The Quality Indicator Survey: Background,Implementation, and Widespread Change

The Quality Indicator Survey (QIS) is the most comprehensive regulatory change to the nursing home survey process since the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). In this article we describe the policy evolution that led to the QIS, summarize the QIS method and implementation, and profile the QIS survey results. Following over a decade of development, in 2007 the Centers for Medicare and Medicaid Services (CMS) began the national rollout of QIS. The intent was to improve consistency in the nursing home survey and to render the survey process more resident-centered and aligned with the intent of OBRA-87. We reviewed policy reports and firsthand accounts from the lead developer of the QIS methodology and leader of the national training contract for QIS. Changes in survey findings are profiled based on analysis of the publicly available Nursing Home Compare database from 2004 to 2010. Nineteen states implemented the QIS between 2007 and 2010, with nearly 20% of U.S. nursing homes receiving QIS surveys in 2010. Nursing homes surveyed with the QIS received more survey deficiencies on average than in the traditional survey; however, average numbers of deficiencies across states became more similar over the early implementation of QIS, with lower-than-average geographic areas experiencing increases and higher-than-average geographic areas experiencing decreases in survey deficiencies. The explicit and structured questioning of residents in the QIS is associated with increases in deficiencies related to choice, dignity, dental care, and nurse staffing. We describe ways in which the QIS affected the regulatory agencies, providers, and resident communities, although these effects are difficult to quantify. CMS's implementation of QIS is a significant step toward a more resident-centered, comprehensive, and consistent survey process. Substantial changes, however, are required not only among regulators but also among nursing homes. We argue that these new expectations and norms surrounding quality assessment and quality assurance are an important component of achieving culture change in U.S. nursing homes.     

Does Home- and Community-Based Care Affect Nursing Home Use?

A study was conducted to assess change in numbers, expenditures, and case mix of nursing home residents as Medicaid investment in home- and community-based services (HCBS) 1915(c) waivers increased in seven states. The seven states provided Medicaid expenditure and utilization data from 2001 to 2005, including waiver and state plan utilization. The Minimum Data Set was used for nursing home residents. For three states, community assessment data were also used. In six states, the number of nursing home clients decreased as the numbers of HCBS clients grew. However, in most states, the number of additional waiver clients often greatly exceeded reductions in nursing home residents. Nursing home payments decreased moderately, but this decrease was offset by increases in HCBS waiver and state plan expenditures, leading to a net increase in long-term support services (LTSS) expenditures from 2001 to 2005. Increases in waiver expenditures outpaced increases in waiver clients, indicating expansion of services on top of expansion in clients. States that showed substantial increases in HCBS showed only modest increases in nursing home case mix. The case mix for nursing home residents was more acute than that for HCBS users. The expectation that greater HCBS use would siphon off less severe LTSS users and hence lead to a higher case mix in nursing homes was partially met. The more acute case mix in nursing homes suggests that HCBS serves some individuals who were previously cared for in nursing homes but many who were not. Efforts to promote substitution of HCBS for institutional care will require more proactive strategies such as diversion.     

Inequality of Pension Arrangements Among Different Segments of the Labor Force in China

Social security for older people in China today has been established institutionally. However, there are substantial problems such as coverage, affordability, fund management, and corruption. This paper aims to provide a general picture of China's social security system for older people and to argue that the inequality of pension arrangements among different segments of the labor force is one of the most conspicuous problems challenging the Chinese government. Four unequal aspects of the pension system concerning the financing resources and pension levels are examined in this paper: (1) unequal institutional arrangements among different sectors, (2) unbalanced governmental expenditure in pension provision, (3) an increasing gap in pension levels between urban and rural areas, and (4) uncovered groups such as the unemployed and self-employed. Historical, economic, and political reasons all contribute to this unequal institution under transition from socialism to a market-oriented economy. At present, it is urgent for the central government to take measures to integrate the various pension arrangements into the unified Old Age Insurance and to reduce the gaps among different regions.     

The Woodwork Effect in Medicaid Long-Term Services and Supports

This paper examines annual real per capita Medicaid long-term services and supports (LTSS) expenditures (in 2010 $) over the period 1995 to 2010. Medicaid community LTSS expenditures increased substantially. If that trend constituted a woodwork effect, expenditures on institutional services should have declined more slowly than community expenditures increased, resulting in total expenditures increasing over time. Such a woodwork effect is observed for the population with intellectual and developmental disabilities (IDD) but not for the non-IDD population, composed of persons with disabilities other than IDD, including older persons. During this time period, the goals for serving people with IDD changed; institutional and community cost-neutrality rules were relaxed (and with that concerns over a woodwork effect), and instead goals of community involvement and participation were emphasized for all eligible persons. For the non-IDD population, tighter adherence to cost-neutrality rules and controls over nursing home reimbursements may have helped avoid a woodwork effect as community expenditures increased. With the passage of the Americans with Disabilities Act in 1990, goals have changed for people with disabilities of all ages, and the notion of a simple trade-off between institutional and community service costs that constitutes the woodwork effect must be complemented with a much broader idea of cost analysis that values independence and community participation for people with disabilities of all ages.     

Commentary: Barriers to a Sustained Restraint-Free Environment

A restraint-free culture is becoming a standard practice in the provision of long-term care services for older people, a standard by which licensure and accreditation agencies evaluate providers. Although most health care providers initiate restraint-elimination processes, many fail to achieve the intended result or sustain the practice because of a variety of barriers. Faltering organizations find themselves faced with monumental changes in administrative and supervisory staff, substantial recruitment and retention crises, and inadequate attention to a culture of continuous learning, teamwork, and leadership skill building. This article informs policy makers about the barriers to achieving and sustaining a restraint-free environment and suggests public policy agendas and processes to improve conditions for the aging population.     

Least Restrictive or Least Understood? Waist Restraints,Provider Practices,and Risk of Harm

Since implementation of The Omnibus Budget Reconciliation Act of 1987, restraint use in American nursing homes has reduced dramatically. The reduction in vest restraints has resulted in an increase in “least restrictive” devices such as waist restraints. Although this analysis of U.S. Food and Drug Administration Adverse Event Reporting Data Files found that waist devices pose the same potential risk for asphyxial death as vest restraints, few health professionals and consumers are aware of this outcome. Post-marketing device reporting needs better data quality and surveillance, which can certainly benefit the Centers for Medicare and Medicaid Services in their efforts to regulate and enforce standards of care that reduce deaths and injuries to vulnerable nursing home residents.     

Pension Reforms in Hong Kong: Using Residual and Collaborative Strategies to Deal With the Government's Financial Responsibility in Providing Retirement Protection

In 2000, the Hong Kong government introduced the first compulsory retirement saving scheme intended to protect the entire workforce, the Mandatory Provident Fund (MPF). Prior to the introduction of this scheme, the government's main measure for giving financial protection to retirees was the Comprehensive Social Security Assistance (CSSA) scheme, which is a noncontributory, means-tested financial assistance scheme. This paper studies the government's attempt to introduce the MPF on top of the CSSA scheme as a means to illustrate how governments might address their financial responsibilities in providing pension schemes by adopting both the residual strategy-centered reform approach and the collaborative strategy-centered reform approach. The former approach is concerned with developing noncontributory schemes using residual strategies, and the latter is concerned with developing contributory schemes using collaborative strategies. The paper shows the difficulties involved in carrying out these two reform approaches simultaneously.     

The Power of Silver: Age and Identity Politics in the 21st Century

Pensioner political movements emerged in the interwar years in America and Europe. Documentary and empirical analyses confirm the influential role such movements played in helping shape the postwar social security systems of Western societies. Pensioner movements, qua pensioner movements, have failed to retain their influence, despite that “old age” and its demographic significance have become more salient. We propose three explanations for this: the first concerns the failure of old age to connect with the generational ethos of identity politics; the second reflects the nature of the actors now involved in the governance of old age; and the third concerns the individualization of retirement as a phase of life.     

Florida's Efforts to Improve Quality of Nursing Home Care Through Nurse Staffing Standards,Regulation, and Medicaid Reimbursement

Between 1999 and 2007, Florida implemented two initiatives combining legislative, regulatory, and reimbursement strategies to increase nurse staffing levels in nursing homes to improve quality of care. Despite a $40 million incentive package allocated for direct-care staffing, per-resident-day staffing increased only after legislative requirements mandated minimum nursing hours per resident day. Total Medicaid expenditures grew by $1.1 billion over the 8 years; per diem rates increased 65% to reimburse providers' costs. Registered nurses' hours decreased, while licensed nurses' and paraprofessionals' hours increased. This article describes the impact of staffing policy changes, includes stakeholders' views about approaches to achieve quality outcomes, and documents state policy implementation efforts. Seven lessons from the implementation of state nurse staffing standards to improve quality of care outcomes are also presented.     

International Policy Perspectives on Independence in Old Age

The promotion of independence in old age has become a common principle in aging policies internationally. The term independence, however, has a variety of meanings that are shaped by social/political/economic contexts and the values and attitudes toward older people. Interpretations of independence affect the ways in which policies are translated into strategies and services. The promotion of independence features prominently in the aging policies of the United Nations and the World Health Organization but does not fit well with the cultural values and social contexts of some countries. A comparison of aging policies in four countries—Australia, Denmark, India, and United Kingdom—found that the principle of promoting independence is not universally adopted. The author proposes that the profile and meaning of independence in policy is shaped by values surrounding individual, family, and social responsibilities. Consideration is given to the limitations and culturally bound nature of independence as a policy principle.