Ohio Access is clear that publicly funded long-term services and supports need to meet a high standard of quality. Historically, "quality" has been defined as the state's responsibility to ensure consumer safety. However, a new paradigm is emerging that expands the concept of quality to include consumer expectations about autonomy, self-direction, and choice. With these new conceptions of quality in mind, the Ohio Access cabinet will:
- Measure service satisfaction and outcomes;
- Address healthcare workforce shortage issues;
- Enhance quality in nursing facilities; and
- Provide training for teachers who work with children with disabilities.
C.1 Measure Service Satisfaction and Outcomes
In order to meet a high standard of quality, it is necessary to measure customer satisfaction with services and outcomes. Satisfaction and outcome data allow state agencies and service providers to better understand and respond to the needs of consumers and engage in quality improvement on a continuous basis. It also aids in making decisions about how to allocate public resources and in ensuring accountability for how those resources are spent. Several state agencies have made important progress in this area.
ODMH has worked for nearly a decade to develop standardized quality measures and a statewide infrastructure for assessing consumer outcomes and satisfaction. Most providers are required to use the Ohio Mental Health Consumer Outcomes System, a set of surveys administered to consumers, family members and providers. The system measures actual outcomes for people who receive publicly funded services, including severity of symptoms, quality of life and empowerment, safety and health, and community functioning. The data are used for provider-level quality improvement and to benchmark performance. In addition, ODMH supports Consumer Quality Review Teams that measure consumer satisfaction with services.
ODADAS is implementing a statewide Outcome Framework Initiative to improve service delivery and determine the effectiveness of specific prevention and treatment approaches. The department will use this data to promote best practices and to guide decisions about resource allocation.
ODJFS and ODA are using the CMS-developed Participant Experience Survey to assess overall satisfaction with PASSPORT and the Ohio Home Care Waiver program. In addition, ODA has extensively tested a sophisticated new satisfaction instrument that measures consumer experience with the specific services they are receiving. ODA also conducts a more traditional consumer satisfaction survey by mail for PASSPORT.
| C.1.1 | ODMH will monitor and support statewide implementation of Consumer Outcomes System in SFY 2004, expand Consumer Quality Review Teams as funds allow, and identify a target audience and resources to support a satisfaction and outcome survey. |
| C.1.2 | ODADAS will integrate its Outcome Framework Initiative into its resource allocation processes and community planning guidelines in SFY 2005. |
| C.1.3 | Each Ohio Access agency will be able to measure service satisfaction and outcomes in all of its long-term service and support programs by SFY 2008. |
| C.1.4 | ODMR/DD through the QA/QI grant will identify areas of improvement in effectiveness and efficiency specific to the management and delivery of services and supports to individuals with disabilities, as part of the design and development of the quality management information system. |
C.2 Address Healthcare Workforce Shortage Issues
Many frail elders and people with disabilities rely on the availability of a trained, dependable direct care workforce in order to maximize their quality of life. A direct care workforce shortage has a detrimental effect on individuals' choices and quality of life, and the state's ability to expand home and community based services. It is essential that a direct support workforce is available and prepared to provide the types of services and supports that people with disabilities want and need to live successfully in their communities.
Ohio already has taken steps to address workforce shortage issues. The General Assembly required ODH to convene the Ohio Health Care Workforce Shortage Task Force to review health care workforce shortage issues related to licensing standards, scopes of practice, technology to alleviate workload, recruitment and retention, and education. ODA coordinates the Ohio Health Care Workforce Advisory Board in conjunction with the Governor's Workforce Policy Board to bring together consumers, providers, and state agencies to develop strategies to address health care workforce shortage issues. Consistent with earlier work in these two groups, the Ohio Access cabinet will:
- Focus on strategies to recruit and retain direct support workers; and
- Credential workers across systems.
Choice isn't real without reliable, competent aides.
(G.M.)
Focus on Strategies to Recruit and Retain Direct Support Workers
The shortage of direct support workers affects the entire health care system and is, in part, a result of Medicaid and Medicare policies that control reimbursement rates for services. However, the state and private sector can work together to develop strategies to improve the recruitment and retention of direct support workers. The following promising strategies are designed to have a positive impact on recruitment and retention of direct caregivers.
| C.2.1 | The Ohio Healthcare Workforce Advisory Council under the leadership of ODA will implement a statewide public awareness campaign in SFY 2004 with funding from the Governor's Workforce Policy Board to promote the value of direct support workers in all settings (nursing homes, home care, day activity centers) and service recipient groups (frail elders, adults with physical disabilities or behavioral health needs, etc.) |
Credential Workers Across Systems
Each service system has a different set of training requirements for direct support workers. Only the Ohio Department of Health has a required curriculum, test, and state registry for state tested nursing assistants (STNAs) who work in nursing homes. While many required skills are consistent across systems, there is no "reciprocity" for training. The result is duplication of effort, added expense, and inconsistency. A statewide certification of direct support workers in the health and human services systems would provide a common starting place from which workers could advance into other health care professions. A statewide certification process would allow the state to collect data about certified workers and to track the types of settings they are working in, their average hours in a work week, their continuing education, length of time in a particular job, etc. Such a statewide process would also be advantageous for the direct support workers themselves as it would allow them access to employment in different systems. Another advantage of a statewide certification process is a recognition of the skills and abilities of workers and, over time, can increase esteem for the work they perform by the general public. Increased esteem and understanding can lead to improved wages, benefits, and opportunities for workers.
| C.2.2 | The Ohio Healthcare Workforce Advisory Council will convene an interagency workgroup in SFY 2004 to identify core skill competencies for direct support workers across work settings and client populations to serve as the foundation for developing a statewide credential process. |
C.3 Enhance Quality in Nursing Facilities
Nursing facilities are an important and well-established service setting in Ohio's continuum of long-term services and supports. It is critically important to sustain nursing facility capacity at an appropriate level, and to assure Ohioans that services in these settings are of the highest possible quality. Nursing facility regulations need to directly contribute to quality and patient outcomes or, if they do not, be reconsidered. State regulatory reform cannot be separated from federal requirements, and Ohio's progress in this area will depend on federal support. The Ohio Access cabinet will:
- Expand technical assistance to improve quality;
- Modify regulations to support quality; and
- Develop a more efficient regulatory model.
Expand Assistance to Improve Quality
Ohio's Technical Assistance Program (TAP) provides education to improve the quality of care within nursing facilities. TAP works directly with nursing facilities to implement programs that evidence shows improve quality. The program was only recently implemented but already has demonstrated quality improvement in the areas of self-care for seniors, functional improvement (activities of daily living), and preventing dehydration.
| C.3.1 | ODH will expand the TAP program to more nursing facilities during SFY 2006-2007 and enhance the program to include training sessions for implementing new practices. |
Modify Regulations to Support Quality
Ohio has requested approval for a waiver from the federal Centers for Medicare and Medicaid Services (CMS) to change the way ODH surveys nursing facilities. Nursing facilities with good past surveys and complaint records and which are in the top ten percent of all facilities according to CMS Quality Indicators would receive an abbreviated survey. The resources freed up as a result of conducting abbreviated surveys would be used to provide greater monitoring of facilities with a history of non-compliance. If the CMS waiver is not approved, Ohio will consider pursuing a waiver in federal statute.
| C.3.2 | ODH will request a statutory waiver in SFY 2004 to conduct an abbreviated annual survey for the top ten percent of nursing facilities based on their performance the previous year. |
Develop a More Efficient Regulatory Model
Over the long term, Ohio plans to develop and test an alternative regulatory model. A coalition of regulators, funders, providers, consumers, advocates and researchers will be formed to re-design the regulatory process. Examples of possible changes might include varying the size and frequency of survey visits, reducing the number of regulatory standards, incorporating improvement activities into the regulatory process, and linking reimbursement incentives to quality improvement. Ohio would need to seek a waiver from CMS in order to test the new model. If granted, volunteer nursing homes would be randomly assigned to test the new approach or to continue to be regulated under the traditional system. Resident and facility outcomes and costs would be compared for the two groups. The findings would then be used as a basis for regulatory reform in Ohio.
| C.3.3 | ODH will initiate a research-based initiative with foundation funding to redesign the federal survey process to better focus patient outcomes, key processes, and a less predictable survey schedule. |
C.4 Provide Training for Teachers Who Work with Children with Disabilities
Many children with disabilities are in mainstream educational settings. The opportunity for these children to maximize their personal development and involvement with peers is related to their teacher's knowledge and understanding about their disability. It is critically important to provide teachers with appropriate training for their interactions with children with disabilities. Increasing teacher knowledge creates more choice and opportunity in out-of-home educational settings for young children and their families.
ODH already is coordinating an interagency effort to improve teacher training. The plan is to assess training needs of teachers (pre-school to grade 12) and childcare providers and develop training opportunities for teachers and child care providers based upon needs assessment and environmental scans. This initiative requires input and resources from ODH, Education, ODMR/DD and ODMH, and state partnerships with the Ohio Head Start Association, Ohio Association for the Education of Young Children, Ohio School Nurses Association, Ohio Chapter of the American Academy of Pediatrics and Ohio Child Care Resource and Referral Association.
| C.4.1 | ODH will convene a workgroup in SFY 2005 to assess the training needs of childcare providers and pre-school teachers related to children with disabilities and special health care needs and implement training opportunities statewide in SFY 2006. |
| C.4.2 | ODH will expand the scope of the workgroup (same as C.4.1 above) in SFY 2006 to assess the training needs of teachers K-12 related to children with disabilities and special health care needs and implement training opportunities statewide in SFY 2007. |