Texas State Health Plan: 1987-1988 Page: 65
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The plan survey identified several factors related to
quality care in nursing homes. These respondents
recommended improvement in the following areas:
(I) the leadership and management skills of
administrators; (2) a "human dignity" approach to
care; (3) the training and regulation of employees
who handle disoriented and Alzheimer's disease
patients; (4) the level of staff training, (5) the
upgrading and enforcement of nursing home
licensing standards; (6) bilingual-bicultural health
professionals in nursing homes; and (7) a
baccalaureate program for long-term care
administrators. State agencies, advocacy groups,
and long-term care providers are encouraged to
consider these factors as they evaluate the quality of
care provided in Texas nursing homes.
INTERVENTION ALTERNATIVES
Alternative 1: Change licensing and certification
standards to require nursing homes to improve
quality.
The report to the 69th Legislature by the House
Joint Interim Committee on Nursing Home Reform
recommended the following as efforts to improve the
quality of care in nursing homes: (1) improve the
training and consider the registration or licensing of
nurses' aides and other direct care personnel; (2)
provide a licensed vocational nurse on the 11 p.m. to
7 a.m. shift; (3) increase the required minimum
average staffing hours per patient; (4) authorize
appropriate penalties in cases of noncompliance with
rules and regulations; (5) provide protection from
reprisal for employees who report violations; and (6)
require additional hours of dietary consultation.
Legislation was enacted to address numbers (4) and
(5) above.
TDH is responsible for nursing home inspections for
state licensure and certification for participation in the
Medicaid and Medicare programs. Facilities which
are found to be deficient can be placed on vendor
hold, decertified, or have their license revoked. The
69th Legislature authorized TDH to develop
administrative penalties to impose fines on facilities
which are found to be deficient. These punitive
measures are used to ensure care which meets
current standards. In this alternative, facilities which
meet the minimum standards may be considered as
providing quality care.
Alternative 2: Development and implementation
of a "case-mix" method for Medicaid reimbursement
of nursing home care.A "case-mix" reimbursement system is based upon
the care needs of the patient and the time required
of the various staff members to provide this care.
Patients are classified according to the types and
complexity of services required to meet their needs.
A "case-mix" reimbursement system pays providers
according to the care actually provided to patients,
thus providing more equitable reimbursement for
the services.
ALTERNATIVE SELECTED
Alternative 2 was selected. Texas is one of only four
states which still uses a flat rate method for Medicaid
reimbursement for nursing home care. Past efforts
to assure delivery of quality care through regulation
have failed to provide nursing home administrators
with incentives to provide services beyond the
minimum requirements of the standards. An incen-
tive/penalty system which provides bonuses for
admission of patients requiring special care, achieve-
ments in rehabilitation of patients, and discharge of
patients; and penalties when these goals are not
met, should be included. The "case-mix" reimburse-
ment system with incentives and penalities should
stimulate innovative management techniques which
will bring the nursing home additional revenues while
improving patient care. Other anticipated outcomes
include improved access to care for patients,
improved management, and improved staff morale
with a reduction in staff turnover.
The TDHS is currently working on a "case-mix"
reimbursement methodology. Development of
recommendations for "indexing" patients (grouping
patients according to care needs and staff time
requirements) is scheduled for late 1986. Devel-
opment of the reimbursement methodology and a
test are scheduled for 1987.
Recommendations
1. Expedite the development and implementation
by the Texas Department of Human Services of a
"case-mix" reimbursement system for Medicaid
reimbursement of nursing home care.
2. Include an incentive/penalty system in the "case-
mix" reimbursement system including admission,
outcome and discharge bonuses.
3. Encourage nursing homes to use the "case-mix"
scale for charges applied to private pay patients.
4. Include in the "case-mix" system pass-through
bonuses to staff personnel who are directly and
indirectly involved with achievement of these
outcomes and discharge bonuses which are paid
to the facility.1987-88 TEXAS STATE HEALTH PLAN65
65
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Texas. Statewide Health Coordinating Council. Texas State Health Plan: 1987-1988, report, 1986; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth1586615/m1/77/?rotate=90: accessed July 16, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.