We present a theory-driven quantitative analysis of the quality of 40 Almost half of the MHPSS programmes (45%) were implemented in the. Apparently, the examples of 40 Principles may be found in communication, mass media, literature, art, .. o Accuracy of quality costs estimates (typically 85%). To design potentially successful quality improvement (QI) interventions, it is . a practice visit (40%), the median number of practice visits was 2 (range 1–13).
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These potential users need quality measures that can facilitate relevant comparisons among different models or types of ALFs, between AL and traditional board and care or residential care homes, and between ALFs and nursing homes.
Comparisons among ALFs might reasonably take several forms. For example, because some observers view AL as a new model of LTC, one might wish to determine the degree to which the universe of places that call themselves ALFs adhere to the philosophy that underpins this new model.
The potential quality indicators tied to this philosophy imply a fairly comprehensive role for AL and, thus, a reasonably inclusive concept of quality. The key domains include a range of structure, process, and outcome quality indicators and focus on the key philosophical tenets of AL. These tenets were derived from various sources that sought to articulate the key features of AL. According to the definition propounded by the Assisted Living Quality Coalition , p. Provision of key services, including: Provision of services designed so as to minimize the residents' need to move; accommodate individual residents' changing needs and preferences; and maximize residents' dignity, autonomy, independence, and safety.
The translation of this philosophy into operational definitions and measures is both challenging and fraught with potentially disparate concepts of such issues as which structures and processes facilitate aging in place or minimize a resident's need to move; what consumer autonomy means in practice, particularly for consumers with different levels of physical and cognitive functioning; and what unscheduled needs actually are.
Having said that, there is some general agreement of what the philosophy might mean in practice. Table 1 provides an illustrative list of potential indicators.
The service components of the philosophy are typically translated into an operational definition of an ALF as a facility that provides or arranges at least the following: ALFs may provide these services directly with their own staff or arrange for the provision of services through an external provider, such as a home health agency.
However, there has been some erosion of agreement about whether aging in place is part of AL, and there is no consensus about whether licensed nursing services are essential to meeting scheduled and unscheduled needs or whether such services facilitate aging in place. However, if one focuses on the key philosophical tenets, quality indicators should include availability of those key services, as well as indicators of process quality related to whether services are arranged and provided so as to maximize a resident's independence.
Furthermore, this concept of the role of AL may imply the need for measurement of policies that are intended to promote autonomy, dignity, and choice. For example, some ALFs restrict the use of wheelchairs and walkers in the public spaces of the facility. Although such policies may meet the preferences of physically intact residents, they may limit the ability of residents to age in place. Experts should develop a similar set of indicators to assess the features of the setting and the environment within the facilities.
For example, although there is some disagreement among the providers about whether private accommodations and bathrooms are essential components of AL, privacy is typically considered a key element of AL Jenkens, ; Kane et al.
However, privacy is not the only aspect of the environment that may contribute to resident autonomy and independence. Focus groups with residents and family members suggest that environmental autonomy might also include residents having the ability to personalize their private space by bringing in and arranging furniture; having adequate storage for clothing and other possessions; and being able to store and prepare food usually small meals or snacks , control the environment, lock the door, and, in some cases, have a pet.
Finally, this expansive concept of AL and its role in meeting the needs and preferences of frail elders could include a more direct examination of what AL actually accomplishes, rather than merely its capacity to achieve philosophical goals. This would necessitate the development of process and outcome indicators that attempt to capture the goals of AL at the resident level, assessing residents' day-to-day experience living in an ALF and the outcomes of this arrangement. Asking residents directly about their experiences and their assessment of the facility's performance is one key aspect of such an undertaking.
Rather than merely asking about satisfaction, the indicators might assess the residents' views on the choices and control they have, how they are treated by staff, the level of social interaction and community involvement, whether activities meet their preferences, and so on.
In addition, if one accepts the premise that ALFs should meet residents' scheduled and unscheduled needs, one might look not only at policies and service availability but also at residents' unmet needs. Furthermore, length of stay, discharge location, and reasons for exit may be relevant indicators of whether residents are able to age in place—or, in conjunction with indicators of unmet needs, at least the degree to which residents are able to have changing needs and preferences met in the facility.
For Medicaid waiver programs, the underlying issue, by regulation, is whether AL can reduce nursing home use. In addition, states wishing to contain nursing home use and costs are increasingly interested in the potential of various types of residential care settings to delay or prevent nursing home care for some proportion of residents or potential residents Mollica, , The Olmstead decision has also encouraged states to examine noninstitutional settings for persons with disabilities and to expand the use of residential LTC settings U.
Government Accountability Office, Despite this growth in state policy involvement, states continue to vary in the role they define for AL, as noted previously. Some states have redefined all residential care facilities as AL, retaining a traditional board and care orientation. Other states have structured their licensure regulations and Medicaid waiver policies to divert frail elders from nursing homes. Some states have allowed ALFs to provide daily nursing care, whereas others explicitly prohibit such services.
In addition, even within the constraints imposed by licensure, individual facilities and multistate chains have selected models with varying degrees of privacy and accommodations Hawes et al. As a result, there is considerable variation among places known as AL in ownership, auspice, size, target resident population, accommodations, services, staffing, and price.
Thus, both public and private policies have contributed to the emergence of different types of ALFs across the country. The result can be seen in national and multistate studies Hawes et al. These different models suggest a variety of research issues and the need for diverse quality indicators.
Are differences in outcomes, such as prevented or delayed nursing home use, associated with different types or models of AL? Are ALFs capable of providing appropriate care for an increasingly frail and disabled population of residents, and does this care differ across various types of ALFs? The answers to these questions require empirical data.
Researchers must better understand the characteristics of the ALFs and potentially other types of residential care facilities , particularly along critical dimensions that might affect resident outcomes. Thus, experts need a wide variety of structural, process, and outcome quality indicators to make relevant comparisons among ALFs, between different types of ALFs e.
There are a variety of audiences interested in such issues. For example, sophisticated consumers and their advocates need such information to make informed choices among facilities in order to maximize the services, environment, and outcomes that the individual consumer desires. Policymakers also need measures that assess the effect of different types of models of ALFs. For example, Mollica's , surveys suggested that states have envisioned different roles for AL in their portfolio of LTC services.
However, research is needed to determine whether one model of AL is more or less likely to achieve specific goals.
Such research can inform licensure policy and Medicaid payment and coverage policies. The only study that has produced national estimates about the universe of ALFs across the country was the one conducted for the U.
This study was restricted to places that were self-proclaimed ALFs or that provided a specified range of basic services common to most ALFs i.
Despite this restriction, the study still found tremendous variation among the facilities. For example, fewer than half of the resident units were apartments; most accommodations were bedrooms.
The study found similar variability with respect to services, particularly in terms of whether ALFs had a registered nurse on staff and offered nursing care with their own staff Hawes et al. Indeed, the study found what one might describe as four different models of AL, depending on the mix of services and privacy each offered.
Although this study was largely descriptive, it did find variation across these four different types of ALFs in such features as their policies on admission and retention of residents, service availability, the level of resident functional impairment, length of stay, and likelihood of discharge to a nursing home Hawes et al. All of these might reasonably be considered structural and outcome-oriented measures of quality and might well be of interest to consumers and policy makers.
They found differences across these facilities in 10 different process quality indicators, such as the amount of health services they offered, their admission policies, privacy, policy clarity, resident control, and individual freedom or autonomy, as well as the average level of resident impairment Zimmerman et al.
These studies raise important questions about the effect of different models or types of AL and suggest the need for the development and use of a a variety of structural measures that adequately capture key features of the facilities and b process and outcome quality indicators to assess the effects of these different facility features.
When assessing the performance of ALFs, one could examine many areas of health care monitoring, oversight, or provision. However, the most visible difference among ALFs relates to nursing services, in particular whether facilities offer nursing care with their own staff, arrange nursing care, or do not offer such care or monitoring.
Although variation in staffing among ALFs appears to be largely a result of choice by facilities, this is clearly an issue that is amenable to regulation Mollica, Moreover, it is also clear that states differ on the issue of staffing type and staffing levels in AL, and this was also an area of contention among members of the Assisted Living Workgroup Whatever their position on whether to require licensed nurses on ALF staff, many states have allowed such residential care facilities to house residents with greater levels of impairment.
By the mids, the majority of state licensing agencies allowed ALFs to house residents who were chairfast because of health problems or who used wheelchairs to get around inside the facility.
These strategies include permitting the provision of daily or intermittent nursing care including skilled care and hospice care in these facilities, allowing retention of residents with greater levels of impairment, and modifying nurse practice acts to allow nonlicensed personnel to provide certain services independently or under supervision. As a result, there is variation within and across states and facilities in the types of residents they serve and in the way they approach meeting residents' health needs.
Examining the effect of differences in staffing type could inform public policy as well as programmatic decisions by ALFs. Clearly, one challenge inherent in evaluating the impact of such differences is to conceptualize the types of effects such a structural feature might reasonably be expected to produce.
However, from a policy perspective, one would certainly wish to know how staffing differences affect an ALF's ability to provide appropriate quality of care and quality of life, meet resident preferences, minimize the need for residents to move, promote aging in place, and prevent or delay nursing home use.
It is important to note that some proponents of AL might view these measures as inconsistent with a social model of AL. A related set of policy concerns arises from variation across states in the role assigned to AL by ALFs themselves and by policy makers.
These embrace concerns about the capacity of ALFs to care for more impaired residents and issues of eligibility and level of care in ALFs and other residential care facilities. Increasingly, state regulators are expressing some apprehension that the combination of public policies and consumer preferences for aging in place in a noninstitutional environment may present ALFs with a mix of residents whose health-related needs cannot be adequately met.
Furthermore, there is some evidence to support such concerns. In addition, a four-state study by the U. Government Accountability Office the U. General Accounting Office at the time of this report; raised serious concerns about quality of care in ALFs and other residential care facilities.
Initial results suggested some types of ALFs produce better process quality. Thus, there are reasonable arguments for including a variety of health outcomes among quality measures when examining some aspects of AL Table 2 shows an illustrative list.
Another dimension on which ALFs differ is accommodations. In terms of privacy of accommodations, there was even greater variability. One might expect such variations to affect residents' satisfaction with their accommodations, as well as their ability to control their living space in a variety of ways, which are displayed in Table 3.
What is less expected is that variations in privacy in one study were associated with statistically significant differences in admission and retention policies, with high-privacy ALFs having much more restrictive policies.
As a result of this finding, policy makers who seek to provide privacy to consumers but want ALFs to serve a nursing-home-eligible population or to prevent or delay nursing home admission may want to assess the impact of privacy on the types of residents ALFs serve, the effect on aging in place, and whether policies can be developed and implemented that encourage both high privacy and greater flexibility on admission and discharge policies.
At the same time, it is important to consider not only the appropriateness of different quality measures—that is, validity and the conceptual relationship to the features being examined—but also whether comparisons between very different models of AL are appropriate.
In addition to finding differences in process quality related to care e. They also found that small facilities did poorly on most of the indicators the investigators used to compare the different types of facilities. Studies have suggested that consumers typically spend little time evaluating different LTC settings before they are faced with needing residential LTC—and needing it pretty immediately Castle, For example, many consumers reported that the physical appearance of the facility and accommodations were often central to their decisions, particularly when selecting a facility.
Family members stressed the importance of loved ones having as homelike an environment as possible, focusing on privacy of accommodations and the attractiveness of public spaces of the facility, as well as the ability to furnish the unit with the resident's possessions.
Interviews revealed similar preferences. This is consistent with other studies that found that residents overwhelmingly prefer private accommodations in AL Jenkens, ; Kane et al. Residents and family members also cited the importance of staffing type, staffing levels, and the availability of needed services.
Family members also discussed the importance of staff treating residents with courtesy, respect, and affection. In addition, family members of residents with dementia discussed the importance of communication—communication with family members about the resident's health and well-being, and the nature and appropriateness of communication between staff and residents Greene et al.
Residents and family members also reported that their major concerns related to the ability of the ALF to meet their future needs Curtis et al. More studies of consumer preferences and concepts of quality are needed, but the initial findings are important.
Most of these have been discussed here as aspects of quality that might be examined in the context of comparing different models of AL and assessing their effects on potential public policy goals.
However, in all of these endeavors that involve defining and measuring quality, it is important to keep consumer preferences and needs at the core of the attempts. This consumer focus, after all, is the essence of the philosophy of AL and the very feature that, if widely emulated, could transform all LTC. The struggle to define, measure, and assure quality in LTC has something of a Sisyphean cast to it. Achieving this with respect to nursing home quality has been both a conceptual and a regulatory challenge for decades.
And now, as one might feel that there has been substantial progress with nursing home care, at least at a conceptual level, the rock slips and one is then faced with the uphill challenge of considering quality's meaning in a new and different care modality—AL. This is particularly true given the diversity in the AL industry and the variety of goals and expectations held for AL by different consumers, providers, and policy makers.
For the industry and some researchers, such a commitment means that the formidable superstructure of regulation and monitoring that has come to characterize nursing homes must not be replicated in the world of AL. These analysts take what they see as the failures of quality assurance in nursing homes to mean that comprehensive regulation will not work in AL and that another path must be sought.
In this view, creativity and responsiveness to consumer and market pressures are important engines of quality, and quality is likely to be harmed, if not killed, by the rigidity of regulatory requirements. Also, given the tender age of the AL industry, these observers argue that the interests of all are best served by allowing the industry to mature more fully before any consideration is given to regulatory standards that may stifle innovation. From this perspective, quality measurement and quality indicators are best aimed at meeting the internal requirements of the industry.
Quality measures will be based on specialized assessment tools that vary from facility to facility or that focus solely on consumer satisfaction measures.
The instruments and indicators will be adequate to the degree that they meet what providers consider their needs. Providers will use this information internally or as part of an advertising campaign asserting the special place occupied by a particular facility in this burgeoning industry.
Mowrey Quality – 40 + Years of Quality
Purpose This regulation establishes policies, procedures, and responsibilities for the administration of the Army Medical Department (AMEDD) Clinical Quality. AR 25–50 Preparing and Managing Correspondence AR 40–1 Composition, AFMAN 23–; MCO Material Quality Storage Standards Policy for. Scientific output quality of 40 globally top-ranked medical researchers in the .. Only six authors (%) did not change their ranking position.