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Quality Of Care Protocols Needed In LTC

The following is an excerpt from an article which appeared in the October 12, 1998 edition of National Underwriter:

Quality Of Care Protocols Needed In LTC

By Samuel X. Kaplan

Everyone in the long-term care insurance business is looking for an angle to set its product apart from the crowd. Well, I've got an idea for a real LTC innovation. How about quality? 

Right now, quality is the missing link in the LTC insurance industry. 

No one, including the government, seems to have the desire to measure, quantify and qualify the quality of LTC. Most government regulation and oversight focuses on reimbursement abuses—i.e., measuring the intensity of care, not the quality. The same is true for LTC insurers. 

Everyone gives "quality of care" lip service, but it is a reimbursement mentality that's driving what little regulation there is in the LTC industry. The focus is on how much care rather than what kind of care is best for the individual. 

The licensing of nursing homes is accomplished through the use of token "quality" measurements established by the government. There is little oversight of assisted living facilities, adult day care, ECHO (elder cottage housing opportunities) and CCRCs (continuing care retirement communities) and there are virtually no regulations or standard quality measurements for home health care. 

If the LTC industry is to continue to grow, we must move beyond standard risk-adjusted datasets to develop unique quality measures that can monitor and quantify the quality of care. 

I submit that the insurance business is ideally positioned to make major strides in this area. 

The first step forward will be on-site proprietary credentialing. This would include protocols to measure quality through the following: 1) treatment observation; 2) patient satisfaction; 3) assessment of pharmacy utilization; and 4) administrative practice review. 

LTC provider networks should incorporate these measurements, at a minimum, into their quality standards credentialing of providers. Are any insurers doing this today with their own provider networks? 

To be chosen as part of a quality provider network (and national LTC networks will soon be the norm, rather than the exception), a chronic care site must be a suitable home for the chronically ill/disabled. It also must meet, at a minimum, the following "quality of life" standards: 1) maximize functioning/minimize decline; 2) resident/family control over life decisions; and 3) a "good place to live." 

Quality measurements can further be divided into two general categories, with quantitative and qualitative measurements for each of the following: 

Technical Quality. This would include evaluations of: accidents and falls; behavioral/emotional patterns; skin care; cognitive impairment; infection control; clinical management; nutrition; physical functioning; psychotropic drugs; and restraints and activities. 

"Good Place to Live" Components. These would include: individualization; activities; cultural sensitivity and resident rights; family/volunteers; physical environment and personal security; medical and nursing care; meals/nutrition; administrative and clinical on-site review; and improvement/philosophy/mission. 

When credentialing facilities, the selection and evaluation process should include: 1) mandatory training requirements; 2) quality assurance program; and 3) contract requirements for quality care tied to reimbursement. (The last is the essential element in building the missing link for LTC insurance.) 

The conclusion of the credentialing process should result in a grading of the LTC providers. The providers that scored high in quality of care would be paid more for their services than those scored low. This provides an impetus for providers to make substantial efforts to increase the quality of care. 

An additional motivating factor in increasing the quality of care will be the release of "report card" type scores (e.g., A, B, C, D, F) to potential customers (e.g., the LTC consumer has the right to know how a facility scores on a quality-rated scale). 

Regular monitoring and review of results will enable LTC networks to enhance the overall quality of care, working with providers to improve results or dropping providers who fail to meet quality standards. 

Those seeking innovation in the LTC industry need look no further than the concept of true quality-based credentialing of providers. This is a step that is long overdue. 

The introduction of quality standards will elevate LTC insurance products, and the care they facilitate, to a new level of sophistication by enhancing access to quality care in appropriate setting, promoting care choice and options, and adapting coverage to rapidly changing LTC delivery system. The standards will also help participants maximize value of benefits, help manage costs, and integrate more readily with acute care "quality" standards. 

The policyholder is in no position to evaluate and judge the quality of services offered by LTC providers. It must be the responsibility of the insurer to judge and rate the providers based on quantifiable quality of care protocols. Then let informed policyholders decide which provider they wish to use after they have reviewed the ratings. 

Is any insurer doing this today? If not, shouldn't they start? 

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