Engaging consumers in medicaid nursing home reimbursement policy: lessons from New York and Minnesota.

PURPOSE OF THE STUDY: This study draws lessons for successful consumer engagement in Medicaid nursing home (NH) reimbursement policy from New York and Minnesota. In these two states, resident advocates have influenced reimbursement policy to better encourage access, care quality, and quality of life. DESIGN AND METHODS: Twenty-four semi-structured interviews were conducted, including consumer advocates, state agency officials, legislators/legislative staff, and NH industry representatives. Transcripts were coded to identify recurring themes and patterns in responses. Related documents were reviewed as well. FINDINGS: Interviewees report that consumer advocates should participate in NH reimbursement policy making to provide a unique perspective distinct from other stakeholder groups. Skills necessary for successful participation include developing, demonstrating, and sharing expertise to gain credibility as a legitimate actor. Effective strategies include participating on state workgroups and taskforces and developing and accessing relationships with key legislative and executive branch officials. A division of labor may be useful with those consumer advocates possessing expertise in NH reimbursement policy partnering with other organizations with the experience and resources necessary to marshal grassroots support. IMPLICATIONS: State and federal reimbursement reform provide opportunities for consumer advocacy influence during the design and implementation process. The experience of consumer groups in New York and Minnesota provide lessons for advocates looking to influence these and other reimbursement initiatives.

We're on the same side: improving communication between nursing home and family.

Good communication between families and care providers is central to quality care, providing valuable insight into medical history and preferences, increasing family involvement and satisfaction, and reducing complaints. Two studies offer insight into sources of family-staff miscommunication and conflict. The Nursing Home Family Study (Study 1) interviewed 103 family caregivers to nursing home residents. The Long Term Care Community Coalition (Study 2) conducted focus groups and surveys with staff in six facilities: 323 certified nurse's assistants, 52 licensed practical nurses, and 71 registered nurses. Qualitative and quantitative data from both studies identified multiple barriers to good communication associated with both nursing homes and family caregivers. Institutional barriers include understaffing, turnover, inadequate training, policies based in a medical model, rigid routines, poor intrastaff communication, and work schedules that do not coincide with family visits. Psychosocial factors that hinder family communication include guilt, role confusion, clashes of culture and values, unrealistic expectations, and conflicting responsibilities. Specific communication problems identified by families were: making them feel guilty, criticism of their involvement, lack of information, changes made without consultation, staff have too little time to talk, high turnover, rotating shifts, and poor intrastaff communication. Similar issues were raised by nursing staff, who valued trusting, respectful relationships with supervisors and families, being consulted prior to changes, support in addressing racist or abusive comments, adequate staffing, and teamwork. Certified nursing assistants noted that family members are quick to complain but seldom offer praise, and that their intimate knowledge of the resident is rarely acknowledged. These data are applied to develop educational interventions to improve family-staff communication.

Variation in the use of federal and state civil money penalties for nursing homes.

PURPOSE: The study examined factors associated with state variations in the use of federal and state civil money penalties (CMPs) for nursing homes. DESIGN AND METHODS: We collected federal and state CMP data from state survey and certification agencies for 2004. We also used federal CMP data from the federal enforcement action database for 2000-2004. Logistic regressions examined factors related to whether states issued CMPs, and ordinary least squares regressions examined the number and amount of federal CMPs (2000-2004) and the total federal and state CMPs (2004). RESULTS: In 2004, 3,159 federal and state CMPs were collected, for a total of $21.6 million, but CMPs were given for only 2% of deficiencies issued. The number of federal CMPs collected was positively related to average facility occupancy rates, the percentage of facilities with deficiencies for harm or jeopardy, and state survey and certification budgets but was negatively related to the number of facility complaints per nursing home bed. Total federal and state CMPs were positively related to state senators' liberal voting records, having a democratic governor, and the percentage of Medicaid nursing home residents and were negatively related to the population aged 65 and older, complaints per nursing home bed, percentage of hospital-based facilities, and home- and community-based expenditures. IMPLICATIONS: The Centers for Medicare & Medicaid Services should address the state variations in CMPs by providing states and federal regional offices with guidelines on the use of federal CMPs. It should also improve accuracy and completeness by including federal and state CMPs in its enforcement database.

The collection and use of funds from civil money penalties and fines from nursing homes.

PURPOSE: This study examined federal and state civil money penalties and fines collected from nursing homes and how states used the collected funds. DESIGN AND METHODS: We used a telephone survey of state officials, Freedom of Information Act requests, state Web site searches, and stakeholder interviews to describe the funds collected, the availability and the use of funds, public information about penalties and fines, and the state allocation process and policies. RESULTS: In 2004, 43 states collected a total of $21 million from more than 3,000 federal and state penalties and fines. Forty-two states had $60.5 million in fund accounts from penalties and fines available in 2005, and 32 states spent $28 million on a wide range of projects. Fifteen states spent $17.9 million on survey and certification activities, 19 states spent $5.6 million on provider projects, 6 states spent $1.3 million on advocacy projects, and 12 states spent $2.7 million for other projects. Most states did not provide information to the public about issuing penalties and fines, have formal procedures to inform stakeholders and allocate funds, or involve stakeholder groups in the decision-making process. IMPLICATIONS: Funds from federal and state penalties and fines vary widely across states. These funds are a resource for improving the quality of nursing home care that needs more attention from policy makers and stakeholder groups.