Resident-Centered Regulation: Achieving Resident-Centered Nursing Home Care Through the Regulatory Process

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With support from the Centers for Medicare and Medicaid Services and partial funding from The Commonwealth Fund, the Rhode Island Department of Health conducted a project called the Individualized Care Pilot (ICP). It used the mandated federal regulatory survey process to motivate and enable the state’s nursing homes to fully realize the potential for resident-centered care inherent in the Nursing Home Reform Law.

  • As part of the project, the Department’s Office of Facilities Regulation did the following: 
    Conducted enhanced surveyor training prior to and during the pilot period on the principles of culture change, or resident-centered care; 
  •  Piloted supplemental questions and observational exercises while on site in nursing homes during standard federal recertification surveys between November 1, 2007 and April 30, 2008; and
  • Utilized the state’s Quality Improvement Organization (QIO), Quality Partners of Rhode Island, as its educational partner to inform providers about individualized, resident-centered care practices both on-site during the survey and during other informal educational sessions.

To support the project’s activities and achieve its aims, the Individualized Care Pilot Toolbox was developed. The toolbox outlines the project design and offers surveyor training materials that explore common decisional dilemmas faced by surveyors, and includes suggestions and recommendations for survey teams.

The Issue

Even though the federal Nursing Home Reform Law, passed in 1987, established that residents' rights and quality of life are as important as quality of care, many nursing home residents still reside in facilities where these concepts have not been put into practice. The "culture change" movement, begun in the mid 1990’s and led by the Pioneer Network, has been working to effect a transformative change within homes centering around residents' needs, interests and expectations.

The ICP project enhanced understanding among nursing home providers, survey agency staff, professional staff and other stakeholders about how federal and state regulations can be used to proactively support the implementation of an individualized, resident-centered approach. The project focused primarily on three key areas: enabling residents to make choices, particularly regarding waking, sleeping, and bathing schedules; fostering closer relationships between the staff and the residents; and making the environment more home-like by paying attention to sound levels, personalizing bed-rooms and bathing areas, making public/common areas more hospitable and creating alternatives to large impersonal communal dining areas.

Target Audience

Nursing home providers, state and federal regulators, culture change coalitions, nursing home residents and their families, long-term care researchers, and public policymakers.

The Tool

The Individualized Care Pilot Toolbox outlines the project design and includes survey tools and educational components. It is divided into five modules:

Module 1–Recommendations and Dilemmas. This module identifies the challenges different audiences face in trying to become resident-centered and outlines lessons gleaned from Rhode Island’s experience. For example, lessons for culture change coalitions and regulators include:

  1. Ensure the survey process promotes compliance with quality of life regulations. The survey agency can accomplish this by training surveyors to recognize and enforce compliance with federal and state quality of life regulations and through clear communication with providers about the meaning of the regulations.
  2. Encourage collaborations between the state survey agency and QIOs to ensure that providers have the resources needed to implement individualized, resident-centered care practices while at the same time not casting the survey agency in a consultative role.

Module 2–Design Process. This module details the steps and activities taken by the survey agency, including the establishment of a technical expert panel and the conducting of an informal opinion study on perceived regulatory obstacles to individualized care; the study results then helped designers target the three areas for improvement and develop specific survey questions.

Module 3 –Surveyor Training. This module reviews how training was conducted and describes a training initiative held in collaboration with Quality Partners of Rhode Island. It includes in-service learning and written educational materials; consistent quality control processes; and the use of written prompts and guidance.

Module 4 - Survey Tools. This module includes relevant documents and forms.

Module 5 – Educational Materials. This module contains information and educational materials aimed at providers and health care professionals.

For More Information

Read or download the toolkit at http://www.health.ri.gov/programs/facilityregulation/individualizedcarepilot/ . Or contact project director Marie Stoeckel, M.P.H., Chief of Operations, Rhode Island Office of Facilities Regulation, at Marie.Stoeckel@health.ri.gov and Andrew Powers, Quality Improvement/Training Coordinator, Rhode Island Office of Facilities Regulation, at Andrew.Powers@health.ri.gov.

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