To
support your work, use scholarly sources and also use outside sources. As in
all assignments, cite your sources in your work and provide references for the
citations in APA format.
Notes from class
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The increasing need for long-term care has
caused several public and private agencies to participate in its managing
process. These public and private agencies are increasingly attempting to
control costs, providing protection to consumers considered unable to protect
themselves. Public controls are nonvoluntary and are imposed by
government agencies through the implementation of laws and regulations. Private
controls are provided by nongovernment agencies and organizations, and
compliance is voluntary.
Public Control
Public control on long-term care is imposed
by federal, state, or local (including county and municipal) government
units. These units set laws, regulations, and standards to be followed by
long-term facilities in order to:
•
Give better care facilities to the poor, who are unable
to take care of themselves, by making them formal or informal wards of the
state.
•
Provide quality health care facilities to consumers.
•
Create awareness in consumers regarding the types of
services provided in the facilities and let the consumers themselves judge
the quality of the services.
•
Set the minimum level of staffing, cleanliness, and
safety, ensuring consumers needing long-term care are treated properly and
receive the necessary services.
•
Follow all long-term care regulations to provide
quality care.
Private Control
Besides government agencies, several
private organizations are involved in managing long-term care. Both public
and private control focus on long-term care organizations as well as the
individuals in those organizations. The only difference is public control can
maintain both the cost and the quality of care, while private care can focus
only on measuring, evaluating, and ensuring the quality of care.
Private control agencies focusing on the
quality of care of long-term organizations are known as accreditation
bodies, while those focusing on the quality of care provided by
individual health care professionals or practitioners are known as certification
bodies.
Let's discuss some of the most common private
control agencies.
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Long-term
care regulations cover both organizational providers and individuals working in
the field of long-term care. Most of the regulations are aimed at either
maintaining the level of quality in the goods and services produced or
minimizing the level of payment for goods or services.
Regulation of Quality
The
primary reason for the regulation of long-term care is to maintain quality.
Consumers have the right to receive high-quality care. However, to maintain the
level of quality, you must be able to measure quality. Quality can be measured
on the basis of processes, structures, and outcomes. Process-based measurement
looks at how tasks are accomplished and whether they follow accepted
procedures. Structure-based measurement focuses on the capacity of an
organization to provide care. Outcome-based measurement focuses on the result
of treatment by measuring changes in the functional status accrued from the
care provided.
In
November 2002, the Centers for Medicare & Medicaid Services (CMS), an
agency of the United States Department of Health and Human Services, began a
national Nursing Home Quality Initiative (NHQI). This is a federal standard
measure that all residents in a nursing home are being evaluated and compared
with to monitor care. The nursing home quality measures come from resident
assessment data that nursing homes routinely collect on the residents at
specified intervals during their stay. These measures assess residents'
physical and clinical conditions and abilities, as well as preferences and life
care wishes. These assessment data have been converted to develop quality
measures that give consumers another source of information that shows how well
nursing homes are caring for their residents' physical and clinical needs.
Long-term
(chronic care) care residents are evaluated on the percent of:
•
Residents
whose need for help with daily activities has increased
•
Residents
who have moderate to severe pain
•
Residents
who were physically restrained
•
High-risk
residents who have pressure sores
•
Low-risk
residents who have pressure sores
•
Residents
with a urinary tract infection
•
Residents
who spent most of their time in bed or in a chair
•
Residents
who have become more depressed or anxious
•
Low-risk
residents who lose control of their bowel or bladder
•
Chronic
or long term care residents who lose too much weight
•
Residents
who have or had a catheter inserted and left in their bladder
•
Residents
whose ability to move about in and around their room got worse
Short-stay
(temporary) care residents are evaluated on the percent of residents:
•
Who
had moderate to severe pain
•
With
delirium
•
With
pressure sores
Regulation of Payment
The
primary purpose of the regulation of payment is to avoid excessive payment,
save money for government agencies, and prevent fraud and abuse in government
funding programs. The two sources of payment regulation are Medicare and
Medicaid. These two programs represent a major source of reimbursement for
long-term care organizations.
The Health Insurance Portability and Accountability Act
The
primary purpose of Health Insurance Portability and Accountability Act (HIPAA)
is to protect the consumers' health insurance, security, and health care data
and promote standardization and efficiency in the health care industry. HIPAA requires
everyone to use the standard format for processing claims and payments. It has
standards for several types of electronic health information transactions and
maintenance of information and data.
Next,
let's discuss the roles of federal and state governments in long-term care.
n
the United States, reimbursement of long-term care depends on how the care is
financed. The type of reimbursement and the amount reimbursed dictate the
access to care, availability of specific services, and equality of care. Both
public and private sources are available for long-term care reimbursement.
However, neither sector has satisfactory mechanisms for helping individuals
anticipate and pay for their care.
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One of the most important aspects of
managing long-term care is to maintain the quality of care and control the
cost of services. In this respect, several quality improvement programs have
been developed in long-term care that focus on monitoring and evaluating
physical, functional, and psychological indicators over time. To establish
effective quality improvement programs, health care organizations should:
•
Define customers.
•
Identify the demands of customers in terms of quality
and determine standards against which quality is to be measured.
•
Monitor the key indicators to measure quality.
•
Evaluate whether the data produced is sufficient enough
to draw a conclusion.
•
Identify appropriate corrective steps to improve the
measurement of quality in particular areas.
•
Continue the process of quality measurement against
standards.
Besides internal programs for quality
improvement, quality assurance, and quality management, organizations also
take several external initiatives so as to improve the overall quality of the
long-term care system.
As discussed earlier, both federal and
state governments regulate and monitor the quality of care provided to
consumers covered by government-run plans such as Medicaid and Medicare.
Several government agencies are involved in quality-related research, such as
the Agency for Healthcare Research and Quality (AHRQ). These agencies develop
quality indicators that serve as valuable measures, both for researchers and
for individuals, to maintain the quality of care. The government agencies
also develop several nationwide quality initiatives to provide information to
the public about health care quality and ways to judge quality for
themselves.
Some of the significant private quality
improvement programs include Quality First, the American Association of Homes
and Services for Aging (AAHSA), the American Health Care Association (AHCA),
and the American Health Quality Association (AHQA).
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