information they need and how it can be used. Basic information, such as how long it takes to process a client from initial phone call to the receipt of services, is rarely available. In one instance, a case-management organization was surprised to find that it took more than 30 days to enroll a client.

Information must be linked to quality improvement. If improvements are to take place, data from consumers or other sources about program performance must be linked back to an organization. In recent years, organizations have begun to collect program-performance data, but in many instances this information is not used to improve services. The only thing worse than not collecting information about the delivery of services is gathering information that never gets used to improve the program. Information can be used as a benchmark of agency performance. Data can help guide quality if staff compares it to their organization's performance over time or contrasts it with that of similar organizations. For example, comparing program expenditures, termination rates and consumer satisfaction to those in other regions within a state can provide a good indicator of the quality of an organization's performance.

The process is continuous. Providing high-quality services is not a one-shot deal. Organizations must recognize that improvement is both a continuous and evolutionary process. They will always be working to get better.

 

NEXT STEPS
Most care-management agencies have more to do than they can accomplish, and resources are always limited. The idea of using scarce resources to sharpen quality often seems like a luxury agencies simply do not have. The challenge that such agencies face is one I term "the floating-boat dilemma." Like a boat taking on a rush of water, most agencies spend the majority of their time bailing out water to keep it from sinking. Often it seems risky to devote extensive resources to redirecting efforts that could result in the boat sinking before the problem is solved. Yet, the consequence of spending too little effort on a long-term solution is that the bailing will never end.

I have found that agencies able to redirect their energy toward problem solving have been able to improve quality in ways they did not imagine. One simple example involved a care-management agency where the volume of phone calls was so high that staff could not return most of them. Initially, the staff believed the only solution was to hire more people, and there were simply no resources to do that. It turned out that by reallocating staff and seeing that they answered most calls when they first came in to the agency, the organization could reduce the number of times the phone rang by more than half.

Many uncertainties, from funding to regulations, face today's care-management agencies. What we know with certainty, though, is that high-quality organizations will be better able to respond to these challenges.

Robert Applebaum is a professor and director of the Ohio Long-Term Care Project of the Scripps Gerontology Center at Miami University, Oxford, Ohio.