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UBC Theses and Dissertations

Measuring effectiveness in long-term care facilities in British Columbia Levenick, Karen Lynne 1986

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MEASURING EFFECTIVENESS IN LONG-TERM CARE FACILITIES IN BRITISH COLUMBIA By KAREN LYNNE LEVENICK B.Sc.N., The University of Saskatchewan, 1967 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (HEALTH SERVICES PLANNING and ADMINISTRATION) i n THE FACULTY OF GRADUATE STUDIES (Department of Health Care and Epidemiology) We accept t h i s thesis as conforming to the required standards THE UNIVERSITY OF BRITISH COLUMBIA SEPTEMBER 1986 ©Karen L. Levenick I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an advanced degree a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e head o f my department o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f Health Care and Epidemiology The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 Wesbrook P l a c e V a n c ouver, Canada V6T 1W5 Date October 7, 1986 7Q ^ ABSTRACT The involvement of government i n the funding of health care, and e s p e c i a l l y the substantial expenditure of health care d o l l a r s for f a c i l i t y - b a s e d long-term care for the elde r l y , has led to r i s i n g pressure for accountability for the funds expended. The public expectation i s that government w i l l ensure an adequate q u a l i t y of care i s provided while at the same time ensuring the optimum and e f f i c i e n t use of the funds. While government wishes to maintain an arms-length relationship with providers, recently, an interest i n l i n k i n g the payment for care to i t s assessment has been expressed. It has been proposed that these expectations can be met through providing government funders with information about the effectiveness of care, using outcome measures. Such an approach would provide the information needed for assessing the adequacy of care, for use i n cost-effectiveness and e f f i c i e n c y studies and p o t e n t i a l l y for use i n assigning a l l or part of the payment for care. Also, from the funders 1 perspective, i f the outcomes of care are s a t i s f a c t o r y , how these outcomes are achieved need not necessarily be of concern. The purpose of thi s study i s to investigate and, i f possible, to develop an outcome-based approach which l i n k s the assessment of the care provided i n long-term care f a c i l i t i e s i n B r i t i s h Columbia (B.C.) to the current payment system. The long-term care system i n B.C. was reviewed to i d e n t i f y the current mechanisms for assuring adequacy of care, the system of reimbursement and any problems encountered with these. The methodological, d e f i n i t i o n a l and system factors which would act ( i i ) a s c o n s t r a i n i n g v a r i a b l e s t o t h e a p p l i c a t i o n o f a n o u t c o m e - b a s e d r e i m b u r s e m e n t s y s t e m i n B . C . w e r e i d e n t i f i e d . T h e s t u d y r e v i e w e d a n d c r i t i q u e d o r g a n i z a t i o n a l a n d i n d i v i d u a l l e v e l o u t c o m e m e a s u r e m e n t a p p r o a c h e s u s e d i n p r i v a t e i n d u s t r y , t h e p u b l i c s e c t o r , h e a l t h c a r e a n d l o n g - t e r m c a r e f o r t h e i r f e a s i b i l i t y o f a p p l i c a t i o n i n t h e B . C . s i t u a t i o n . O u t c o m e a p p r o a c h e s r e v i e w e d i n c l u d e d g e n e r i c a p p r o a c h e s s u c h a s C B A / C E A , M B O , Z B B a n d h e a l t h c a r e a p p r o a c h e s s u c h a s m o r t a l i t y a n d m o r b i d i t y r a t e s , a n d h e a l t h s t a t u s i n d e x e s . E x i s t i n g a p p l i c a t i o n s i n l o n g - t e r m c a r e o f t h e l a t t e r a p p r o a c h w e r e r e v i e w e d . A s t h e s t u d y p r o g r e s s e d i t b e c a m e c l e a r t h a t e f f e c t i v e n e s s m e a s u r e s m u s t b e d e v e l o p e d a n d t h e I m p a c t o f e f f e c t i v e n e s s o n e f f i c i e n c y d e t e r m i n e d b e f o r e a l i n k t o r e i m b u r s e m e n t c a n b e m a d e . A p r e d i c t o r m o d e l , u s i n g a m u l t i a t t r i b u t e h e a l t h s t a t u s i n d e x a s t h e o u t c o m e m e a s u r e o f e f f e c t i v e n e s s , a n d w h i c h u s e s " e x p e c t e d " v e r s u s " a c t u a l " o u t c o m e s t o d e t e r m i n e i f t h e r e s u l t s w e r e B e t t e r , W o r s e o r t h e S a m e a s p r e d i c t e d w a s r e c o m m e n d e d f o r u s e i n B . C . S u c h a n a p p r o a c h t a k e s i n t o a c c o u n t t h e f a c t t h a t i m p r o v e m e n t o f h e a l t h s t a t u s i s n o t t h e o n l y o u t c o m e e x p e c t e d i n l o n g - t e r m c a r e . I t a l l o w s f o r m u l t i d i m e n s i o n a l m e a s u r e s w h i c h a c c o m m o d a t e t h e h e t e r o g e n e i t y o f l o n g - t e r m c a r e r e s i d e n t s . I t i s p r o p o s e d t h a t t h i s e f f e c t i v e n e s s m e a s u r e m e n t a p p r o a c h b e i m p l e m e n t e d a s a j o i n t r e s e a r c h a n d s e r v i c e a p p l i c a t i o n t o a l l o w f o r e m p i r i c a l t e s t i n g a n d r e s o l u t i o n o f t h e m e t h o d o l o g i c a l a n d f e a s i b i l i t y i s s u e s n o t e d , i n c l u d i n g t h e l i m i t e d e x p e r i e n c e w i t h t h e u s e o f e f f e c t i v e n e s s m e a s u r e s i n f a c i l i t y - b a s e d l o n g - t e r m c a r e . ( i i i ) TABLE OF CONTENTS PAGE ABSTRACT i i LIST OF FIGURES i x ACKNOWLEDGEMENT x CHAPTER I: INTRODUCTION 1 THE PROBLEM 1 NEED FOR THE STUDY 6 PURPOSE OF THE STUDY 8 OBJECTIVES OF THE STUDY 9 THESIS FORMAT 1 0 LIMITATIONS 12 REFERENCES 15 CHAPTER I I : FACILITY-BASED LONG-TERM CARE IN BRITISH COLUMBIA 2 0 INTRODUCTION 2 0 HISTORICAL DEVELOPMENT 2 0 ORGANIZATIONAL STRUCTURE 2 3 ELIGIBILITY AND ASSESSMENT PROCESS 24 ACCOUNTABILITY MECHANISMS: L E G I S L A T I O N , S T A N D A R D S & B U D G E T A R Y G U I D E L I N E S 2 6 FINANCIAL CONTROL AND REIMBURSEMENT SYSTEMS 2 9 F O R - P R O F I T F A C I L I T Y R E I M B U R S E M E N T 3 0 N O N - P R O F I T F A C I L I T Y R E I M B U R S E M E N T 32 PROBLEMS WITH THE CURRENT REIMBURSEMENT SYSTEM 3 3 NEED FOR A NEW REIMBURSEMENT SYSTEM 3 4 REFERENCES 3 5 (iv) Table of Contents (cont'd) PAGE CHAPTER I I I : DETERMINANTS OF FEASIBILITY FOR THE USE OF OUTCOME-BASED MEASURES IN FACILITY-BASED CARE IN B.C.: THE CONSTRAINING FACTORS 37 INTRODUCTION 37 CONSTRAINT - THE NEED FOR VALUING IN THE ASSESSMENT OF LONG-TERM CARE 38 CONSTRAINT - THE DEFINITIONAL CONTEXT OF OUTCOME MEASUREMENT, OUTCOME-BASED REIMBURSEMENT, EFFECTIVENESS AND EFFICIENCY 41 MEASUREMENT OF OUTCOMES IN FACILITY-BASED LONG-TERM CARE 42 REIMBURSEMENT IN FACILITY-BASED LONG-TERM CARE 46 OUTCOME-BASED REIMBURSEMENT IN FACILITY-BASED LONG-TERM CARE 49 EFFECTIVENESS and EFFICIENCY IN FACILITY-BASED LONG-TERM CARE 49 CONSTRAINT: ORGANIZATIONAL STRUCTURE OF LONG-TERM CARE SYSTEM 51 CANADA - UNITED STATES COMPARISONS 51 CANADA 52 SOCIAL POLICY - INCENTIVES AND VALUES 53 THE CONSTITUTIONAL AND LEGAL BASE 54 THE ECONOMIC AND FINANCIAL ENVIRONMENT 56 UNITED STATES 58 SOCIAL POLICY 58 THE CONSTITUTIONAL AND LEGAL BASE 60 THE ECONOMIC AND FINANCIAL ENVIRONMENT 62 THE NEED AND PROBLEMS IN THE CANADIAN SYSTEM 64 SUMMARY 65 REFERENCES 67 (v) T a b l e o f C o n t e n t s ( c o n t ' d ) P A G E C H A P T E R I V : A P P R O A C H E S TO O U T C O M E M E A S U R E M E N T - P U B L I C S E C T O R and H E A L T H C A R E S E R V I C E S 7 2 I N T R O D U C T I O N 7 2 G E N E R I C O R G A N I Z A T I O N A L E F F E C T I V E N E S S A P P R O A C H E S 7 4 C O S T - B E N E F I T AND C O S T - E F F E C T I V E N E S S A N A L Y S I S 7 7 M A N A G E M E N T B Y O B J E C T I V E S 8 1 Z E R O - B A S E B U D G E T I N G 8 5 C O N C L U S I O N S A B O U T T H E U S E O F G E N E R I C O R G A N I Z A T I O N A L E F F E C T I V E N E S S A P P R O A C H E S 8 9 O R G A N I Z A T I O N A L L E V E L A P P R O A C H E S - A P P L I C A T I O N I N H E A L T H C A R E 9 0 Q U A L I T Y A S S U R A N C E AND T H E U S E O F O U T C O M E M E A S U R E M E N T 9 3 I N D I V I D U A L L E V E L O U T C O M E S : 9 8 M E A S U R E M E N T O F O U T C O M E S A T T H E L E V E L O F T H E I N D I V I D U A L I N H E A L T H C A R E 9 8 M O R B I D I T Y A N D M O R T A L I T Y M E A S U R E M E N T S 9 9 H E A L T H S T A T U S I N D E X E S 1 0 2 C O N C L U S I O N S A B O U T T H E U S E O F H E A L T H C A R E O U T C O M E M E A S U R E S 1 0 8 SUMMARY A N D C O N C L U S I O N S 1 1 0 R E F E R E N C E S 1 1 4 C H A P T E R V : C U R R E N T A N D P R O P O S E D A P P R O A C H E S TO O U T C O M E M E A S U R E M E N T I N F A C I L I T Y - B A S E D L O N G - T E R M C A R E 1 2 0 I N T R O D U C T I O N 1 2 0 O U T C O M E M E A S U R E M E N T AT T H E O R G A N I Z A T I O N A L L E V E L 1 2 1 T H E C R I T E R I A M A P P I N G M O D E L . . 1 2 3 T H E I N C E N T I V E R E I M B U R S E M E N T M O D E L 1 2 6 (vi) T a b l e o f C o n t e n t s ( c o n t ' d ) P A G E O U T C O M E M E A S U R E M E N T A T T H E I N D I V I D U A L / R E S I D E N T L E V E L . 1 3 0 T H E E X P E C T E D O U T C O M E S A P P R O A C H 1 3 2 T H E K A N E M O D E L 1 3 7 T H E C O N V E R G E N C E M O D E L 1 4 2 C O N C L U S I O N 1 4 4 R E F E R E N C E S 1 4 8 C H A P T E R V I : M E A S U R I N G E F F E C T I V E N E S S I N F A C I L I T Y - B A S E D L O N G - T E R M C A R E : A N O U T C O M E - B A S E D P R O P O S A L F O R B R I T I S H C O L U M B I A 1 5 2 I N T R O D U C T I O N 1 5 2 C O M P O N E N T S O F E F F E C T I V E N E S S I N F A C I L I T Y - B A S E D L O N G - T E R M C A R E : HOW A R E T H E Y M E T I N B R I T I S H C O L U M B I A ? 1 5 3 A N O U T C O M E - B A S E D A P P R O A C H T O T H E M E A S U R E M E N T O F E F F E C T I V E N E S S I N F A C I L I T Y - B A S E D L O N G - T E R M C A R E I N B R I T I S H C O L U M B I A 1 5 5 1 . I D E N T I F Y I N G T H E R E L E V A N T V A L U E S , A S S U M P T I O N S , G O A L S A N D O B J E C T I V E S 1 5 7 2 . D E V I S I N G A N O U T C O M E - B A S E D A P P R O A C H T O M E A S U R I N G E F F E C T I V E N E S S 1 5 9 T H E P R O P O S E D M O D E L 1 6 0 S E L E C T I O N AND D E V E L O P M E N T O F A N E F F E C T I V E N E S S M E A S U R E 1 6 2 D E V E L O P M E N T O F P R O T O C O L S F O R T E S T I N G AND A P P L Y I N G O U T C O M E M E A S U R E S 1 6 7 O T H E R O P T I O N S F O R O U T C O M E M E A S U R E M E N T O F E F F E C T I V E N E S S 1 6 8 3 . A P P L Y I N G T H E R E S U L T S 1 7 0 C O N C L U S I O N 1 7 1 R E F E R E N C E S 1 7 5 ( v i i ) T a b l e o f C o n t e n t s ( c o n t ' d ) P A G E A P P E N D I C E S 1 7 9 A P P E N D I X A : S C I E N T I F I C AND F E A S I B I L I T Y C R I T E R I A . . . . 1 7 9 A P P E N D I X B : E X C E R P T S F R O M T H E F A C I L I T Y R E I M B U R S E M E N T R E P O R T 1 8 4 A P P E N D I X C : M E T H O D O L O G Y Q U E S T I O N S I N A S S E S S M E N T O F L O N G - T E R M C A R E 1 8 6 B I B L I O G R A P H Y 1 8 9 ( v i i i ) L I S T O F F I G U R E S P A G E 1 . T h e C o n c e p t s o f O u t p u t a n d O u t c o m e a s T h e y A p p l y i n P r i v a t e I n d u s t r y , t h e P u b l i c S e c t o r , t h e H e a l t h C a r e I n d u s t r y a n d L o n g - T e r m C a r e 4 4 2 . T h e P r o s & C o n s o f C B A / C E A a s a n O u t c o m e M e a s u r e m e n t A p p r o a c h i n F a c i l i t y - B a s e d L o n g - T e r m C a r e 8 0 3 . T h e P r o s & C o n s o f MBO a s a n O u t c o m e M e a s u r e m e n t A p p r o a c h i n F a c i l i t y - B a s e d L o n g - T e r m C a r e 8 4 4 . T h e P r o s & C o n s o f Z B B a s a n O u t c o m e M e a s u r e m e n t A p p r o a c h i n F a c i l i t y - B a s e d L o n g - T e r m C a r e 8 8 5 . T h e P r o s & C o n s o f M o r t a l i t y R a t e s a s a n O u t c o m e M e a s u r e m e n t A p p r o a c h i n F a c i l i t y - B a s e d L o n g - T e r m C a r e . 1 0 0 6 . T h e P r o s & C o n s o f M o r b i d i t y R a t e s a s a n O u t c o m e M e a s u r e m e n t A p p r o a c h i n F a c i l i t y - B a s e d L o n g - T e r m C a r e . 1 0 1 7 . T h e P r o s & C o n s o f H S I s a s a n O u t c o m e M e a s u r e m e n t A p p r o a c h f o r F a c i l i t y - B a s e d L o n g - T e r m C a r e 1 0 7 8 . T h e P r o s a n d C o n s o f C r i t e r i a M a p p i n g a n O u t c o m e M e a s u r e m e n t A p p r o a c h i n F a c i l i t y - B a s e d L o n g - T e r m C a r e . 1 2 5 9 . T h e P r o s a n d C o n s o f t h e I n c e n t i v e R e i m b u r s e m e n t M o d e l a s a n O u t c o m e M e a s u r e m e n t A p p r o a c h i n F a c i l i t y - B a s e d L o n g - T e r m C a r e 1 2 8 1 0 . T h e P r o s & C o n s o f t h e K a n e O u t c o m e - B a s e d R e i m b u r s e m e n t M o d e l a s a n O u t c o m e M e a s u r e m e n t A p p r o a c h i n F a c i l i t y - B a s e d L o n g - T e r m C a r e 1 4 1 ( i x ) A C K N O W L E D G E M E N T I w o u l d l i k e t o e x t e n d my h e a r t f e l t t h a n k s a n d a p p r e c i a t i o n t o a n u m b e r o f p e o p l e f o r t h e i r h e l p a n d s u p p o r t w h i l e I w a s r e s e a r c h i n g a n d w r i t i n g t h i s t h e s i s . T h e c o n t r i b u t i o n s o f e a c h a n d e v e r y o n e w e r e v a l u e d . I w o u l d f i r s t l i k e t o t h a n k my t h e s i s c o m m i t t e e - D r . A n n e t t e S t a r k - C h a i r m a n , D r . R o b e r t M o d r o w a n d D r . D e a n U y e n o - f o r t h e i r c o n t i n u e d s u p p o r t , i n v a l u a b l e h e l p a n d c o n s t r u c t i v e c r i t i c i s m . I w o u l d a l s o l i k e t o e x t e n d my t h a n k s t o t h e m e m b e r s o f my f a m i l y w h o p r o v i d e d m u c h a p p r e c i a t e d m o r a l s u p p o r t a n d e n c o u r a g e m e n t . T h a n k s g o e s p e c i a l l y t o my p a r e n t s - M r . a n d M r s . C l i f f o r d L e v e n i c k , t o my s i s t e r R u t h a n d h e r f a m i l y , t o my b r o t h e r K e i t h a n d h i s f a m i l y a n d t o my a u n t a n d u n c l e - M r . a n d M r s . R a y m o n d B r a d f o r d . I w o u l d a l s o l i k e t o e x t e n d my t h a n k s t o my c o l l e a g u e s f o r t h e i r h e l p a n d s u p p o r t , a s w e l l a s s t a f f a t t h e M i n i s t r y o f H e a l t h . ( x ) C H A P T E R I : I N T R O D U C T I O N _ \ T H E P R O B L E M O v e r t h e l a s t t w o d e c a d e s i n w e s t e r n s o c i e t i e s , g o v e r n m e n t s h a v e b e e n i n c r e a s i n g l y i n v o l v e d i n t h e f u n d i n g o f t h e h e a l t h c a r e s y s t e m . A t p r e s e n t , l o n g - t e r m c a r e s e r v i c e s 1 a r e t h e f a s t e s t g r o w i n g a r e a o f t h e s y s t e m [ 1 : 1 1 , 1 8 ; 2 ; 3 ] . O n e m a j o r r e a s o n f o r t h i s g r o w t h i s f o u n d i n t h e c h a n g i n g p o p u l a t i o n d e m o g r a p h i c s . T h e e l d e r l y , p a r t i c u l a r l y t h e m i d d l e -o l d ( 7 5 - 8 4 y e a r s ) a n d o l d - o l d ( 8 5 + y e a r s ) , a r e c u r r e n t l y t h e m a j o r u s e r s o f l o n g - t e r m c a r e s e r v i c e s a n d p o p u l a t i o n t r e n d s s h o w i n c r e a s i n g n u m b e r s a n d p r o p o r t i o n s o f e l d e r l y i n t h e w o r l d p o p u l a t i o n [ 1 ; 3 ; 4 ; 5 : 1 - 6 ; 6 ] . I n C a n a d a , t h e p e r c e n t a g e o f p e r s o n s 6 5 y e a r s a n d o v e r h a s g r o w n f r o m 7 . 6 * i n 1 9 6 0 , t o 8 . 0 * i n 1 9 7 0 , t o 9 . 5 * i n 1 9 8 0 [ 5 : 4 ] . T h e r a t e o f i n c r e a s e i s e v e n g r e a t e r f o r t h e m i d d l e - o l d a n d t h e o l d - o l d g r o u p s . T h e d e m o g r a p h i c s a l s o s h o w a d i s p r o p o r t i o n a t e n u m b e r o f f e m a l e s l i v i n g a l o n e , a n d i n C a n a d a , a n u r b a n - r u r a l s h i f t i n t h e e l d e r l y p o p u l a t i o n ( w h e r e t h e r e i s a h i g h e r p r o p o r t i o n o f e l d e r l y i n s m a l l t o w n s u n d e r 5 , 0 0 0 t h a n i s t r u e f o r t h e g e n e r a l p o p u l a t i o n ) [ 5 : 2 - 7 ; 6 ; 7 ] . T h i s u n d e r l i e s b o t h t h e h i g h e r p r o p o r t i o n o f f e m a l e s i n t h e l o n g - t e r m c a r e p o p u l a t i o n a n d t h e n u m b e r s o f s m a l l l o n g - t e r m c a r e f a c i l i t i e s i n C a n a d a [ 4 ; 5 ] . 1 L o n g - t e r m care services ( L T C ) i s t h e g e n e r i c t e r m u s e d i n t h i s s t u d y t o r e f e r t o a s y s t e m w h i c h p r o v i d e s a c o n t i n u u m o f c o m m u n i t y a n d f a c i l i t y b a s e d s e r v i c e s w h i c h e n a b l e s t h e c h r o n i c a l l y d i s a b l e d a n d t h e e l d e r l y i n f i r m t o m a i n t a i n a s h i g h a l e v e l o f i n d e p e n d e n c e a s p o s s i b l e . C a r e i s p r o v i d e d o v e r a l o n g e r p e r i o d o f t i m e t h a n i s u s u a l i n a c u t e c a r e . C H A P T E R I - 2 -T h e s e d e m o g r a p h i c t r e n d s , w h i c h a r e p r e d i c t e d t o c o n t i n u e , h a v e c r e a t e d a h e i g h t e n e d s o c i a l a w a r e n e s s a n d p u b l i c p r e s s u r e o n g o v e r n m e n t s t o p l a n f o r l o n g - t e r m c a r e s e r v i c e s . A s H a v e n s n o t e s , " C a n a d a h a s r e c e n t l y j o i n e d t h e r a n k s o f t h e o l d n a t i o n s t h a t i s n a t i o n s w h e r e t h o s e 6 5 y e a r s a n d o v e r ( 6 5 + ) e x c e e d 7% o f t h e p o p u l a t i o n [ 7 : 1 ] . C o n c u r r e n t l y t h e r e h a s b e e n a g r o w i n g p u b l i c e x p e c t a t i o n o f a c c o u n t a b i l i t y f o r t h e p u b l i c f u n d s e x p e n d e d i n h e a l t h c a r e g e n e r a l l y . I t i s w e l l e s t a b l i s h e d t h a t i n s t i t u t i o n a l o r f a c i l i t y - b a s e d s e r v i c e s a c c o u n t f o r t h e m a j o r p o r t i o n o f t h e f u n d s e x p e n d e d w i t h i n t h e h e a l t h c a r e s y s t e m a s a w h o l e [ 2 ; 3 : 2 5 3 - 5 6 ; 8 ; 9 : 9 9 ] . A s i m i l a r p a t t e r n i s s e e n i n f a c i l i t y - b a s e d c a r e 2 w i t h i n t h e l o n g - t e r m c a r e s y s t e m [ 9 ; 1 0 ] . E v a n s s u g g e s t s t h a t t w o e q u a l l y i m p o r t a n t t r e n d s i n C a n a d a a r e r e l a t e d t o t h e i n c r e a s i n g u t i l i z a t i o n a n d e x p e n d i t u r e f o r h e a l t h c a r e a m o n g s t t h e p o p u l a t i o n 6 5 y e a r s a n d o v e r . O n e i s t h e t r e n d t o " . . . m o r e f r e q u e n t i n t e n s i v e a c u t e c a r e e p i s o d e s . . . " [ 1 : 1 5 ] , a n d t h e o t h e r i s t h e i n c r e a s e i n t h e p u b l i c p r o g r a m s p r o v i d e d . T h e s e p r o g r a m s e x t e n d t h e r a n g e o f h e a l t h c a r e s e r v i c e s t o t h e e l d e r l y , s u c h a s l o n g - t e r m c a r e f a c i l i t i e s a n d h o m e c a r e s u p p o r t s [ 1 : 1 8 ] . E v a n s n o t e s , i n a c o m p a r i s o n o f r e l a t i v e h o s p i t a l u t i l i z a t i o n r a t e s b y a g e a n d s e x a m o n g t h e e l d e r l y , t h a t " b o t h s e p a r a t i o n a n d l e n g t h o f s t a y r a t e s i n c r e a s e s h a r p l y w i t h a g e " [ 1 : 1 5 ] . F o r i n s t a n c e , i n C a n a d a , f r o m 1 9 6 2 t o 1 9 7 4 t h e 2 F a c i l i t y - b a s e d l o n g - t e r m c a r e r e f e r s t o r e s i d e n t i a l c a r e f a c i l i t i e s p r o v i d i n g c a r e o n a 2 4 h o u r b a s i s s u c h a s n u r s i n g h o m e s o r c o m m u n i t y c a r e f a c i l i t i e s . C H A P T E R I - 3 -s e p a r a t i o n s p e r c a p i t a f o r ' o l d - o l d ' m a l e s r o s e f o r t y p e r c e n t r e l a t i v e t o t h e g e n e r a l p o p u l a t i o n . F o r f e m a l e s t h e i n c r e a s e w a s o v e r t w e n t y p e r c e n t f o r t h e ' y o u n g - o l d ' ( 6 5 t o 7 4 ) a n d u p t o t h i r t y p e r c e n t f o r t h e 1 o l d - o l d 1 [ 1 : 1 5 ] . A r e v i e w o f h e a l t h c a r e e x p e n d i t u r e s i n C a n a d a s h o w s t h a t t h e ' h o m e s f o r s p e c i a l c a r e 1 ( w h i c h i n c l u d e s m o s t l o n g - t e r m c a r e f a c i l i t i e s ) c a t e g o r y o f t h e n a t i o n a l h e a l t h c a r e e x p e n d i t u r e s h a s r i s e n f r o m 5 . 8 * o f t h e t o t a l i n 1 9 6 0 , t o 7 . 2 * i n 1 9 7 0 , t o 1 3 . 7 * i n 1 9 8 2 [ 9 : 2 4 ; 1 1 ] . T h e r e i s a n e x p e c t a t i o n t h a t a c c o u n t a b i l i t y f o r t h e s e e x p e n d i t u r e s w i l l b e d e m o n s t r a t e d i n t w o w a y s : o n e i s b y e n s u r i n g t h e p r o v i s i o n o f a d e q u a t e c a r e ( q u a l i t y c o n t r o l ) ; a n d t h e o t h e r i s e n s u r i n g t h e o p t i m u m a n d e f f i c i e n t u s e o f t h e g o v e r n m e n t f u n d s e x p e n d e d i n p r o v i d i n g c a r e ( c o s t c o n t r o l ) [ 1 1 ; 1 2 ; 1 3 ; 1 4 ; 1 5 : 2 2 - 3 2 ] . T h e i n c r e a s i n g e m p h a s i s o n e f f i c i e n c y i n c a r e p r o v i s i o n , a s w e l l a s o n t h e q u a l i t y o f h e a l t h s e r v i c e s , p a r t i c u l a r l y i n t i m e s o f f i s c a l r e s t r a i n t , h a s i n f l u e n c e d t h e d e v e l o p m e n t o f a p p r o a c h e s f o r a s s e s s i n g e f f i c i e n c y a n d a s s u r i n g q u a l i t y . A r e v i e w o f t h e l i t e r a t u r e s u g g e s t s t h a t e v a l u a t i o n o f t h e a d e q u a c y o r q u a l i t y o f i n s t i t u t i o n a l ( a c u t e o r l o n g - t e r m ) c a r e i s m o v i n g f r o m t h e m e a s u r e m e n t o f t h e s t r u c t u r e s ( i n p u t s ) a n d p r o c e s s e s ( a c t i v i t i e s ) o f c a r e t o m e a s u r e m e n t s b a s e d o n t h e e x p e c t e d outcomes, u s i n g a s o u t c o m e m e a s u r e s e i t h e r t h e h e a l t h s t a t u s o f p a t i e n t s o r o r g a n i z a t i o n a l o u t p u t s , o r b o t h [ 1 3 ; 1 4 ; 1 6 ; 1 7 ; 1 8 ; 1 9 ; 2 0 ; 2 1 ; 2 2 ; 2 3 ; 2 4 ; 2 5 ; 2 6 ; 2 7 ] . C H A P T E R I - 4 -A s i m i l a r e v o l u t i o n h a s o c c u r r e d i n t h e r e i m b u r s e m e n t o f h e a l t h c a r e p r o v i d e r s . R e i m b u r s e m e n t a p p r o a c h e s h a v e e v o l v e d f r o m r e t r o s p e c t i v e ( i . e . p a y m e n t f o r c a r e a l r e a d y r e c e i v e d ) t o p r o s p e c t i v e p a y m e n t s a p p r o a c h e s { b a s e d o n e x p e c t e d o r a v e r a g e c o s t s ) , w i t h t h e u n i t o f p a y m e n t c h a n g i n g f r o m a n o r g a n i z a t i o n a l o r s e r v i c e b a s e a p p r o a c h ( e . g . b y h o s p i t a l o r b y s e r v i c e d e p a r t m e n t ) t o a c a s e m i x a p p r o a c h ( p a y m e n t b a s e d o n t h e n u m b e r s o f p a t i e n t s c a r e d f o r , g r o u p e d b y d i a g n o s t i c r e l a t e d g r o u p i n g s ( D R G ' s ) , a n d f r o m d e t e r m i n a t i o n o f p a y m e n t u s i n g a c o s t b a s e d o r i e n t a t i o n t o a n o u t c o m e - b a s e d a p p r o a c h ( e . g . t h e u s e o f z e r o -b a s e d b u d g e t i n g w i t h o r g a n i z a t i o n a l o u t c o m e s ) [ 2 8 ; 2 9 ; 3 0 ; 3 1 ] . R e i m b u r s e m e n t a p p r o a c h e s i n f a c i l i t y - b a s e d l o n g - t e r m c a r e h a v e e v o l v e d i n a s i m i l a r m a n n e r t o t h o s e i n a c u t e h e a l t h c a r e . B u t t h e m i x o f f o r - p r o f i t a n d n o n - p r o f i t p r o v i d e r s w i t h t h e i r d i f f e r i n g m o t i v a t i o n s f o r e f f e c t i v e n e s s a n d e f f i c i e n c y h a s l e d t o a v a r i e t y o f p r o p o s e d r e i m b u r s e m e n t a p p r o a c h e s [ 3 2 ; 3 3 ; 3 4 ; 3 5 ; 3 6 ; 3 7 ; 3 8 ] . T h e m u l t i d i m e n s i o n a l p r o b l e m s o f l o n g - t e r m c a r e c l i e n t s h a s m a d e r e i m b u r s e m e n t l i n k e d t o c a s e m i x a p p r o a c h e s s u c h a s D i a g n o s t i c R e l a t e d G r o u p s ( D R G ' s ) u n w o r k a b l e [ 3 9 ] , b u t o t h e r c a s e - m i x a p p r o a c h e s w h i c h i n c o r p o r a t e f u n c t i o n a l ( p a t i e n t ) a n d s e r v i c e o r c a r e p r o b l e m c h a r a c t e r i s t i c s h a v e b e e n g a i n i n g s u p p o r t [ 4 0 ; 4 1 ; 4 2 ; 4 3 ] . T h e r e i s a g r o w i n g i n t e r e s t , p a r t i c u l a r l y i n f a c i l i t y - b a s e d l o n g - t e r m c a r e , i n l i n k i n g t h e p a y m e n t s y s t e m w i t h q u a l i t y o f c a r e o r o u t c o m e ( e f f e c t i v e n e s s ) e v a l u a t i o n s [ 3 0 ; 3 2 ; 3 3 ; 3 7 ; 4 1 ; 4 4 ] . T h i s a p p r o a c h e m p h a s i z e s t h e n e e d t o m o v e f r o m r e a c t i v e C H A P T E R I - 5 -e v a l u a t i o n a p p r o a c h e s t o p r o a c t i v e m e t h o d s w h i c h w i l l a s s u r e t h e a d e q u a t e p r o v i s i o n o f c a r e . T h a t i s , w h e n c a l l e d t o a c c o u n t , t h e r e s p o n s i b l e p a r t i e s ( g o v e r n m e n t f u n d e r s , p r o v i d e r s ) m u s t b e a b l e t o s h o w t h a t m e c h a n i s m s a r e i n p l a c e ( o r p r o v i d e e v i d e n c e o f e f f e c t i v e o u t c o m e s ) w h i c h a s s u r e q u a l i t y c a r e i s p r o v i d e d a n d i n a c o s t e f f i c i e n t m a n n e r . A s y e t t h e r e i s l i t t l e a g r e e m e n t o n w h a t m e a s u r e s o f o u t c o m e c a n b e l i n k e d t o t h e r e i m b u r s e m e n t s y s t e m f o r f a c i l i t y - b a s e d l o n g - t e r m c a r e d e s p i t e t h e n u m e r o u s m e a s u r e m e n t t o o l s a n d a p p r o a c h e s t h a t h a v e b e e n d e v e l o p e d [ 2 0 ; 2 1 ; 2 2 ; 2 4 ; 2 7 ; 3 7 ; 3 9 ; 4 1 ] . T w o m a j o r p r o b l e m a r e a s h a v e b e e n i d e n t i f i e d w i t h t h e c u r r e n t a c c o u n t a b i l i t y p r a c t i c e s o f g o v e r n m e n t d e c i s i o n m a k e r s f o r f a c i l i t y - b a s e d l o n g - t e r m c a r e : i n a d e q u a c i e s i n t h e r e g u l a t o r y s y s t e m ; a n d l a c k o f c o n t r o l o f r e i m b u r s e m e n t m e c h a n i s m s [ 1 0 ; 3 4 ; 4 5 ; 4 6 ; 4 7 ; 4 8 ] . T h e s e t w o a s p e c t s h a v e o f t e n d e v e l o p e d s e p a r a t e l y , r e s u l t i n g i n a r e a s o f c o n f l i c t i n g a n d o v e r l a p p i n g a c c o u n t a b i l i t y . F o r i n s t a n c e , o n t h e r e g u l a t o r y s i d e , p u b l i c h e a l t h a g e n c i e s h a v e h a d t h e r e s p o n s i b i l i t y f o r e s t a b l i s h i n g s t r u c t u r a l , l i f e s a f e t y a n d c a r e s t a n d a r d s a i m e d a t e n s u r i n g t h e q u a l i t y o f t h e c a r e p r o v i d e d [ 1 5 ; 4 7 ; 4 9 ] . W h e r e a s p u b l i c f u n d i n g o f f a c i l i t y c a r e w a s i n i t i a l l y t h e r e s p o n s i b i l i t y o f t h e s o c i a l w e l f a r e s y s t e m w h i c h p a i d f o r ( o r s u b s i d i z e d ) t h e c a r e p r o v i d e d t o i n d i g e n t r e s i d e n t s [ 1 5 ; 4 7 ; 4 9 ] . T h u s t h e m i n i m u m c o s t a l l o w a n c e s o f s o c i a l w e l f a r e f u n d i n g o f t e n c a m e i n c o n f l i c t w i t h t h e a b i l i t y o f f a c i l i t i e s t o m e e t t h e r e q u i r e d l i f e - s a f e t y C H A P T E R I - 6 -a n d c a r e s t a n d a r d s e s t a b l i s h e d t h r o u g h h e a l t h c a r e r e g u l a t i o n s . E v e n w h e r e f u n d i n g a n d r e g u l a t i o n s h a v e b e e n l i n k e d , a s u n d e r M e d i c a r e - M e d i c a i d i n t h e U n i t e d S t a t e s , j u r i s d i c t i o n a l d i f f e r e n c e s a n d o v e r l a p s a r e a c o n t i n u i n g p r o b l e m [ 1 1 ; 3 5 ; 4 7 ] a n d w h e r e p u b l i c l y i n s u r e d s e r v i c e s w i t h u n i v e r s a l a c c e s s h a v e b e e n i n t r o d u c e d , a s i n B r i t i s h C o l u m b i a , t h e r e h a s b e e n a l a g i n r e c o n c i l i n g t h e s e t w o a s p e c t s [ 1 5 ; 4 6 ; 4 8 ] . NEED FOR THE STUDY A t p r e s e n t t h e L o n g - T e r m C a r e ( L T C ) P r o g r a m 3 i n B r i t i s h C o l u m b i a d o e s n o t i n c l u d e p r o v i s i o n f o r t h e a s s e s s m e n t o f t h e e f f e c t i v e n e s s o r o u t c o m e s o f c a r e p r o v i d e d i n f a c i l i t i e s n o r d o e s t h e p r o g r a m d i r e c t l y l i n k t h e p a y m e n t s y s t e m t o a s s e s s m e n t o f t h e a d e q u a c y o f c a r e . T h e l i c e n s u r e a n d i n s p e c t i o n s e r v i c e s t o e n s u r e c o m p l i a n c e w i t h t h e r e g u l a t o r y r e q u i r e m e n t s o f t h e C o m m u n i t y C a r e F a c i l i t y A c t ( 1 9 7 9 ) [ 5 0 ; 5 1 ] p r o v i d e s t h e o n l y f o r m a l m o n i t o r i n g o f t h e a d e q u a c y o f l o n g - t e r m f a c i l i t y c a r e i n B r i t i s h C o l u m b i a [ 5 2 ] . T h e s t a n d a r d s e s t a b l i s h e d t h r o u g h t h e A c t c o n s i s t s m a i n l y o f s t r u c t u r a l s t a n d a r d s . T h e a n n u a l r e v i e w b y L o n g - T e r m C a r e P r o g r a m s t a f f o f t h e c a r e l e v e l s o f f a c i l i t y r e s i d e n t s p r o v i d e s s o m e p o t e n t i a l f o r a s s e s s i n g u t i l i z a t i o n o r 3 T h e L o n g - T e r m C a r e P r o g r a m i s o n e o f t h r e e p r o g r a m s a d m i n i s t e r e d u n d e r t h e C o n t i n u i n g C a r e D i v i s i o n , I n s t i t u t i o n a l S e r v i c e s B r a n c h o f t h e M i n i s t r y o f H e a l t h i n B r i t i s h C o l u m b i a . T h e p r o g r a m p r o v i d e s f o r f a c i l i t y - b a s e d l o n g - t e r m c a r e a n d h o m e s u p p o r t p r o g r a m s f o r l o n g t e r m c a r e c l i e n t s l i v i n g i n t h e i r o w n h o m e s [ M i n i s t r y o f H e a l t h , A n n u a l R e p o r t 1 9 8 3 ] C H A P T E R I - 7 -t h e a p p r o p r i a t e n e s s o f c l i e n t p l a c e m e n t [ 5 2 ; 5 3 ] . H o w e v e r , t h e s e r e v i e w s h a v e n e i t h e r b e e n c o n s i s t e n t l y c o m p l e t e d n o r a n a l y z e d f r o m t h i s p e r s p e c t i v e , e x c e p t o n a n i n d i v i d u a l r e s i d e n t b a s i s . M a n a g e m e n t s t a f f o f t h e L o n g - T e r m C a r e P r o g r a m h a v e d e v e l o p e d b u t n o t i m p l e m e n t e d a p r o p o s a l f o r l o n g - t e r m c a r e s t a n d a r d s w h i c h i d e n t i f i e s s t r u c t u r e a n d p r o c e s s s t a n d a r d s f o r t h e c a r e p r o v i d e d i n f a c i l i t i e s ( 1 9 8 1 ) [ 5 3 ] , b u t t h e y n o w f e e l t h a t m e a s u r e s o f o u t c o m e s h o u l d b e i n c l u d e d i n t h e p r o p o s e d s t a n d a r d s . A r e n e w e d i m p e t u s t o r e v i s e a n d i m p l e m e n t c a r e s t a n d a r d s i s e x p e c t e d i n 1 9 8 6 [ 5 4 ] . O n t h e r e i m b u r s e m e n t s i d e , d u r i n g 1 9 8 2 / 8 3 a j o i n t c o m m i t t e e w i t h r e p r e s e n t a t i o n f r o m t h e M i n i s t r y o f H e a l t h a n d p r o v i d e r s r e v i e w e d t h e p r e s e n t r e i m b u r s e m e n t s y s t e m f o r f a c i l i t y - b a s e d l o n g - t e r m c a r e [ 5 2 ] . A s a r e s u l t , a n e w s y s t e m h a s b e e n a p p r o v e d a n d i s t o b e i n t r o d u c e d i n s t a g e s , b e g i n n i n g i n t h e f i s c a l y e a r 1 9 8 4 / 8 5 [ 5 2 ] . Q u e s t i o n s h a v e a l s o b e e n a s k e d a b o u t w h e t h e r a n a s s e s s m e n t o f t h e a d e q u a c y o f t h e c a r e p r o v i d e d s h o u l d f o r m p a r t o f t h i s n e w p a y m e n t s y s t e m . A J a n u a r y 1 9 8 5 r e p o r t n o t e d t h r e e o u t s t a n d i n g i s s u e s t o b e p u r s u e d t h r o u g h i n - d e p t h s t u d i e s : c a p i t a l c o s t s , s t a f f i n g , a n d q u a l i t y o f c a r e s t a n d a r d s [ 5 5 ] . W h i l e t h e n e w s y s t e m a p p e a r s t o h a v e p r o g r e s s e d w e l l i n i d e n t i f y i n g f a c t o r s o n t h e c o s t s i d e o f t h e e q u a t i o n ( w i t h t h e e x c e p t i o n o f c a p i t a l c o s t s ) , k e y i n f o r m a n t s n o t e t h a t t h e a p p r o a c h t o m o n i t o r i n g t h e q u a l i t y o f c a r e i s l e s s w e l l d e v e l o p e d [ 5 4 ] . T h i s s t u d y i s a n a t t e m p t t o s u g g e s t a s o l u t i o n . C H A P T E R I - 8 -PURPOSE OF THE STUDY T h e p u r p o s e o f t h i s s t u d y i s t o i n v e s t i g a t e a n d , i f p o s s i b l e , t o d e v e l o p a n o u t c o m e - b a s e d a p p r o a c h w h i c h l i n k s t h e a s s e s s m e n t o f t h e c a r e p r o v i d e d i n l o n g - t e r m c a r e f a c i l i t i e s i n B r i t i s h C o l u m b i a t o t h e c u r r e n t p a y m e n t s y s t e m . I t i s a s s u m e d t h a t t h e c u r r e n t o r g a n i z a t i o n a l s y s t e m w i l l p r e v a i l . T h i s s t u d y s e e k s t o a n s w e r t h e q u e s t i o n s : 1) How i s t h e c o n c e p t o f o u t c o m e - b a s e d r e i m b u r s e m e n t o p e r a t i o n a l i z e d i n p r i v a t e i n d u s t r y , i n t h e p u b l i c s e c t o r a n d i n t h e h e a l t h c a r e i n d u s t r y ; a n d b a s e d o n t h a t k n o w l e d g e ; 2) W h a t ( i f a n y ) a r e f e a s i b l e a p p r o a c h e s t o e s t a b l i s h i n g a n o u t c o m e - b a s e d s y s t e m o f r e i m b u r s e m e n t f o r t h e c a r e p r o v i d e d i n l o n g - t e r m c a r e f a c i l i t i e s i n B r i t i s h C o l u m b i a ? T o b e f e a s i b l e , a n o u t c o m e - b a s e d s y s t e m o f r e i m b u r s e m e n t f o r t h e c a r e p r o v i d e d i n l o n g - t e r m c a r e f a c i l i t i e s i n B r i t i s h C o l u m b i a m u s t : i ) m e e t a c c e p t a b l e s c i e n t i f i c s t a n d a r d s f o r t h e m e a s u r e m e n t o f o u t c o m e s ( e . g . v a l i d i t y , r e l i a b i l i t y , a g g r e g a t i o n a n d v a l u i n g m e t h o d s ) ; i i ) a d d r e s s t h e m u l t i d i m e n s i o n a l n e e d s o f t h e l o n g -t e r m c a r e i n d u s t r y ( e . g . r e s i d e n t s w i t h m u l t i d i m e n s i o n a l p r o b l e m s ; t h e v a r y i n g l e v e l s o f c a r e r e q u i r e d b y r e s i d e n t s ; a m i x e d p r o v i d e r g r o u p o f f o r - p r o f i t a n d n o n - p r o f i t p r o v i d e r s ; a n d d i f f e r e n c e s i n s i z e , l o c a t i o n a n d s t r u c t u r e o f f a c i l i t i e s ) ; i i i ) r e c o g n i z e t h e s p e c i f i c c o n s t r a i n t s o f t h e g o v e r n m e n t ( f u n d e r s ) i n B r i t i s h C o l u m b i a ( e . g . g o v e r n m e n t r e s t r a i n t p r o g r a m s , s t a t u t o r y r e q u i r e m e n t s , p r o v i n c i a l a n d l o c a l c o m m u n i t y v a l u e s a n d a s s u m p t i o n s , m a i n t e n a n c e o f a n a r m s l e n g t h r e l a t i o n s h i p w i t h p r o v i d e r s , a d m i n i s t r a t i v e f e a s i b i l i t y , e t c . ) . ( S e e A p p e n d i x A f o r d e t a i l s o f t h e s e c r i t e r i a ) C H A P T E R I - 9 -OBJECTIVES OF THE STUDY I t i s t h e p u r p o s e o f t h i s s t u d y t o : 1 . R e v i e w t h e c u r r e n t s y s t e m f o r t h e p r o v i s i o n o f l o n g - t e r m f a c i l i t y c a r e i n B r i t i s h C o l u m b i a i n o r d e r t o i d e n t i f y t h e c u r r e n t m e c h a n i s m s f o r e n s u r i n g a d e q u a c y o f c a r e , t h e s y s t e m ( s ) o f r e i m b u r s e m e n t f o r t h e c a r e p r o v i d e d , a n d a n y a c c o u n t a b i l i t y p r o b l e m s e n c o u n t e r e d w i t h t h e s e m e c h a n i s m s . 2. I d e n t i f y t h e m e t h o d o l o g i c a l , d e f i n i t i o n a l a n d s y s t e m f a c t o r s w h i c h w o u l d a c t a s c o n s t r a i n i n g v a r i a b l e s t o t h e a p p l i c a t i o n o f a n o u t c o m e - b a s e d r e i m b u r s e m e n t s y s t e m f o r f a c i l i t y - b a s e d l o n g - t e r m c a r e i n B r i t i s h C o l u m b i a . 3. I d e n t i f y a l t e r n a t i v e a p p r o a c h e s t o o u t c o m e - b a s e d f i n a n c i a l m a n a g e m e n t o r q u a l i t y c o n t r o l t a k e n b y i n p r i v a t e i n d u s t r y , t h e p u b l i c s e c t o r a n d t h e h e a l t h c a r e i n d u s t r y . 4. D e t e r m i n e t h e a p p r o p r i a t e n e s s o f t h e a l t e r n a t i v e o u t c o m e m e a s u r e m e n t a p p r o a c h e s i d e n t i f i e d f o r u s e i n t h e m e a s u r e m e n t o f e f f e c t i v e n e s s a n d f o r l i n k i n g t o t h e r e i m b u r s e m e n t f o r t h e c a r e p r o v i d e d i n f a c i l i t i e s w i t h i n t h e l o n g - t e r m c a r e i n d u s t r y . 5. D e t e r m i n e t h e r e l a t i v e f e a s i b i l i t y o f u s i n g t h e s e a p p r o a c h e s t o o u t c o m e m e a s u r e m e n t a s a b a s i s f o r r e i m b u r s e m e n t f o r t h e c a r e p r o v i d e d i n f a c i l i t i e s w i t h i n t h e L o n g - T e r m C a r e P r o g r a m i n B r i t i s h C o l u m b i a . 6. D e v e l o p , i f p o s s i b l e , a n a p p r o a c h f o r o u t c o m e -b a s e d r e i m b u r s e m e n t f o r t h e c a r e p r o v i d e d i n l o n g -t e r m c a r e f a c i l i t i e s i n B r i t i s h C o l u m b i a . C H A P T E R I - 10 -THESIS FORMAT C H A P T E R TWO p r o v i d e s t h e c o n t e x t f o r t h e s t u d y - t h e L o n g -T e r m C a r e P r o g r a m i n B r i t i s h C o l u m b i a . A r e v i e w a n d a n a l y s i s o f t h e a c c o u n t a b i l i t y a n d r e i m b u r s e m e n t m e c h a n i s m s i n p l a c e i s p r e s e n t e d . I n C H A P T E R T H R E E s o m e o f t h e f a c t o r s w h i c h w o u l d a c t a s c o n s t r a i n t s w h e n c o n s i d e r i n g t h e f e a s i b i l i t y o f a p p l y i n g a n o u t c o m e - b a s e d r e i m b u r s e m e n t a p p r o a c h i n f a c i l i t y - b a s e d l o n g - t e r m c a r e i n B r i t i s h C o l u m b i a a r e e x a m i n e d . T h e n e e d f o r v a l u e p r e f e r e n c e m e a s u r e m e n t i n h e a l t h c a r e , a n d i n p a r t i c u l a r i n l o n g - t e r m c a r e , i s p r e s e n t e d a s a m a j o r m e t h o d o l o g i c a l c o n s t r a i n t . T h e d e f i n i t i o n a l c o n t e x t u s e d i n t h i s s t u d y f o r t h e c o n c e p t s o f o u t c o m e m e a s u r e m e n t , r e i m b u r s e m e n t a n d o u t c o m e - b a s e d r e i m b u r s e m e n t , e f f e c t i v e n e s s a n d e f f i c i e n c y a s t h e y a p p l y i n f a c i l i t y - b a s e d l o n g - t e r m c a r e a r e d i s c u s s e d . O t h e r s y s t e m v a r i a b l e s s u c h a s t h e c o n s t i t u t i o n a l a n d s o c i a l p o l i c y b a s e f o r h e a l t h c a r e p r o v i s i o n a n d t h e e c o n o m i c a n d f i n a n c i a l e n v i r o n m e n t a r e a l s o e x a m i n e d . D i f f e r e n c e s b e t w e e n C a n a d a a n d t h e U n i t e d S t a t e s a r e n o t e d a s m a n y o f t h e a p p r o a c h e s r e v i e w e d w e r e b a s e d o n t h e U n i t e d S t a t e s e x p e r i e n c e . C H A P T E R F O U R p r e s e n t s a n i n - d e p t h r e v i e w o f t h e w a y s i n w h i c h o u t c o m e a p p r o a c h e s h a v e e v o l v e d i n t h e p r i v a t e a n d p u b l i c s e c t o r s i n g e n e r a l , i n c l u d i n g a p p r o a c h e s u s e d i n t h e h e a l t h c a r e C H A P T E R I - 11 -s e c t o r . T h e f i r s t s e c t i o n p r e s e n t s t h e b r o a d - b a s e d , g e n e r i c a p p r o a c h e s t o e f f e c t i v e n e s s m e a s u r e m e n t a n d o u t c o m e - b a s e d r e i m b u r s e m e n t , t h a t i s t h e o r g a n i z a t i o n a l l e v e l a p p r o a c h e s u s e d . T h e s e c o n d s e c t i o n r e v i e w s t h e m o r e s p e c i f i c , i n d i v i d u a l l e v e l a p p r o a c h e s u s e d i n h e a l t h c a r e . T h e a p p r o a c h e s e x a m i n e d i n C H A P T E R ' S F O U R a n d F I V E w e r e e v a l u a t e d f o r t h e i r s c i e n t i f i c m e r i t a n d f o r t h e i r f e a s i b i l i t y f o r u s e i n f a c i l i t y - b a s e d l o n g - t e r m c a r e a s s e s s m e n t a n d r e i m b u r s e m e n t ( s e e A p p e n d i x A f o r t h e s c i e n t i f i c a n d f e a s i b i l i t y c r i t e r i a u s e d ) . C H A P T E R F I V E c o n s i d e r s h o w o u t c o m e a p p r o a c h e s h a v e b e e n a d a p t e d t o ' f i t ' t h e r e q u i r e m e n t s a n d c o m p l e x i t i e s o f f a c i l i t y -b a s e d l o n g - t e r m c a r e , i n c l u d i n g b o t h o r g a n i z a t i o n a l l e v e l a n d i n d i v i d u a l l e v e l a p p r o a c h e s . T h i s c h a p t e r a l s o c o n s i d e r s t h e w a y s i n w h i c h t h e s e t w o t y p e s o f a p p r o a c h e s m a y c o n v e r g e t o a d d r e s s t h e d i f f e r e n c e s i n r e i m b u r s e m e n t i n c e n t i v e s a m o n g p r o v i d e r s a n d t h e i n f o r m a t i o n n e e d s o f a s s e s s o r s , p r o v i d e r s a n d g o v e r n m e n t d e c i s i o n m a k e r s . C H A P T E R 6 p r e s e n t s a p r o p o s a l f o r t h e d e v e l o p m e n t a n d i m p l e m e n t a t i o n o f a n a p p r o a c h t o m e a s u r e t h e e f f e c t i v e n e s s o f t h e c a r e p r o v i d e d i n l o n g - t e r m c a r e f a c i l i t i e s i n B r i t i s h C o l u m b i a . T h e r e i s a l s o a b r i e f d i s c u s s i o n o f t h e p o t e n t i a l a p p l i c a t i o n o f o u t c o m e - b a s e d e f f e c t i v e n e s s m e a s u r e s i n e f f i c i e n c y s t u d i e s a n d / o r i n r e i m b u r s e m e n t . C H A P T E R I - 12 -LIMITATIONS T h i s i s a n e x p l o r a t o r y s t u d y i n w h i c h i n f o r m a t i o n w a s c o l l e c t e d f r o m m a n y s o u r c e s a n d i n m a n y f o r m s . T h e s y n t h e s i s o f t h e i n f o r m a t i o n c o l l e c t e d i s s u b j e c t t o t h e u s u a l e r r o r s , o m i s s i o n s a n d m i s i n t e r p r e t a t i o n s o f s u c h a r e v i e w , e s p e c i a l l y t h e i n a b i l i t y t o o b t a i n a c c u r a t e o r c o m p l e t e i n f o r m a t i o n f r o m a l l s o u r c e s a n d t h e n e e d t o r e l y o n s u m m a r y m a t e r i a l o n t h e a p p r o a c h e s r e v i e w e d i n o r d e r t o c o n t a i n t h e s c o p e o f t h e l i t e r a t u r e r e v i e w . M i s i n t e r p r e t a t i o n m a y a l s o c o m e f r o m a l a c k o f r e c o g n i t i o n o f a l l t h e u n d e r l y i n g a s s u m p t i o n s b a s i c t o t h e i n f o r m a t i o n p r e s e n t e d . T h i s i s a p a r t i c u l a r p r o b l e m i n t h i s s t u d y w h e r e s o m u c h o f t h e m a t e r i a l r e v i e w e d w a s b a s e d o n e x p e r i e n c e s i n o t h e r s y s t e m s o r o t h e r c o u n t r i e s , i n p a r t i c u l a r t h e U n i t e d S t a t e s . A n a t t e m p t t o d e l i n e a t e t h e s y s t e m d i f f e r e n c e s b e t w e e n C a n a d a a n d t h e U n i t e d S t a t e s h a s b e e n m a d e i n C H A P T E R T H R E E . H o w e v e r a l a c k o f k n o w l e d g e a b o u t t h e e x p e r i e n c e o f c o u n t r i e s o t h e r t h a n t h e U n i t e d S t a t e s a n d t h e r e l e v a n c e o f t h e i r e x p e r i e n c e f o r C a n a d a i s a l i m i t a t i o n . T h e a b i l i t y t o t e s t t h e v a l i d i t y a n d r e l i a b i l i t y o f t h e i n f o r m a t i o n u s e d i n a n e x p l o r a t o r y s t u d y i s m o r e l i m i t e d t h a n i n t h e m o r e r i g o r o u s a p p r o a c h e s u s e d i n e x p e r i m e n t a l s t u d i e s . I n o r d e r t o t e s t v a l i d i t y a n d r e l i a b i l i t y i n a n e x p l o r a t o r y s t u d y t h e a n a l y s i s m u s t m o v e b a c k a n d f o r t h b e t w e e n d i s c o v e r y ( r e v i e w o f t h e l i t e r a t u r e ) a n d v e r i f i c a t i o n ( r e v i e w o f d o c u m e n t a t i o n o f t h e p r o g r a m e x p e r i e n c e , k e y i n f o r m a n t s o u r c e s ) ; b e t w e e n t h e C H A P T E R I - 13 -p a r t s ( o u t c o m e m e a s u r e m e n t a p p r o a c h e s , r e i m b u r s e m e n t m e c h a n i s m s , s y s t e m f a c t o r s ) a n d t h e w h o l e ( o u t c o m e - b a s e d r e i m b u r s e m e n t o f f a c i l i t y - b a s e d c a r e , t h e l o n g - t e r m c a r e s y s t e m a s w h o l e ) ; a n d b e t w e e n e x p e r i e n c e a n d r e f l e c t i o n [ 5 6 ] . T h e s t u d y i s l i m i t e d t o a d e s c r i p t i o n o f t h e c h a r a c t e r i s t i c s o f t h e p h e n o m e n o n u n d e r s t u d y ( i . e . o u t c o m e -b a s e d r e i m b u r s e m e n t f o r f a c i l i t y - b a s e d c a r e ) a n d a d i s c u s s i o n o f i t s f e a s i b i l i t y f o r i m p l e m e n t a t i o n i n a g i v e n s e t t i n g . T h i s t y p e o f s t u d y d o e s n o t p r o v i d e a n s w e r s t o q u e s t i o n s o f c a u s a l i t y o r c o n s e q u e n c e [ 5 7 ; 5 8 ] . I n o r d e r t o d o t h a t , a h y p o t h e s i s t e s t i n g a p p r o a c h , u s i n g q u a n t i t a t i v e d a t a d e r i v e d f r o m a n e x p e r i m e n t a l o r e m p i r i c a l e x p e r i e n c e w o u l d b e r e q u i r e d . T h i s p r e s u p p o s e s t h a t t h e r e i s s u f f i c i e n t r e a d i n e s s a n d k n o w l e d g e a b o u t t h e q u e s t i o n u n d e r s t u d y t o p r o c e e d . W h e r e a s , i n B r i t i s h C o l u m b i a , t h e r e i m b u r s e m e n t s y s t e m f o r f a c i l i t y - b a s e d l o n g - t e r m c a r e i s n e i t h e r o u t c o m e - b a s e d n o r a r e o u t c o m e m e a s u r e m e n t s u s e d t o e n s u r e t h e e f f e c t i v e n e s s o r q u a l i t y o f c a r e . T h e f e a s i b i l i t y o f s u c h m e t h o d s m u s t b e e x p l o r e d f i r s t b e f o r e e x p e r i m e n t a l a p p r o a c h e s c a n b e u s e d t o t e s t c a u s a l i t y o r c o n s e q u e n c e s . T h a t i s , t h i s s t u d y w i l l n o t d e m o n s t r a t e t h e e f f e c t o f o u t c o m e - b a s e d r e i m b u r s e m e n t o n c o s t c o n t a i n m e n t o r o n t h e a d e q u a c y o f t h e c a r e p r o v i d e d i n t h e s e t t i n g o f i n t e r e s t . H o w e v e r , " s p e c u l a t i o n o n t h e c a u s a l r e l a t i o n s h i p s a r e e n t i r e l y a p p r o p r i a t e - a s l o n g a s t h e y a r e c l e a r l y l a b e l e d a s s p e c u l a t i v e " [ 5 8 ] . C H A P T E R I - 14 -B i a s c a n n o t b e c o m p l e t e l y e l i m i n a t e d d u e t o t h e u n s t r u c t u r e d n a t u r e o f a n e x p l o r a t o r y s t u d y [ 5 9 ] . T h e q u a l i t a t i v e n a t u r e o f a n e x p l o r a t o r y s t u d y a l s o l i m i t s t h e g e n e r a l i z a b i l i t y o f t h e s t u d y . T h e g e n e r a l i z a b i l i t y o f t h i s s t u d y f o r u s e b y o t h e r p r o v i n c i a l l o n g - t e r m c a r e p r o g r a m s w i l l b e l i m i t e d t o t h e e x t e n t t o w h i c h t h e i r s y s t e m a n d o t h e r c o n s t r a i n i n g v a r i a b l e s a r e s i m i l a r t o t h o s e e x p e r i e n c e d i n B r i t i s h C o l u m b i a . F o r e x a m p l e , t h e p r o p o s e d a p p r o a c h w o u l d b e m o s t a p p r o p r i a t e t o s y s t e m s w h i c h h a v e a s i n g l e p o i n t o f e n t r y , a c o n t i n u u m o f c o m m u n i t y a n d f a c i l i t y - b a s e d c a r e , a n i n t e g r a t e d a p p r o a c h t o r e i m b u r s e m e n t f o r b o t h n o n - p r o f i t a n d f o r - p r o f i t f a c i l i t i e s a n d u n i v e r s a l a c c e s s t o s e r v i c e s b a s e d o n n e e d . F u r t h e r , l i m i t e d e m p i r i c a l e x p e r i e n c e w i t h t h e u s e o f a n o u t c o m e - b a s e d e f f e c t i v e n e s s m e a s u r e m e n t a p p r o a c h ( u s i n g m u l t i -a t t r i b u t e h e a l t h s t a t u s i n d e x e s ) i n t h e f a c i l i t y - b a s e d l o n g - t e r m c a r e s y s t e m l i m i t s , t o s o m e d e g r e e , t h e s p e c i f i c i t y o f t h e r e c o m m e n d a t i o n s a b o u t w h i c h a p p r o a c h e s t o u s e i n t h e e v a l u a t i o n a n d m o n i t o r i n g o f f a c i l i t y c a r e i n B r i t i s h C o l u m b i a . I t i s a n t i c i p a t e d , g i v e n t h e l i m i t e d e m p i r i c a l e x p e r i e n c e e l s e w h e r e , t h a t a n y a p p r o a c h t a k e n i n B r i t i s h C o l u m b i a w o u l d b e i m p l e m e n t e d a s a j o i n t r e s e a r c h a n d s e r v i c e a p p l i c a t i o n , t h a t i s a d e m o n s t r a t i o n p r o j e c t t o p r o v i d e t h e n e e d e d e m p i r i c a l t e s t i n g . C H A P T E R I - 1 5 -R E F E R E N C E S 1 . E v a n s , R o b e r t . We H a v e S e e n t h e F u t u r e a n d T h e y ' s U s :  H e a l t h C a r e a n d t h e G r a y i n g o f C a n a d a . P a p e r p r e s e n t e d a t t h e C o m m o n w e a l t h F u n d F o r u m o n t h e H e a l t h C a r e o f t h e A g e d . L o n d o n , E n g l a n d , M a y 2 3 - 2 6 , 1 9 8 3 . ( M i m e o g r a p h e d . ) 2 . K i n g s o n , E r i c a n d S c h e f f e r , R i c h a r d M . " A g i n g I s s u e s a n d E c o n o m i c T r e n d s f o r t h e 1 9 8 0 ' s . " I n q u i r y 18 ( F a l l 1 9 8 1 ) : 1 9 7 - 2 1 3 . 3 . S c h w e n g e r , C o p e a n d G r o s s , J o h n . " I n s t i t u t i o n a l C a r e a n d I n s t i t u t i o n a l i z a t i o n o f t h e E l d e r l y i n C a n a d a . " I n A g i n g  i n C a n a d a S o c i a l P e r s p e c t i v e s , p p . 2 6 9 - 8 5 . E d i t e d b y V i c t o r M a r s h a l l . D o n M i l l s , O n t a r i o : F i t z h e n r y a n d W h i t e s i d e , 1 9 8 0 . 4. C a n a d a . D e p a r t m e n t o f N a t i o n a l H e a l t h a n d W e l f a r e . C a n a d i a n  G o v e r n m e n t a l R e p o r t o n A g i n g . O t t a w a , O n t a r i o , 1 9 8 2 . 5 . C a n a d a . S t a t i s t i c s C a n a d a . C a n a d a ' s E l d e r l y . O t t a w a , O n t a r i o , M a r c h 1 9 7 9 . 6 . D e n t o n , F r a n k , a n d S p e n c e r , B y r o n . " H e a l t h C a r e C o s t s W h e n t h e P o p u l a t i o n C h a n g e s . " I n A g i n g i n C a n a d a : S o c i a l  P e r s p e c t i v e s , p p . 23-44. E d i t e d b y V i c t o r M a r s h a l l . D o n M i l l s , O n t a r i o : F i t z h e n r y a n d W h i t e s i d e , 1 9 8 0 . 7 . H a v e n s , B e t t y . " P o p u l a t i o n P r o j e c t i o n s : C e r t a i n t i e s a n d U n c e r t a i n t i e s . " I n C a n a d a ' s C h a n g i n g A g e S t r u c t u r e :  I m p l i c a t i o n s f o r t h e F u t u r e , p p . 1 - 3 2 . E d i t e d b y G l o r i a G u t m a n . B u r n a b y , B r i t i s h C o l u m b i a : S i m o n F r a s e r U n i v e r s i t y P u b l i c a t i o n s , 1 9 8 2 . 8 . C a n a d a . D e p a r t m e n t o f H e a l t h a n d W e l f a r e . N a t i o n a l H e a l t h  E x p e n d i t u r e s i n C a n a d a : 1 9 7 0 - 1 9 7 9 . O t t a w a , O n t a r i o , 1 9 8 2 . 9 . C a n a d a . F i s c a l F e d e r a l i s m i n C a n a d a : R e p o r t o f t h e  P a r l i a m e n t a r y T a s k F o r c e i n F e d e r a l - P r o v i n c i a l F i s c a l  A r r a n g e m e n t s . O t t a w a , 1 9 8 1 . 1 0 . K a n e , R o b e r t a n d K a n e , R o s a l i e , A . " T h e E x t e n t a n d N a t u r e o f P u b l i c R e s p o n s i b i l i t y f o r L o n g - T e r m C a r e . " I n P o l i c y  O p t i o n s i n L o n g - T e r m C a r e , p p . 7 8 - 1 1 7 . E d i t e d b y J . M e l t z e r , F . F a r r o w , a n d H . R i c h m a n . C h i c a g o : U n i v e r s i t y o f C h i c a g o P r e s s , 1 9 8 1 . C H A P T E R I - 16 -1 1 . H a m m e r , M a r k a n d L e v e n i c k , K a r e n . " N u r s i n g Home C a r e I n W a s h i n g t o n S t a t e a n d B r i t i s h C o l u m b i a : S i m i l a r i t i e s a n d D i f f e r e n c e s . " T h e l e a d p a p e r f o r t h e S y m p o s i u m o n R e g u l a t o r y I n f l u e n c e s o n t h e M a n a g e m e n t o f N u r s i n g H o m e s p r e s e n t e d a t t h e W e s t e r n A c a d e m y o f M a n a g e m e n t A n n u a l M e e t i n g , V a n c o u v e r , B . C . , A p r i l 1 9 8 4 . ( M i m e o g r a p h e d . ) 1 2 . B e n n e t t , J a m e s , a n d K r a s n e y , J a c q u e s . H e a l t h C a r e i n C a n a d a : A S e r i e s o n t h e N a t i o n s H e a l t h . T h e F i n a n c i a l  P o s t M a r c h 2 6 - M a y 7 , 1 9 7 7 . 1 3 . B r o o k , R o b e r t H . ; W i l l i a m s , K a t h l e e n ; a n d A v e r y , A l l y s o n D . " Q u a l i t y A s s u r a n c e i n t h e 2 0 t h C e n t u r y : W i l l I t L e a d t o I m p r o v e d H e a l t h i n t h e 2 1 s t ? " I n Q u a l i t y A s s u r a n c e i n  H e a l t h C a r e , p p . 3 - 2 9 . E d i t e d b y R i c h a r d H . E g d a h l a n d P a u l M . G e r t m a n . G e r m a n t o w n , M a r y l a n d : A s p e n S y s t e m s C o r p . , 1 9 7 6 . 1 4 . H a v i g h u r s t , C l a r k a n d B l u m s t e i n , J a m e s . " C o p i n g w i t h Q u a l i t y / C o s t T r a d e - o f f s i n M e d i c a l C a r e : T h e R o l e o f P S R O ' s . " N o r t h w e s t e r n U n i v e r s i t y L a w R e v i e w 7 0 ( 1 9 7 5 ) 1 : 6 -3 0 . 1 5 . L e v e n i c k , K a r e n . " A R e v i e w o f G o v e r n m e n t R e g u l a t o r y R e s p o n s i b i l i t y f o r A d u l t C a r e F a c i l i t i e s a n d O p t i o n s o r R e g u l a t i o n i n B r i t i s h C o l u m b i a . " C l e r k s h i p R e p o r t . B r i t i s h C o l u m b i a M i n i s t r y o f H e a l t h , 1 9 8 2 . ( M i m e o g r a p h e d . ) 1 6 . B e r g , R o b e r t L . e d . H e a l t h S t a t u s I n d e x e s : C o n f e r e n c e  P r o c e e d i n g s . C h i c a g o : H o s p i t a l R e s e a r c h a n d E d u c a t i o n a l T r u s t , 1 9 7 3 . 1 7 . G r e e n e , R i c h a r d . A s s u r i n g Q u a l i t y l n M e d i c a l C a r e : T h e  S t a t e o f t h e A r t . C a m b r i d g e , M a s s . : B a l l i n g e r P u b . C o . , 1 9 7 6 . 1 8 . J a c o b s , C h a r l e s M . ; C h r i s t o f f e l , T o m H . ; a n d D i x o n , N a n c y . M e a s u r i n g t h e Q u a l i t y o f P a t i e n t C a r e : T h e R a t i o n a l f o r  O u t c o m e A u d i t . C a m b r i d g e , M a s s . : B a l l i n g e r P u b l i s h i n g C o . , 1 9 7 6 . 1 9 . M c C a f f r e e , K . , a n d H a r k i n s , E . F i n a l R e p o r t f o r E v a l u a t i o n  o f t h e O u t c o m e s o f N u r s i n g Home C a r e . W a s h i n g t o n , D . C . . : N a t i o n a l C e n t r e f o r H e a l t h S e r v i c e s R e s e a r c h (DHEW P u b l . 7 7 -1 1 8 ) , 1 9 7 6 . 2 0 . E l i n s o n , J a c k ; M o o n e y , A n n e ; a n d S l e g m a n n , A t h i l i a E . , e d s . H e a l t h G o a l s a n d H e a l t h I n d i c a t o r s : P o l i c y , P l a n n i n g , a n d  E v a l u a t i o n , A A A S S e l e c t e d S y m p o s i u m 2 . B o u l d e r , C o l o r a d o : W e s t v i e w P r e s s I n c . , 1 9 7 7 . C H A P T E R I - 1 7 -2 1 . L i n n , M a r g a r e t W . ; G u r e l , L e e ; a n d L i n n , B e r n a r d S . " P a t i e n t O u t c o m e a s a M e a s u r e o f Q u a l i t y o f N u r s i n g Home C a r e . " A J P H ( A p r i l 1 9 7 7 ) : 3 3 7 - 3 4 2 . 2 2 . P l a n t , J a n e t . " V a r i o u s A p p r o a c h e s P r o p o s e d t o A s s e s s Q u a l i t y i n L o n g - T e r m C a r e . " H o s p i t a l s 5 1 ( S e p t e m b e r 1 , 1 9 7 7 ) : 9 3 - 9 8 . 2 3 . R e s s n e r , D a v i d M . " Q u a l i t y A s s e s s m e n t a n d A s s u r a n c e : E a r l y S i g n s o f C o g n i t i v e D i s s o n a n c e . " T h e New E n g l a n d  J o u r n a l o f M e d i c i n e 2 9 8 ( F e b r u a r y 1 8 , 1 9 7 8 ) : 3 8 1 - 3 8 6 . 2 4 . B u c h a n , J a n e . " T h e D e v e l o p m e n t o f a G e r i a t r i c A s s e s s m e n t I n s t r u m e n t f o r L o n g - T e r m C a r e F a c i l i t i e s . " M . S c . N . T h e s i s , U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1 9 7 9 . 2 5 . M a c A u l i f f e , W i l l i a m E . " M e a s u r i n g t h e Q u a l i t y o f M e d i c a l C a r e : P r o c e s s V e r s u s O u t c o m e . " M i l l b a n k M e m o r i a l F u n d  Q u a r t e r l y 5 7 ( W i n t e r 1 9 7 9 ) : 1 1 8 - 1 5 2 . 2 6 . B e c k e r , B a b e t t e . " T h e N u r s i n g Home S c o r i n g S y s t e m : A P o l i c y A n a l y s i s . " T h e G e r o n t o l o g i s t 22 ( 1 9 8 2 ) : 3 9 - 4 4 . 2 7 . K u r o w s k i , B e t t i n a D . a n d S h a u g h n e s s y , P e t e r W. " T h e M e a s u r e m e n t a n d A s s u r a n c e o f Q u a l i t y " I n L o n g - T e r m C a r e :  P e r s p e c t i v e s f r o m R e s e a r c h a n d D e m o n s t r a t i o n s , p p . 1 0 3 - 1 3 3 . E d i t e d b y R o n a l d J . V o g e l a n d H a n s C . P a l m e r . U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s , H e a l t h C a r e F i n a n c i n g A d m i n i s t r a t i o n , 1 9 8 2 . 2 8 . B e r k i , S . E . H o s p i t a l E c o n o m i c s , p p . 1 8 3 - 1 9 3 . 1 9 7 2 . 2 9 . H e b e r t , J o s e p h L . , e d . E x p e r i e n c e s i n Z e r o - B a s e B u d g e t i n g . New Y o r k : P e t r o c e l l i B o o k s , 1 9 7 7 . 3 0 . D u n l o p , B u r t o n D a v i d . T h e G r o w t h o f N u r s i n g Home C a r e . L e x i n g t o n , M a s s . : L e x i n g t o n B o o k s , 1 9 7 9 . 3 1 . J a c o b s , P . E c o n o m i c s o f H e a l t h a n d M e d i c a l C a r e : A n  I n t r o d u c t i o n , p p . 1 5 5 - 1 8 5 . B a l t i m o r e : U n i v e r s i t y P a r k P r e s s , 1 9 8 0 . 3 2 . R u c h l i n , H i r s c h S . ; L e v y , S a m u e l ; a n d M u l l e n , C h a r l o t t e . " T h e L o n g - T e r m C a r e M a r k e t p l a c e : A n a l y s i s o f D e f i c i e n c i e s a n d P o t e n t i a l R e f o r m b y M e a n s o f I n c e n t i v e R e i m b u r s e m e n t . " M e d i c a l C a r e X I I I ( D e c e m b e r 1 9 7 5 ) : 9 7 9 - 9 9 1 . 3 3 . K a n e , R o b e r t L . " P a y N u r s i n g H o m e s f o r B e t t e r C a r e . " J o u r n a l o f C o m m u n i t y H e a l t h . 2 ( F a l l 1 9 7 6 ) : l - 4 . 3 4 . L a P o r t e , V a l e r i e a n d R u b i n , J e f f r y , e d s . R e f o r m a n d  R e g u l a t i o n i n L o n g - T e r m C a r e . New Y o r k : P r a e g e r P u b l i s h e r s , 1 9 7 9 . C H A P T E R I - 18 -3 5 . B u c h a n a n , R o b e r t J . H e a l t h C a r e F i n a n c e : a n A n a l y s i s o f  C o s t a n d U t i l i z a t i o n I s s u e s . T o r o n t o : L e x i n g t o n B o o k s , 1 9 8 1 . 3 6 . F o t t l e r , M y r o n , S m i t h , H o w a r d L . , a n d J a m e s , W i l l i a m L . " P r o f i t s a n d P a t i e n t C a r e Q u a l i t y i n N u r s i n g H o m e s : A r e T h e y C o m p a t i b l e ? " T h e G e r o n t o l o g i s t 2 1 { 1 9 8 1 ) : 5 3 2 - 5 3 8 . 3 7 . K a n e , R o b e r t a n d K a n e , R o s a l i e . " O u t c o m e M e a s u r e m e n t i n L o n g - T e r m C a r e a n d R e i m b u r s e m e n t : A P r o p o s a l . " R a n d C o r p o r a t i o n . 1 9 8 2 . ( M i m e o g r p h e d . ) 3 8 . S h a u g h n e s s y , P e t e r W . , a n d K u r o w s k i , B e t t i n a . " Q u a l i t y A s s u r a n c e T h r o u g h R e i m b u r s e m e n t . " H e a l t h S e r v i c e s R e s e a r c h 17 ( S u m m e r 1 9 8 2 ) : 1 5 7 - 1 8 3 . 3 9 . K a n e , R o b e r t a n d K a n e , R o s a l i e A . A s s e s s i n g t h e E l d e r l y : A  P r a c t i c a l G u i d e t o M e a s u r e m e n t . L e x i n g t o n , M a s s . : L e x i n g t o n B o o k s , 1 9 8 1 . 4 0 . S t . J o h n , D o n a l d B . ; D o b i n , D a r r y l R . ; a n d F l a s n e r , B r u c e . " A n A u t o m a t e d S y s t e m f o r R e g u l a t i o n a n d M e d i c a l R e v i e w o f L o n g - T e r m C a r e F a c i l i t i e s a n d P a t i e n t s . " A J P H 5 3 ( J u l y 1 9 7 3 ) : 6 1 9 - 6 3 0 . 4 1 . W e i s s e t , W i l l i a m ; S c a n l o n , W i i l i a m J . ; W a n , T h o m a s T . H . a n d S k i n n e r , D o u g l a s . " C a r e f o r t h e C h r o n i c a l l y 1 1 1 : N u r s i n g Home I n c e n t i v e P a y m e n t E x p e r i m e n t . " H e a l t h C a r e F i n a n c i n g  R e v i e w 5 ( W i n t e r 1 9 8 3 ) : 4 1 - 4 9 . 4 2 . S m i t s , H e l e n L . " I n c e n t i v e s i n C a s e - M i x M e a s u r e s f o r L o n g -T e r m C a r e . " H e a l t h C a r e F i n a n c i n g R e v i e w 6 ( W i n t e r 1 9 8 4 ) : 5 3 - 5 9 . 4 3 . S c h l e n k e r , R o b e r t E . ; S h a u g h n e s s y , P e t e r W . ; a n d Y s l a s , I n e z . " E s t i m a t i n g P a t i e n t - L e v e l N u r s i n g Home C o s t s . " H e a l t h S e r v i c e s R e s e a r c h . 2 0 l A p r i l 1 9 8 5 ) : 1 0 3 - 1 2 8 . 4 4 . T a f t , C y n t h i a , a n d L e v i n e , S o l . " P r o b l e m s o f F e d e r a l P o l i c i e s a n d S t r a t e g i e s t o I n f l u e n c e t h e Q u a l i t y o f C a r e . " I n Q u a l i t y A s s u r a n c e i n H e a l t h C a r e , p p . 3 1 - 5 7 . E d i t e d b y R i c h a r d E g d a h l a n d P a u l G e r t m a n . M a r y l a n d : A s p e n S y s t e m s C o r p . , 1 9 7 6 . 4 5 . C a l l a h a n , J a m e s J . , J r . a n d W a l l a c k , S t a n l e y S . " M a j o r R e f o r m s i n L o n g - T e r m C a r e . " R e f o r m i n g t h e L o n g - T e r m C a r e  S y s t e m : F i n a n c i a l a n d O r g a n i z a t i o n a l O p t i o n s , p p . 3 - 1 0 . E d i t e d b y J . J . C a l l a h a n a n d S . W a l l a c k . L e x i n g t o n , M a s s . : L e x i n g t o n B o o k s , 1 9 8 1 . 4 6 . H e a l t h E m p l o y e e s U n i o n . L o n g - T e r m C a r e i n B r i t i s h  C o l u m b i a : T h e U n i o n M e m b e r s P e r s p e c t i v e . M a y 1 9 8 1 . C H A P T E R I - 1 9 -4 7 . S m i t h , D a v i d B a r t o n . L o n g - T e r m C a r e i n T r a n s i t i o n : T h e  R e g u l a t i o n o f N u r s i n g H o m e s . A n n A r b o r , M i c h i g a n : A U P H A , 1 9 8 1 . 4 8 . B o l t o n , P a t r i c i a " R e i m b u r s e m e n t f o r L o n g - T e r m C a r e i n B r i t i s h C o l u m b i a " C l e r k s h i p R e p o r t . B r i t i s h C o l u m b i a M i n i s t r y o f H e a l t h . S e p t e m b e r 1 9 8 3 . ( M i m e o g r p h e d . ) 4 9 . W a l d m a n , S a u l " A L e g i s l a t i v e H i s t o r y o f N u r s i n g H o m e C a r e . " I n L o n g - T e r m C a r e : P e r s p e c t i v e s f r o m R e s e a r c h a n d  D e m o n s t r a t i o n s , p p . 5 0 7 - 5 3 6 . E d i t e d b y R . J . V o g e l a n d H . P a l m e r . U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s , H e a l t h C a r e F i n a n c i n g A d m i n i s t r a t i o n , 1 9 8 2 . 5 0 . B a i n b r i d g e , J a c k . " B r i t i s h C o l u m b i a ' s L o n g - T e r m C a r e P r o g a m : t h e F i r s t T w o Y e a r s " . H e a l t h M a n a g e m e n t F o r u m 1 ( S u m m e r 1 9 8 0 ) : 2 8 - 3 6 5 1 . B r i t i s h C o l u m b i a . C o m m u n i t y C a r e F a c i l i t y A c t 1 9 7 9 a n d  A d u l t C a r e R e g u l a t i o n s 1 9 8 0 . 5 2 . B r i t i s h C o l u m b i a , M i n i s t r y o f H e a l t h . C o n t i n u i n g C a r e D i v i s i o n , I n s t i t u t i o n a l S e r v i c e s . " I n t r o d u c t i o n o f t h e New R e i m b u r s e m e n t S y s t e m f o r L o n g T e r m C a r e F a c i l i t i e s i n B r i t i s h C o l u m b i a . " M a r c h 1 6 , 1 9 8 4 . ( M i m e o g r a p h e d . ) 5 3 . B r i t i s h C o l u m b i a , M i n i s t r y o f H e a l t h . H o m e C a r e / L o n g - T e r m C a r e P r o g r a m . P r o p o s a l f o r I m p l e m e n t a t i o n a n d M o n i t o r i n g  o f R e s i d e n t i a l C a r e S t a n d a r d s . A u g u s t 7 , 1 9 8 1 . 5 4 . D a v i s , P a t r i c i a . M a n a g e r , S t a n d a r d s a n d Q u a l i t y o f C a r e , C o n t i n u i n g C a r e D i v i s i o n , M i n i s t r y o f H e a l t h . M a y 1 9 8 6 ( P e r s o n a l C o m m u n i c a t i o n . ) 5 5 . B r i t i s h C o l u m b i a , M i n i s t r y o f H e a l t h . F a c i l i t y  R e i m b u r s e m e n t S y s t e m . L o n g T e r m C a r e P r o g r a m , C o n t i n u i n g C a r e D i v i s i o n . J a n u a r y 1 9 8 5 . 5 6 . P a t t o n , M i c h a e l Q u i n n . Q u a l i t a t i v e E v a l u a t i o n M e t h o d s . B e v e r l y H i l l s , C a l i f o r n i a : S a g e P u b l i c a t i o n s , 1 9 8 0 . 5 7 . B r i n k , P a m e l a J . , a n d W o o d , M a r i l y n J . B a s i c S t e p s i n  P l a n n i n g N u r s i n g R e s e a r c h : F r o m Q u e s t i o n t o P r o p o s a l . N o r t h S c i t u a t e , M a s s : D u x b u r y P r e s s , 1 9 7 8 . 5 8 . L o f l a n d , J o h n . A n a l y s i n g S o c i a l S e t t i n g s : A G u i d e t o  Q u a n t i t a t i v e O b s e r v a t i o n a n d A n a l y s i s . B e l m o n t , C a l i f o r n i a : W a d s w o r t h P u b l i s h i n g C o . , 1 9 7 1 . 5 9 . P o l i t , D e n i s e F . , a n d H u n g l e r , B e r n a d e t t e P . N u r s i n g  R e s e a r c h : P r i n c i p l e s a n d M e t h o d s . T o r o n t o : J . B . L i p p e n c o t t C o . , 1 9 7 8 . -2.0-CHAPTER I I : FACILITY-BASED LONG-TERM CARE IN BRITISH COLUMBIA INTRODUCTION B e f o r e c o n s i d e r i n g a p p r o a c h e s t o a n o u t c o m e - b a s e d s y s t e m f o r t h e m e a s u r e m e n t o f e f f e c t i v e n e s s a n d r e i m b u r s e m e n t f o r f a c i l i t y - b a s e d l o n g - t e r m c a r e i n B r i t i s h C o l u m b i a , i t i s n e c e s s a r y t o u n d e r s t a n d t h e s e t t i n g i n t o w h i c h t h e s y s t e m w o u l d b e i n t r o d u c e d . T h i s c h a p t e r e x a m i n e s : t h e h i s t o r i c a l d e v e l o p m e n t o f l o n g - t e r m c a r e s e r v i c e s ; t h e c u r r e n t m a n d a t e ; t h e o r g a n i z a t i o n a l s t r u c t u r e ; a n d t h e c u r r e n t s t a t u s o f q u a l i t y o f c a r e s t a n d a r d s a n d t h e r e i m b u r s e m e n t s y s t e m i n B r i t i s h C o l u m b i a . S p e c i f i c a l l y t h i s c h a p t e r a d d r e s s e s O b j e c t i v e 1 : R e v i e w t h e p r e s e n t s y s t e m o f p r o v i d i n g f a c i l i t y - b a s e d l o n g - t e r m c a r e i n B r i t i s h C o l u m b i a i n o r d e r t o i d e n t i f y t h e c u r r e n t m e c h a n i s m s f o r e n s u r i n g a d e q u a c y o f c a r e , t h e s y s t e m ( s ) o f r e i m b u r s e m e n t f o r t h e c a r e p r o v i d e d , a n d a n y a c c o u n t a b i l i t y p r o b l e m s e n c o u n t e r e d w i t h t h e s e m e c h a n i s m s . HISTORICAL DEVELOPMENT G o v e r n m e n t i n t e r e s t i n t h e d e v e l o p m e n t o f a l o n g - t e r m c a r e s y s t e m , p a r t i c u l a r l y f a c i l i t y - b a s e d l o n g - t e r m c a r e , i n B r i t i s h C o l u m b i a f o l l o w e d a p a t t e r n s i m i l a r t o t h a t i n o t h e r N o r t h A m e r i c a n j u r i s d i c t i o n s . T h a t i s , s e r v i c e s b e g a n i n r e s p o n s e t o s o c i a l w e l f a r e n e e d s a n d s u b s e q u e n t l y a c q u i r e d m o r e o f a h e a l t h c a r e o r i e n t a t i o n . G o v e r n m e n t i n v o l v e m e n t i n B r i t i s h C o l u m b i a b e g a n a s e a r l y a s 1 9 3 8 w i t h t h e r e g u l a t i o n s e s t a b l i s h e d u n d e r t h e W e l f a r e I n s t i t u t i o n s A c t [ 1 ] . T h e s e r e g u l a t i o n s w e r e C H A P T E R I I - 21 -d e s i g n e d t o e n s u r e t h e p r o t e c t i o n a n d s a f e t y o f d e p e n d e n t r e s i d e n t s i n a d u l t a n d c h i l d c a r e f a c i l i t i e s . O v e r t h e y e a r s , r e s p o n s i b i l i t y f o r f a c i l i t y - b a s e d c a r e m o v e d b a c k a n d f o r t h b e t w e e n t h e s o c i a l s e r v i c e a n d h e a l t h m i n i s t r i e s . I n 1 9 7 0 t h e M i n i s t r y o f H e a l t h w a s d e s i g n a t e d a s r e s p o n s i b l e f o r t h e r e g u l a t i o n o f f a c i l i t y - b a s e d l o n g - t e r m c a r e i n B . C . [ 2 ] . S i n c e t h a t t i m e t h e M i n i s t r y o f H e a l t h A n n u a l R e p o r t s [ 3 ] s u g g e s t t h a t q u a l i t y o f c a r e h a s b e e n a c o n t i n u i n g c o n c e r n . S e v e r a l o r g a n i z a t i o n a l c h a n g e s s h o u l d b e n o t e d [ 3 ] : 1 9 7 0 - t h e n e w C o m m u n i t y C a r e F a c i l i t y A c t , e s t a b l i s h e d r e g u l a t o r y a c c o u n t a b i l i t y f o r f a c i l i t y - b a s e d c a r e o f c h i l d r e n a n d d e p e n d e n t a d u l t s u n d e r o n e r e g u l a t o r y b o a r d r e s p o n s i b l e t o t h e M i n i s t e r o f H e a l t h . 1 9 7 5 - t h e g r o w i n g n u m b e r o f f a c i l i t i e s r e s u l t e d i n s e p a r a t e b o a r d s ( a n d r e g u l a t i o n s ) f o r a d u l t a n d c h i l d c a r e f a c i l i t i e s . C o m m u n i t y r e p r e s e n t a t i o n w a s a d d e d t o t h e r e g u l a t o r y b o a r d s t o r e f l e c t a g r o w i n g p u b l i c c o n c e r n a b o u t f a c i l i t y - b a s e d c a r e . T h e A d u l t C a r e B o a r d i n c l u d e d r e p r e s e n t a t i v e s f r o m t h e M i n i s t r i e s o f E d u c a t i o n , H e a l t h a n d H u m a n R e s o u r c e s . 1 9 7 7 - s a w a m a j o r r e v i s i o n t o t h e A d u l t C a r e R e g u l a t i o n s i n w h i c h t h e g o v e r n m e n t ' s c o n c e r n f o r q u a l i t y o f c a r e f o r e l d e r l y r e s i d e n t s w a s r e f l e c t e d . T h e A d u l t C a r e B o a r d w a s g i v e n t h e a d d e d r e s p o n s i b i l i t y o f d e v e l o p i n g a p r o p o s a l f o r a L o n g - T e r m C a r e P r o g r a m t o b e i n a u g u r a t e d i n 1 9 7 8 . 1 9 7 8 - u n d e r t h e c o o r d i n a t i o n o f t h e A d u l t C a r e B o a r d t h e Home C a r e / L o n g - T e r m C a r e P r o g r a m w a s i m p l e m e n t e d J a n u a r y 1 , 1 9 7 8 . T h e p r o g r a m w a s t o p r o v i d e a n i n t e g r a t e d a p p r o a c h t o t h e p r o v i s i o n o f h o m e n u r s i n g c a r e , h o m e c a r e s u p p o r t s e r v i c e s , a n d f a c i l i t y - b a s e d l o n g - t e r m c a r e t h r o u g h t h e a d m i n i s t r a t i o n o f c l i e n t a s s e s s m e n t s a n d r e f e r r a l s , a n d a p u r c h a s e / p a y m e n t s y s t e m t o p r o v i d e r s . C H A P T E R I I - 22 -1 9 8 3 - t h e d e p a r t m e n t o f t h e M i n i s t r y o f H e a l t h r e s p o n s i b l e f o r t h e L o n g - T e r m C a r e ( L T C ) P r o g r a m w a s r e n a m e d t h e C o n t i n u i n g C a r e D i v i s i o n , I n s t i t u t i o n a l S e r v i c e s B r a n c h . T h i s d i v i s i o n i s r e s p o n s i b l e f o r t h e L o n g - T e r m C a r e P r o g r a m ( f a c i l i t y - b a s e d c a r e a n d h o m e s u p p o r t s ) , Home N u r s i n g C a r e a n d C o m m u n i t y T h e r a p y S e r v i c e s . F a c i l i t y -b a s e d l o n g - t e r m c a r e i n B r i t i s h C o l u m b i a i s , t h e r e f o r e , j u s t o n e a r e a o f t h e C o n t i n u i n g C a r e D i v i s i o n ' s r e s p o n s i b i l i t i e s . A s o f 1 9 8 3 , r e s p o n s i b i l i t y f o r t h e o v e r a l l d e v e l o p m e n t , i m p l e m e n t a t i o n a n d o p e r a t i o n a l c o n t r o l o f t h e C o n t i n u i n g C a r e D i v i s i o n w a s m o v e d f r o m c o o r d i n a t i o n u n d e r t h e A d u l t C a r e B o a r d t o m a n a g e m e n t b y t h e E x e c u t i v e D i r e c t o r a n d m a n a g e m e n t t e a m o f t h e C o n t i n u i n g C a r e D i v i s i o n . U n d e r t h e d i r e c t i o n o f t h e E x e c u t i v e D i r e c t o r , t h e m a n a g e m e n t t e a m w o r k s c l o s e l y w i t h t h e A d u l t C a r e B o a r d t o e n s u r e c o n g r u e n c e b e t w e e n t h e r e g u l a t i o n s a n d p r o g r a m g u i d e l i n e s f o r f a c i l i t y - b a s e d c a r e . T h e D i r e c t o r ( s ) o f t h e r e g i o n a l p u b l i c h e a l t h u n i t s c o n t i n u e t o a d m i n i s t e r f a c i l i t y l i c e n s u r e a n d e n f o r c e m e n t a c t i v i t i e s , a l o n g w i t h t h e a s s e s s m e n t a n d r e f e r r a l a c t i v i t i e s o f t h e L o n g - T e r m C a r e P r o g r a m [4] . T h e g o a l o f t h e L o n g - T e r m C a r e P r o g r a m i s t o p r o v i d e " h o m e a n d i n s t i t u t i o n a l c a r e t o p e r s o n s w h o n o l o n g e r f u n c t i o n i n d e p e n d e n t l y a s t h e r e s u l t o f h e a l t h - r e l a t e d p r o b l e m s " . [ 5 ] . T h e p r o g r a m ' s i n t r o d u c t o r y g u i d e f u r t h e r e l a b o r a t e s t h a t t h e a i m o f t h e p r o g r a m i s " t o p r o m o t e t h e h i g h e s t l e v e l o f i n d e p e n d e n c e p o s s i b l e . . . t o a l l o w t h e b e n e f i c i a r i e s t o l i v e a s n o r m a l a n e x i s t e n c e i n t h e i r o w n c o m m u n i t i e s a s t h e i r i n f i r m i t i e s p e r m i t " [ 6 : 4 ] . C H A P T E R I I - 2 3 -ORGANIZATIONAL STRUCTURE OF THE FACILITY-BASED SECTOR A s i n o t h e r j u r i s d i c t i o n s , f a c i l i t y - b a s e d l o n g - t e r m c a r e i n B r i t i s h C o l u m b i a i s a m i x e d p r o v i d e r s y s t e m o f f o r - p r o f i t a n d n o n - p r o f i t f a c i l i t i e s . I n t h e l i t e r a t u r e a v a r i e t y o f n a m e s h a v e b e e n u s e d t o d e n o t e f a c i l i t y - b a s e d c a r e f o r d e p e n d e n t a d u l t s w h o r e q u i r e c a r e b e c a u s e o f a g e a n d / o r c h r o n i c d i s e a s e a n d d i s a b i l i t y . T h e t e r m n u r s i n g home i s t h e m o s t c o m m o n o r ' g e n e r i c ' t e r m a p p l i e d t o s u c h f a c i l i t i e s , b u t i n B r i t i s h C o l u m b i a t h e s e h o m e s a r e m o s t o f t e n r e f e r r e d t o a s l o n g - t e r m c a r e f a c i l i t i e s [ 4 ; 7 ] . A l t h o u g h t h e L o n g - T e r m C a r e p r o g r a m i n c l u d e s s e v e r a l t y p e s o f f a c i l i t i e s , t h e m a j o r i t y o f r e s i d e n t s a r e p l a c e d i n n o n - p r o f i t o r f o r - p r o f i t l o n g - t e r m c a r e f a c i l i t i e s w h i c h p r o v i d e P e r s o n a l ( P C ) a n d I n t e r m e d i a t e L e v e l s ( I C ) o f c a r e 4 . I n 1 9 8 1 , s l i g h t l y m o r e t h a n h a l f ( 5 8 p e r c e n t ) o f t h e 2 7 0 l o n g - t e r m c a r e f a c i l i t i e s ( P C a n d I C ) w e r e p r o p r i e t a r y ( i . e . p r i v a t e l y o w n e d , f o r - p r o f i t f a c i l i t i e s ) , b u t n o n - p r o f i t f a c i l i t i e s p r o v i d e d c a r e 4 F i v e l e v e l s o f c a r e h a v e b e e n d e f i n e d , e a c h o f w h i c h c a n b e p r o v i d e d e i t h e r a t h o m e o r i n a f a c i l i t y . T h e l e v e l s , f r o m l o w e s t t o h i g h e s t a r e : P e r s o n a l C a r e ( P C ) ; t h r e e l e v e l s o f I n t e r m e d i a t e C a r e ( I j , 1 2 / I 3 ) ; a n d E x t e n d e d C a r e ( E C ) . P e r s o n a l C a r e ( P C ) c l i e n t s a r e i n d e p e n d e n t l y m o b i l e a n d a b l e t o e a t a n d t o i l e t w i t h o u t a s s i s t a n c e b u t m a y r e q u i r e m i n i m a l h e l p w i t h b a t h i n g a n d d r e s s i n g . S u c h c l i e n t s m a y b e m i l d l y c o n f u s e d a n d f o r g e t f u l b u t i n g e n e r a l t h e i r m e d i c a l c o n d i t i o n s a r e s t a b i l i z e d t o t h e p o i n t w h e r e t h e y d o n o t r e q u i r e d a i l y p r o f e s s i o n a l s u p e r v i s i o n . T h o s e a s s e s s e d a s r e q u i r i n g o n e o f t h e l e v e l s o f I n t e r m e d i a t e C a r e ( I ] . , I 2 , I 3 ) a r e m o r e i m p a i r e d . A l t h o u g h t e c h n i c a l l y s t i l l i n d e p e n d e n t l y m o b i l e , t h e s e c l i e n t s m a y r e q u i r e a s s i s t a n c e w i t h t o i l e t i n g , h a v e m i l d t o m o d e r a t e m e n t a l i m p a i r m e n t , a n d r e q u i r e d a i l y p r o f e s s i o n a l s u p e r v i s i o n o f m e d i c a t i o n , a p p l i c a t i o n o f s p e c i a l a p p l i a n c e s , e t c . E x t e n d e d ( E C ) , o n t h e o t h e r h a n d , i m p l i e s t h a t t h e c l i e n t i s v i r t u a l l y b e d r i d d e n a n d i n n e e d o f 2 4 -h o u r s k i l l e d n u r s i n g c a r e " i n S t a r k , A n n e t t e J . ; K l i e w e r , E r i c h ; G u t m a n , G l o r i a M.; a n d M c C a s h i n , B r i a n . " P l a c e m e n t C h a n g e s i n L o n g - T e r m C a r e : T h r e e Y e a r s ' E x p e r i e n c e . " A J P H 7 5 ( M a y 1 9 8 4 ) : 4 5 9 . C H A P T E R I I - 24 -t o m o r e t h a n 6 5 p e r c e n t (N= 8 , 7 4 5 ) o f t h e t o t a l 1 5 , 0 0 0 p e r s o n s i n f a c i l i t i e s [ 5 ] . I n 1 9 8 3 t h e r e w a s a s l i g h t l y h i g h e r p r o p o r t i o n o f f o r - p r o f i t f a c i l i t i e s , a l m o s t s i x t y p e r c e n t o f t h e t o t a l 3 0 1 f a c i l i t i e s . T h e m a j o r i t y o f t h e r e s i d e n t s a r e e l d e r l y , w i t h c h r o n i c d i s e a s e o r d i s a b i l i t y [ 5 : 4 3 - 4 4 ; 8 ] . ELIGIBILITY AND ASSESSMENT PROCESS A s i d e f r o m a r e s i d e n c y r e q u i r e m e n t 5 a n d t h e l i m i t a t i o n s o f a v a i l a b l e l o n g - t e r m c a r e r e s o u r c e s i n s o m e a r e a s , a n y r e s i d e n t o f B r i t i s h C o l u m b i a i n n e e d o f c a r e m a y a p p l y t o t h e L T C p r o g r a m . R e f e r r a l s m a y b e i n i t i a t e d b y a n y o n e w h o h a s k n o w l e d g e o f a n i n d i v i d u a l ' s n e e d a n d n o d i s t i n c t i o n i s m a d e o n t h e b a s i s o f t h e i n d i v i d u a l ' s f i n a n c i a l r e s o u r c e s [ 6 : 5 ] . C o s t t o t h e s y s t e m i s o n e f a c t o r c o n s i d e r e d i n d e c i d i n g w h i c h c a r e a l t e r n a t i v e ( h o m e c a r e o r f a c i l i t y c a r e ) b e s t m e e t s t h e c l i e n t ' s n e e d s . A l l r e s i d e n t s i n l o n g - t e r m c a r e f a c i l i t i e s i n B r i t i s h C o l u m b i a h a v e b e e n a s s e s s e d a s e l i g i b l e f o r b e n e f i t s u n d e r t h e L T C P r o g r a m a n d i t h a s b e e n j u d g e d t h a t f a c i l i t y c a r e , r a t h e r t h a n c a r e a t h o m e , i s t h e m o s t a p p r o p r i a t e c a r e a l t e r n a t i v e . P e r h a p s t h e m o s t o u t s t a n d i n g f e a t u r e o f t h e L o n g - T e r m C a r e P r o g r a m i n B . C . , a n d o n e f o u n d i n o n l y t w o o t h e r p r o v i n c e s i n C a n a d a , i s t h e s i n g l e p o i n t o f e n t r y f o r a d m i s s i o n t o t h e p r o g r a m [ 9 ; 1 0 ; 1 1 ] . A p p l i c a n t s a r e a s s e s s e d b y L o n g - T e r m C a r e P r o g r a m a s s e s s o r s ( e m p l o y e e s , u s u a l l y g r a d u a t e n u r s e s l o c a t e d i n 5 T h e r e s i d e n c y r e q u i r e m e n t i s a d u l t C a n a d i a n c i t i z e n s o r l a n d e d i m m i g r a n t s w h o h a v e l i v e d i n B . C . a t l e a s t t w e l v e m o n t h s p r i o r t o a p p l i c a t i o n f o r b e n e f i t s . C H A P T E R I I - 2 5 -l o c a l p u b l i c h e a l t h u n i t s ) t o d e t e r m i n e w h e t h e r t h e y r e q u i r e l o n g - t e r m c a r e a n d h o w t h e i r n e e d c a n m o s t a p p r o p r i a t e l y b e m e t . A n i m p o r t a n t a s p e c t o f t h e p r o g r a m i s t h e u n d e r l y i n g c o m m i t m e n t t o a c o n t i n u u m o f c a r e w h i c h p r o v i d e s a p p r o p r i a t e a n d r e a l i s t i c c a r e o p t i o n s , a n d w h i c h e n c o u r a g e s c a r e a t h o m e u n t i l t h i s i s n o l o n g e r f e a s i b l e . I n c o m p l e x s i t u a t i o n s , t h e a s s e s s m e n t m a y t a k e a n i n t e r d i s c i p l i n a r y a p p r o a c h i n w h i c h p r o f e s s i o n a l s w i t h n u r s i n g , s o c i a l w o r k , m e n t a l h e a l t h o r r e h a b i l i t a t i o n e x p e r t i s e , a s w e l l a s p h y s i c i a n a n d f a c i l i t y r e p r e s e n t a t i o n m a y p a r t i c i p a t e . I f t h e n e e d f o r p l a c e m e n t i n a f a c i l i t y i s e s t a b l i s h e d , a p p l i c a n t s a n d t h e i r f a m i l i e s a r e e n c o u r a g e d t o v i s i t a v a i l a b l e f a c i l i t i e s a n d i d e n t i f y t h e i r p r e f e r e n c e s . F a c i l i t i e s w i t h i n t h e L T C P r o g r a m h a v e t h e r i g h t t o r e f u s e a n a p p l i c a n t , b u t t h e f a c i l i t y o p e r a t o r d o e s n o t h a v e f i r s t o r o n l y i n p u t i n t o t h e d e c i s i o n a b o u t t h e n e e d f o r p l a c e m e n t [ 6 ] . P r o g r a m s t a f f m o n i t o r t h e w a i t i n g l i s t s f o r f a c i l i t y p l a c e m e n t ( b a s e d o n a p r i o r i t y s y s t e m e s t a b l i s h e d b y t h e p r o g r a m ) a n d p l a n f o r c a r e s u p p o r t a t h o m e w h i l e t h e a p p l i c a n t i s a w a i t i n g p l a c e m e n t . L o n g - t e r m c a r e a s s e s s o r s a l s o p e r i o d i c a l l y ( a t l e a s t a n n u a l l y ) r e - a s s e s s f a c i l i t y r e s i d e n t s a n d h o m e c a r e c l i e n t s t o d e t e r m i n e t h e c u r r e n t l e v e l o f c a r e r e q u i r e d . R e - a s s e s s m e n t m a y b e i n i t i a t e d a t t h e r e q u e s t o f t h e f a c i l i t y i f t h e r e i s a c o n c e r n a b o u t t h e c l i e n t s c h a n g i n g c o n d i t i o n o r a b o u t t h e a p p r o p r i a t e n e s s o f t h e p l a c e m e n t d e c i s i o n [ 1 2 ; 1 3 : 4 5 9 ] . C H A P T E R I I - 2 6 -A C C O U N T A B I L I T Y M E C H A N I S M S : L E G I S L A T I O N , S T A N D A R D S A N D B U D G E T A R Y G U I D E L I N E S G o v e r n m e n t a c c o u n t a b i l i t y f o r e n s u r i n g t h e a d e q u a c y o f c a r e p r o v i d e d i n l o n g - t e r m c a r e f a c i l i t i e s l n B r i t i s h C o l u m b i a i s c u r r e n t l y a c c o m p l i s h e d t h r o u g h a n u m b e r o f m e c h a n i s m s w h i c h h a v e n o t a l w a y s b e e n e n t i r e l y c o m p a t i b l e . T h e m o s t f o r m a l i z e d m e c h a n i s m s a r e t h e s t a t u t o r y r e g u l a t i o n s w h i c h w e r e i n p l a c e p r i o r t o t h e i m p l e m e n t a t i o n o f t h e L o n g - T e r m C a r e P r o g r a m . T h e s p e c i f i c l e g i s l a t i o n g o v e r n i n g l o n g - t e r m c a r e f a c i l i t i e s i s f o u n d i n t w o a c t s : 1 ) T h e C o m m u n i t y C a r e F a c i l i t y A c t ( 1 9 7 9 ) a n d A d u l t C a r e  R e g u l a t i o n s ( 1 9 8 0 ) w h i c h g o v e r n s t h e l i c e n s i n g a n d o p e r a t i o n o f t h e P e r s o n a l / I n t e r m e d i a t e C a r e f a c i l i t i e s a n d t h e M e n t a l H e a l t h B o a r d i n g H o m e s a d m i n i s t e r e d b y t h e P r o v i n c i a l A d u l t C a r e F a c i l i t i e s L i c e n s i n g B o a r d ( P A C F L B ) . 2 ) T h e H o s p i t a l A c t ( 1 9 7 8 ) w h i c h g o v e r n s t h e o p e r a t i o n o f P r i v a t e H o s p i t a l s a n d E x t e n d e d C a r e U n i t s 6 i n P u b l i c H o s p i t a l s a n d i s a d m i n i s t e r e d t h r o u g h t h e H o s p i t a l P r o g r a m s b r a n c h o f t h e M i n i s t r y o f H e a l t h [ 1 4 ] T h e m a j o r i t y o f t h e l o n g - t e r m c a r e f a c i l i t i e s ( P e r s o n a l a n d I n t e r m e d i a t e C a r e ) a r e r e g u l a t e d u n d e r t h e A d u l t C a r e R e g u l a t i o n s ( 1 9 8 0 ) o f t h e C o m m u n i t y C a r e F a c i l i t y A c t ( 1 9 7 9 ) [ 2 ] . T h e r e g u l a t i o n s e s t a b l i s h s t r u c t u r a l s t a n d a r d s f o r t h e s a f e t y a n d p r o t e c t i o n o f r e s i d e n t s , t h e r e q u i r e d q u a l i f i c a t i o n s o f s t a f f , s t a f f i n g r a t i o s , a n d t h e t y p e s o f s e r v i c e s o r p r o g r a m s 6 E x t e n d e d c a r e u n i t s / h o s p i t a l s p r o v i d e c a r e f o r c l i e n t s r e q u i r i n g t h e h e a v i e s t l e v e l o f c a r e , t h a t i s t h o s e t h a t a r e " v i r t u a l l y b e d r i d d e n a n d i n n e e d o f 24 h o u r s k i l l e d n u r s i n g c a r e " [ S t a r k e t a l . " P l a c e m e n t C h a n g e s i n L o n g - T e r m C a r e : T h r e e Y e a r s ' E x p e r i e n c e . " A J P H 7 5 ( M a y 1 9 8 4 ) : 4 5 9 . ] M o s t o f t h e s e t y p e s o f b e d s a r e h o s p i t a l b a s e d . C H A P T E R I I - 27 -t o b e p r o v i d e d . T h e r e g u l a t i o n s a l s o m a k e p r o v i s i o n f o r t h e e s t a b l i s h m e n t o f a f i n a n c i a l r e p o r t i n g s y s t e m f o r a l l l i c e n s e d f a c i l i t i e s . T h e m o n i t o r i n g o f f a c i l i t i e s t o e n s u r e c o m p l i a n c e w i t h t h e r e g u l a t i o n s h a s b e e n a d e c e n t r a l i z e d f u n c t i o n o f t h e r e g i o n a l p u b l i c h e a l t h u n i t s . T h e P A C F L B p r o v i d e s g e n e r a l g u i d e l i n e s f o r t h e m o n i t o r i n g a n d e n f o r c e m e n t p r o c e s s . H o w e v e r , t h e s p e c i f i c s a r e l e f t t o t h e d i s c r e t i o n o f i n d i v i d u a l H e a l t h U n i t D i r e c t o r s . T h i s p r o v i d e s t h e f l e x i b i l i t y t o a p p r o a c h e a c h f a c i l i t y ' s n e e d s a n d p r o b l e m s i n a n i n d i v i d u a l i z e d m a n n e r b u t l i m i t s t h e a b i l i t y t o d e v e l o p a c o m m o n a n d c o n s i s t e n t d a t a / i n f o r m a t i o n b a s e f o r p r o v i n c i a l d e c i s i o n m a k e r s [ 4 ] . T h e r e h a s b e e n s o m e c r i t i c i s m t h a t t h e A d u l t C a r e R e g u l a t i o n s a r e m i n i m a l a n d , a s a r e s u l t o f t h e d i f f e r e n t r e i m b u r s e m e n t m e t h o d s u s e d , w e r e u n e q u a l l y a p p l i e d ( e . g . i n t e r m s o f s t a f f i n g ) t o f o r - p r o f i t a n d n o n - p r o f i t f a c i l i t i e s . T o a d d t o t h e c o n f u s i o n , t h e r e g u l a t i o n s g o v e r n i n g P r i v a t e H o s p i t a l s ( w h i c h p r o v i d e I n t e r m e d i a t e C a r e ) a n d E x t e n d e d C a r e u n i t s c o m e u n d e r t h e H o s p i t a l A c t . T h i s A c t i s a d m i n i s t e r e d b y a n o t h e r s e c t i o n o f t h e M i n i s t r y ( H o s p i t a l P r o g r a m s D i v i s i o n ) , h a s d i f f e r e n t m o n i t o r i n g g u i d e l i n e s a n d , i n t h e c a s e o f E x t e n d e d C a r e , d i f f e r e n t f u n d i n g m e c h a n i s m s . S o m e f e e l t h e s e d i f f e r e n c e s v a r y t o a g r e a t e r e x t e n t t h a n i s n e c e s s a r y t o a c c o m m o d a t e t h e v a r i o u s l e v e l s o f c a r e p r o v i d e d [ 1 5 ; 1 6 ] . C H A P T E R I I - 2 8 -S t a n d a r d s f o r l o n g - t e r m c a r e f a c i l i t i e s , w h i c h " w o u l d e n s u r e a m i n i m u m s t a n d a r d o f c a r e t h r o u g h o u t a l l f a c i l i t i e s i n t h e p r o v i n c e " h a v e b e e n d r a f t e d , b u t h a v e n o t y e t b e e n i m p l e m e n t e d [ 5 : 4 2 ; 1 7 ; 1 8 ] . T h e s t a n d a r d s f o r f a c i l i t y c a r e a r e m a i n l y o f a p r o c e s s ( a c t i v i t i e s ) a n d s t r u c t u r a l ( i n p u t s ) n a t u r e . T h e y d o , h o w e v e r , a t t e m p t t o a d d r e s s m o r e s p e c i f i c a l l y t h e n e e d s o f c l i e n t s i n f a c i l i t y - b a s e d l o n g - t e r m c a r e t h a n i s p o s s i b l e u n d e r t h e m o r e g e n e r a l A d u l t C a r e r e g u l a t i o n s [ 1 7 ] . T h e M i n i s t r y o f H e a l t h p l a n n e d t o i n t r o d u c e t h e s e s t a n d a r d s t h r o u g h a d e m o n s t r a t i o n p r o j e c t i n w h i c h o u t c o m e s t a n d a r d s w e r e t o b e i n c l u d e d [ 1 7 ; 1 8 ; 1 9 ] . A l t h o u g h t h i s h a s n o t h a p p e n e d t o d a t e , n e w i n i t i a t i v e s a r e e x p e c t e d f o l l o w i n g t h e r e c e n t a p p o i n t m e n t o f a M a n a g e r f o r S t a n d a r d s a n d Q u a l i t y o f C a r e [ 1 8 ] . A s t h e F a c i l i t y R e i m b u r s e m e n t R e p o r t n o t e s " W i t h t h e e x c e p t i o n o f t h e L i c e n s i n g B o a r d , t h e r e [ a r e ] f e w p r o g r a m i n c e n t i v e s t o p r o v i d e g o o d q u a l i t y c a r e a n d t h e r e [ i s ] l i t t l e o n g o i n g m o n i t o r i n g a n d e v a l u a t i o n b y t h e C o n t i n u i n g C a r e s t a f f o f t h e q u a l i t y o f t h e c a r e p r o v i d e d . " [ 2 0 : 2 ] . U p t o 1 9 8 4 t h e L o n g - T e r m C a r e P r o g r a m b u d g e t a r y g u i d e l i n e s ( m a i n l y f o r s t a f f i n g ) w e r e u s e d t o d e t e r m i n e w h a t i n p u t s w o u l d b e f u n d e d i n n o n - p r o f i t f a c i l i t i e s . T h e y d i d n o t a p p l y t o f o r - p r o f i t f a c i l i t i e s . T o t h e e x t e n t t h a t s t a f f i n g i n p u t s a f f e c t a d e q u a c y o f c a r e , t h e g u i d e l i n e s p r o v i d e d a t l e a s t a n i m p l i c i t s t a n d a r d o f c a r e i n t h e n o n - p r o f i t f a c i l i t i e s . T h e f o l l o w i n g s e c t i o n e x a m i n e s t h e r e i m b u r s e m e n t m e c h a n i s m s i n m o r e d e t a i l . C H A P T E R I I - 2 9 -F I N A N C I A L C O N T R O L A N D R E I M B U R S E M E N T S Y S T E M S T h e f o l l o w i n g d e s c r i p t i o n o f t h e r e i m b u r s e m e n t s y s t e m i n B r i t i s h C o l u m b i a i s c o n f i n e d t o t h e p a y m e n t s y s t e m s u s e d f o r t h e l o n g - t e r m c a r e f a c i l i t i e s u n d e r t h e d i r e c t r e s p o n s i b i l i t y o f t h e L o n g - T e r m C a r e P r o g r a m ( i . e . l i c e n s e d P e r s o n a l a n d I n t e r m e d i a t e C a r e F a c i l i t i e s ) . U p t o t h e e n d o f t h e 1 9 8 3 / 8 4 f i s c a l y e a r , t h e m e t h o d o f r e i m b u r s e m e n t a n d f i n a n c i a l c o n t r o l d i f f e r e d d e p e n d i n g o n w h e t h e r a f a c i l i t y o p e r a t e d a s a f o r - p r o f i t o r n o n - p r o f i t f a c i l i t y [ 1 9 ; 2 0 ; 2 1 ] . T h a t i s , a d u a l s y s t e m w a s i n p l a c e . A l t h o u g h t h e g u i d e l i n e s i n t h e F i n a n c i a l S e c t i o n o f t h e L o n g - T e r m C a r e P r o g r a m M a n u a l ( 1 9 7 8 ) [ 1 2 ] a n d a s e c t i o n o f t h e A d u l t C a r e R e g u l a t i o n s ( 1 9 8 0 ) [ 2 ] m a d e p r o v i s i o n f o r a f i n a n c i a l r e p o r t i n g s y s t e m f o r a l l l o n g - t e r m c a r e f a c i l i t i e s , t h i s h a d n o t b e e n t h e p r a c t i c e . U n t i l t h e 1 9 8 3 / 8 4 f i s c a l y e a r , o n l y t h e n o n -p r o f i t f a c i l i t i e s w e r e r e q u i r e d t o s u b m i t b u d g e t s a n d q u a r t e r l y f i n a n c i a l r e p o r t s t o g o v e r n m e n t f u n d e r s [ 1 9 ] . D u r i n g 1 9 8 3 a j o i n t c o m m i t t e e w i t h r e p r e s e n t a t i o n f r o m t h e M i n i s t r y o f H e a l t h a n d p r o v i d e r a g e n c i e s w a s e s t a b l i s h e d t o e x p l o r e t h e d e v e l o p m e n t o f s u c h a r e p o r t i n g s y s t e m w i t h i n t h e c o n t e x t o f a n e w , c o m m o n r e i m b u r s e m e n t s y s t e m . F o r - p r o f i t f a c i l i t y r e p o r t i n g o f q u a r t e r l y f i n a n c i a l s t a t e m e n t s w a s i n t r o d u c e d f o r t h e f i r s t t i m e d u r i n g t h e l a t t e r p a r t o f t h e 1 9 8 3 / 8 4 f i s c a l y e a r . T h i s w a s j u s t p r i o r t o t h e i m p l e m e n t a t i o n o f t h e a r e v i s e d r e i m b u r s e m e n t s y s t e m w h i c h w a s p h a s e d i n , b e g i n i n g i n A p r i l 1 9 8 4 [ 1 9 ; 2 0 ] . C H A P T E R I I - 3 0 -O n t h e o t h e r h a n d , t h e a s s e s s m e n t o f a c o - p a y m e n t o r u s e r f e e f o r a l l r e s i d e n t s ( $ 1 5 . 2 5 a s o f A p r i l 1 , 1 9 8 6 ) w a s c o m m o n t o b o t h t h e f o r - p r o f i t a n d n o n - p r o f i t f a c i l i t i e s . T h e u s e r f e e i s e s s e n t i a l l y a d a i l y b o a r d a n d r o o m c h a r g e a n d d o e s n o t e x c e e d t h e a m o u n t a v a i l a b l e t o i n d i v i d u a l s t h r o u g h t h e s u p p l e m e n t e d O l d A g e S e c u r i t y P e n s i o n [ 1 3 : 4 6 0 ] . T h e c o - p a y m e n t a c c o u n t s f o r a p p r o x i m a t e l y o n e t h i r d ( 3 3 p e r c e n t ) o f t h e e s t a b l i s h e d p e r d i e m r a t e [ 2 1 : A p p . B . ] . T h e b a l a n c e o f p a y m e n t c o m e s f r o m g o v e r n m e n t f u n d i n g s o u r c e s . S o m e i n c o m e m a y b e d e r i v e d f r o m a r o o m d i f f e r e n t i a l f e e ( c h a r g e d w i t h i n s e t l i m i t s ) . U p t o f i f t e e n p e r c e n t o f n e w l y c o n s t r u c t e d b e d s i n a f a c i l i t y m a y b e d e s i g n a t e d a s p r e f e r r e d a c c o m m o d a t i o n . D a t a o n t h e p e r c e n t a g e o f b e d s s o d e s i g n a t e d a n d f o r w h i c h a c h a r g e i s m a d e i s n o t a v a i l a b l e [18]. F O R - P R O F I T F A C I L I T Y R E I M B U R S E M E N T U n t i l 1 9 8 4 / 8 5 f o r - p r o f i t ( p r i v a t e ) f a c i l i t i e s w e r e r e i m b u r s e d b y t h e L o n g - T e r m C a r e P r o g r a m o n a f l a t - r a t e p e r d i e m b a s i s b y l e v e l o f c a r e . T h i s r a t e w a s e x p e c t e d t o c o v e r a l l o p e r a t i n g c o s t s i n c l u d i n g n e g o t i a t e d w a g e s e t t l e m e n t s . H o w e v e r , s i n c e 1 9 8 2 , e x c e p t i o n s h a v e b e e n m a d e f o r s o m e f a c i l i t i e s i n o r d e r t o a d j u s t f o r w a g e s e t t l e m e n t s . A s n o t e d b y B a i n b r i d g e [ 7 : 3 2 ] , t h e o r i g i n a l r a t e s s e t w h e n t h e p r o g r a m w a s i m p l e m e n t e d i n 1 9 7 8 w e r e b a s e d o n a s u r v e y o f f a c i l i t y c o s t s a t t h a t t i m e . T h e r e h a d b e e n y e a r l y p e r c e n t a g e i n c r e a s e s , b u t b y 1 9 8 3 t h i s f l a t - r a t e w a s l o w e r ( b y a p p r o x i m a t e l y $ 6 . 0 0 ) t h a n t h e a v e r a g e n o n - p r o f i t p e r d i e m r a t e [ 1 9 ; 2 1 : 1 1 ] . P r i o r t o 1 9 8 4 , t h e f o r -CHAPTER II - 31 -p r o f i t f a c i l i t i e s were not required to submit f i n a n c i a l statements. The following problems have been noted with t h i s f o r - p r o f i t f l a t - r a t e reimbursement system: - Operator/owners claim the rates have been i n s u f f i c i e n t to meet operational requirements, and some f a c i l i t i e s have closed for t h i s reason. Concerns have also been raised about c a p i t a l costs - are they or should they be considered i n the f l a t rate, are operating costs eroded to cover c a p i t a l costs, and does th i s e f f e c t i v e l y reduce the q u a l i t y of care? - Large private nursing home chains have been reluctant to enter the B.C. market; these chains are perceived to be more e f f i c i e n t l y management. Their lack of p a r t i c i p a t i o n i s seen by some as a loss to the industry i n B.C., at least i n terms of management s k i l l s and the a b i l i t y to maintain viable f a c i l i t i e s [22; 23:248] - The widening gap between the per diem reimbursement of non-profit and f o r - p r o f i t f a c i l i t i e s . The Ministry could not maintain a f l a t rate payment due to union contract settlements [20]. - Perhaps a greater issue i s the concern that lower reimbursement rates 'potentially' create an even greater l i k e l i h o o d that profit-maximizing f a c i l i t i e s w i l l introduce e f f i c i e n c y measures at the expense of q u a l i t y care. The lack of f i n a n c i a l reporting hampered the Ministry's a b i l i t y to evaluate expenditure patterns. For the private, f o r - p r o f i t f a c i l i t i e s the Incentive of the f l a t rate reimbursement system has been to accept c l i e n t s requiring higher l e v e l s of care and/or to require reassessment of c l i e n t s to higher l e v e l s once they are i n the f a c i l i t y . This i n turn creates the potential for c o n f l i c t i n g pressures on the LTC assessors and/or discourages the f a c i l i t y from promoting independence i n i t s residents. A lack of effectiveness measures makes i t impossible to e s t a b l i s h i f t h i s was the case. The r e s u l t may be greater costs to the funders i n terms of more s t a f f time spent assessing f a c i l i t y residents or i n reimbursing, C H A P T E R I I - 32 -p e r h a p s i n a p p r o p r i a t e l y , f o r g r e a t e r n u m b e r s o f c l i e n t s a t h i g h e r l e v e l s o f c a r e . O n t h e o t h e r h a n d , t h e f l a t - r a t e f e e e n c o u r a g e s e f f i c i e n t e x p e n d i t u r e o f f u n d s a n d d i s c o u r a g e s i n f l a t i o n a r y c o s t s e t t i n g . N O N - P R O F I T F A C I L I T Y R E I M B U R S E M E N T P r i o r t o t h e 1 9 8 4 / 8 5 f i s c a l y e a r , n o n - p r o f i t f a c i l i t i e s w e r e r e i m b u r s e d t h r o u g h a b u d g e t r e v i e w / i n d i v i d u a l - r a t e s y s t e m . E a c h n o n - p r o f i t f a c i l i t y w a s r e q u i r e d t o s u b m i t a b u d g e t f o r r e v i e w a n d a s i n g l e p e r d i e m r a t e w a s t h e n d e t e r m i n e d f o r e a c h f a c i l i t y . A d j u s t m e n t s w e r e m a d e b a s e d o n a n u m b e r o f f a c t o r s : t h e m i x o f r e s i d e n t s a t e a c h l e v e l o f c a r e ( a n d t h e c o n s e q u e n t e f f e c t o n s t a f f i n g n e e d s ) ; f i n a n c i n g a r r a n g e m e n t s f o r c a p i t a l c o s t s ; w a g e a g r e e m e n t s ; l i m i t a t i o n s i n b u i l d i n g s t r u c t u r e s w h i c h m a y a f f e c t c o s t s ( e . g . c o m m u n a l b a t h r o o m s w h i c h r e q u i r e m o r e s t a f f t o a s s i s t d e p e n d e n t r e s i d e n t s ) . T h i s r e s u l t e d i n d i f f e r i n g p e r d i e m r a t e s f o r e a c h f a c i l i t y , a n d a n a v e r a g e r a t e w h i c h w a s h i g h e r t h a n t h e r a t e d e t e r m i n e d f o r t h e p r i v a t e f a c i l i t i e s [ 1 9 ; 2 0 ; 2 1 ] . P r o b l e m s n o t e d w i t h t h e n o n - p r o f i t , i n d i v i d u a l l y s e t r a t e o f r e i m b u r s e m e n t i n c l u d e : - a m o r e c o m p l e x p r o c e s s a n d m o r e d i r e c t i n v o l v e m e n t o f t h e L T C P r o g r a m ( g o v e r n m e n t ) i n a f a c i l i t y ' s b u d g e t a r y p r o c e s s , t h u s e r o d i n g t h e g o a l o f a n a r m s - l e n g t h r e l a t i o n s h i p . - t h e r e i s n o r e a l i n c e n t i v e f o r m o r e e f f i c i e n t o p e r a t i o n o f t h e n o n - p r o f i t f a c i l i t y o r f o r t h e f a c i l i t y t o a c c e p t r e s i d e n t s a t h i g h e r l e v e l s o f c a r e . - n o n - p r o f i t f a c i l i t i e s o c c a s i o n a l l y f o u n d t h e m s e l v e s i n a d e f i c i t p o s i t i o n a n d n e e d e d g o v e r n m e n t a s s i s t a n c e t o m e e t t h e s h o r t f a l l [ 2 0 : 2 ] . C H A P T E R I I - 33 -O n t h e p o s i t i v e s i d e t h i s p r o c e s s d i d r e q u i r e n o n - p r o f i t f a c i l i t i e s t o p r o v i d e t h e f u n d e r w i t h c o n s i d e r a b l e f i n a n c i a l i n f o r m a t i o n . H o w e v e r , t h e F a c i l i t y R e i m b u r s e m e n t R e p o r t n o t e s t h a t n o n - p r o f i t f a c i l i t i e s w e r e o f t e n s l o w w i t h q u a r t e r l y r e p o r t s , t h u s r e d u c i n g t h e g o v e r n m e n t ' s a b i l i t y t o c o n t r o l c o s t s [ 2 0 : 2 ] . S i n c e 1 9 8 4 , a l l f a c i l i t i e s p r o v i d e f i n a n c i a l r e p o r t s o n a q u a r t e r l y b a s i s g i v i n g t h e L o n g - T e r m C a r e P r o g r a m t h e p o t e n t i a l t o d e v e l o p c o m p a r a t i v e d a t a a n a l y s e s o n c o s t s a n d e f f i c i e n c i e s a m o n g s t a l l p r o g r a m f a c i l i t i e s [ 1 9 ; 2 0 ; 2 1 ] . P R O B L E M S W I T H T H E R E I M B U R S E M E N T S Y S T E M A s d e s c r i b e d a b o v e , t h e r e w a s a d u a l r e i m b u r s e m e n t s y s t e m i n o p e r a t i o n i n B r i t i s h C o l u m b i a u n t i l t h e 1 9 8 4 / 8 5 f i s c a l y e a r -o n e f o r f o r - p r o f i t f a c i l i t i e s a n d a n o t h e r f o r n o n - p r o f i t f a c i l i t i e s . A n u m b e r o f p r o b l e m s w e r e e x p e r i e n c e d w i t h d u a l s y s t e m : [ 4 ; 1 9 ; 2 0 ; 2 1 ] . - T h e d i f f e r e n c e s i n t h e m e t h o d u s e d t o r e i m b u r s e f o r - p r o f i t a n d n o n - p r o f i t f a c i l i t i e s p r o v i d e d d i f f e r e n t i n c e n t i v e s f o r e f f e c t i v e n e s s a n d e f f i c i e n c y i n t h e m a n a g e m e n t o f f a c i l i t y c a r e i n B r i t i s h C o l u m b i a ( I n f a c t t h e F a c i l i t y R e i m b u r s e m e n t R e p o r t n o t e s t h a t t h e r e w e r e i n s u f f i c i e n t i n c e n t i v e s f o r e f f i c i e n c y i n n o n - p r o f i t f a c i l i t i e s a n d f e w i n c e n t i v e s f o r p r o v i d i n g q u a l i t y o f c a r e i n e i t h e r t y p e o f f a c i l i t y . ) [ 2 0 : 2 ] ; - T h e s e d i f f e r e n c e s c r e a t e d a n u n e v e n d a t a b a s e f o r d e c i s i o n m a k e r s c o n c e r n i n g t h e a c t u a l c o s t s i n v o l v e d i n p r o v i d i n g e f f e c t i v e a n d e f f i c i e n t f a c i l i t y - b a s e d l o n g - t e r m c a r e ; - G o v e r n m e n t d e c i s i o n m a k e r s ( f u n d e r s ) w e r e a l s o m o r e d i r e c t l y i n v o l v e d i n d e t e r m i n i n g i n p u t s s u c h a s s t a f f i n g a n d o t h e r s t r u c t u r a l a s p e c t s f o r t h e n o n - p r o f i t f a c i l i t i e s , t h u s r e d u c i n g a f a c i l i t i e s ' s c o p e a n d f l e x i b i l i t y i n m a k i n g d e c i s i o n s ; C H A P T E R I I - 34 -- T h e d i f f e r e n c e s i n t h e a c t s a n d g u i d e l i n e s w h i c h g o v e r n f a c i l i t y o p e r a t i o n s f u r t h e r c o m p l i c a t e m a t t e r s . N E E D F O R A NEW R E I M B U R S E M E N T S Y S T E M I t w a s f e l t b y c a r e p r o v i d e r s a n d g o v e r n m e n t s t a f f a l i k e t h a t , w h i l e m a i n t a i n i n g a m i x e d p r o v i d e r s y s t e m , s o m e o t h e r r e i m b u r s e m e n t p r o c e s s s h o u l d b e c o n s i d e r e d w h i c h w o u l d g i v e m o r e a u t o n o m y a n d f l e x i b i l i t y t o t h e m a n a g e r s o f f a c i l i t i e s , r e t a i n a n a r m s - l e n g t h i n v o l v e m e n t b y t h e f u n d e r s , a n d s t i l l m e e t t h e a c c o u n t a b i l i t y r e s p o n s i b i l i t i e s o f g o v e r n m e n t ( f u n d e r s ) t o e n s u r e a d e q u a c y o f c a r e a n d e f f i c i e n t e x p e n d i t u r e o f f u n d s [ 1 9 ; 2 0 ; 2 1 ] . T h e g o a l o f t h e n e w i n t e g r a t e d r e i m b u r s e m e n t s y s t e m i s t o d e v e l o p o n e s y s t e m o f r e i m b u r s e m e n t f o r a l l p r o v i d e r s w h i c h c a n b e a d a p t e d t o a c c o u n t f o r t h e d i f f e r i n g n e e d s , p u r p o s e s a n d p r o g r a m s o f a l l f a c i l i t i e s . I t i s p l a n n e d t o i n c l u d e v a r i a b l e s w h i c h a d d r e s s t h e i s s u e o f e n s u r i n g o r p r o v i d i n g i n c e n t i v e s f o r a d e q u a c y o f c a r e [ 2 0 ; 2 1 ] , a s w e l l a s i n c e n t i v e s f o r e f f i c i e n t o p e r a t i o n o f a f a c i l i t y . T h e F a c i l i t y R e i m b u r s e m e n t R e p o r t s p e c i f i c a l l y n o t e s t h a t t h e n e w s y s t e m w o u l d n o t r e w a r d e f f i c i e n c y a t t h e e x p e n s e o f q u a l i t y ( s e e A p p e n d i x B f o r d e t a i l s a b o u t t h e g o a l s a n d h o w t h e y a r e t o b e a c h i e v e d ) . A d m i n i s t r a t i v e f e a s i b i l i t y , p r o v i s i o n f o r a n a r m s - l e n g t h r e l a t i o n s h i p b e t w e e n g o v e r n m e n t f u n d e r s a n d p r o v i d e r s , a n d t h e a b i l i t y t o a d j u s t p r o v i n c i a l b e d r e q u i r e m e n t s a r e o t h e r a s p e c t s w h i c h , w e r e i d e n t i f i e d b y t h e f u n d e r s a s n e e d i n g t o b e a d d r e s s e d [ 2 1 : 1 1 , 2 5 ] i n o r d e r t o o v e r c o m e c u r r e n t p r o b l e m s a n d t o m e e t t h e i r o b j e c t i v e s f o r a n e f f i c i e n t a n d e f f e c t i v e s y s t e m . C H A P T E R I I - 3 5 -R E F E R E N C E S 1 . B r i t i s h C o l u m b i a . W e l f a r e I n s t i t u t i o n s A c t 1 9 3 8 2 . B r i t i s h C o l u m b i a . C o m m u n i t y C a r e F a c i l i t y A c t 1 9 7 9 a n d  A d u l t C a r e R e g u l a t i o n s 1 9 8 0 . 3 . B r i t i s h C o l u m b i a . M i n i s t r y o f H e a l t h A n n u a l R e p o r t s : 1 9 7 0 - 1 9 8 3 . 1 9 7 0 - 1 9 8 3 . 4 . L e v e n i c k , K a r e n . " A R e v i e w o f G o v e r n m e n t R e g u l a t o r y R e s p o n s i b i l i t y f o r A d u l t C a r e F a c i l i t i e s a n d O p t i o n s o r R e g u l a t i o n i n B r i t i s h C o l u m b i a . " C l e r k s h i p R e p o r t . B r i t i s h C o l u m b i a M i n i s t r y o f H e a l t h , 1 9 8 2 . ( M i m e o g r a p h e d . ) 5 . B r i t i s h C o l u m b i a . M i n i s t r y o f H e a l t h A n n u a l R e p o r t : 1 9 8 1 . 1 9 8 1 . 6 . B r i t i s h C o l u m b i a , M i n i s t r y o f H e a l t h . I n t r o d u c t i o n t o t h e  P r o g r a m f o r L o n g - T e r m C a r e : E f f e c t i v e J a n u a r y , 1 9 7 8 . 1 9 7 7 . 7 . B a i n b r i d g e , J a c k . " B r i t i s h C o l u m b i a ' s L o n g - T e r m C a r e P r o g a m : t h e F i r s t T w o Y e a r s " . H e a l t h M a n a g e m e n t F o r u m 1 ( S u m m e r 1 9 8 0 ) : 2 8 - 3 6 8 . B r i t i s h C o l u m b i a . M i n i s t r y o f H e a l t h A n n u a l R e p o r t : 1 9 8 3 . 1 9 8 3 . 9 . A l b e r t a D e p a r t m e n t o f H e a l t h a n d M e d i c a l C a r e . R e c o m m e n d a t i o n s : A l b e r t a N u r s i n g Home R e v i e w P a n e l , M a r c h 1 9 8 2 . 1 0 . H a m m e r , M a r k a n d L e v e n i c k , K a r e n . " N u r s i n g H o m e C a r e I n W a s h i n g t o n S t a t e a n d B r i t i s h C o l u m b i a : S i m i l a r i t i e s a n d D i f f e r e n c e s . " T h e l e a d p a p e r f o r t h e S y m p o s i u m o n R e g u l a t o r y I n f l u e n c e s o n t h e M a n a g e m e n t o f N u r s i n g H o m e s p r e s e n t e d a t t h e W e s t e r n A c a d e m y o f M a n a g e m e n t A n n u a l M e e t i n g , V a n c o u v e r , B . C . , A p r i l 1 9 8 4 . ( M i m e o g r a p h e d . ) 1 1 . C a n a d a . D e p a r t m e n t o f N a t i o n a l H e a l t h a n d W e l f a r e . C a n a d i a n  G o v e r n m e n t a l R e p o r t o n A g i n g . O t t a w a , O n t a r i o , 1 9 8 2 . 1 2 . B r i t i s h C o l u m b i a , M i n i s t r y o f H e a l t h . M a n u a l o f  A d m i n i s t r a t i o n : L o n g - T e r m C a r e P r o g r a m . 1 9 7 8 . 1 3 . S t a r k , A n n e t t e J . ; K l i e w e r , E r i c h ; G u t m a n , G l o r i a M . ; a n d M c C a s h i n , B r i a n . " P l a c e m e n t C h a n g e s i n L o n g - T e r m C a r e : T h r e e Y e a r s ' E x p e r i e n c e " . A J P H 7 5 ( M a y 1 9 8 4 ) : 4 5 9 - 4 6 3 . C H A P T E R I I - 3 6 -1 4 . B r i t i s h C o l u m b i a . H O S P I T A L A C T 1 9 7 B 1 5 . B r i t i s h C o l u m b i a H e a l t h A s s o c i a t i o n . B r i e f t o t h e L o n g T e r m  C a r e R e v i e w T e a m o n L o n g T e r m C a r e P h i l o s o p h y a n d S t a f f i n g . S e p t e m b e r 1 9 8 0 . 1 6 . H e a l t h E m p l o y e e s U n i o n . L o n g - T e r m C a r e i n B r i t i s h  C o l u m b i a : T h e U n i o n M e m b e r s P e r s p e c t i v e . M a y 1 9 8 1 . 1 7 . B r i t i s h C o l u m b i a , M i n i s t r y o f H e a l t h . H o m e C a r e / L o n g - T e r m C a r e P r o g r a m . P r o p o s a l f o r I m p l e m e n t a t i o n a n d M o n i t o r i n g  o f R e s i d e n t i a l C a r e S t a n d a r d s . A u g u s t 7 , 1 9 8 1 . 1 8 . D a v i s , P a t r i c i a . M a n a g e r , S t a n d a r d s a n d Q u a l i t y o f C a r e , C o n t i n u i n g C a r e D i v i s i o n , M i n i s t r y o f H e a l t h . M a y 1 9 8 6 ( P e r s o n a l C o m m u n i c a t i o n . ) 1 9 . B r i t i s h C o l u m b i a , M i n i s t r y o f H e a l t h . C o n t i n u i n g C a r e D i v i s i o n , I n s t i t u t i o n a l S e r v i c e s . " I n t r o d u c t i o n o f t h e New R e i m b u r s e m e n t S y s t e m f o r L o n g T e r m C a r e F a c i l i t i e s i n B r i t i s h C o l u m b i a . " M a r c h 1 6 , 1 9 8 4 . ( M i m e o g r a p h e d . ) 2 0 . B r i t i s h C o l u m b i a , M i n i s t r y o f H e a l t h . L o n g T e r m C a r e P r o g r a m , C o n t i n u i n g C a r e D i v i s i o n . F a c i l i t y R e i m b u r s e m e n t  S y s t e m . J a n u a r y 1 9 8 5 . 2 1 . B o l t o n , P a t r i c i a " R e i m b u r s e m e n t f o r L o n g - T e r m C a r e i n B r i t i s h C o l u m b i a " C l e r k s h i p R e p o r t . B r i t i s h C o l u m b i a M i n i s t r y o f H e a l t h . S e p t e m b e r 1 9 8 3 . ( M i m e o g r a p h e d . ) 2 2 . H a l l , M y r n a . E x e c u t i v e D i r e c t o r , C o n t i n u i n g C a r e D i v i s i o n , I n s t i t u t i o n a l S e r v i c e s , M i n i s t r y o f H e a l t h . A u g u s t 1 9 8 3 . ( P e r s o n a l C o m m u n i c a t i o n . ) 2 3 . K a n e , R o b e r t L . a n d K a n e , R o s a l i e . A W i l l a n d A W a y : W h a t  t h e U n i t e d S t a t e s C a n L e a r n a b o u t C a r i n g f o r t h e E l d e r l y . New Y o r k : C o l u m b i a U n i v e r s i t y P r e s s , 1 9 8 5 . CHAPTER I I I : DETERMINANTS OF FEASIBILITY FOR THE USE OF OUTCOME-BASED MEASURES IN FACILITY-BASED CARE IN B.C.: THE CONSTRAINING FACTORS INTRODUCTION In t h i s chapter the constraints or li m i t a t i o n s which a f f e c t the successful a p p l i c a t i o n of an approach to measuring effectiveness and outcome-based reimbursement for f a c i l i t y - b a s e d long-term care are discussed. While Chapter 2 describes the current system of monitoring the adequacy of care and reimbursement i n B r i t i s h Columbia, i n t h i s chapter some of the system constraints to introducing the measurement of cli e n t / c a r e outcomes into a reimbursement system for f a c i l i t y - b a s e d long-term care are developed. Included i n the discussion i s an exploration of the need and methods for valuing i n the development of assessment measures for f a c i l i t y - b a s e d long-term care. For instance the determination of the underlying values or b e l i e f s about health and long-term care can be a major methodological constraint i n the development of an outcome-based reimbursement system: what outcomes are desired, by whom and to what extent? The major concepts of the study - outcome measurement, reimbursement, outcome-based reimbursement, effectiveness and e f f i c i e n c y as they apply i n the study are then presented. The remainder of the chapter presents the organizational and s t r u c t u r a l constraints imposed by s o c i a l policy, the C H A P T E R I I I - 3 8 -c o n s t i t u t i o n a l a n d l e g a l b a s e , a n d t h e e c o n o m i c a n d f i n a n c i a l e n v i r o n m e n t o f t h e l o n g - t e r m c a r e s y s t e m i n C a n a d a . I n t h i s a s p e c t o f t h e a n a l y s i s i t w a s i m p o r t a n t , p r i o r t o a r e v i e w o f t h e o u t c o m e - b a s e d m e a s u r e m e n t a n d / o r r e i m b u r s e m e n t a p p r o a c h e s , t o i d e n t i f y t h e c o n s t r a i n t s p e c u l i a r t o C a n a d a a s m o s t o f t h e e x p e r i e n c e a n d r e s e a r c h h a s b e e n b a s e d o n a p p l i c a t i o n s f r o m t h e U n i t e d S t a t e s . T o t h a t e n d , a c o m p a r i s o n o f t h e l o n g - t e r m c a r e s y s t e m i n C a n a d a a n d t h e U n i t e d S t a t e s i s p r e s e n t e d . I n f l u e n c e s f r o m t h e U n i t e d S t a t e s i n c l u d e t h e e a r l y j o i n t a c c r e d i t a t i o n v e n t u r e s i n h o s p i t a l s [ 1 ] , i n t e r n a t i o n a l e x c h a n g e s a m o n g h e a l t h c a r e p r o f e s s i o n a l s a n d / o r p r o v i d e r s , a n d t h e v o l u m i n o u s A m e r i c a n h e a l t h c a r e l i t e r a t u r e . C O N S T R A I N T - T H E N E E D F O R V A L U I N G I N T H E A S S E S S M E N T O F L O N G - T E R M C A R E I n a n y p o l i t i c a l ( o r p r o d u c t i o n ) s y s t e m , p o l i c y d e c i s i o n s a n d t h e a s s u m p t i o n s o n w h i c h t h o s e d e c i s i o n s a r e b a s e d , r e f l e c t c e r t a i n v a l u e s o r b e l i e f s . I n t h e c o m p e t i t i v e m a r k e t s y s t e m , c o n s u m e r b e h a v i o u r a c t s a s t h e " n o r m a t i v e " m e a s u r e o f a s o c i e t y ' s v a l u e s a n d i s a c o n s t r a i n i n g f a c t o r i n d e t e r m i n i n g w h a t i s p r o d u c e d . I n t h e C a n a d i a n p u b l i c s e r v i c e s e c t o r , w h i c h i s a n o n - c o m p e t i t i v e m a r k e t s y s t e m g o v e r n e d b y e l e c t e d r e p r e s e n t a t i v e s , i t i s e x p e c t e d t h a t s u c h p o l i c y d e c i s i o n s w i l l r e f l e c t n o t o n l y t h e v a l u e p r e f e r e n c e s o f t h e s y s t e m ' s u s e r s , b u t a l s o t h e c o l l e c t i v e p r e f e r e n c e s o f t h e s o c i e t y . [ 2 : 3 ] . I n t h e h e a l t h c a r e s y s t e m t h e c h o i c e o f w h i c h s e r v i c e s t o c o n s u m e ( o r p u r c h a s e ) m a y n o t b e d i r e c t l y o r s o l e l y a d e c i s i o n C H A P T E R I I I - 3 9 -o f t h e c o n s u m e r , n o r i s t h e d e c i s i o n n e c e s s a r i l y b a s e d o n t h e c o n s u m e r ' s v a l u e s o r p r e f e r e n c e s a l o n e [ 3 : 2 8 - 2 9 ] . S u c h d e c i s i o n s u s u a l l y i n v o l v e a n a g e n t s u c h a s a p h y s i c i a n o r o t h e r h e a l t h c a r e w o r k e r w h o a c t s i n w h o l e o r i n p a r t f o r t h e c o n s u m e r . I n h e a l t h c a r e , t h e r e f o r e , a n a l t e r n a t i v e t o t h e c o m p e t i t i v e m a r k e t s y s t e m o f v a l u e s e t t i n g i s n e e d e d t o d e t e r m i n e c o n s u m e r p r e f e r e n c e s o r v a l u e s . T h i s a p p r o a c h t o v a l u i n g i s c a l l e d value preference measurement. L i p s c o m b [ 3 ] s t a t e s t h a t c u r r e n t l y t h e r e a r e t h r e e m e c h a n i s m s t h r o u g h w h i c h p u b l i c p o l i c y o p t i o n s a r e v a l u e d . T w o a r e i n d i r e c t m e c h a n i s m s : a d m i n i s t r a t i v e d e c r e e a n d l e g i s l a t i o n . T h e s e a r e t h e m o s t c o m m o n l y u s e d i n h e a l t h c a r e d e c i s i o n m a k i n g [ 3 : 3 6 ] . I n t h e s e i n s t a n c e s t h e d e c i s i o n m a k e r m a k e s t h e d e c i s i o n o n b e h a l f o f t h e p o p u l a t i o n s e r v e d . O n e a d v a n t a g e o f t h e i n d i r e c t m e c h a n i s m s i s t h a t d e c i s i o n s a r e m a d e o n t h e b a s i s o f t h e i m p l i c i t v a l u e s o f t h e p e o p l e s e r v e d , t h u s a v o i d i n g t h e p r o b l e m s a s s o c i a t e d w i t h d e t e r m i n i n g e x p l i c i t v a l u e s . H o w e v e r , o n t h e n e g a t i v e s i d e , t h e d e c i s i o n m a k e r s ' k n o w l e d g e o r u n d e r s t a n d i n g o f c o n s u m e r p r e f e r e n c e s m a y n o t c o i n c i d e w i t h t h e " t r u e " s o c i e t a l v a l u e [ 3 : 3 3 - 3 4 ] . T h e t h i r d m e c h a n i s m i s d i r e c t a s s e s s m e n t o f t h e p r e f e r e n c e s o f t h e i n d i v i d u a l s i n a p o p u l a t i o n , t o w h i c h s o m e a g g r e g a t i o n r u l e i s t h e n a p p l i e d t o t r a n s l a t e t h i s i n f o r m a t i o n i n t o a s o c i e t a l v a l u e . L i p s c o m b s u g g e s t s t h a t f o r h e a l t h p o l i c y m a k e r s , " . . . t h e p u r p o s e o f m e a s u r i n g v a l u e p r e f e r e n c e s . . . i s t o c o n s t r u c t e f f e c t i v e n e s s o r b e n e f i t i n d e x e s t h a t f a c i l i t a t e e i t h e r t h e r e t r o s p e c t i v e e v a l u a t i o n o f p r o g r a m s o f t h e C H A P T E R I I I - 4 0 -p r o s p e c t i v e a l l o c a t i o n o f r e s o u r c e s . . . " [ 3 : 2 8 ] . B o t h o f t h e s e p u r p o s e s a r e o f i n t e r e s t i n t h i s s t u d y . I n a c u t e c a r e a c o n s i d e r a b l e b o d y o f r e s e a r c h a b o u t t h e d i r e c t a p p r o a c h t o v a l u i n g h a s b e e n d e v e l o p e d , u s i n g d i r e c t s u r v e y m e c h a n i s m s i n w h i c h t h e c o n c e n t r a t i o n h a s b e e n o n m e a s u r i n g p r e f e r e n c e s f o r a l t e r n a t i v e t y p e s o f h e a l t h c a r e s e r v i c e s [ 3 : 2 8 - 5 4 ; 4 : 2 2 8 ; 5 : 2 3 3 - 5 4 ; 6 : 2 7 7 - 9 0 ] . K a n e a n d K a n e n o t e t h a t i n l o n g - t e r m c a r e t h e r e i s n o s i m i l a r b o d y o f w o r k o n v a l u i n g . T h e y a l s o s u g g e s t t h a t i n a d d i t i o n t o t h e m e t h o d o l o g i c a l p r o b l e m s e x p e r i e n c e d i n a c u t e c a r e , t h e r e a r e a d d i t i o n a l p r o b l e m s t o a d d r e s s i n t h e m e a s u r e m e n t o f h e a l t h s t a t u s a n d i t s a s s o c i a t e d v a l u i n g i n l o n g - t e r m c a r e [ 6 : 3 - 2 6 ] . T h e h e t e r o g e n e i t y o f t h e r e s i d e n t s o f a l o n g - t e r m c a r e f a c i l i t y a n d t h e l o n g - t e r m n a t u r e o f f a c i l i t y p l a c e m e n t a r e m a j o r f a c t o r s w h i c h c o n t r i b u t e t o t h e s e p r o b l e m s [ 6 : 2 7 7 - 9 0 ] . T h e p r e s e n t a t i o n o n H e a l t h S t a t u s I n d e x e s ( H S I s ) i n C h a p t e r s F o u r a n d F i v e r e v i e w t h e s e m e t h o d o l o g i c a l p r o b l e m s a n d d i s c u s s s o m e o f t h e s p e c i f i c a p p r o a c h e s p r o p o s e d f o r r e s o l v i n g t h e m . F r o m a n o t h e r p e r s p e c t i v e , p e r h a p s t h e m o r e c r i t i c a l i s s u e f o r t h i s s t u d y i s w h e t h e r , i f t h e m e t h o d o l o g i c a l i s s u e s c a n b e s o l v e d , v a l u e p r e f e r e n c e i n f o r m a t i o n c a n o r w i l l b e u s e d b y h e a l t h p o l i c y m a k e r s . N e u s t a t e s t h a t , t o h i s k n o w l e d g e , " t h e r e h a s n e v e r b e e n . . . a s u c c e s s f u l d i r e c t a p p l i c a t i o n o f t h i s c o n c e p t t o h e a l t h p o l i c y p l a n n i n g " [ 7 ] . M c N e i l a n d P a u k e r p o i n t o u t t h a t i t i s a l m o s t i m p o s s i b l e t o m a k e p o l i c y d e c i s i o n s t h a t r e f l e c t a l l o r e v e n t h e r a n g e o f i n d i v i d u a l p r e f e r e n c e s i n a C H A P T E R I I I - 4 1 -s o c i e t y [ 4 : 2 2 8 ] . N e u f u r t h e r s u g g e s t s t h a t m e a s u r i n g v a l u e p r e f e r e n c e s m a y p r o v i d e m o r e i n f o r m a t i o n t h a n t h e p o l i c y m a k e r w a n t s o r c a n u s e [ 7 ] . A c c e s s t o s u r v e y r e s u l t s w i l l m a k e t h e i m p l i c a t i o n s o f a d e c i s i o n b a s e d o n t h e s u r v e y r e s u l t s m o r e e x p l i c i t . G r o u p ( s ) l e s s p o s i t i v e l y a f f e c t e d i n s u c h a d e c i s i o n p r o c e s s m a y b e o f s p e c i f i c c o n c e r n t o t h e p o l i c y m a k e r w h o m a y n o t w i s h t o m a k e d e c i s i o n s w i t h s u c h a c l e a r k n o w l e d g e ( o r a t l e a s t w i t h p u b l i c k n o w l e d g e ) o f t h e s e i m p l i c a t i o n s [ 7 : 2 6 1 ] ! M u c h t h e o r e t i c a l ( a n d e m p i r i c a l ) w o r k h a s b e e n d o n e i n v a l u e p r e f e r e n c e m e a s u r e m e n t f o r h e a l t h c a r e : h o w e v e r , a n u m b e r o f i s s u e s r e m a i n u n r e s o l v e d , p a r t i c u l a r l y i n t h e l o n g - t e r m c a r e s e c t o r [ 6 : 2 7 7 - 8 5 ] . T h e v a l u e w e i g h t i n g p r o c e s s i s o n e o f t h e m a j o r f e a s i b i l i t y p r o b l e m s y e t t o b e f u l l y a d d r e s s e d i n r e i m b u r s e m e n t s c h e m e s f o r l o n g - t e r m c a r e . C O N S T R A I N T - T H E D E F I N I T I O N A L C O N T E X T O F O U T C O M E M E A S U R E M E N T , O U T C O M E - B A S E D R E I M B U R S E M E N T , E F F E C T I V E N E S S A N D E F F I C I E N C Y T h e r e a r e s e v e r a l k e y c o n c e p t s w h i c h f o r m t h e u n d e r l y i n g b a s i s o f t h i s s t u d y : o u t c o m e m e a s u r e m e n t , r e i m b u r s e m e n t , o u t c o m e - b a s e d r e i m b u r s e m e n t , e f f e c t i v e n e s s a n d e f f i c i e n c y i n l o n g - t e r m f a c i l i t y c a r e . I n o r d e r t o d e t e r m i n e t h e f e a s i b i l i t y o f a p p l y i n g s p e c i f i c o u t c o m e m e a s u r e m e n t a n d o u t c o m e - b a s e d r e i m b u r s e m e n t a p p r o a c h e s i n t h e B r i t i s h C o l u m b i a s e t t i n g , i t i s n e c e s s a r y t o h a v e s o m e u n d e r s t a n d i n g o f h o w t h e s e c o n c e p t s a p p l y i n g e n e r a l t o C H A P T E R I I I - 4 2 -f a c i l i t y - b a s e d l o n g - t e r m c a r e . T h e d e f i n i t i o n o f t h e s e c o n c e p t s a s t h e y a r e u s e d i n t h i s s t u d y i s p r e s e n t e d i n t h e f o l l o w i n g s e c t i o n s . MEASUREMENT OF OUTCOMES IN FACILITY-BASED LONG-TERM CARE F u n k a n d W a g n a l l s d i c t i o n a r y d e f i n e s outcome a s " a r e s u l t t h a t m a k e s v i s i b l e o r e v i d e n t t h e w o r k i n g o f a n a g e n c y . " [ 8 : 4 2 1 ] . A n o t h e r s u g g e s t s t h a t o u t c o m e i s t h e e n d r e s u l t o f t h e p r o d u c t i o n p r o c e s s . I n p r i v a t e i n d u s t r y " o u t p u t " i s a t e r m w h i c h i s s y n o n y m o u s w i t h o u t c o m e a n d w h i c h i s u s e d t o d e n o t e e i t h e r t h e r e s u l t o f a p r o d u c t i o n p r o c e s s o r t h e " a m o u n t o f a n y t h i n g p r o d u c e d i n a g i v e n t i m e " [ 8 : 9 5 9 ] . B o t h o f t h e s e c o n c e p t s , o u t c o m e a n d o u t p u t , s u g g e s t a p h e n o m e n o n t h a t c a n b e i d e n t i f i e d a n d m e a s u r e d . I n h e a l t h c a r e , P a l m e r n o t e s t h a t a n u m b e r o f c l a s s i f i c a t i o n s o f o u t c o m e h a v e b e e n p r o p o s e d ( e . g . p a t i e n t o u t c o m e s , p r o c e s s o u t c o m e s , a d m i n i s t r a t i v e o u t c o m e ) b u t s u g g e s t s t h a t f o r c l a r i t y S t a r f i e l d ' s c o n c e p t o f a h e a l t h o u t c o m e a s " t h e a c t u a l c h a n g e i n h e a l t h s t a t u s o f p a t i e n t s " b e a d o p t e d [ 9 : 3 2 -3 3 ] . Outcome measurement i s t h e p r o c e s s o f m e a s u r i n g o r i d e n t i f y i n g t h e e x t e n t t o w h i c h t h e o b j e c t i v e s o f t h e p r o d u c t i o n p r o c e s s h a v e b e e n m e t ( i . e . w h e t h e r o r n o t t h e p r o c e s s r e s u l t e d i n t h e e x p e c t e d o u t c o m e ) . I n o r d e r t o m e a s u r e o u t c o m e , t h e o b j e c t i v e s o f t h e p r o d u c t i o n p r o c e s s m u s t b e d e f i n e d i n a m e a s u r a b l e w a y . C H A P T E R I I I - 43 -I n t h i s s t u d y a p p r o a c h e s t o o u t c o m e m e a s u r e m e n t u s e d i n p r i v a t e i n d u s t r y , i n t h e p u b l i c s e c t o r a n d i n t h e h e a l t h c a r e s e c t o r i n p a r t i c u l a r , a r e i n v e s t i g a t e d f o r t h e i r r e l e v a n c e t o t h e f a c i l i t y - b a s e d s e c t o r o f t h e l o n g - t e r m c a r e i n d u s t r y . F i g u r e 1 b r i e f l y o u t l i n e s h o w t h e c o n c e p t s o f o u t p u t a n d o u t c o m e m i g h t b e d e f i n e d f r o m a s h a r e h o l d e r s o r f u n d e r s p e r s p e c t i v e i n t h e v a r i o u s s e c t o r s . F i g u r e 1 i l l u s t r a t e s t h a t a s o n e m o v e s f r o m t h e p r i v a t e t o t h e p u b l i c s e c t o r , a n d t h e n t o t h e h e a l t h c a r e i n d u s t r y t h e e x p e c t e d o u t c o m e s b e c o m e l e s s c o n c r e t e a n d t h e r e l a t i o n s h i p b e t w e e n t h e f u n d e r a n d t h e p r o d u c t i o n f u n c t i o n b e c o m e m o r e c o m p l e x . T h i s i n c r e a s e d c o m p l e x i t y h a s a d i r e c t b e a r i n g o n t h e a b i l i t y t o m e a s u r e t h e o u t c o m e o f p r o d u c t i o n i n h e a l t h c a r e . W h e n ' g o o d s ' a r e b e i n g p r o d u c e d o u t c o m e m e a s u r e m e n t i s a r e l a t i v e l y e a s y m a t t e r , b o t h c o n c e p t u a l l y a n d i n f a c t . H o w e v e r , w h e n t h e e n t i t y o f i n t e r e s t i s a ' s e r v i c e ' , m e a s u r e m e n t b e c o m e s m o r e d i f f i c u l t . T h e c o n c e p t o f ' s e r v i c e ' i m p l i e s a r e l a t i o n s h i p w i t h o r i m p a c t o n t h e c o n s u m e r . S e r v i c e p r o d u c t i o n i s t h e r e f o r e s u b j e c t t o a l l t h e v a r i a b i l i t y t h a t c h a r a c t e r i z e s h u m a n i n t e r a c t i o n s , m a k i n g t h e m e a s u r e m e n t o f o u t c o m e s m o r e c o m p l e x . T h e p r i v a t e s e c t o r o f t h e s e r v i c e i n d u s t r y u s u a l l y o p e r a t e s w i t h i n t h e c o m p e t i t i v e m a r k e t m o d e l , " w h e r e m a n y s u p p l i e r s a r e c o m p e t i n g f o r c o n s u m e r s " [ 1 0 : 1 5 6 - 5 9 ] . I n t h i s s i t u a t i o n c u s t o m e r s a t i s f a c t i o n a n d t h e p r i c e o f t h e s e r v i c e a t e q u i l i b r i u m ( r e p r e s e n t i n g m a x i m i z e d p r o f i t s ) a c t a s o u t c o m e m e a s u r e s [ 1 0 : 1 5 6 - 5 9 ] . F i g u r e 1: T h e C o n c e p t s o f O u t p u t & O u t c o m e a s t h e y A p p l y i n P r i v a t e I n d u s t r y , t h e P u b l i c S e c t o r , t h e H e a l t h C a r e I n d u s t r y a n d L o n g - t e r m C a r e . SECTORS OUTPUTS EXPECTED OUTCOMES SHAREH0LDERS\GOVERNMENT RELATIONSHIP TO THE PRODUCTION PROCESS PRIVATE INDUSTRY The amount o f p r o d u c t ( g o o d s / s e r v i c e s ) p r o d u c e d f o r c o n s u m p t i o n i n a g i v e n t i m e p e r i o d . T h a t p r o f i t s w i l l b e m a x i m i z e d w h i l e m i n i m i z i n g t h e c o s t o f p r o d u c t i o n . S h a r e h o l d e r s h a v e i n v e s t e d i n t h e company a n d may o r may n o t h a v e i n p u t i n t o t h e manage-ment p o l i c y . PUBLIC SECTOR T h e amount o f g o o d s o r s e r v i c e s p r o v i d e d i n a g i v e n t i m e p e r i o d ( e . g . y e a r l y ) . T h a t t h e s e r v i c e s w i l l meet p u b l i c needs a n d a t t h e l e a s t p o s s i b l e e x p e n d i t u r e o f p u b l i c f u n d s . Government a c t s a s t h e f u n d i n g a g e n t f o r t h e p u b l i c a n d u s u a l l y s e t s some management g u i d e l i n e s o r p o l i c y ; may o r may n o t p r o v i d e g o o d s o r s e r v i c e s d i r e c t l y . HEALTH CARE INDUSTRY T h e amount o f h e a l t h c a r e s e r v i c e s ( p r e v e n t i v e , a c u t e , r e h a b i l i t a t i o n , l o n g - t e r m c a r e ) p r o v i d e d i n a g i v e n p e r i o d ( e . g . y e a r l y ) . T h a t t h e c a r e p r o v i d e d r e s u l t s i n a s a t i s f a c t o r y ( u s u a l l y improved) l e v e l o r s t a t e o f h e a l t h , a n d a t t h e l e a s t p o s s i b l e e x p e n d i t u r e o f p u b l i c f u n d s . Government a c t s a s t h e f u n d i n g a g e n t f o r t h e c l i e n t a n d i s g u i d e d b y l e g i s l a t i o n ; may p r o v i d e s e r v i c e s t h r o u g h t h i r d p a r t y a g e n c i e s ( p r o f i t a n d n o n - p r o f i t ) ; consumers may i n c u r some d i r e c t c o s t s . LONG-TERM CARE INDUSTRY T h e amount o f l o n g - t e r m c a r e s e r v i c e s p r o v i d e d t o s u p p o r t m a i n t a i n , o r r e s t o r e r e s i d e n t s a t home o r i n a l o n g - t e r m c a r e f a c i l i t y i n a g i v e n t i m e p e r i o d ( e . g . y e a r l y ) . T h a t t h e l o n g - t e r m c a r e p r o v i d e d r e s u l t s i n t h e h i g h e s t l e v e l o f i n d e p e n d e n c e p o s s i b l e f o r r e s i d e n t s o f a f a c i l i t y a n d a t t h e l e a s t p o s s i b l e e x p e n d i t u r e o f p u b l i c f u n d s . Government a c t s a s t h e m a j o r f u n d i n g a g e n t ; s e t s o v e r a l l p o l i c y g u i d e l i n e s ; r e g u l a t e s f o r s a f e t y a n d p r o t e c t i o n o f t h e c l i e n t ; most s e r v i c e s a r e p r o v i d e d t h r o u g h t h i r d p a r t y a g e n c i e s ( p r o f i t a n d n o n -p r o f i t ) ; c o n s u m e r s ( r e s i d e n t s ) u s u a l l y i n c u r some d i r e c t c o s t C H A P T E R I I I - 4 5 -I n t h e p u b l i c s e c t o r t h e m e a s u r e m e n t o f o u t c o m e b e c o m e s m o r e c o m p l i c a t e d . I n t h i s s i t u a t i o n g o v e r n m e n t f u n d s t h e p r o v i s i o n o f s e r v i c e s d e e m e d n e c e s s a r y f o r t h e p u b l i c g o o d , f o r e x a m p l e t r a n s p o r t a t i o n , e d u c a t i o n , h e a l t h c a r e . F o r t h e m o s t p a r t t h e s e s e r v i c e s a r e s u p p l i e d o n a n o n - p r o f i t ( o r e v e n a l o s s ) b a s i s a n d t h e o u t c o m e t o b e m e a s u r e d i s w h e t h e r t h e s p e c i f i c n e e d i d e n t i f i e d h a s b e e n m e t t o the p u b l i c ' s s a t i s f a c t i o n . I n t h e h e a l t h c a r e s e c t o r , s t r u c t u r a l ( i n p u t s ) a n d p r o c e s s ( a c t i v i t i e s o f p r o d u c t i o n ) m e a s u r e m e n t s h a v e o f t e n b e e n u s e d i n l i e u o f m e a s u r e m e n t o f t h e o u t c o m e o f a p r o d u c t i o n p r o c e s s , b o t h b e c a u s e o f m e a s u r e m e n t d i f f i c u l t i e s a n d b e c a u s e o f t h e a c c e p t a n c e o f s t r u c t u r e a n d p r o c e s s a s p r o x i e s f o r o u t c o m e [ 1 1 : 5 ] . A c c o r d i n g t o D o n a b e d i a n , h o w e v e r , h e a l t h p l a n n e r s , p o l i c y m a k e r s a n d m a n a g e r s o f t e n s u p p o r t t h e u s e o f o u t c o m e m e a s u r e m e n t s , c i t i n g c o s t e f f e c t i v e n e s s r e a s o n s [ 1 1 : 1 1 7 ] . F r o m t h e f u n d e r s p e r s p e c t i v e , i f a l l t h a t i s n e e d e d i s t o e s t a b l i s h t h e v a l u e o r i m p a c t o f c a r e ( r e g a r d l e s s o f t h e p r o c e s s u s e d ) o u t c o m e s a r e a " l o g i c a l " a n d " e a s y " c h o i c e [ 1 1 : 1 0 7 ] . A s s u c h , o u t c o m e s w o u l d p r o v i d e s o m e m e a s u r e o f g e n e r a l p r o g r a m e f f e c t i v e n e s s [ 1 1 : 1 2 0 ] . O u t c o m e m e a s u r e m e n t i s a l s o s e e n a s a n a d v a n t a g e w h e n t h e c a u s a l l i n k b e t w e e n p r o c e s s a n d o u t c o m e i s n o t c l e a r l y e s t a b l i s h e d . T h u s r i g i d a d h e r e n c e t o u n p r o v e n i n t e r v e n t i o n s m a y b e d i s c o u r a g e d w h i l e e n c o u r a g i n g i n n o v a t i o n a n d f l e x i b i l i t y i n m a n a g e m e n t , w h i c h m a y r e s u l t i n l e s s c o s t l y c a r e [ 1 1 : 1 2 0 ] . C H A P T E R III - 4 6 -S o m e o f t h e d i s a d v a n t a g e s o f o u t c o m e m e a s u r e m e n t , h o w e v e r i n c l u d e t h e d i f f i c u l t i e s i n s p e c i f y i n g o u t c o m e s t h a t c a n b e m e a s u r e d , a l o n g w i t h t h e i n a b i l i t y t o i d e n t i f y w h a t o r w h o i s r e s p o n s i b l e , p a r t i c u l a r l y i f t h e r e s u l t s a r e n o t s a t i s f a c t o r y . T h e r e i s a l s o t h e p i t f a l l o f c h o o s i n g o u t c o m e s t h a t a r e n o t r e l e v a n t t o t h e o b j e c t i v e s o f c a r e [ 9 : 3 4 - 3 8 ; 1 1 : 1 2 0 ] . T h e f e a s i b i l i t y o f a n y s y s t e m , p a r t i c u l a r l y i n t i m e s o f r e s t r a i n t , m u s t i n c l u d e c o n s i d e r a t i o n o f t h e c o s t o f i m p l e m e n t i n g a n d u s i n g a p a r t i c u l a r a p p r o a c h . N o d e f i n i t i v e s t u d i e s i n a c u t e o r l o n g - t e r m c a r e w e r e f o u n d w h i c h c o m p a r e d t h e c o s t o f i m p l e m e n t i n g a n o u t c o m e m e a s u r e m e n t s y s t e m t o t h e c o s t o f u s i n g a p r o c e s s m e a s u r e m e n t a p p r o a c h . T h e l e v e l o f c a r e t h a t s o c i e t y w i s h e s ( v a l u e s ) o r i s w i l l i n g t o p a y f o r i s a m a j o r d e t e r m i n a n t o f c o s t s . O u t c o m e m e a s u r e m e n t s c l e a r l y s h o u l d b e e s t a b l i s h e d i n r e l a t i o n t o s o m e d e f i n i t i o n o f " e x p e c t e d " o u t c o m e w h i c h i s b a s e d o n t h e o b j e c t i v e o f t h e h e a l t h c a r e p r o g r a m t o a c h i e v e a n a d e q u a t e q u a l i t y o r l e v e l o f e f f e c t i v e n e s s o f c a r e . REIMBURSEMENT IN FACILITY-BASED LONG-TERM CARE T h e t e r m r e i m b u r s e m e n t a s u s e d i n t h i s s t u d y r e f e r s t o t h e m e t h o d s d e v e l o p e d b y p r o v i n c i a l g o v e r n m e n t s f o r p a y m e n t t o p r o v i d e r s o f f a c i l i t y - b a s e d l o n g - t e r m c a r e , n o t t h e o v e r a l l f i n a n c i n g o r r e s o u r c e a l l o c a t i o n w i t h i n t h e l o n g - t e r m c a r e s y s t e m . R e i m b u r s e m e n t p o l i c i e s i n f l u e n c e t h e q u a l i t y o r e f f e c t i v e n e s s o f c a r e , t h e e f f i c i e n c y o f p r o d u c t i o n a n d t h e s c o p e o f s e r v i c e a v a i l a b l e [ 1 2 : 1 8 5 ] . C H A P T E R I I I - 4 7 -I n t h e l o n g - t e r m c a r e i n d u s t r y , r e i m b u r s e m e n t i s t h e p a y m e n t m a d e t o a n a g e n t ( p h y s i c i a n ) o r a g e n c y ( n u r s i n g h o m e o r c o m m u n i t y c a r e a g e n c y ) f o r s e r v i c e s p r o v i d e d t o a c o n s u m e r ( p a t i e n t / r e s i d e n t ) . B u c h a n a n s e t s o u t f i v e o b j e c t i v e s t o c o n s i d e r i n a r e i m b u r s e m e n t s y s t e m i n f a c i l i t y - b a s e d l o n g - t e r m c a r e [ 1 3 : 2 8 - 2 9 ] : - e n c o u r a g i n g d e l i v e r y o f c a r e c o n s i s t e n t w i t h e s t a b l i s h e d s t a n d a r d s ( e f f e c t i v e n e s s ) ; - e n c o u r a g i n g d e l i v e r y o n l y o f n e c e s s a r y s e r v i c e s , t h a t i s t h e r e s h o u l d b e a m e a s u r e o f e f f e c t i v e n e s s ( s u c h a s o u t c o m e m e a s u r e s ) a n d t h e p a y m e n t s h o u l d b e r e l a t e d t o t h a t m e a s u r e ; - e n c o u r a g i n g e f f i c i e n c y ( i . e . u s i n g i n c e n t i v e s t o m i n i m i z e c o s t s ) ; - a l l o w i n g p r o p r i e t a r y f a c i l i t i e s t o m a k e a c o m p e t i t i v e r a t e o f r e t u r n o n i n v e s t m e n t . - e n c o u r a g i n g e f f i c i e n t o v e r a l l u s e o f r e s o u r c e s , i . e . t h e f u n d i n g o f a r a n g e o f s e r v i c e s . i n c l u d i n g a l t e r n a t i v e s t o f a c i l i t y c a r e . T h e f o r m a r e i m b u r s e m e n t s y s t e m t a k e s d e p e n d s o n : t h e t i m i n g o f p a y m e n t s ; t h e m e t h o d o f r a t e s e t t i n g ; a n d t h e o r g a n i z a t i o n a l l e v e l a t w h i c h t h e p a y m e n t i s m a d e . T i m i n g i s a m a j o r i s s u e i n l o n g - t e r m c a r e r e i m b u r s e m e n t [ 1 3 : 5 9 , - 6 0 , 3 2 ; 1 4 : 1 3 ] . I t i s f e l t t h a t r e t r o s p e c t i v e r e i m b u r s e m e n t ( p a y m e n t m a d e a f t e r c o s t s a r e i n c u r r e d ) d o e s n o t e n c o u r a g e c o s t c o n t r o l a n d i n d e e d m a y b e " a n i n v i t a t i o n t o w a s t e " [ 1 2 : 1 8 8 ] . R e t r o s p e c t i v e r e i m b u r s e m e n t , i t i s g e n e r a l l y a s s u m e d , w i l l p r o m o t e q u a l i t y o f c a r e [ 1 4 : 1 3 ] . C H A P T E R I I I - 48 -P r o s p e c t i v e r e i m b u r s e m e n t h a s b e e n p r o m o t e d b y f u n d e r s a s a n i n c e n t i v e f o r c o s t c o n t a i n m e n t . C o n c e r n s h a v e b e e n e x p r e s s e d , h o w e v e r , a b o u t t h e p o t e n t i a l t h r e a t t o t h e q u a l i t y u n d e r a p r o s p e c t i v e r e i m b u r s e m e n t s y s t e m , p a r t i c u l a r l y w h e r e p r o f i t m a x i m i z i n g i s a f a c t o r . A l s o a b o u t t h e e f f e c t o n u t i l i z a t i o n o r a c c e s s t o a l l l e v e l s o f c a r e . C o m p a r a t i v e s t u d i e s o f r e t r o s p e c t i v e a n d p r o s p e c t i v e r e i m b u r s e m e n t i n l o n g - t e r m c a r e f a c i l i t i e s i n t h e U n i t e d S t a t e s s h o w e d n o s i g n i f i c a n t d i f f e r e n c e i n u t i l i z a t i o n o r a c c e s s , b u t d i d s h o w t h a t p e r d i e m c o s t s w e r e l o w e r u s i n g p r o s p e c t i v e m e t h o d s [ 1 3 : 6 2 - 6 3 ; 1 4 ; 1 5 ] . S e v e r a l m e t h o d s o f r a t e s e t t i n g a r e u s e d ( o r p r o p o s e d f o r u s e ) i n f u n d i n g f a c i l i t y - b a s e d l o n g - t e r m c a r e , i n c l u d i n g : f i x e d o r n e g o t i a t e d r a t e s , u s u a l l y b a s e d o n a l e v e l o f c a r e ; c o s t b a s e d ( b a s e d o n a c t u a l o r a v e r a g e d c o s t s , o r a c o s t - p l u s p r o f i t f a c t o r ) ; a n d i n c e n t i v e o r o u t c o m e - b a s e d r e i m b u r s e m e n t ( o f t e n p r o p o s e d a s e f f i c i e n c y i n c e n t i v e s ) [ 1 3 : 5 9 - 6 3 ; 1 4 ; 1 5 ] . T h e o r g a n i z a t i o n a l l e v e l o r u n i t o f s e r v i c e a t w h i c h t h e r a t e i s s e t i n c l u d e s d e c i s i o n s a b o u t w h e t h e r t o a s s i g n c o s t ( s ) o n a g l o b a l b u d g e t b a s i s ; b y d e p a r t m e n t o r f u n c t i o n a l a r e a s ; b y l e v e l s o f c a r e o r o t h e r c a s e m i x c r i t e r i a ; b y t h e a v e r a g e c o s t o f a p e e r g r o u p o f f a c i l i t i e s ; o r b y o r g a n i z a t i o n a l o u t c o m e s a n d / o r t h e o u t c o m e s o f c a r e a s e x p r e s s e d b y t h e h e a l t h s t a t u s o f t h e i n d i v i d u a l s r e c e i v i n g c a r e [ 1 3 ; 1 4 ; 1 5 ] . C H A P T E R I I I - 4 9 -OUTCOME-BASED REIMBURSEMENT IN FACILITY-BASED LONG-TERM CARE I n f a c i l i t y - b a s e d l o n g - t e r m c a r e , o u t c o m e - b a s e d r e i m b u r s e m e n t i n v o l v e s t h e m e a s u r e m e n t o f t h e o u t c o m e o r e f f e c t i v e n e s s o f t h e c a r e p r o v i d e d t o r e s i d e n t s . T h i s m e a s u r e o f e f f e c t i v e n e s s i s t h e n t r a n s f o r m e d i n t o s o m e a g g r e g a t e i n d e x o f t h e f a c i l i t y ' s e f f e c t i v e n e s s , w h i c h m a y b e u s e d a s t h e b a s i s f o r r e i m b u r s e m e n t . E f f i c i e n c y o u t c o m e s m a y a l s o b e c o n s i d e r e d . EFFECTIVENESS and EFFICIENCY IN FACILITY-BASED LONG-TERM CARE A s n o t e d a b o v e , m e a s u r e s o f e f f e c t i v e n e s s a n d e f f i c i e n c y m a y b o t h b e p a r t o f a n o u t c o m e - b a s e d r e i m b u r s e m e n t s y s t e m . A s S t o d d a r t n o t e s , e v a l u a t i o n o f e f f i c i e n c y s h o u l d n o t t a k e p l a c e u n l e s s t h e r e i s a " p r i o r v a l i d a t i o n o f e f f e c t i v e n e s s " a n d f u r t h e r t h a t " e f f i c i e n c y e v a l u a t i o n s , b y t h e m s e l v e s , a r e i n c a p a b l e o f e s t a b l i s h i n g e f f e c t i v e n e s s " [ 1 6 : 1 4 ] E f f i c a c y a n d e f f e c t i v e n e s s a r e t w o c l o s e l y r e l a t e d t e r m s w h i c h r e f e r t o t h e e x t e n t t o w h i c h h e a l t h c a r e i n t e r v e n t i o n s b e n e f i t o r h a v e a n i m p a c t o n t h e h e a l t h p r o b l e m s o r h e a l t h s t a t u s o f t h e p a t i e n t . T h e e f f i c a c y o f a p r o g r a m o r i n t e r v e n t i o n a s I b r a h i m s t a t e s , r e f e r s t o " t h e b e n e f i t a c c r u e d a b o v e a n d b e y o n d n o p r o g r a m o r a s t a n d a r d p r o g r a m " o r a s o t h e r s s u g g e s t , t h e r e s u l t s o b t a i n e d i n t h e i d e a l s i t u a t i o n [ 1 7 : 9 ] . I b r a h i m f u r t h e r s t a t e s t h a t t h e " e f f e c t i v e n e s s o f a h e a l t h s e r v i c e r e l a t e s t o t h e a c c e p t a n c e a n d u s e o f e f f i c a c i o u s s e r v i c e s . . . b y t h o s e m e m b e r s o f t h e p o p u l a t i o n t o whom i t i s o f f e r e d . " , i n o t h e r w o r d s t h e r e s u l t s a c h i e v e d i n t h e u s u a l c l i n i c a l e n v i r o n m e n t [ 1 7 : 9 ] . D e t e r m i n i n g e f f e c t i v e n e s s r e q u i r e s C H A P T E R I I I - 5 0 -s o m e f o r m o f m e a s u r e m e n t o f t h e o u t c o m e o f t h e i n t e r v e n t i o n , t h a t i s a d e t e r m i n a t i o n o f t h e e x t e n t t o w h i c h t h e i n t e r v e n t i o n m a d e a d i f f e r e n c e [ 1 8 ] . B r o o k a n d L o h r s u g g e s t t h a t a s s e s s m e n t o f t h e q u a l i t y o f c a r e s h o u l d b e i n t e g r a t e d i n t o a m o r e ' m a c r o ' a p p r o a c h w h i c h i n t e g r a t e s e f f i c a c y , e f f e c t i v e n e s s a n d q u a l i t y o f c a r e i n a n a p p r o a c h w h i c h w o u l d a l l o w t h e s p e c i f i c a t i o n o f t h e " p e r m i s s i b l e r a n g e s o f e f f e c t i v e n e s s " [ 1 9 : 7 1 4 ] . F o r f a c i l i t y - b a s e d l o n g - t e r m c a r e t o b e e f f e c t i v e t h e r e a r e t h r e e e s s e n t i a l c o m p o n e n t s : o n e i s a b o d y o f k n o w l e d g e a n d e x p e r i e n c e a b o u t w h a t p r o c e s s e s a n d i n t e r v e n t i o n s c o n s t i t u t e a d e q u a t e c a r e ( i . e . a r e c a p a b l e o f p r o d u c i n g e f f i c a c i o u s r e s u l t s ) ; a n o t h e r i s p l a c e m e n t i n f a c i l i t i e s w i t h t h e s t r u c t u r a l c a p a b i l i t y a n d r e s o u r c e s t o p r o v i d e a d e q u a t e c a r e ; a n d t h e t h i r d i s t h e a p p r o p r i a t e p l a c e m e n t o f r e s i d e n t s ( i . e . t h e r i g h t c l i e n t p l a c e d i n t h e r i g h t p l a c e f o r h i s / h e r l e v e l o f c a r e n e e d ) [ 2 0 ] . O n t h e c o s t s i d e , P a l m e r s t a t e s t h a t " e f f i c i e n c y r e q u i r e s m a x i m i z i n g t h e u n i t s o f e f f e c t i v e h e a l t h c a r e d e l i v e r e d , t o a l l w h o a r e e l i g i b l e , f o r a g i v e n u n i t o f h e a l t h r e s o u r c e s u s e d " [ 9 : 1 7 ] a n d t h a t a s s e s s m e n t o f e f f i c i e n c y s h o u l d i n c l u d e c o n s i d e r a t i o n o f b o t h t h e q u a l i t y a n d q u a n t i t y o f o u t p u t , a s w e l l a s t h e c o s t o f r e s o u r c e s u s e d [ 9 : 1 7 ] . O t h e r s i n d i s c u s s i n g c o s t e f f e c t i v e n e s s a n a l y s i s , s u g g e s t t h a t s u c h a n e c o n o m i c a n a l y s i s m u s t a l s o i n c l u d e t h e o p p o r t u n i t y c o s t s [ 1 6 ] . A m o r e d e t a i l e d d i s c u s s i o n o n t h e u s e o f c o s t - e f f e c t i v e n e s s a n d c o s t -C H A P T E R I I I - 51 -b e n e f i t a n a l y s i s i n h e a l t h c a r e i s p r e s e n t e d i n C h a p t e r F o u r . T h e e x p e c t a t i o n t h a t g o v e r n m e n t i s t o p r o v i d e a d e q u a t e c a r e f o r i t s c i t i z e n s ( i n c l u d i n g l o n g - t e r m c a r e ) , w h i l e [ 2 1 ] . e n s u r i n g t h a t t h e f u n d i n g p r o v i d e d f o r h e a l t h c a r e i s e f f i c i e n t l y e x p e n d e d h a s b e c o m e a c o n c e r n . T h e s e e x p e c t a t i o n s g i v e r i s e t o a p o t e n t i a l c o n f l i c t k n o w n a s t h e ' q u a l i t y / c o s t t r a d e - o f f o r t h e c o n f l i c t o f e f f e c t i v e n e s s v e r s u s e f f i c i e n c y [ 2 2 ; 2 3 ] . C O N C L U S I O N A r e v i e w o f t h e u n d e r l y i n g c o n c e p t s o f t h e s t u d y i l l u s t r a t e s t h a t s o m e o f t h e c o n s t r a i n i n g f a c t o r s o n t h e f e a s i b i l i t y o f o u t c o m e m e a s u r e m e n t a n d o u t c o m e - b a s e d r e i m b u r s e m e n t a p p r o a c h e s l i e , i n p a r t , i n t h e d i f f i c u l t y o f d e t e r m i n i n g a n d m e a s u r i n g t h e o u t c o m e ( s ) o r e f f e c t i v e n e s s o f c a r e i n s u c h a c o m p l e x h u m a n s e r v i c e s y s t e m a s l o n g - t e r m f a c i l i t y c a r e . A d d e d t o t h a t a r e t h e c o n s t r a i n t s o n t h e r e i m b u r s e m e n t s i d e s u c h a s t h e n e e d t o p r o m o t e e f f i c i e n c y , a n d t h e f a c t o r s r e l a t e d t o t i m i n g , t h e m e t h o d s o f r a t e s e t t i n g a n d t h e l e v e l s o r u n i t s a t w h i c h p a y m e n t i s m a d e . C O N S T R A I N T : O R G A N I Z A T I O N A L S T R U C T U R E O F L O N G - T E R M C A R E S Y S T E M C A N A D A - U N I T E D S T A T E S C O M P A R I S O N S A t f i r s t g l a n c e t h e o r g a n i z a t i o n a l a n d s t r u c t u r a l m a k e - u p o f t h e f a c i l i t y - b a s e d l o n g - t e r m c a r e s y s t e m s i n C a n a d a a n d t h e U n i t e d S t a t e s a p p e a r d e c e p t i v e l y s i m i l a r . B o t h c o u n t r i e s h a v e a m i x e d p r o v i d e r s y s t e m , e x t e n s i v e g o v e r n m e n t f u n d i n g , a n d s i m i l a r C H A P T E R I I I - 5 2 -l e v e l s o f c a r e p r o v i s i o n , t y p e s o f c l i e n t s a n d m a n p o w e r u t i l i z a t i o n . T h e m e t h o d o f r e g u l a t i o n i n b o t h c o u n t r i e s i s t h r o u g h f a c i l i t y l i c e n s u r e , r e g u l a t o r y s t a n d a r d s , a n d s e l f -g o v e r n i n g p r o f e s s i o n a l s g r o u p s . B o t h c o u n t i e s a l s o f a c e s i m i l a r i s s u e s s u c h a s t h e n e e d f o r c o s t - e f f e c t i v e n e s s a n d e f f i c i e n c y , a p p r o p r i a t e u t i l i z a t i o n a n d c l i e n t p l a c e m e n t , c o n c e r n s a b o u t t h e q u a l i t y o f c a r e / l i f e p r o v i d e d a n d h o w t o b e s t a p p r o a c h r e i m b u r s e m e n t . T h e f o l l o w i n g d i s c u s s i o n n o t e s s o m e o f t h e p o t e n t i a l i m p l e m e n t a t i o n p r o b l e m s i f o u t c o m e - b a s e d m e a s u r e s o f e f f e c t i v e n e s s o r o u t c o m e - b a s e d r e i m b u r s e m e n t a p p r o a c h e s d e r i v e d i n t h e U n i t e d S t a t e s w e r e t o b e c o n s i d e r e d f o r d i r e c t a p p l i c a t i o n i n C a n a d a . B e c a u s e o f d i f f e r e n c e s b e t w e e n t h e t w o c o u n t r i e s i n t h e i r s o c i a l p o l i c y , c o n s t i t u t i o n a l , l e g a l a n d e c o n o m i c b a s e s , a p p l i c a t i o n o f r e i m b u r s e m e n t a p p r o a c h e s m a y m o r e p r o b l e m a t i c t h a n m e a s u r e s o f e f f e c t i v e n e s s . CANADA T h e h e a l t h c a r e s y s t e m i n C a n a d a i s o r g a n i z e d a s a p u b l i c l y a d m i n i s t e r e d , n a t i o n a l s y s t e m o f i n t e r l o c k i n g p r o v i n c i a l m e d i c a l a n d h o s p i t a l c a r e i n s u r a n c e p l a n s e l i g i b l e f o r f e d e r a l b l o c k f u n d i n g . U n d e r a s u b - a g r e e m e n t o f t h e b l o c k f u n d i n g a g r e e m e n t s o m e p r o v i n c e s , s u c h a s B r i t i s h C o l u m b i a , h a v e e x p a n d e d t h e i n s u r a n c e p l a n t o i n c l u d e f a c i l i t y - b a s e d a n d h o m e - b a s e d l o n g -t e r m c a r e s e r v i c e s [ 2 4 : 2 9 - 4 4 ; 2 5 ] , S o c i a l p o l i c y , t h e c o n s t i t u t i o n a l a n d l e g a l b a s e , a n d t h e e c o n o m i c a n d f i n a n c i a l e n v i r o n m e n t i n C a n a d a h a v e l e d t o t h i s o r g a n i z a t i o n a l a p p r o a c h t o h e a l t h c a r e i n C a n a d a . C H A P T E R I I I - 5 3 -SOCIAL POLICY - INCENTIVES AND VALUES S o c i a l p o l i c y i n C a n a d a i s e s s e n t i a l l y d e r i v e d f r o m t h e s o c i a l w e l f a r e m o d e l w h e r e i n t h e s t a t e ( g o v e r n m e n t ) a s s u m e s a m a j o r r e s p o n s i b i l i t y f o r t h e p r o v i s i o n o f s o c i a l s e r v i c e s . P r i m e e x a m p l e s i n c l u d e t h e d e v e l o p m e n t o f t h e p u b l i c l y i n s u r e d a n d a d m i n i s t e r e d h o s p i t a l ( 1 9 5 8 ) a n d m e d i c a l c a r e ( 1 9 6 6 ) s y s t e m s [ 2 1 ; 2 5 ; 2 6 ] a n d t h e r e c e n t m o v e m e n t i n m o s t p r o v i n c e s t o s o m e l e v e l o f i n s u r e d l o n g - t e r m c a r e s e r v i c e s [ 2 4 ; 2 5 ] . E q u i t y o f a c c e s s f o r t h o s e i n n e e d o f h e a l t h c a r e a n d s o c i a l s u p p o r t h a s b e e n a n u n d e r l y i n g s o c i a l v a l u e [ 2 1 ] . E l i g i b i l i t y c r i t e r i a f o r g o v e r n m e n t f u n d e d h e a l t h c a r e s e r v i c e s i n C a n a d a i s b a s e d o n t h e n e e d f o r h e a l t h c a r e o n l y , n o t o n n e e d p l u s s o m e f i n a n c i a l a n d / o r o t h e r s o c i a l d e p e n d e n c y c r i t e r i a . O t h e r e l i g i b i l i t y c r i t e r i a ( e . g . a g e ) m a y b e a p p l i e d , b u t s t i l l w i t h i n t h e o v e r a l l c o n c e p t o f u n i v e r s a l a c c e s s b a s e d o n n e e d . M o s t l o n g - t e r m c a r e p r o g r a m s a r e d e r i v e d f r o m a p e r s p e c t i v e o f p r o m o t i n g o r m a i n t a i n i n g i n d e p e n d e n c e w h i c h i s o f t e n t r a n s l a t e d a s t h e a b i l i t y t o r e m a i n i n a c o m m u n i t y ( i n d e p e n d e n t l i v i n g ) s i t u a t i o n . W i t h i n t h i s f r a m e w o r k i n s t i t u t i o n a l i z a t i o n i s s o m e t i m e s s e e n a s a s o c i e t a l f a i l u r e t o p r o v i d e s u f f i c i e n t o r a p p r o p r i a t e c o m m u n i t y s u p p o r t s s u c h a s h o m e c a r e , w h i c h w o u l d a l l o w a n i n d i v i d u a l t o r e m a i n i n a n n o n - i n s t i t u t i o n a l s e t t i n g . B u t a l l p r o v i n c e s i n C a n a d a r e c o g n i z e t h a t s o m e i n d i v i d u a l s h a v e a n e e d f o r s u p p o r t w h i c h m a y o n l y b e p r o v i d e d t h r o u g h c a r e i n a n i n s t i t u t i o n . C H A P T E R I I I - 5 4 -THE CONSTITUTIONAL AND LEGAL BASE W i t h i n C a n a d a t h e g o v e r n i n g l e g i s l a t i v e b o d i e s - t h e f e d e r a l a n d p r o v i n c i a l p a r l i a m e n t s - h a v e s u p r e m a c y o v e r t h e j u d i c i a l a n d a d m i n i s t r a t i v e b o d i e s . A p a r l i a m e n t c a n t h e r e f o r e c h a n g e t h e r e g u l a t i o n , o r g a n i z a t i o n a l s t r u c t u r e , a n d f u n d i n g o r r e i m b u r s e m e n t m e c h a n i s m s o f t h e h e a l t h c a r e s y s t e m . C o n s t i t u t i o n a l l y t h e p r o v i s i o n o f h e a l t h c a r e i n C a n a d a i s a p r o v i n c i a l r e s p o n s i b i l i t y , w h i l e t h e f e d e r a l g o v e r n m e n t h a s t h e m a j o r t a x i n g p o w e r [ 2 5 ; 2 7 ] . H i s t o r i c a l l y , i n C a n a d a t h e s t a t u t o r y b a s i s f o r g o v e r n m e n t i n v o l v e m e n t i n t h e p r o v i s i o n o f l o n g - t e r m c a r e s e r v i c e s b e g a n w i t h c a t e g o r i c a l f u n d i n g m a n d a t e d b y s o c i a l w e l f a r e a c t s s u c h a s t h e O l d A g e P e n s i o n A c t o f 1 9 2 7 a n d c u l m i n a t i n g w i t h t h e C a n a d a A s s i s t a n c e A c t o f 1 9 6 5 [ 2 8 : 1 0 2 - 0 9 ] . T h e l a t t e r a c t p r o v i d e d f o r t h e f u n d i n g o f h e a l t h c a r e s e r v i c e s , i n c l u d i n g l o n g - t e r m c a r e s e r v i c e s , f o r r e c i p i e n t s o f s o c i a l a s s i s t a n c e . S i n c e t h e 1 9 5 0 ' s , t h r e e f e d e r a l g o v e r n m e n t s t a t u t e s : t h e H o s p i t a l I n s u r a n c e a n d D i a g n o s t i c S e r v i c e s A c t ( 1 9 5 8 ) ; t h e M e d i c a l C a r e A c t ( 1 9 6 6 ) ; a n d t h e E s t a b l i s h e d P r o g r a m F i n a n c i n g A c t ( 1 9 7 7 ) [ 2 1 ; 2 5 ; 2 6 ] h a v e e s t a b l i s h e d t h e p r i n c i p l e s a n d f u n d i n g m e c h a n i s m s f o r C a n a d i a n h e a l t h c a r e . T h e E s t a b l i s h e d P r o g r a m F i n a n c i n g A c t i n c l u d e d a n a g r e e m e n t k n o w n a s t h e E x t e n d e d H e a l t h S e r v i c e s P r o g r a m w h i c h p r o v i d e d f o r t h e f u n d i n g o f a l t e r n a t i v e c a r e s e r v i c e s i n c l u d i n g l o n g - t e r m i n s t i t u t i o n a l c a r e a n d h o m e h e a l t h c a r e [ 2 1 : 1 0 1 ; 2 6 : 4 8 ; 2 8 : 1 0 8 - 1 0 ; 2 9 ] . C H A P T E R I I I - 55 -T h e s e h e a l t h a c t s e s t a b l i s h e d t h e n a t i o n a l h e a l t h i n s u r a n c e s y s t e m i n C a n a d a i n w h i c h t h e p r o v i n c e s m u s t e n s u r e c o m p l i a n c e w i t h t h e f i v e b r o a d p r i n c i p l e s : u n i v e r s a l i t y ; a c c e s s i b i l i t y ; p o r t a b i l i t y ; u n i f o r m i t y o f t e r m s a n d c o n d i t i o n s ; a n d p u b l i c a d m i n i s t r a t i o n i n o r d e r t o b e e l i g i b l e f o r f e d e r a l b l o c k f u n d i n g [ 3 0 ] . S o m e p r o v i n c e s r e c e n t l y h a v e m o v e d t o w a r d s t h e p r o v i s i o n o f l o n g - t e r m c a r e s e r v i c e s w h i c h a r e p u b l i c l y a d m i n i s t e r e d , i n s u r e d s e r v i c e s w i t h u n i v e r s a l a c c e s s . I n a l l p r o v i n c e s , f a c i l i t y - b a s e d l o n g - t e r m c a r e s e r v i c e s a r e p r o v i d e d t h r o u g h a m i x e d p r o v i d e r s y s t e m o f f o r - p r o f i t ( p r i v a t e ) a n d n o n - p r o f i t ( p u b l i c a n d v o l u n t a r y ) f a c i l i t i e s . M o s t p r o v i n c e s h a v e m o r e n o n - p r o f i t b e d s [ 2 4 : 4 1 - 4 2 ; 2 6 : 1 0 1 ] . E a c h o f t h e p r o v i n c e s h a v e s t a t u t e s a n d g u i d e l i n e s w h i c h e s t a b l i s h t h e s p e c i f i c r e s p o n s i b i l i t i e s a n d s e r v i c e s t h e y h a v e u n d e r t a k e n t o p r o v i d e i n l o n g - t e r m c a r e , i n c l u d i n g e l i g i b i l i t y f o r b e n e f i t s , r e i m b u r s e m e n t m e c h a n i s m s , t h e e x p e c t e d s t a n d a r d s f o r s a f e t y a n d p r o t e c t i o n o f r e s i d e n t s , a n d l a t t e r l y , t h e q u a l i t y o f c a r e t o b e p r o v i d e d t o f a c i l i t y r e s i d e n t s . T h e e n f o r c e m e n t o f r e g u l a t i o n s c o n c e r n i n g f a c i l i t y - b a s e d c a r e i s s e e n a s a n a d m i n i s t r a t i v e f u n c t i o n , w i t h t h e e s t a b l i s h e d s t a n d a r d s u s u a l l y o f a s t r u c t u r a l a n d p r o c e s s n a t u r e . T h e s e r e g u l a t o r y r e s p o n s i b i l i t i e s h a v e l e d t o q u e s t i o n s a b o u t h o w b e s t t o d e t e r m i n e r e i m b u r s e m e n t l e v e l s a n d a b o u t t h e s t a n d a r d s w h i c h w o u l d e n s u r e t h a t a d e q u a t e c a r e i s p r o v i d e d [ 3 1 : 8 7 - 9 1 ] . C H A P T E R I I I - 5 6 -R e i m b u r s e m e n t i s n o t d i r e c t l y t i e d t o r e g u l a t o r y c o m p l i a n c e i n a n y o f t h e p r o v i n c e s . L i c e n s u r e m a y , h o w e v e r , b e a p r e -r e q u i s i t e t o p a r t i c i p a t i o n i n a p r o v i n c i a l l y s p o n s o r e d , f a c i l i t y - b a s e d l o n g - t e r m c a r e p r o g r a m , a s i t i s i n B r i t i s h C o l u m b i a . I t i s c o n c e i v a b l e t h a t r e g u l a t i o n s c o u l d b e m a d e w h i c h w o u l d r e q u i r e r e i m b u r s e m e n t t o b e l i n k e d t o r e g u l a t o r y c o m p l i a n c e , a s w a s d o n e i n M a n i t o b a f o r s p e c i a l c a r e f a c i l i t i e s a n d g r o u p h o m e s f o r t h e a d u l t m e n t a l l y r e t a r d e d [ 3 2 ] , THE ECONOMIC AND FINANCIAL ENVIRONMENT K i n g s o n a n d S c h e f f l e r p r e d i c t t h a t f o r t h e U S A " l o n g - t e r m c a r e a n d i t s f i n a n c i n g w i l l b e t h e s i n g l e m o s t i m p o r t a n t i s s u e i n h e a l t h c a r e i n t h e n e x t d e c a d e " [ 3 3 : 2 1 2 ) . T h e p o t e n t i a l i n C a n a d a f o r a s i m i l a r s c e n a r i o a p p e a r s t o b e e v e n g r e a t e r g i v e n : - t h a t i n s t i t u t i o n a l c a r e ( h o s p i t a l a n d n u r s i n g h o m e ) c u r r e n t l y a c c o u n t s f o r t h e l a r g e s t p o r t i o n o f a l l h e a l t h c a r e e x p e n d i t u r e s f o r t h e e l d e r l y a n d t h e c h r o n i c a l l y d i s a b l e d [ 2 7 : 4 ; 2 9 : 9 8 ; 3 4 ] ; - t h a t t h e p r e d i c t i o n s f o r t h e n e x t t h i r t y t o f i f t y y e a r s a r e f o r b o t h i n c r e a s i n g a b s o l u t e n u m b e r s a n d a n i n c r e a s e d a v e r a g e a g e f o r p e r s o n s r e q u i r i n g i n s t i t u t i o n a l c a r e i n C a n a d a [ 3 5 : 2 3 8 - 4 8 ] . ( V a r i a t i o n s i n b o t h f e r t i l i t y a n d m i g r a t i o n r a t e s m a y e i t h e r a m e l i o r a t e o r i n t e n s i f y t h i s i m p a c t ) - C a n a d a ' s h i g h e r r a t e o f i n s t i t u t i o n a l i z a t i o n [ 3 6 ] a n d m o r e e x t e n d e d r a n g e o f p u b l i c l y f u n d e d l o n g - t e r m c a r e s e r v i c e s [ 3 4 ] ; - t h a t t h e c u r r e n t t r e n d i n C a n a d a i s t o w a r d s a n i n f l a t i o n a r y e c o n o m y w i t h l o w e r e d e c o n o m i c g r o w t h , a n d c o n t i n u e d p u b l i c p r e s s u r e t o r e d u c e o r m a i n t a i n t a x a t i o n . C H A P T E R I I I - 5 7 -T h e s e e c o n o m i c a n d d e m o g r a p h i c p r e s s u r e s , a l o n g w i t h t h e f u n d i n g m e c h a n i s m s n o t e d e a r l i e r f o r h e a l t h c a r e a n d l o n g - t e r m c a r e , s e t t h e l i m i t a t i o n s a n d c o n t e x t w i t h i n w h i c h o u t c o m e - b a s e d r e i m b u r s e m e n t a p p r o a c h e s c a n b e d e v e l o p e d i n C a n a d a . W i t h i n t h e p u b l i c l y a d m i n i s t e r e d s y s t e m i n C a n a d a , m o s t o f t h e r e v e n u e r e s o u r c e s f o r a c u t e a n d l o n g - t e r m c a r e c o m e f r o m t h e f e d e r a l -p r o v i n c i a l t a x b a s e . M u n i c i p a l t a x c o n t r i b u t i o n s a r e n o t s i g n i f i c a n t , p a r t i c u l a r l y f o r o p e r a t i n g c o s t s . I n 1 9 6 0 , p r i v a t e s e c t o r f u n d s a c c o u n t e d f o r f i f t y s e v e n p e r c e n t o f t h e t o t a l h e a l t h c a r e e x p e n d i t u r e s i n C a n a d a a n d s i n c e t h e e a r l y ' 7 0 ' s , l e s s t h a n t w e n t y f i v e p e r c e n t [ 3 7 ] . O n l y t h r e e p r o v i n c e s a s s e s s h o s p i t a l a n d m e d i c a l c a r e p r e m i u m s . I n p r o v i n c e s w i t h " i n s u r e d " f a c i l i t y - b a s e d l o n g - t e r m c a r e , c l i e n t s a r e a s s e s s e d a u s e r f e e , u s u a l l y a t t h e r a t e o f a p p r o x i m a t e l y t w e n t y f i v e t o t h i r t y t h r e e p e r c e n t o f t h e p e r d i e m r a t e [ 2 4 ] . T h e b a l a n c e i s p a i d o u t o f b y p r o v i n c i a l r e v e n u e s . T h e p r o p o r t i o n o f t h e G r o s s N a t i o n a l P r o d u c t ( G N P ) a n d t h e r a t e o f g r o w t h o f h e a l t h a n d l o n g - t e r m c a r e f r o m 1 9 7 0 t o 1 9 3 - 8 3 i n C a n a d a a r e a s f o l l o w s : - f r o m 1 9 7 0 - 1 9 8 0 T o t a l H e a l t h C a r e e x p e n d i t u r e s w e r e r e l a t i v e l y s t a b l e a t j u s t o v e r s e v e n p e r c e n t ; - f r o m 1 9 7 0 - 7 8 N u r s i n g Home C a r e e x p e n d i t u r e s , a s a p e r c e n t a g e o f t h e G N P , i n c r e a s e d f r o m . 5 2 * t o . 8 8 * ; - f r o m 1 9 7 0 - 7 8 N u r s i n g Home e x p e n d i t u r e s , a s a p e r c e n t a g e o f T o t a l H e a l t h C a r e e x p e n d i t u r e s , i n c r e a s e d f r o m 7 . 2 * t o 1 2 * [ 3 7 ; 3 8 ] . C H A P T E R I I I - 5 8 -A l l p r o v i n c e s e x c e p t o n e ( O n t a r i o ) a r e u s i n g o r h a v e e n d o r s e d t h e s i n g l e p o i n t o f e n t r y c o n c e p t f o r n u r s i n g h o m e p l a c e m e n t , a n d e v e n O n t a r i o i s m a k i n g s o m e m o v e m e n t i n t h i s d i r e c t i o n [ 2 4 : 2 9 - 3 0 ] . A t l e a s t t w o p r o v i n c e s ( M a n i t o b a a n d B r i t i s h C o l u m b i a ) h a v e f o r m a l l y e x p a n d e d t h i s c o n c e p t t o i n c l u d e t h e w h o l e c o n t i n u u m o f l o n g - t e r m c a r e s e r v i c e s - h o m e c a r e , c o m m u n i t y s e r v i c e s a n d f a c i l i t y c a r e , w h i l e i n o t h e r p r o v i n c e s t h e r e a r e c l o s e w o r k i n g r e l a t i o n s h i p s b e t w e e n t h e s e s e c t o r s [ 2 4 : 4 1 ; 2 6 : 4 8 - 4 9 , 9 5 - 1 0 1 ] . UNITED STATES I n t h e U n i t e d S t a t e s , o n t h e o t h e r h a n d , a l l h e a l t h c a r e s e r v i c e s ( h o s p i t a l , m e d i c a l a n d l o n g - t e r m c a r e ) a r e p r o v i d e d t h r o u g h a c o m b i n a t i o n o f p r i v a t e , v o l u n t a r y a n d p u b l i c p r o v i d e r s w h o a r e f u n d e d t h r o u g h a c o m b i n a t i o n o f p r i v a t e - p a y , t h i r d p a r t y i n s u r a n c e , a n d c a t e g o r i c a l s o c i a l a s s i s t a n c e a n d h e a l t h c a r e b e n e f i t s f o r t h e m e d i c a l l y a n d f i n a n c i a l l y i n d i g e n t . T h e l a t t e r a r e p r o v i d e d b y a t l e a s t t w o l e v e l s o f g o v e r n m e n t - s t a t e a n d f e d e r a l . A s w i t h C a n a d a , s o c i a l p o l i c y , c o n s t i t u t i o n a l p o w e r s a n d l e g i s l a t i o n , a l o n g w i t h t h e e c o n o m i c a n d f i n a n c i a l c l i m a t e h a v e i n f l u e n c e d t h e o r g a n i z a t i o n a l s t r u c t u r e o f l o n g - t e r m c a r e a n d i t s f a c i l i t y - b a s e d s y s t e m i n t h e U n i t e d S t a t e s . SOCIAL POLICY S o c i a l p o l i c y i n t h e U n i t e d S t a t e s h a s l e a n e d m o r e t o w a r d s t h e f r e e e n t e r p r i s e i d e o l o g y w h i c h s u g g e s t s t h a t i n d i v i d u a l s s h o u l d t a k e r e s p o n s i b i l i t y f o r t h e i r o w n s o c i a l n e e d s ( w h i l e C H A P T E R I I I - 5 9 -a l l o w i n g t h a t t h e r e m a y b e a n e e d f o r s o m e c a t e g o r i c a l s u b s i d y f o r t h e i n d i g e n t ) a n d ' t h e l e a s t g o v e r n m e n t i s t h e b e s t g o v e r n m e n t ' p h i l o s o p h y . T h e r e h a s b e e n c o n t i n u e d a n d s t r o n g r e s i s t a n c e i n t h e U n i t e d S t a t e s t o a n y p r o p o s a l s f o r a n a t i o n a l h e a l t h i n s u r a n c e s c h e m e [ 2 3 ; 3 9 : 5 0 9 , 5 1 1 - 6 6 ; 4 0 ; 4 1 ] . H o w e v e r , i n t h e f a c i l i t y - b a s e d l o n g - t e r m c a r e s e c t o r t h e g r o w i n g c o s t s , t h e n u m b e r s o f t h e p o p u l a t i o n w h o r e c e i v e s u b s i d i e s f o r s u c h c a r e t h r o u g h t h e M e d i c a r e a n d M e d i c a i d p r o g r a m s a n d t h e p r e d o m i n a n c e o f f o r - p r o f i t f a c i l i t i e s ( 7 6 . 8 * o f t h e f a c i l i t i e s a n d 6 9 . 3 * o f t h e b e d s i n 1 9 7 7 ) [ 3 9 : 5 2 0 ] h a s l e d t o a s t r o n g p u b l i c e x p e c t a t i o n a n d a c t u a l f e d e r a l a n d s t a t e g o v e r n m e n t i n v o l v e m e n t i n f u n d i n g a n d r e g u l a t i o n . E l i g i b i l i t y f o r g o v e r n m e n t f u n d e d l o n g - t e r m c a r e ( h o m e a n d f a c i l i t y ) i s l a r g e l y b a s e d o n t h e n e e d f o r h e a l t h c a r e , n o t o n a n e e d f o r s o c i a l s u p p o r t a n d i t i s o n l y f o r t h o s e e l i g i b l e b e c a u s e o f l o w i n c o m e , o r m e d i c a l i n d i g e n c e a n d a g e ( e . g . 6 5 y e a r s a n d o v e r f o r M e d i c a r e ) [ 3 9 ; 4 1 : 1 0 , 1 4 ; 4 2 ] . T h u s , o n o n e h a n d , o n e s e e s i n t h e U n i t e d S t a t e s a r e s i s t a n c e t o g o v e r n m e n t i n v o l v e m e n t , a n d o n t h e o t h e r t h e a c t u a l g r o w t h i n ( a n d p r e d i c t e d n e e d f o r ) f a c i l i t y - b a s e d l o n g -t e r m c a r e c r e a t i n g p r e s s u r e f o r i n c r e a s e d m o n i t o r i n g a n d o t h e r g o v e r n m e n t i n i t i a t i v e s t o e n s u r e a n a c c o u n t a b l e s y s t e m . A d d e d t o t h i s a r e t h e q u e s t i o n s r a i s e d a b o u t e q u i t y o f a c c e s s t o f a c i l i t y - b a s e d l o n g - t e r m c a r e . P r e s s u r e f r o m t h e i n c r e a s i n g n u m b e r s o f f r a i l e l d e r l y o n l o w i n c o m e s , h a s h a d a n d w i l l c o n t i n u e t o h a v e a d i r e c t i m p a c t o n t h e c a t e g o r i c a l b e n e f i c i a r y C H A P T E R I I I - 60 -g r o u p a p p r o a c h u s e d b y t h e U n i t e d S t a t e s g o v e r n m e n t t o f u n d l o n g - t e r m c a r e s e r v i c e s [ 2 3 ; 4 2 ] . T h e s e p r e s s u r e s h a v e l e d t o p r o p o s a l s f o r a v a r i e t y o f f u n d i n g a n d r e i m b u r s e m e n t a p p r o a c h e s . A n u m b e r o f t h e s e a p p r o a c h e s a t t e m p t t o r e s o l v e t h e e q u i t y p r o b l e m i n t h e U n i t e d S t a t e s r e l a t e d t o t h e g a t e k e e p e r r o l e o f p r o p r i e t a r y f a c i l i t i e s w h i c h d o m i n a t e t h e i n d u s t r y . S o m e s e e t h e s o l u t i o n i s t o f u n d a n a t i o n a l s y s t e m o f h e a l t h i n s u r a n c e , p a r t i c u l a r l y f o r l o n g - t e r m c a r e s e r v i c e s [ 2 3 ] . O t h e r s p r o p o s e r e i m b u r s e m e n t a p p r o a c h e s a i m e d a t n u l l i f y i n g t h e g a t e k e e p e r r o l e o f p r i v a t e , f o r - p r o f i t p r o v i d e r s w h o s e r e v e n u e s a r e b a s e d o n a m i x o f p u b l i c l y f u n d e d ( w i t h g o v e r n m e n t s e t r a t e s ) a n d p r i v a t e p a y ( w i t h m a r k e t o r p r o v i d e r s e t r a t e s ) c l i e n t s [ 4 3 ; 4 4 ; 4 5 ; 4 7 ; 4 8 ] . A l t h o u g h s e v e r a l t h e o r i e s h a v e b e e n p r o p o s e d i t i s n o t c l e a r w h a t d r i v e s t h e p r i v a t e p a y r a t e s o r w h a t c o m b i n a t i o n o f ' p r o v i d e r i n c e n t i v e s ' t o f o r - p r o f i t o p e r a t o r s w o u l d e n s u r e b o t h e q u i t y o f a c c e s s a n d a d e q u a c y o f t h e c a r e p r o v i d e d . T h i s h a s l e d t o r e i m b u r s e m e n t p r o p o s a l s s u c h a s v o u c h e r s y s t e m s a n d m a r k e t m o d e l f o r m u l a s [ 1 4 ; 4 8 ; 4 9 ] . THE CONSTITUTIONAL AND LEGAL BASE I n t h e U n i t e d S t a t e s t h e l e g a l b a s i s f o r t h e p r o v i s i o n o f g o v e r n m e n t s e r v i c e s , i n c l u d i n g h e a l t h c a r e s e r v i c e s , i s r o o t e d i n t h e t r i p a r t i t e s y s t e m o f c h e c k s a n d b a l a n c e s o f t h e J u d i c i a l , l e g i s l a t i v e a n d a d m i n i s t r a t i v e b o d i e s a t b o t h t h e f e d e r a l a n d s t a t e l e v e l s o f g o v e r n m e n t [ 4 8 ] . T h i s a l l o w s c h a n g e t o c o m e f r o m a v a r i e t y o f s o u r c e s a n d m o r e p u b l i c s c r u t i n y . C o n s t i t u t i o n a l l y , r e s p o n s i b i l i t y f o r h e a l t h s e r v i c e s i n t h e U n i t e d S t a t e s r e s t s C H A P T E R I I I - 61 -w i t h t h e f e d e r a l g o v e r n m e n t , w i t h r e s i d u a l p o w e r s o n l y a t t h e s t a t e l e v e l . L e g i s l a t i o n a t t h e s t a t e l e v e l h a s t a k e n t h e t r a d i t i o n a l r o l e o f r e g u l a t i n g f o r t h e p r o t e c t i o n a n d s a f e t y o f f a c i l i t y - b a s e d c l i e n t s u n d e r w h a t i s n o w c o m m o n l y r e f e r r e d t o a s l i f e - s a f e t y c o d e s [ 3 9 ] . T h e s t a t e s a l s o h a v e a n e n f o r c e m e n t f u n c t i o n f o r a l l f e d e r a l a n d s t a t e h e a l t h c a r e l e g i s l a t i o n [ 5 0 ] . G o v e r n m e n t i n v o l v e m e n t i n t h e f u n d i n g a n d p r o v i s i o n o f h e a l t h c a r e s e r v i c e s c a m e i n i t i a l l y t h r o u g h c a t e g o r i c a l b e n e f i t s u n d e r s o c i a l w e l f a r e p r o g r a m s a n d s i n c e 1 9 6 6 h a s d e v e l o p e d u n d e r t h e M e d i c a r e ( f e d e r a l ) a n d t h e M e d i c a i d ( f e d e r a l - s t a t e ) p r o g r a m s [ 3 9 ; 4 1 ] . T h e l a t t e r a r e p r i m a r i l y l o n g - t e r m c a r e p r o g r a m s . T h e r e s u l t a n t i n c r e a s e d g o v e r n m e n t i n v o l v e m e n t i n f u n d i n g f o r a l l a s p e c t s o f t h e h e a l t h c a r e i n d u s t r y , p l u s c o n c e r n s r a i s e d b y t h e p u b l i c a b o u t t h e q u a l i t y o f c a r e , l e d t o s t a t u t o r y r e q u i r e m e n t s d e s i g n e d t o e n s u r e e f f i c i e n c y a n d e f f e c t i v e n e s s f o r t h e f u n d s e x p e n d e d . T h u s i n t h e U n i t e d S t a t e s h o s p i t a l s a n d l o n g - t e r m c a r e f a c i l i t i e s m u s t m e e t e x t e n s i v e r e g u l a t i o n s i n o r d e r t o b e c e r t i f i e d a s e l i g i b l e t o a c c e p t a n d r e c e i v e p a y m e n t f o r r e s i d e n t s w h o a r e r e c i p i e n t s o f M e d i c a r e o r M e d i c a i d [ 2 3 ; 4 8 ; 4 9 ; 5 1 ] . T h i s m u l t i - l a y e r e d i n v o l v e m e n t o f t h e f e d e r a l a n d s t a t e g o v e r n m e n t s h a s l e d t o s o m e v e r y c o m p l i c a t e d a n d o n e r o u s r e g u l a t o r y r e q u i r e m e n t s f o r f a c i l i t y - b a s e d l o n g - t e r m c a r e . T h e r e g u l a t i o n s o f t e n o v e r l a p , a n d a r e a d m i n i s t r a t i v e l y c o s t l y t o e n f o r c e ( o f t e n b y t h i r d p a r t y , q u a s i - g o v e r n m e n t a g e n c i e s ) , a n d l e a v e v e r y l i t t l e f l e x i b i l i t y f o r i n n o v a t i v e m a n a g e m e n t a n d c a r e C H A P T E R I I I - 62 -p r o v i s i o n [ 4 1 : 4 0 ] . M o s t o f t h e s t a t u t o r y r e g u l a t i o n s a r e d i r e c t e d e i t h e r t o w a r d s t h e p r i v a t e , f o r p r o f i t p r o v i d e r s w i t h a f o c u s o n t h e p r o t e c t i v e m e c h a n i s m s , o r , t o w a r d s a s s u r i n g a c c e s s i b i l i t y t o f a c i l i t y c a r e f o r i n d i g e n t i n d i v i d u a l s w h o m e e t t h e a g e a n d / o r c a r e r e q u i r e m e n t s [ 2 3 : 8 2 2 , 8 8 8 ; 4 2 ; 5 0 ; 5 2 ] . ECONOMIC AND FINANCIAL ENVIRONMENT A l t h o u g h t h e e c o n o m i c e n v i r o n m e n t i n t h e U n i t e d S t a t e s m a y b e s o m e w h a t m o r e p o s i t i v e , t h e r e h a s b e e n c o n t i n u e d a n d g r o w i n g c o n c e r n a b o u t t h e i m p a c t o f l o n g - t e r m c a r e e x p e n d i t u r e s o n g o v e r n m e n t a n d p u b l i c e x p e n d i t u r e s o v e r a l l . K i n g s o n a n d S h e f f l e r p r e d i c t e d i n 1 9 8 1 t h a t " l o n g - t e r m c a r e a n d i t s f i n a n c i n g w i l l b e t h e s i n g l e m o s t i m p o r t a n t i s s u e i n h e a l t h c a r e i n t h e n e x t d e c a d e " [ 3 3 : 2 1 2 ] f o r t h e U n i t e d S t a t e s . I n t h e U n i t e d S t a t e s t h e g o v e r n m e n t f u n d s a r e a l l o c a t e d f r o m g e n e r a l t a x r e v e n u e s a t t h e f e d e r a l , s t a t e a n d l o c a l l e v e l s . S o m e p r o g r a m s a r e s o l e l y f u n d e d b y t h e f e d e r a l g o v e r n m e n t ( M e d i c a r e ) a n d o t h e r s a r e f e d e r a l - s t a t e c o s t - s h a r e d p r o g r a m s ( M e d i c a i d ) w i t h t h e f e d e r a l p o r t i o n r a n g i n g f r o m 2 5 t o 8 5 p e r c e n t [ 3 9 : 5 1 8 ; 4 1 : 1 0 ] . I n d i v i d u a l s w h o d o n o t q u a l i f y f o r c a t e g o r i c a l b e n e f i t s m u s t p a y t h e c o s t s f o r l o n g - t e r m c a r e . F o r a c u t e c a r e t h e c o s t s a r e u s u a l l y c o v e r e d b y i n s u r a n c e . T h i r d p a r t y i n s u r a n c e i s l i m i t e d f o r l o n g - t e r m c a r e , a n d o f t e n t i e d t o M e d i c a r e . S i n c e t h e 1 9 7 0 ' s t h e p r i v a t e s e c t o r f u n d i n g s h a r e h a s s h o w n s o m e d e c l i n e - f r o m 6 2 . 8 * i n 1 9 7 0 t o 5 7 . 8 * i n 1 9 8 0 . I n 1 9 8 0 , 3 8 . 4 % o f a l l l o n g - t e r m c a r e r e s i d e n t s u s e d t h e i r o w n o r f a m i l y i n c o m e . I n t h e p e r i o d f r o m 1 9 7 0 - 1 9 8 2 , t h e p r o p o r t i o n o f T o t a l C H A P T E R I I I - 6 3 -H e a l t h C a r e e x p e n d i t u r e s r o s e f r o m 7 . 5 2 * t o 1 0 . 4 9 * o f t h e GNP a n d d u r i n g 1 9 7 0 - 1 9 8 0 , e x p e n d i t u r e s f o r N u r s i n g H o m e s , a s p e r c e n t a g e o f T o t a l H e a l t h C a r e e x p e n d i t u r e s , r o s e f r o m 6 . 3 * t o 8 . 3 * [ 3 9 : 5 2 7 ; 5 3 ] . I n summary, t h e e x i s t e n c e o f a n d c o m m i t m e n t t o a n a t i o n a l s y s t e m o f p u b l i c l y a d m i n i s t e r e d , i n s u r e d h e a l t h c a r e s e r v i c e s w i t h u n i v e r s a l a c c e s s i n C a n a d a w h i c h i s m o v i n g t o w a r d s i n c l u s i o n o f l o n g - t e r m c a r e s e r v i c e s v e r s u s a m i x e d f u n d i n g s y s t e m o f c a t e g o r i c a l b e n e f i t s , f u n d e d b y t a x r e v e n u e a n d p r i v a t e s e c t o r f u n d i n g i n t h e U n i t e d S t a t e s i s o n e o f t h e m a j o r o r g a n i z a t i o n a l d i f f e r e n c e s b e t w e e n t h e L T C s y s t e m i n t h e U n i t e d S t a t e s a n d C a n a d a . I n t h e U n i t e d S t a t e s , a m o r e d i r e c t l i n k a g e o f t h e p a y m e n t t o p r o v i d e r s b a s e d o n m e e t i n g r e g u l a t o r y r e q u i r e m e n t s h a s l e d t o r e i m b u r s e m e n t p r o p o s a l s b e i n g d e v e l o p e d w h i c h l a r g e l y a d d r e s s p r o b l e m s o f e q u i t y i n t h e m i x e d r e v e n u e s y s t e m r a t h e r t h a n a d d r e s s i n g t h e p r o b l e m s o f b u d g e t a r y c o n s t r a i n t s , c o s t c o n t a i n m e n t a n d a s s u r i n g a d e q u a c y o f c a r e t h a t i s n e e d e d i n C a n a d a . T o b e f e a s i b l e i n t h e e c o n o m i c a n d f i n a n c i a l e n v i r o n m e n t i n C a n a d a ( a n d B . C . ) t h e o u t c o m e m e a s u r e m e n t a p p r o a c h e s m u s t n o t a d d s i g n i f i c a n t l y t o t h e a d m i n i s t r a t i v e o r o t h e r c o s t s o f a p u b l i c l y a d m i n i s t e r e d f a c i l i t y - b a s e d l o n g - t e r m c a r e s y s t e m . T h i s i s o f p a r t i c u l a r i m p o r t a n c e s i n c e h e a l t h e c o n o m i s t s s u g g e s t t h a t l o w a d m i n i s t r a t i v e c o s t s h a s b e e n t h e m a i n r e a s o n f o r t h e c o m p a r a t i v e l y l o w p e r c e n t a g e o f t h e GNP e x p e n d e d f o r h e a l t h c a r e i n C a n a d a [ 5 4 ] . CHAPTER I I I - 6 4 -THE NEED AND PROBLEMS IN THE CANADIAN SYSTEM The need i n Canada i s for better approaches to the provision of incentives (and cost control) which w i l l promote provider e f f i c i e n c y and effectiveness i n both the f o r - p r o f i t and non-profit sectors. Outcome-based reimbursement approaches developed i n the United States, p a r t i c u l a r l y from the reimbursement side, tend to be designed to resolve problems i n the system which do not exist (or not to as great a degree) i n Canada. These approaches must be viewed with caution for t h e i r use and g e n e r a l i z a b i l i t y i n f a c i l i t y - b a s e d care i n Canada. Notwithstanding the trends noted i n the Canadian system, there are a number of factors which continue to contribute to the lack of achievement of the objectives of optimum use of resources while assuring the provision of adequate care: - h i s t o r i c a l l y government r e s p o n s i b i l i t y for reimbursement and regulation has s h i f t e d back and forth , or been s p l i t between health and s o c i a l service departments , leading to fragmentation and rea l or perceived discrepancies i n the i r goals and guidelines; - the o r i g i n a l thrust of much of the e x i s t i n g l e g i s l a t i o n was the safety and protection of dependent adults, as opposed to the recent trend towards assurances of an acceptable q u a l i t y of care and/or l i f e ; - the a b i l i t y to obtain an accounting of f a c i l i t y expenditures i s more d i f f i c u l t i n the private sector of the industry; - present funding mechanisms are not viewed by the industry as an incentive either to maintain or upgrade the q u a l i t y of care, or to achieve optimal, e f f i c i e n t expenditure of funds; C H A P T E R I I I - 65 -T w o o t h e r a s p e c t s o f f e a s i b i l i t y a r e i m p o r t a n t . O n e i s c o n s i d e r a t i o n o f t h e c o s t s o f i m p l e m e n t a t i o n a n d o n g o i n g o p e r a t i o n o f a p a r t i c u l a r a p p r o a c h , e s p e c i a l l y i n t i m e s o f e c o n o m i c r e s t r a i n t . T h e o t h e r r e l a t e s t o w h e t h e r t h e r e s u l t s w i l l p r o v i d e g o v e r n m e n t p o l i c y m a k e r s w i t h t h e i n f o r m a t i o n o n w h i c h t o b a s e f u n d i n g d e c i s i o n s . F o r i n s t a n c e , c a n t h e m e a s u r e m e n t m e t h o d o r a p p r o a c h : - p r o v i d e t h e i n f o r m a t i o n n e e d e d i n a c l e a r a n d c o n c i s e f o r m w h i c h w i l l m i n i m i z e t h e n e e d f o r f u r t h e r s u b j e c t i v e j u d g e m e n t o r q u a l i t a t i v e a s s e s s m e n t s ; - b e a p p l i e d e q u a l l y t o f o r - p r o f i t a n d n o - p r o f i t p r o v i d e r s ; - b e a p p l i e d e i t h e r p r o s p e c t i v e l y o r r e t r o s p e c t i v e l y ; - a c t a s a n i n c e n t i v e f o r p r o v i d i n g e f f e c t i v e c a r e o r m o r e e f f i c i e n t e x p e n d i t u r e o f f u n d s ? I n a d d i t i o n , i s t h e m e t h o d p o l i t i c a l l y a c c e p t a b l e ? T h a t i s , d o e s i t : - s u p p o r t / p r o m o t e t h e o b j e c t i v e s o f t h e p r o g r a m ; - r e p r e s e n t a n i n c r e m e n t a l c h a n g e o r a m a j o r r e f o r m ; - r e c o g n i z e c o s t r e s t r a i n t g u i d e l i n e s a n d / o r o t h e r e c o n o m i c r e a l i t i e s ; - m e e t / c o n c u r w i t h f e d e r a l a n d p r o v i n c i a l l e g i s l a t i v e r e q u i r e m e n t s ? SUMMARY We h a v e n o t e d i n t h i s c h a p t e r a n u m b e r o f c o n s t r a i n t s w h i c h m u s t b e a d d r e s s e d i n o r d e r f o r a n o u t c o m e m e a s u r e m e n t o r o u t c o m e - b a s e d r e i m b u r s e m e n t a p p r o a c h t o b e f e a s i b l e f o r u s e b y C H A P T E R I I I - 66 -b y g o v e r n m e n t f u n d e r s a n d r e g u l a t o r s i n t h e f a c i l i t y - b a s e d l o n g -t e r m c a r e i n d u s t r y i n B r i t i s h C o l u m b i a . T h e f i r s t c o n s t r a i n t n o t e d w a s t h e m e t h o d o l o g i c a l c o n s t r a i n t o f t h e n e e d f o r t h e m e a s u r e m e n t o f v a l u e p r e f e r e n c e s i n a p u b l i c s e r v i c e i n d u s t r y s u c h a s l o n g - t e r m c a r e w h e r e t h e r e i s a l a c k o f c o m p e t i t i v e m a r k e t f o r c e s t o d e t e r m i n e c o n s u m e r c h o i c e . A m e t h o d o f v a l u e p r e f e r e n c e m e a s u r e m e n t i s n e e d e d t o d e t e r m i n e w h a t o u t c o m e s a r e v a l u e d a n d t h e r e f o r e e x p e c t e d f r o m f a c i l i t y - b a s e d c a r e . T h e d e f i n i t i o n a l c o n t e x t o f t h e t h e m e a s u r e m e n t o f o u t c o m e s , t h e a p p l i c a t i o n o f o u t c o m e - b a s e d r e i m b u r s e m e n t , e f f e c t i v e n e s s a n d e f f i c i e n c y m e a s u r e s i n h u m a n s e r v i c e i n d u s t r i e s s u c h a s l o n g - t e r m c a r e w i t h i t s c o m p l e x a n d m u l t i d i m e n s i o n a l n e e d s t r u c t u r e w e r e a l s o n o t e d . O t h e r s y s t e m v a r i a b l e s , s u c h a s s o c i a l p o l i c y , c o n s t i t u t i o n a l r o l e s a n d t h e e c o n o m i c a n d f i n a n c i a l e n v i r o n m e n t w h i c h m a y a c t a s c o n s t r a i n t s t o o u t c o m e m e a s u r e m e n t , p a r t i c u l a r l y t h o s e a r i s i n g f r o m d i f f e r e n c e s b e t w e e n t h e s y s t e m i n C a n a d a ( a n d B . C . ) a n d t h e U n i t e d S t a t e s w e r e n o t e d a s t h e y w o u l d a f f e c t t h e f e a s i b i l i t y o f a p p l y i n g o u t c o m e a p p r o a c h e s d e v e l o p e d i n t h e U n i t e d S t a t e s . I t m a y b e t h a t t h e s e d i f f e r e n c e s a r e m o r e s i g n i f i c a n t i n t e r m s o f o u t c o m e - b a s e d r e i m b u r s e m e n t a p p r o a c h e s t h a n f o r e f f e c t i v e n e s s m e a s u r e m e n t a p p r o a c h e s . T h e m e t h o d o l o g i c a l , d e f i n i t i o n a l , p o l i t i c a l a n d s y s t e m c o n s t r a i n t s n o t e d i n t h i s c h a p t e r a r e u s e d a s g u i d e s t o a s s e s s t h e o u t c o m e m e a s u r e m e n t a n d o u t c o m e - b a s e d r e i m b u r s e m e n t a p p r o a c h e s e x p l o r e d i n t h e f o l l o w i n g c h a p t e r s . C H A P T E R I I I - 6 7 -R E F E R E N C E S 1 . J o i n t C o m m i s s i o n o n A c c r e d i t a t i o n o f H o s p i t a l s . A c c r e d i t a t i o n  M a n u a l f o r L o n g - T e r m C a r e F a c i l i t i e s . C h i c a g o , I l l i n o i s , 1 9 7 5 . 2 . K a n e , R o b e r t a n d K a n e , R o s a l i e A . " L o n g - T e r m C a r e : A F i e l d i n S e a r c h o f V a l u e s . " I n V a l u e s a n d L o n g - T e r m C a r e , p p . 3 -2 6 . E d i t e d b y R o b e r t K a n e a n d R o s a l i e K a n e . T o r o n t o : L e x i n g t o n B o o k s , 1 9 8 2 . 3 . L i p s c o m b , J o s e p h . " V a l u e P r e f e r e n c e f o r H e a l t h : M e a n i n g , M e a s u r e m e n t a n d U s e i n P r o g r a m E v a l u a t i o n . " I n V a l u e s a n d  L o n g - T e r m C a r e , p p . 2 7 - 8 4 . E d i t e d b y R o b e r t a n d R o s a l i e K a n e . T o r o n t o : L e x i n g t o n B o o k s , 1 9 8 2 . 4 . M c N e i l , B a r b a r a J . , a n d P a u k e r , S t e p h e n G . " O p t i m i z i n g P a t i e n t a n d S o c i e t a l D e c i s i o n M a k i n g b y t h e I n c o r p o r a t i o n o f I n d i v i d u a l V a l u e s . " I n V a l u e s a n d L o n g - T e r m C a r e , p p . 2 1 5 - 3 0 . E d i t e d b y R o b e r t a n d R o s a l i e K a n e . T o r o n t o : L e x i n g t o n B o o k s , 1 9 8 2 . 5 . V e i t , C l a r i c e T . a n d W a r e , J o h n E . " M e a s u r i n g H e a l t h a n d H e a l t h O u t c o m e s : I s s u e s a n d R e c o m m e n d a t i o n s . " I n V a l u e s a n d  L o n g - T e r m C a r e , p p . 2 3 3 - 6 0 . E d i t e d b y R o b e r t K a n e a n d R o s a l i e K a n e . T o r o n t o : L e x i n g t o n B o o k s , 1 9 8 2 . 6 . K a n e , R o b e r t a n d K a n e , R o s a l i e A . , e d s . V a l u e s a n d L o n g - T e r m  C a r e , p p . 2 7 7 - 9 0 . T o r o n t o : L e x i n g t o n B o o k s , 1 9 8 2 . 7 . N e u , C a r l R . " I n d i v i d u a l P r e f e r e n c e s f o r L i f e a n d H e a l t h : M i s u s e s a n d P o s s i b l e U s e s . " I n V a l u e s a n d L o n g - T e r m C a r e , p p . 2 6 1 - 7 6 . E d i t e d b y R o b e r t K a n e a n d R o s a l i e K a n e . T o r o n t o : L e x i n g t o n B o o k s , 1 9 8 2 . 8 . R e a d e r s D i g e s t G r e a t E n c y c l o p e d i c D i c t i o n a r y i n c l u d i n g F u n k a n d W a g n a l l s S t a n d a r d C o l l e g e D i c t i o n a r y . 1 9 7 7 . s . v . o u t c o m e , o u t p u t . 9 . P a l m e r , R . H e a t h e r . " D e f i n i t i o n s a n d D a t a . " I n A s s u r i n g  Q u a l i t y i n M e d i c a l C a r e : T h e S t a t e o f t h e A r t , p p . 1 3 - 6 0 . E d i t e d b y R. G r e e n . C a m b r i d g e , M a s s : B a l l i n g e r P u b l i s h i n g C o . , 1 9 7 6 . 1 0 . J a c o b s , P . E c o n o m i c s o f H e a l t h a n d M e d i c a l C a r e : A n  I n t r o d u c t i o n , p p . 1 5 5 - 1 8 5 . B a l t i m o r e : U n i v e r s i t y P a r k P r e s s , 1 9 8 0 . 1 1 . D o n a b e d i a n , A v e d i s . E x p l o r a t i o n s i n Q u a l i t y A s s e s s m e n t a n d  M o n i t o r i n g V o l u m e I : T h e D e f i n i t i o n s o f Q u a l i t y a n d  A p p r o a c h e s t o A s s e s s m e n t . A n n A r b o r , M i c h . : H e a l t h A d m i n i s t r a t i o n P r e s s , 1 9 8 0 . 1 2 . B e r k i , S . E . H o s p i t a l E c o n o m i c s , p p . 1 8 3 - 1 9 3 . 1 9 7 2 . C H A P T E R I I I - 6 8 -1 3 . B u c h a n a n , R o b e r t J . H e a l t h C a r e F i n a n c e : a n A n a l y s i s o f C o s t  a n d U t i l i z a t i o n I s s u e s . T o r o n t o : L e x i n g t o n B o o k s , 1 9 8 1 . 1 4 . L a v e , J u d i t h R. " C o s t C o n t a i n m e n t P o l i c i e s i n L o n g - T e r m C a r e . " I n q u i r y X X I I ( S P R I N G ) 1 9 8 5 ) : 7 - 2 2 . 1 5 . H a r r i n g t o n , C h a r l e n e , a n d S w a n , J a m e s H . " M e d i c a i d N u r s i n g Home R e i m b u r s e m e n t P o l i c i e s , R a t e s a n d E x p e n d i t u r e s . " H e a l t h  C a r e F i n a n c i n g R e v i e w 6 ( F a l l 1 9 8 4 ) : 3 9 - 4 9 . 1 6 . S t o d d a r t , G . L . E c o n o m i c E v a l u a t i o n M e t h o d s a n d H e a l t h  P o l i c y . H a m i l t o n , O n t a r i o : M c M a s t e r U n i v e r s i t y Q S E P R e s e a r c h R e p o r t , 1 9 8 1 . 1 7 . I b r a h i m , M i c h e l A . E p i d e m i o l o g y a n d H e a l t h P o l i c y . R o c k v i l l e , M a r y l a n d : A s p e n S y s t e m C o r p o r a t i o n , 1 9 8 5 . 1 8 . W i l l i a m s o n , J o h n W. A s s e s s i n g a n d I m p r o v i n g H e a l t h C a r e  O u t c o m e s : T h e H e a l t h A c c o u n t A p p r o a c h t o Q u a l i t y A s s u r a n c e . C a m b r i d g e , M a s s . B a l l i n g e r P u b l i s h i n g C o . , 1 9 7 8 . 1 9 . B r o o k , R o b e r t H . a n d L o h r , K a t h l e e n N . " E f f i c a c y , E f f e c t i v e n e s s , V a r i a t i o n s a n d Q a u l i t y : B o u n d a r y - C r o s s i n g R e s e a r c h . " M e d i c a l C a r e . V o l . 2 3 N o . 5 ( M a y 1 9 8 5 ) : 7 1 0 - 7 2 1 . 2 0 . M e i n e r s , M a r k R . " A n E c o n o m i c A n a l y s i s o f t h e M a j o r D e t e r m i n a n t s o f N u r s i n g Home C o s t s i n t h e U n i t e d S t a t e s . " J o u r n a l o f S o c i a l S c i e n c e a n d M e d i c i n e 16 ( 1 9 8 2 ) : 8 8 7 - 8 9 8 . 2 1 . H a l l , E m m e t t . C a n a d a ' s N a t i o n a l - P r o v i n c i a l H e a l t h P r o g r a m  f o r t h e 1 9 8 0 ' s : A C o m m i t m e n t f o r R e n e w a l . O t t a w a , 1 9 8 0 . 2 2 . H a v i g h u r s t , C l a r k a n d B l u m s t e i n , J a m e s . " C o p i n g w i t h Q u a l i t y / C o s t T r a d e - o f f s i n M e d i c a l C a r e : T h e R o l e o f P S R O ' s " N o r t h w e s t e r n U n i v e r s i t y L a w R e v i e w . 7 0 ( 1 9 7 5 ) : 6 - 3 0 . 2 3 . R a n g o , N i c h o l a s . " N u r s i n g - H o m e C a r e i n t h e U n i t e d S t a t e s : P r e v a i l i n g C o n d i t i o n s a n d P o l i c y I m p l i c a t i o n s . " New E n g l a n d  J o u r n a l o f M e d i c i n e 3 0 7 ( S e p t e m b e r 3 0 , 1 9 8 2 ) : 8 8 3 - 8 8 9 . 2 4 . A l b e r t a D e p a r t m e n t o f H e a l t h a n d M e d i c a l C a r e . R e c o m m e n d a t i o n s : A l b e r t a N u r i s n g Home R e v i e w P a n e l , M a r c h 1 9 8 2 . 2 5 . A u c o i n , P . " F e d e r a l H e a l t h C a r e P o l i c y " I n P e r s p e c t i v e s o n  C a n a d i a n H e a l t h a n d S o c i a l S e r v i c e s P o l i c y : H i s t o r y a n d  E m e r g i n g T r e n d s , p p . 2 4 4 - 6 8 . E d i t e d b y C a r l A . M e i l i c k e a n d J a n e t L . S t o r c h . A n n A r b o r P r e s s , M i c h i g a n : H e a l t h A d m i n i s t r a t i o n P r e s s , 1 9 8 0 . 2 6 . C a n a d a . D e p a r t m e n t o f N a t i o n a l H e a l t h a n d W e l f a r e . C a n a d i a n  G o v e r n m e n t a l R e p o r t o n A g i n g . O t t a w a , O n t a r i o , 1 9 8 2 . C H A P T E R I I I - 6 9 -2 7 . B e n n e t t , J a m e s , a n d K r a s n e y , J a c q u e s . H e a l t h C a r e i n C a n a d a : A S e r i e s o n t h e N a t i o n s H e a l t h . T h e F i n a n c i a l P o s t M a r c h 2 6 - M a y 7 , 1 9 7 7 . 2 8 . W a l k e r , C h a r l e s B . " S o c i a l S e c u r i t y P a s t a n d P r e s e n t . " I n C a n a d a ' s C h a n g i n g A g e S t r u c t u r e : I m p l i c a t i o n s f o r t h e  F u t u r e . p p . 1 - 3 2 . E d i t e d b y G l o r i a G u t m a n . B u r n a b y , B . C . : S F U P u b l i c a t i o n s , 1 9 8 2 . 2 9 . C a n a d a . F i s c a l F e d e r a l i s m i n C a n a d a : R e p o r t o f t h e  P a r l i a m e n t a r y T a s k F o r c e i n F e d e r a l - P r o v i n c i a l F i s c a l  A r r a n g e m e n t s . O t t a w a 1 9 8 1 . 3 0 . H a s t i n g s , J . E . F . " F e d e r a l - P r o v i n c i a l I n s u r a n c e f o r H o s p i t a l s a n d P h y s i c i a n s C a r e i n C a n a d a . " I n P e r s p e c t i v e s o n C a n a d i a n  H e a l t h a n d S o c i a l S e r v i c e s P o l i c y : H i s t o r y a n d E m e r g i n g  T r e n d s , p p . 1 9 9 - 2 1 8 . E d i t e d b y M . M e i l i k e a n d J . S t o r c h . A n n A r b o r P r e s s , M i c h i g a n : H e a l t h A d m i n i s t r a t i o n P r e s s , 1 9 8 0 . 3 1 . L e v e n i c k , K a r e n . " A R e v i e w o f G o v e r n m e n t R e g u l a t o r y R e s p o n s i b i l i t y f o r A d u l t C a r e F a c i l i t i e s a n d O p t i o n s o r R e g u l a t i o n i n B r i t i s h C o l u m b i a . " C l e r k s h i p R e p o r t . B r i t i s h C o l u m b i a M i n i s t r y o f H e a l t h , 1 9 8 2 . ( M i m e o g r a p h e d . ) 3 2 . M a n i t o b a , D e p a r t m e n t o f C o m m u n i t y S e r v i c e s a n d C o r r e c t i o n , O f f i c e o f R e s i d e n t i a l C a r e . M a n u a l f o r F a c i l i t i e s f o r A d u l t s S e c t i o n 3 - 1 : R e g u l a t i o n s P e r t a i n i n g t o L i c e n s i n g . M a r c h 1 9 8 1 . 3 3 . K i n g s o n , E r i c a n d S c h e f f l e r , R i c h a r d M . " A g i n g : I s s u e s a n d E c o n o m i c T r e n d s f o r t h e 1 9 8 0 ' s . " I n q u i r y 18 ( F a l l 1 9 8 1 ) : 1 9 7 - 2 1 3 . 3 4 . E v a n s , R o b e r t . "We H a v e S e e n t h e F u t u r e a n d T h e y ' s U s : H e a l t h C a r e a n d t h e G r a y i n g o f C a n a d a . " P a p e r p r e s e n t e d a t t h e C o m m o n w e a l t h F u n d F o r u m o n t h e H e a l t h C a r e o f t h e A g e d . L o n d o n , E n g l a n d , M a y 2 3 - 2 6 , 1 9 8 3 . ( M i m e o g r a p h e d . ) 3 5 . D e n t o n , F r a n k , a n d S p e n c e r , B y r o n . " H e a l t h C a r e C o s t s W h e n t h e P o p u l a t i o n C h a n g e s . " I n A g i n g l n C a n a d a : S o c i a l  P e r s p e c t i v e s , p p . 2 3 - 4 4 . E d i t e d b y V i c t o r M a r s h a l l . D o n M i l l s , O n t a r i o : F i t z h e n r y a n d W h i t e s i d e , 1 9 8 0 . 3 6 . S c h w e n g e r , C o p e a n d G r o s s , J o h n . " I n s t i t u t i o n a l C a r e a n d I n s t i t u t i o n a l i z a t i o n o f t h e E l d e r l y i n C a n a d a . " I n A g i n g i n  C a n a d a S o c i a l P e r s p e c t i v e s , p p . 2 6 9 - 8 5 . E d i t e d b y V i c t o r M a r s h a l l . D o n M i l l s , O n t a r i o : F i t z h e n r y a n d W h i t e s i d e , 1 9 8 0 . 3 7 . C a n a d a . D e p a r t m e n t o f H e a l t h a n d W e l f a r e . N a t i o n a l H e a l t h  E x p e n d i t u r e s i n C a n a d a : 1 9 7 0 - 1 9 7 9 . O t t a w a , O n t a r i o , 1 9 8 2 . C H A P T E R I I I - 7 0 -3 8 . H a m m e r , M a r k a n d L e v e n i c k , K a r e n . " N u r s i n g H o m e C a r e I n W a s h i n g t o n S t a t e a n d B r i t i s h C o l u m b i a : S i m i l a r i t i e s a n d D i f f e r e n c e s . " T h e l e a d p a p e r f o r t h e S y m p o s i u m o n R e g u l a t o r y I n f l u e n c e s o n t h e M a n a g e m e n t o f N u r s i n g H o m e s p r e s e n t e d a t t h e W e s t e r n A c a d e m y o f M a n a g e m e n t A n n u a l M e e t i n g , V a n c o u v e r , B . C . , A p r i l 1 9 8 4 . ( M i m e o g r a p h e d . ) 3 9 . W a l d m a n , S a u l " A L e g i s l a t i v e H i s t o r y o f N u r s i n g H o m e C a r e . " I n L o n g - T e r m C a r e : P e r s p e c t i v e s f r o m R e s e a r c h a n d  D e m o n s t r a t i o n s , p p . 5 0 7 - 5 3 6 . E d i t e d b y R . J . V o g e l a n d H . P a l m e r . U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s , H e a l t h C a r e F i n a n c i n g A d m i n i s t r a t i o n , 1 9 8 2 . 4 0 . C a l l a h a n , J a m e s J . , J r . a n d W a l l a c k , S t a n l e y S . " M a j o r R e f o r m s i n L o n g - T e r m C a r e . " R e f o r m i n g t h e L o n g - T e r m C a r e  S y s t e m : F i n a n c i a l a n d O r g a n i z a t i o n a l O p t i o n s , p p . 3 - 1 0 . E d i t e d b y J . J . C a l l a h a n a n d S . W a l l a c k . L e x i n g t o n , M a s s . : L e x i n g t o n B o o k s , 1 9 8 1 . 4 1 . U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s . L o n g - T e r m C a r e :  R e p o r t t o t h e S e c r e t a r y . S e r v i c e D e l i v e r y O f f i c e o f I n s p e c t o r G e n e r a l , 1 9 8 1 . 4 2 . K a n e , R o b e r t a n d K a n e , R o s a l i e , A . " T h e E x t e n t a n d N a t u r e o f P u b l i c R e s p o n s i b i l i t y f o r L o n g - T e r m C a r e . " I n P o l i c y O p t i o n s  i n L o n g - T e r m C a r e , p p . 7 8 - 1 1 7 . E d i t e d b y J . M e l t z e r , F . F a r r o w , a n d H . R i c h m a n . C h i c a g o : U n i v e r s i t y o f C h i c a g o P r e s s , 1 9 8 1 . 4 3 . Hamm, L i n d a V . ; K i c k h a m , T h o m a s M . ; a n d C u t l e r , D o l o r e s A . " R e s e a r c h , D e m o n s t r a t i o n s , a n d E v a l u a t i o n s . " I n L o n g - T e r m  C a r e : P e r s p e c t i v e s f r o m R e s e a r c h a n d D e m o n s t r a t i o n s , p p . 1 6 7 - 2 5 3 . E d i t e d b y R . J . V o g e l a n d H . P a l m e r . U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s , H e a l t h C a r e F i n a n c i n g A d m i n i s t r a t i o n , 1 9 8 2 . 4 4 . W e i s s e t , W i l l i a m ; S c a n l o n , W i i l i a m J . ; W a n , T h o m a s T . H . a n d S k i n n e r , D o u g l a s . " C a r e f o r t h e C h r o n i c a l l y 1 1 1 : N u r s i n g H o m e I n c e n t i v e P a y m e n t E x p e r i m e n t . " H e a l t h C a r e F i n a n c i n g  R e v i e w 5 ( W i n t e r 1 9 8 3 ) : 4 1 - 4 9 . 4 5 . F o t t l e r , M y r o n , S m i t h , H o w a r d L . , a n d J a m e s , W i l l i a m L . " P r o f i t s a n d P a t i e n t C a r e Q u a l i t y i n N u r s i n g H o m e s : A r e T h e y C o m p a t i b l e ? " T h e G e r o n t o l o g i s t 21 ( 1 9 8 1 ) : 5 3 2 - 5 3 8 . 4 6 . R u c h l i n , H i r s c h S . ; L e v y , S a m u e l ; a n d M u l l e n , C h a r l o t t e . " T h e L o n g - T e r m C a r e M a r k e t p l a c e : A n a l y s i s o f D e f i c i e n c i e s a n d P o t e n t i a l R e f o r m b y M e a n s o f I n c e n t i v e R e i m b u r s e m e n t . " M e d i c a l C a r e X I I I ( D e c e m b e r 1 9 7 5 ) : 9 7 9 - 9 9 1 . 4 7 . R u c h l i n , H i r s c h S . a n d L e v e y , S a m u e l . " A n E c o n o m i c P e r s p e c t i v e o f L o n g - T e r m C a r e " I n L o n g - T e r m C a r e : A H a n d b o o k  f o r R e s e a r c h e r s , P l a n n e r s , a n d P r o v i d e r s , p p . 2 5 - 7 8 . E d i t e d b y S . S h e r w o o d . New Y o r k : S p e c k P u b l i c a t i o n s , I n c . , 1 9 7 5 . C H A P T E R I I I - 7 1 -4 8 . V o g e l , R o n a l d J . " T h e I n d u s t r i a l O r g a n i z a t i o n o f t h e N u r s i n g H o m e I n d u s t r y . " I n L o n g - T e r m C a r e : P e r s p e c t i v e s f r o m  R e s e a r c h a n d D e m o n s t r a t i o n s , p p . 5 7 9 - 6 2 4 . E d i t e d b y R . J . V o g e l a n d H . P a l m e r . U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s , H e a l t h C a r e F i n a n c i n g A d m i n i s t r a t i o n , 1 9 8 2 . 4 9 . C o t t e r i l l , P h i l l i p G . " P r o v i d e r I n c e n t i v e s U n d e r A l t e r n a t e R e i m b u r s e m e n t S y s t e m s . " I n L o n g - T e r m C a r e : P e r s p e c t i v e s f r o m  R e s e a r c h a n d D e m o n s t r a t i o n s , p p . 1 6 7 - 2 5 3 . E d i t e d b y R . J . - V o g e l a n d H . P a l m e r . U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s , H e a l t h C a r e F i n a n c i n g A d m i n i s t r a t i o n , 1 9 8 2 . 5 0 . S m i t h , D a v i d B a r t o n . L o n g - T e r m C a r e I n T r a n s i t i o n : T h e  R e g u l a t i o n o f N u r s i n g H o m e s . A n n A r b o r , M i c h i g a n : A U P H A , 1 9 8 1 . 5 1 . P a l m e r , H a n s a n d C o t t e r i l l , P h i l l i p G . " S t u d i e s o f N u r s i n g Home C o s t s . " I n L o n g - T e r m C a r e : P e r s p e c t i v e s f r o m R e s e a r c h  a n d D e m o n s t r a t i o n s . E d i t e d b y R . V o g e l a n d H . C . P a l m e r . U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s , H e a l t h C a r e F i n a n c i n g A d m i n i s t r a t i o n , 1 9 8 2 . 5 2 . L a P o r t e , V a l e r i e a n d R u b i n , J e f f r y . , e d s . R e f o r m a n d  R e g u l a t i o n i n L o n g - T e r m C a r e . New Y o r k : P r a e g e r P u b l i s h e r s , 1 9 7 9 . 5 3 . G i b s o n , R o b e r t ; W a l d o , D a n i e l R . a n d L e v i t , K a t h e r i n e R . " N a t i o n a l H e a l t h E x p e n d i t u r e s , 1 9 8 2 . " H e a l t h C a r e F i n a n c i n g  R e v i e w 5 ( F a l l 1 9 8 3 ) : l - 3 2 . 5 4 . E v a n s , R o b e r t . P r o f e s s o r o f H e a l t h E c o n o m i c s , U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1 9 8 3 . ( P e r s o n a l C o m m u n i c a t i o n . ) CHAPTER IV: APPROACHES TO OUTCOME MEASUREMENT - PUBLIC SECTOR and HEALTH CARE SERVICES INTRODUCTION Given acceptance of the need for a common reimbursement system for the mixed provider system of f a c i l i t y - b a s e d long-term care i n B.C., and more s p e c i f i c a l l y , one which would promote both e f f e c t i v e and e f f i c i e n t expenditure of funds, an outcome-based reimbursement system has been proposed as one solut i o n . Various forms of outcome measures of effectiveness and outcome-based reimbursement have evolved i n both the private and public sectors of industry, including some approaches that are s p e c i f i c a l l y oriented to health care. A s e l e c t i o n of these approaches are reviewed i n t h i s chapter for the i r f e a s i b i l i t y for a p p l i c a t i o n i n outcome-based reimbursement for f a c i l i t y -based long-term care i n B r i t i s h Columbia. Keeping i n mind the constraints, problems and needs noted i n Chapter 3, two sets of c r i t e r i a were used to evaluate the various outcome measurement and outcome-based reimbursement, approaches. One set of c r i t e r i a was used to assess the s c i e n t i f i c merit of the approaches such such as i d e n t i f i c a t i o n of the problem, design and methodology c r i t e r i a (e.g v a l i d i t y and r e l i a b i l i t y ) , l i m i t a t i o n s and findings noted. The second set was used to determine the f e a s i b i l i t y of the approaches for implementation i n the long-term care industry, such as did the study problem and objective relate to outcome measurement, did the design and methodology recognize population variance and the C H A P T E R I V - 7 3 -m u l t i d i m e n s i o n a l i t y o f l o n g - t e r m c a r e , d i d t h e f i n d i n g s a n d l i m i t a t i o n s r e l a t e t o o u t c o m e m e a s u r e m e n t a n d / o r r e i m b u r s e m e n t ( s e e A p p e n d i x A f o r t h e d e t a i l e d c r i t e r i a ) . T h e c r i t e r i a f o r t h e s c i e n t i f i c a c c e p t a b i l i t y w e r e d e v e l o p e d f r o m g u i d e s u s e d f o r c r i t i q u i n g e x i s t i n g w o r k s . T h e f e a s i b i l i t y c r i t e r i a w e r e d r a w n f r o m t h e c o n s t r a i n t f a c t o r s n o t e d i n C h a p t e r T h r e e a n d f r o m t h e l i t e r a t u r e r e l a t e d t o t h e u s e o f o u t c o m e m e a s u r e m e n t a n d o u t c o m e - b a s e d a s s e s s m e n t t o o l s i n h e a l t h o r l o n g - t e r m c a r e [ 1 ; 2 ; 3 ; 4; 5 ; 6 ] . M e a s u r e m e n t o f o u t c o m e s h a s b e e n a t t w o l e v e l s - o n e f o c u s i s t h e e f f e c t o r o u t c o m e s o f t h e o r g a n i z a t i o n a s a w h o l e a n d t h e o t h e r i s a f o c u s o n o u t c o m e s a t t h e i n d i v i d u a l p r o d u c t , o r i n t h e c a s e o f h e a l t h c a r e , t h e i n d i v i d u a l p a t i e n t l e v e l . T h e organizational l e v e l approaches r e v i e w e d i n c l u d e d : g e n e r i c o r g a n i z a t i o n a l e f f e c t i v e n e s s a p p r o a c h e s i n c l u d i n g c o s t - b e n e f i t a n d c o s t - e f f e c t i v e n e s s a n a l y s i s , m a n a g e m e n t b y o b j e c t i v e s , a n d z e r o b a s e d b u d g e t i n g ; a n d a s p e c i f i c c o n c e p t u s e d i n h e a l t h c a r e k n o w n a s Q u a l i t y A s s u r a n c e P r o g r a m s i n w h i c h o u t c o m e m e a s u r e s m a y b e u s e d . T h e s e a p p r o a c h e s h a v e b e e n u s e d i n b o t h t h e p r i v a t e a n d p u b l i c s e c t o r , i n c l u d i n g t h e h e a l t h c a r e s e c t o r . F r o m t h e r e v i e w o f t h e s e a p p r o a c h e s a h i s t o r i c a l t r e n d w a s n o t e d w h i c h s h o w e d t h a t i n i t i a l l y t h e e m p h a s i s w a s o n m e a s u r e s o f e f f e c t i v e n e s s b u t l a t e r m o r e a p p r o a c h e s s u p p o r t e d t h e i n c l u s i o n o f m e a s u r e s o f e f f i c i e n c y [ 7 ; 8 ; 9 ; 1 0 ; 1 1 ; 1 2 ; 1 3 ] . C H A P T E R I V - 7 4 -A t t h e i n d i v i d u a l p r o d u c t o r p a t i e n t l e v e l t h e a p p r o a c h e s p r e s e n t e d h e r e a r e t h o s e a p p l i c a b l e o n l y i n h e a l t h c a r e , s i n c e t h e m o r e g e n e r i c a p p r o a c h e s t o p r o d u c t i v i t y m e a s u r e m e n t a n d q u a l i t y c o n t r o l c o u l d n o t b e r e a d i l y a d a p t e d f o r t e s t i n g t h e r e s u l t s o f h e a l t h c a r e o n h u m a n i n d i v i d u a l s . T h e i n d i v i d u a l l e v e l a p p r o a c h e s r e v i e w e d i n c l u d e d t h e f o l l o w i n g : h e a l t h c a r e i n d u s t r y a p p r o a c h e s i n c l u d i n g m o r t a l i t y , m o r b i d i t y ; a n d h e a l t h s t a t u s i n d e x e s . GENERIC ORGANIZATIONAL EFFECTIVENESS APPROACHES T h e m e a s u r e m e n t o f o r g a n i z a t i o n a l e f f e c t i v e n e s s i s a m a j o r t h e o r e t i c a l o r i e n t a t i o n d e v e l o p e d t o a n s w e r d e c i s i o n m a k e r s q u e s t i o n s a b o u t t h e p e r f o r m a n c e o f a n o r g a n i z a t i o n . O r g a n i z a t i o n a l e f f e c t i v e n e s s m o d e l s h a v e u s u a l l y t a k e n a b r o a d , m a c r o a p p r o a c h . M a n y o f t h e e a r l y e v a l u a t i o n m o d e l s w e r e u n i v a r i a t e i n t h a t t h e y m e a s u r e d o n l y o n e a s p e c t o f t h e o r g a n i z a t i o n ' s p e r f o r m a n c e , s u c h a s p r o d u c t i v i t y ( e . g . a c t u a l o u t p u t , p r o f i t o r r a t e s o r r e t u r n , e m p l o y e e s a t i s f a c t i o n , e t c . ) [ 7 : 5 4 6 - 4 7 ] . Q u e s t i o n s h a v e b e e n r a i s e d a b o u t h o w r e p r e s e n t a t i v e s u c h u n i v a r i a t e m e a s u r e m e n t s a r e o f t h e o v e r a l l e f f e c t i v e n e s s o f a n o r g a n i z a t i o n . E v a l u a t o r s t h e n d e v e l o p e d m u l t i v a r i a t e m o d e l s , m o s t o f w h i c h w e r e d e r i v e d f r o m a s y s t e m s p e r s p e c t i v e . T h e s e m o d e l s w e r e o f t e n n o r m a t i v e o r p r e s c r i p t i v e r a t h e r t h a n d e s c r i p t i v e . T h e y s u g g e s t e d w h a t s h o u l d b e a n d d i d n o t m e a s u r e w h a t w a s . C H A P T E R I V - 7 5 -M a n y p r o b l e m s w e r e e n c o u n t e r e d i n d e f i n i n g t h e e f f e c t i v e n e s s c o n s t r u c t f o r t h e s e m o d e l s i n c l u d i n g : - h o w t o a c c o m m o d a t e t h e c o m p l e x i t y o f o r g a n i z a t i o n s ; - a l a c k o f g e n e r a l i z a b i l i t y ; - h o w o r w h e t h e r t o c o m b i n e m i c r o a n d m a c r o l e v e l s o f a n a l y s e s [ 7 : 5 4 7 - 5 4 ] . F o r t h e s e r e a s o n s , a s S t e e r s p o i n t s o u t , t h e s e m o d e l s a r e n o t v e r y h e l p f u l i n e x p l a i n i n g o r m e a s u r i n g o r g a n i z a t i o n a l e f f e c t i v e n e s s . H e t h e r e f o r e s u g g e s t s a n e w t y p e o f m o d e l , t h e " w e i g h t e d g o a l o p t i m i z a t i o n m o d e l " . S u c h a n a p p r o a c h t o e v a l u a t i n g o r g a n i z a t i o n a l e f f e c t i v e n e s s s h o u l d , h e s u g g e s t s ; - d e v e l o p m e a s u r e m e n t s i n r e l a t i o n t o t h e o p e r a t i o n a l g o a l s ( b e h a v i o u r a l i n t e n t i o n s ) o f t h e o r g a n i z a t i o n a n d m e a s u r e g o a l a t t a i n m e n t ; - b e f l e x i b l e e n o u g h t o a c c o u n t f o r t h e d i v e r s i t y o f g o a l s ; - w e i g h t t h e m e a s u r e m e n t s t o a c c o u n t f o r t h e d i f f e r e n t v a l u e s p l a c e d o n e a c h o f t h e g o a l s ; a n d - r e c o g n i z e t h a t t h e r e a r e s o m e c o n s t r a i n t s t h a t w i l l i m p e d e g o a l a t t a i n m e n t . T h e r e f o r e w h a t i s t o b e m e a s u r e d i s t h e ' o p t i m i z e d ' o r r e a l i s t i c a l l y a c h i e v a b l e g o a l [ 7 : 5 5 5 - 5 7 ] . T h e S t e e r s m o d e l a p p e a r s t o b e s i m i l a r t o w h a t C a m p b e l l [ 1 4 ] d e s c r i b e s a s t h e g o a l - o r i e n t e d v i e w o f o r g a n i z a t i o n a l e f f e c t i v e n e s s [ 1 4 : 3 1 ] . B a s e d o n C a m p b e l l ' s d e s c r i p t i o n o f g o a l -o r i e n t e d a n d s y s t e m s a p p r o a c h e s t o o r g a n i z a t i o n a l e f f e c t i v e n e s s , C H A P T E R I V - 7 6 -t h e g o a l - o r i e n t e d a p p r o a c h i s e s s e n t i a l l y a n o u t c o m e m e a s u r e m e n t p e r s p e c t i v e , w h e r e a s t h e s y s t e m s v i e w c o n s i d e r s t h e c h a r a c t e r i s t i c s ( t h e s t r u c t u r e a n d p r o c e s s v a r i a b l e s ) o f t h e s y s t e m a n d h o w t h e y a f f e c t p e r f o r m a n c e . C a m p b e l l i d e n t i f i e s c o s t - b e n e f i t a n a l y s i s , m a n a g e m e n t b y o b j e c t i v e , a n d a c r i t e r i o n p r o b l e m m o d e l a s o p e r a t i o n a l e x a m p l e s o f t h e g o a l - o r i e n t e d p e r s p e c t i v e [ 1 4 : 3 1 - 4 0 ] . I n c o n t r a s t t o S t e e r s s u g g e s t i o n s , C a m p b e l l c a u t i o n s a g a i n s t a m u l t i v a r i a t e a p p r o a c h t o d e v e l o p i n g e f f e c t i v e n e s s m e a s u r e s a n d a n y " a t t e m p t s t o d e v e l o p r e s u l t s - o r i e n t e d m e a s u r e s ( e . g . ) t e r m i n a l o u t c o m e s . . . s u c h a s r e t u r n o n i n v e s t m e n t , p r o d u c t i v i t y a n d t h e l i k e " [ 1 4 : 3 9 - 4 0 ] . H i s c o n c e r n s a r i s e f r o m t h e d i f f i c u l t y i n i d e n t i f y i n g t h e v a r i a b l e s w h i c h a c t u a l l y a f f e c t o u t c o m e s a n d w h e t h e r t h e s e v a r i a b l e s , i f i d e n t i f i e d , c a n b e s p e c i f i c a l l y a t t r i b u t e d t o t h e o r g a n i z a t i o n [ 1 4 : 3 9 - 4 0 ] . S p r a y n o t e s t h a t m u c h o f t h e a c a d e m i c ( t h e o r e t i c a l ) r e s e a r c h o n o r g a n i z a t i o n a l e f f e c t i v e n e s s h a s b e e n b a s e d o n s y s t e m s p e r s p e c t i v e , a n d n o t o n g o a l o r i e n t e d m o d e l s . H e s u g g e s t s t h a t t h i s m a y a c c o u n t f o r t h e c o m m u n i c a t i o n g a p b e t w e e n a c a d e m i c s a n d p r a c t i t i o n e r s [ 1 5 : 1 6 6 - 7 2 ] . I t w o u l d s e e m , t h e r e f o r e , t h a t a l t h o u g h o u t c o m e m o d e l s h a v e b e e n i n h e r e n t l y a t t r a c t i v e t o m a n a g e r s , o r g a n i z a t i o n a l r e s e a r c h h a s n o t f o c u s e d m u c h o f i t s e f f o r t i n t h a t d i r e c t i o n . N o t w i t h s t a n d i n g t h e s e c o n c e r n s , t h e f o c u s o f t h i s s t u d y i s o u t c o m e m e a s u r e m e n t o f e f f e c t i v e n e s s a n d s e v e r a l o f t h e C H A P T E R I V - 77 -o r g a n i z a t i o n a l e f f e c t i v e n e s s m o d e l s a r e e x p l o r e d f o r t h e i r p o s s i b l e u s e i n f a c i l i t y - b a s e d l o n g - t e r m c a r e . T h e m o d e l s i n c l u d e : t h e g e n e r i c m o d e l s o f c o s t - b e n e f i t a n a l y s i s ; m a n a g e m e n t b y o b j e c t i v e s ; a n d z e r o - b a s e d b u d g e t i n g a s u s e d i n p r i v a t e i n d u s t r y a n d t h e p u b l i c s e c t o r - i n c l u d i n g h e a l t h c a r e a n d t h e a p p l i c a t i o n o f o u t c o m e m e a s u r e m e n t i n h e a l t h c a r e t h r o u g h t h e Q u a l i t y A s s u r a n c e P r o g r a m c o n c e p t . COST-BENEFIT AND COST-EFFECTIVENESS ANALYSIS (CBA-CEA) T h e t h r u s t o f t h e c o s t - b e n e f i t a n d c o s t - e f f e c t i v e n e s s m o d e l s i s t o a s s i s t d e c i s i o n m a k e r s t o r a t i o n a l i z e r e s o u r c e a l l o c a t i o n b y c o n s i d e r i n g t h e r e l a t i v e e f f e c t i v e n e s s ( t h e c o s t a n d t h e b e n e f i t s ) o f a l t e r n a t i v e a p p r o a c h e s t o a c h i e v i n g t h e o b j e c t i v e s o f a n a g e n c y o r p r o g r a m . T h i s i s d o n e b y a n a l y z i n g t h e r e s u l t s ( o u t c o m e s ) , m e a s u r i n g t h e c o s t s , a n d c o m p a r i n g t h e m w i t h a l t e r n a t i v e w a y s t o a c h i e v e t h e o b j e c t i v e s [ 1 3 : 3 , 8 0 ] . T h e s e a p p r o a c h e s e s s e n t i a l l y a t t e m p t t o c o m b i n e e f f e c t i v e n e s s a n d e f f i c i e n c y m e a s u r e m e n t . I n t h e p u b l i c s e c t o r t h e l a c k o f c o m p e t i t i v e m a r k e t f o r c e s , t h e v a r y i n g t y p e s o f c o s t s a n d b e n e f i t s , a n d t h e d i f f e r i n g p e r s p e c t i v e s a m o n g t h e i n t e r e s t g r o u p s ( f u n d e r s , p r o v i d e r s , c o n s u m e r s ) a l l s u g g e s t t h e n e e d f o r a n d t h e c o m p l e x i t y o f a n a l y z i n g r e s o u r c e a l l o c a t i o n . C B A / C E A i s p r o p o s e d a s o n e a p p r o a c h t o t h i s p r o b l e m . C H A P T E R I V - 7 8 -I n t h i s s t u d y , t h e a n a l y s i s o f t h e c o s t - b e n e f i t / c o s t -e f f e c t i v e n e s s a p p r o a c h i s b a s e d o n C a m p b e l l ' s r e v i e w o f o r g a n i z a t i o n a l a p p r o a c h e s [ 1 4 : 3 2 - 3 3 ] ; g o v e r n m e n t ( o r p u b l i c s e c t o r ) a p p l i c a t i o n s a s d e s c r i b e d b y H o v e y a n d S t o n e r [ 1 6 ; 1 7 : 6 0 7 - 0 8 ] ; a n d h e a l t h c a r e i n d u s t r y a p p l i c a t i o n s a s d e s c r i b e d b y W a r n e r / L u c e , M u s g r a v e , a n d S t o d d a r t [ 1 2 ; 1 3 : 1 1 4 - 2 9 ; 1 8 ] . I n t h e p u b l i c s e r v i c e s e c t o r , t h e m a j o r i m p e t u s f o r t h e r e c e n t u s e o f C B A - C E A i n t h e U n i t e d S t a t e s d a t e s f r o m t h e 1 9 6 0 ' s w i t h t h e i m p l e m e n t a t i o n o f t h e p l a n n i n g - p r o g r a m m i n g - b u d g e t i n g ( P P B ) s y s t e m [ 1 6 ] . I n t h i s f o r m , C B A h a d a l i m i t e d l i f e s p a n . A c c o r d i n g t o W a r n e r / L u c e a n d M u s g r a v e c o s t - b e n e f i t a n a l y s i s h a s b e e n u s e d i n o n e f o r m o r a n o t h e r i n h e a l t h c a r e f o r h u n d r e d s o f y e a r s [ 1 3 : 4 6 ; 1 8 : 1 1 5 ] . W a r n e r / L u c e a n d S t o d d a r t s u g g e s t t h a t C B A a n d C E A b e c o n s i d e r e d a s e s s e n t i a l l y o n e t y p e o f a n a l y s i s . E a c h b a s i c a l l y u s e t h e s a m e m e t h o d o l o g y w h i l e d i f f e r i n g s o m e w h a t i n t h e v a r i a b l e s i n c l u d e d i n t h e a n a l y s i s , a n d t h u s t h e o u t c o m e i n f o r m a t i o n p r o v i d e d [ 1 2 : 3 ; 1 3 : 6 0 ] . C B A i n c l u d e s a m o n e t a r y v a l u e f o r b o t h t h e c o s t s a n d b e n e f i t s , w h i l e w i t h C E A t h e o u t c o m e s o r c o n s e q u e n c e s a r e m e a s u r e d i n n o n - m o n e t a r y u n i t s . T h e l i t e r a t u r e r e v i e w e d o n C B A a n d C E A e s s e n t i a l l y m e t t h e s c i e n t i f i c a s s e s s m e n t c r i t e r i a : t h e p r o b l e m w a s i d e n t i f i e d ( i . e . t h e n e e d f o r m o r e s y s t e m a t i c b u d g e t a r y c o n t r o l i n g o v e r n m e n t , c o n t r o l o f i n c r e a s i n g g o v e r n m e n t h e a l t h c a r e e x p e n d i t u r e s ) , a s C H A P T E R I V - 7 9 -w a s t h e o b j e c t i v e o f p r o v i d i n g d e c i s i o n m a k e r s w i t h i n f o r m a t i o n t o i d e n t i f y a n d p r o m o t e c o s t e f f e c t i v e n e s s a n d e f f i c i e n c y . B o t h H o v e y a n d W a r n e r / L u c e p r o v i d e c o n s i d e r a b l e i n f o r m a t i o n o n d e s i g n a n d m e t h o d o l o g y , i n c l u d i n g a d i s c u s s i o n o f b o t h t h e • p r i n c i p l e s a n d t h e e m p i r i c a l a p p l i c a t i o n s o f t h e a p p r o a c h [ 1 3 ; 1 6 ] . W a r n e r a n d L u c e n o t e t h e c o n s i d e r a b l e g a p t h a t c u r r e n t l y e x i s t s b e t w e e n t h e p r i n c i p l e s a n d t h e p r a c t i c a l a p p l i c a t i o n s o f t h i s a p p r o a c h i n h e a l t h c a r e , a s w e l l a s t h e n u m e r o u s t e c h n i c a l a n d e n v i r o n m e n t a l ( e . g . p o l i t i c a l , e c o n o m i c ) c o n s t r a i n t s [ 1 3 : 1 3 0 - 2 3 8 ] . T h e f i n d i n g s i n c l u d e d a d e s c r i p t i o n o f c u r r e n t p r a c t i c e , c o v e r i n g b o t h t h e m e t h o d o l o g i e s u s e d a n d e x a m p l e s o f a p p l i c a t i o n s . T h e c o n c l u s i o n s d r a w n b y t h e s e r e s e a r c h e r s c o n s i d e r e d b o t h t h e p o t e n t i a l a n d t h e f u t u r e u s e o f t h e C B A - C E A a p p r o a c h a n d p r o v i d e g u i d a n c e f o r u s e o f t h e a p p r o a c h i n d i f f e r e n t t y p e s o f d e c i s i o n m a k i n g s i t u a t i o n s ( e . g . m o n i t o r i n g , r e i m b u r s e m e n t ) [ 1 3 : 1 7 6 - 2 0 6 ] . F i g u r e 2 s u m m a r i z e s t h e p r o s a n d c o n s o f t h e e x i s t i n g m e t h o d s o f C B A - C E A a s a p p r o a c h e s w h i c h m i g h t b e a p p l i e d t o o u t c o m e - b a s e d r e i m b u r s e m e n t i n f a c i l i t y -b a s e d l o n g - t e r m c a r e . CHAPTER IV - 8 0 -Figure 2: THE PROS and CONS of CBA/CEA AS AN OUTCOME MEASUREMENT APPROACH In FACILITY-BASED LONG-TERM CARE PROS The problems and objectives addressed f i t with those of long-term care. Uses outcome measurements. Has the potential to provide information to decision makers, i f the technical and environmental problems can be resolved. Is seen, at the very least, as a consciousness r a i s i n g approach for considering the need for outcome measurement. CONS D i f f i c u l t to develop measurements for both the cost and benefit sides i n health care. Approaches to date have not considered the information needs from the funders perspective or values - would need more development i n t h i s aspect. Measurements have been la r g e l y disease based, and developed for acute care and/or high technology concerns, or to compare i n s t i t u t i o n a l care to a l t e r n a t i v e services i n long-term care. Is t r a d i t i o n a l l y used to choose among al t e r n a t i v e programs and not to monitor re s u l t s among the providers within a program. I n t u i t i v e l y t h i s approach i s appealing as a soluti o n for outcome-based reimbursement i n f a c i l i t y - b a s e d long-term care as i t would seem to answer the need for effectiveness and e f f i c i e n c y information. That i s , i f you can measure the effectiveness and at what cost, you would have the basic ingredients for an outcome-based based reimbursement approach. However, a major d i f f i c u l t y with t h i s approach i s i n i t s a p p l i c a t i o n i n health care. As w i l l be noted l a t e r , measuring effectiveness i n health care i s a very complex process i t s e l f , C H A P T E R I V - 8 1 -w h i l e a s W a r n e r a n d L u c e s u g g e s t t h e a b i l i t y t o d e r i v e c o s t m e a s u r e s i s e q u a l l y c o m p l e x . T h e m u l t i d i m e n s i o n a l n a t u r e o f l o n g - t e r m c a r e r e s i d e n t s w i t h m u l t i p l e p r o b l e m s , t h e d i f f e r i n g g o a l s o f p r o v i d e r s , a s s e s s o r s a n d g o v e r n m e n t f u n d e r s , a n d t h e q u a l i t y o f c a r e v e r s u s q u a l i t y o f l i f e i s s u e s a l l a d d t o t h e c o m p l e x i t y . R e c o m m e n d a t i o n : T o b e a p p l i e d t o l o n g - t e r m c a r e r e i m b u r s e m e n t , t h i s a p p r o a c h w o u l d n e e d m o r e d e v e l o p m e n t f r o m a n e x t e r n a l f u n d e r s p e r s p e c t i v e , a s w e l l a s m o r e d e v e l o p m e n t a n d u s e i n t h e m e a s u r e m e n t o f o u t c o m e s a p p l i c a b l e t o l o n g - t e r m f a c i l i t y c a r e . H o w e v e r , i t c o u l d b e u s e f u l a s a c o n c e p t u a l f r a m e w o r k a n d m a y h a v e p o t e n t i a l i n t h e d e v e l o p m e n t o f c o s t d a t a , e f f i c i e n c y s t u d i e s a n d / o r o u t c o m e - b a s e d r e i m b u r s e m e n t o n c e e f f e c t i v e n e s s m e a s u r e m e n t i s i n p l a c e i n f a c i l i t y - b a s e d l o n g - t e r m c a r e . MANAGEMENT BY OBJECTIVES (MBO) T h e r e i s g e n e r a l a g r e e m e n t t h a t t h e t h r e e m a i n c o m p o n e n t s o f t h e MBO a p p r o a c h i n c l u d e [ 3 : 2 5 1 ; 9 : 1 6 - 1 7 ; 1 0 : 2 2 7 - 3 1 ; 1 7 : 1 5 5 -7 1 ; 1 9 ] : 1 . E s t a b l i s h i n g o b j e c t i v e s , w i t h a n e m p h a s i s o n m a n a g e m e n t p a r t i c i p a t i o n a t a l l l e v e l s ; 2 . D e v e l o p i n g a n d d i r e c t i n g t h e p l a n s t o a c h i e v e t h e o b j e c t i v e s , w i t h a n e m p h a s i s o n t h e f l e x i b i l i t y t o c h o o s e t h e m e a n s o f a c h i e v e m e n t ; 3 . E s t a b l i s h i n g t h e m e a s u r e m e n t s o r t h e r e s u l t s , w i t h a n e m p h a s i s o n r e v i e w a n d m e a s u r a b l e r e s u l t s o r o u t c o m e s T h i s a n a l y s i s o f t h e m a n a g e m e n t b y o b j e c t i v e s (MBO) a p p r o a c h i s b a s e d o n t h e u s e o f MBO i n t h e p r i v a t e s e c t o r a s n o t e d b y S t o n e r a n d I v a n c e v i c h [ 1 7 : 1 5 1 - 6 1 ; 2 0 : 4 6 0 - 6 5 ] ; i n t h e p u b l i c s e c t o r a s d e s c r i b e d b y O d i o r n e , M o r r i s e y , M c C o n k e y , M a l i a n d B a l k , [ 7 ; 9 ; 1 0 ; 1 1 ; 1 9 ] ; a n d i n t h e h e a l t h c a r e s e c t o r a s d e s c r i b e d b y K a l u z n y [ 3 : 2 5 1 - 5 2 , 3 0 0 ] . C H A P T E R I V - 82 -A r e v i e w o f t h i s l i t e r a t u r e s h o w e d a l a c k o f a g r e e m e n t a b o u t t h e e x a c t p u r p o s e o r t h r u s t o f M B O . G e n e r a l l y MBO i s p r e s e n t e d i n t h i s l i t e r a t u r e a s h a v i n g t w o m a j o r p u r p o s e s - i ) p l a n n i n g a n d i i ) c o n t r o l , w i t h s o m e p r o p o n e n t s s u p p o r t i n g o n e p u r p o s e m o r e t h a n t h e o t h e r . D r u c k e r ( w h o o r i g i n a t e d t h e t e r m MBO) s e e s t h e a p p r o a c h a s a p l a n n i n g m e t h o d t o " a c h i e v e a n e f f i c i e n t o p e r a t i o n " , w h e r e a s M c G r e g o r s t r e s s e s t h e c o n t r o l a s p e c t a s u s e d i n p e r f o r m a n c e a p p r a i s a l p r o g r a m s [ 1 7 : 1 5 2 ] . I v a n c e v i c h , h o w e v e r , s u g g e s t s t h a t MBO f o r m a l i z e s t h e s t r o n g r e l a t i o n s h i p b e t w e e n p l a n n i n g a n d c o n t r o l [ 2 0 : 4 6 0 ] . M c C o n k e y a n d M o r r i s e y p o s t u l a t e t h a t t h e r e a l i m p a c t o f MBO h a s b e e n o n m e a s u r i n g t h e e f f e c t i v e n e s s o f m a n a g e m e n t p e r f o r m a n c e a n d t h e m o r e r e c e n t t r e n d t o w a r d s i n c l u d i n g e f f i c i e n c y m e a s u r e s . M o r r i s s e y c a l l s t h i s l a t t e r a d a p t a t i o n t h e MOR a p p r o a c h ( M a n a g e m e n t b y O b j e c t i v e s a n d R e s u l t s ) [ 9 : 2 4 - 2 5 ; 1 0 : 2 2 6 - 3 2 ] . M a l i t a k e s t h e MBO a p p r o a c h e s o n e s t e p f u r t h e r . H e p r o p o s e s a n a p p r o a c h c a l l e d M a n a g e m e n t o f P r o d u c t i v i t y b y O b j e c t i v e s ( M P B O ) a s t h e m e t h o d t o m e e t t h e g o a l o f t o d a y ' s m a n a g e r s f o r i m p r o v e d a c c o u n t a b i l i t y [ 1 1 : 3 - 2 1 ] . B o t h M a l i a n d B a l k s e e m e a s u r e m e n t o f p r o d u c t i v i t y a s a m a j o r m e t h o d f o r u n d e r s t a n d i n g p u b l i c s e c t o r p e r f o r m a n c e , a n d t h a t p r o d u c t i v i t y i n c l u d e s b o t h e f f e c t i v e n e s s a n d e f f i c i e n c y m e a s u r e s . B o t h a u t h o r s a l s o e m p h a s i z e t h e n e e d f o r m e a s u r a b l e i n p u t s a n d o u t c o m e s . T h e y a l s o r e c o g n i z e t h a t t h e s e i n p u t s a n d o u t c o m e s a r e l e s s w e l l C H A P T E R I V - 8 3 -d e f i n e d t h a n f i n a n c i a l m e a s u r e m e n t s a n d m a y r e q u i r e t h e u s e o f b o t h q u a l i t a t i v e a n d q u a n t i t a t i v e m e a s u r e m e n t s [ 1 1 : 3 - 2 1 , 7 7 - 1 0 3 ; 7 : 2 1 0 - 1 5 ] . B a l k p o i n t s o u t , a s d i d N e u w h e n d i s c u s s i n g v a l u e p r e f e r e n c e m e a s u r e m e n t , t h a t t o o m u c h " . . . c l a r i f i c a t i o n m a y b e d y s f u n c t i o n a l t o t h e p r o c e s s o f g o v e r n m e n t . . . " g i v e n t h e v a r y i n g p e r s p e c t i v e s a n d g o a l s a m o n g l e g i s l a t o r s a n d o t h e r c o n s u m e r s [ 7 : 2 1 5 ] . I n a s s e s s i n g t h e s c i e n t i f i c m e r i t o f t h e MBO a p p r o a c h i t a p p e a r s t h a t , f r o m t h e l i t e r a t u r e r e v i e w e d , t h e r e i s n o c l e a r c o n s e n s u s a b o u t w h i c h p r o b l e m ( p l a n n i n g o r c o n t r o l ) t h e MBO a p p r o a c h a d d r e s s e s , o r w h e t h e r t h e o b j e c t i v e s i n c l u d e t h o s e f o r b o t h e f f e c t i v e n e s s a n d e f f i c i e n c y . T h e p r e s e n t a t i o n o f t h e f i n d i n g s , t h e l i m i t a t i o n s a n d t h e c o n c l u s i o n s a n d r e c o m m e n d a t i o n s a r e m o r e c l e a r l y p r e s e n t e d . B u t t h e p r e s e n t a t i o n o f d e s i g n a n d m e t h o d o l o g y i n f o r m a t i o n i s s o m e w h a t l i m i t e d . O f c o n c e r n i s t h e f a c t t h a t s p e c i f i c i n f o r m a t i o n a b o u t t h e i n s t r u m e n t s u s e d t o m e a s u r e r e s u l t s i s n o t p r e s e n t e d o r d i s c u s s e d , n o r a r e a n y d e t a i l s g i v e n a b o u t t e s t i n g t h e m e a s u r e m e n t i n s t r u m e n t s f o r v a l i d i t y a n d r e l i a b i l i t y . F i g u r e 3 i s a s u m m a r y o f t h e p r o s a n d c o n s o f e x i s t i n g a p p r o a c h e s t o MBO a s a n a p p r o a c h w h i c h m i g h t b e a p p l i e d t o o u t c o m e - b a s e d r e i m b u r s e m e n t i n f a c i l i t y - b a s e d l o n g - t e r m c a r e . C H A P T E R I V - 84 -Figure 3: THE PROS AND CONS OF MBO AS AN OUTCOME APPROACH IN FACILITY-BASED LONG-TERM CARE P R O S T h e p h i l o s o p h y a n d c o n c e p t o f s e t t i n g o b j e c t i v e s , A l l o w i n g m a n a g e r s f l e x i b i l i t y t o a c h i e v e o u t c o m e s a n d M e a s u r i n g r e s u l t s i n t e r m s o f e f f e c t i v e n e s s a n d e f f i c i e n c y f i t w i t h t h e n e e d i n L o n g - t e r m C a r e c u r r e n t l y b e i n g u s e d b y p r o v i d e r s t o m e e t g o v e r n m e n t f u n d i n g c o n s t r a i n t s . C O N S N o c o n s e n s u s a b o u t t h e p r o b l e m ( p l a n n i n g o r c o n t r o l ) o r a b o u t t h e o b j e c t i v e s ( e f f e c t i v e n e s s o r e f f i c i e n c y ) - w h i c h l e a d s t o d i f f e r e n t d e s i g n s a n d u s a g e , L i m i t e d i n f o r m a t i o n a b o u t d e s i g n s , m e t h o d o l o g i e s , o r m e a s u r e m e n t i n s t r u m e n t s u s e d -t h e r e f o r e g e n e r a l i z a b i l i t y n o t c l e a r . T i m e a n d c o s t t o i m p l e m e n t a n d m o n i t o r m a y b e c o n s i d e r a b l e . T h e u n d e r l y i n g p h i l o s o p h y o f a m a n a g e m e n t a p p r o a c h u s i n g m e a s u r a b l e o b j e c t i v e s a n d t h e t r e n d t o w a r d s t h e i n c l u s i o n o f b o t h e f f e c t i v e n e s s a n d e f f i c i e n c y m e a s u r e s l e n d s i t s e l f t o a d a p t a t i o n f o r o u t c o m e - b a s e d r e i m b u r s e m e n t i n f a c i l i t y - b a s e d l o n g - t e r m c a r e . H o w e v e r , t h e l i m i t e d i n f o r m a t i o n a v a i l a b l e a b o u t t h e a c t u a l m e a s u r e s u s e d m a y b e a p r o b l e m d u e t o t h e p o t e n t i a l l y c o n f l i c t i n g o b j e c t i v e s o f f u n d e r s , p r o v i d e r s a n d c o n s u m e r s , r e s t r i c t i o n s o f s t a t u t o r y m a n d a t e s a n d g u i d e l i n e s , t h e c o m p l e x i t y o f a m i x e d p r o v i d e r s y s t e m , a n d t h e m u l t i d i m e n s i o n a l n e e d s o f c l i e n t s . R e c o m m e n d a t i o n : T h i s a p p r o a c h c o u l d b e u s e d a s t h e o r e t i c a l f r a m e w o r k , i n c o r p o r a t i n g b o t h e f f e c t i v e n e s s a n d e f f i c i e n c y a s p a r t o f t h e o b j e c t i v e s . F u r t h e r u s e o f t h i s a p p r o a c h b y l o n g -t e r m c a r e p r o v i d e r s w o u l d p r o v i d e a g r e a t e r e m p i r i c a l e x p e r i e n c e o n w h i c h t o a s s e s s i t s f e a s i b i l i t y f o r m o r e g e n e r a l u s e b y e x t e r n a l f u n d e r s . C H A P T E R I V - 8 5 -ZERO-BASE BUDGETING (ZBB) Z B B ( z e r o - b a s e b u d g e t i n g ) i s p r e s e n t e d a s a n a l t e r n a t i v e t o t h e t r a d i t i o n a l i n c r e m e n t a l a p p r o a c h t o b u d g e t a r y c o n t r o l a n d p l a n n i n g . I n Z B B , t h e b u d g e t i s c o n s i d e r e d e a c h y e a r f r o m a ' z e r o - b a s e 1 , t h a t i s a l l p r i o r i t i e s a n d a c t i v i t i e s h a v e t o b e j u s t i f i e d e a c h y e a r . Z B B i s t h e r e f o r e s e e n a s a m a n a g e m e n t o r i e n t e d , f l e x i b l e a n d r e s p o n s i v e a p p r o a c h w h i c h s u p p o r t s p l a n n i n g , b u d g e t a r y c o n t r o l a n d o p e r a t i o n a l d e c i s i o n m a k i n g [ 2 1 : 3 7 ; 2 2 : 3 6 ] . A b a s i c p a r t o f t h e a p p r o a c h i s t h e d e v e l o p m e n t o f o b j e c t i v e s a n d t h e m e a s u r e m e n t o f r e s u l t s [ 3 : 1 1 1 ; 2 1 ; 2 2 ; 2 3 : 2 3 ] . T h e a p p r o a c h a l l o w s d e c i s i o n m a k e r s t o c o n s i d e r b u d g e t a r y i n c r e a s e s o r r e d u c t i o n s , n e w p r o p o s a l s a n d a r a n g e o f c h o i c e s a t d i f f e r e n t l e v e l s o f f u n d i n g [ 2 1 : 5 ] . T h e p r o c e s s r e q u i r e s t h e p a r t i c i p a t i o n o f m a n a g e r s a t a l l l e v e l s . O b j e c t i v e s m u s t b e s e t a t e a c h m a n a g e m e n t l e v e l a n d f o r e a c h a c t i v i t y ( d e c i s i o n u n i t ) a s w e l l . P e r f o r m a n c e c r i t e r i a , i n c l u d i n g t h e b e n e f i t s a n d c o s t s f o r e a c h d e c i s i o n u n i t a t v a r i o u s l e v e l s o r p e r c e n t a g e s o f f u n d i n g m u s t b e e s t a b l i s h e d . I n t h i s w a y , c o m p a r a t i v e e v a l u a t i o n o f t h e b e n e f i t s a n d c o s t s o f c o m p e t i n g a c t i v i t i e s w i t h i n a n o r g a n i z a t i o n c a n b e m a d e [ 1 7 : 6 0 8 -0 9 ; 2 1 : 6 ] . T h e r e v i e w o f z e r o - b a s e b u d g e t i n g a s a n o u t c o m e m e a s u r e m e n t a p p r o a c h i s b a s e d o n t h e f o l l o w i n g r e f e r e n c e s : H e b e r t ' s e d i t e d w o r k w h i c h e x p l o r e s t h e c o n c e p t o f Z B B , w i t h t h e m a j o r f o c u s C H A P T E R I V - 8 6 -b e i n g t h e u s e o f Z B B b y U n i t e d S t a t e s f e d e r a l g o v e r n m e n t s e r v i c e s [ 2 1 ] ; S t o n e r w h o s e e m p h a s i s i s u s e i n t h e p u b l i c s e c t o r [ 1 7 : 6 0 8 - 0 9 ] ; a n d t h e d i s c u s s i o n s b y K a l u z n y , B o e h m , D i l l o n , a n d C l a y t o n o n t h e u s e o f Z B B i n t h e h e a l t h c a r e i n d u s t r y [ 3 : 1 1 1 - 1 2 ; 2 2 ; 2 3 ; 2 4 ] . E s s e n t i a l l y t h e l i t e r a t u r e r e v i e w e d m e t t h e s c i e n t i f i c a s s e s s m e n t c r i t e r i a : t h e p r o b l e m ( t h e n e e d f o r m a n a g e m e n t a c c o u n t a b i l i t y ) a n d t h e o b j e c t i v e s ( e . g . c o s t c o n t a i n m e n t , i m p r o v e d p r o d u c t i v i t y , e t c . ) w e r e i d e n t i f i e d ; t h e d e s c r i p t i o n o f d e s i g n a n d m e t h o d o l o g y f o c u s e d o n t h e u s e o f Z B B i n t h e p u b l i c s e c t o r w h e r e n u m e r o u s d e s i g n s t r a t e g i e s h a v e b e e n d e v e l o p e d . T h e r e w a s n o c l e a r p r e s e n t a t i o n o f t h e m e a s u r e m e n t i n s t r u m e n t s u s e d , a l t h o u g h t h e u s e o f p r o c e s s o u t c o m e s ( w o r k u n i t s p e r s t a f f r a t i o s ) i s i m p l i e d a n d e c o n o m i c o u t c o m e ( c o s t - e f f e c t i v e n e s s ) i s t h e o n e o u t c o m e m e a s u r e m e n t a p p r o a c h s p e c i f i c a l l y s u g g e s t e d [ 2 3 : 3 1 ; 2 4 : 3 ] . I m p r o v e d e f f i c i e n c y a n d p r o d u c t i v i t y w i t h i n a c t i v i t y a r e a s o r o v e r a l l , i s n o t i n h e r e n t i n t h e Z B B a p p r o a c h . B u t e f f i c i e n c i e s m a y c o m e a s a r e s u l t o f u s i n g t h e p r o c e s s o r a d a p t a t i o n s m a y b e m a d e w h i c h s p e c i f i c a l l y e n c o u r a g e e f f i c i e n c y [ 2 1 : 1 3 7 ; 2 3 : 3 2 ; 2 4 : 3 ] . C H A P T E R I V - 8 7 -O t h e r l i m i t a t i o n s t h a t w e r e n o t e d i n c l u d e d : t h e p r o b l e m s t h a t a r i s e d u e t o t h e l a c k o r i n a d e q u a c y o f m e a s u r e m e n t i n f o r m a t i o n ( w h i c h p r e v e n t s m e a n i n g f u l c o m p a r i s o n o f t h e c o s t s a n d b e n e f i t s a m o n g s t d i f f e r e n t a c t i v i t i e s ) ; t h e n e e d f o r d i r e c t i n v o l v e m e n t o f m a n a g e r s a t a l l l e v e l s ; a n d t h e t i m e a n d e f f o r t n e e d e d t o d e v e l o p a n d r e v i e w t h e i n f o r m a t i o n [ 2 2 : 3 7 ; 2 1 ; 2 3 ] . C o n c l u s i o n s a b o u t t h e s u c c e s s o f t h e a p p r o a c h i n t h e p u b l i c ( h e a l t h c a r e ) s e c t o r w e r e o p t i m i s t i c t h o u g h s o m e w h a t c a u t i o u s , b a s e d o n t h e l i m i t e d e x p e r i e n c e t o d a t e [ 2 3 ; 2 4 : 4 ] . I t w a s , h o w e v e r , a r e c o m m e n d e d a p p r o a c h i n i n d u s t r i e s ( s u c h a s h e a l t h c a r e ) w h e r e o v e r h e a d c o s t s ( l a b o u r ) r e p r e s e n t a s u b s t a n t i a l o u t l a y . S u i t a b l e c a u t i o n a r y n o t e s a n d r e c o m m e n d a t i o n s f o r f u t u r e s t u d y w e r e m a d e [ 2 4 : 4 ] . F i g u r e 4 p r e s e n t s t h e p r o s a n d c o n s o f Z B B a s a f e a s i b l e a p p r o a c h f o r o u t c o m e - b a s e d r e i m b u r s e m e n t i n f a c i l i t y - b a s e d l o n g -t e r m c a r e . C H A P T E R I V - 88 -Figure 4: THE PROS & CONS OF ZBB AS AN OUTCOME MEASUREMENT APPROACH TO FACILITY-BASED LONG-TERM CARE P R O S I n f o r m a t i o n d e v e l o p e d c o u l d b e u s e d b y f u n d e r s ; U s e s o b j e c t i v e s a n d m e a s u r e m e n t o f r e s u l t s , p a r t i c u l a r l y e f f e c t -i v e n e s s m e a s u r e s ; H a s b e e n u s e d i n h e a l t h a n d l o n g -t e r m c a r e f a c i l i t i e s i n C a n a d a ; C o m b i n e s MBO a n d C B A ; A l l o w s f o r t h e u s e o f a v a r i e t y o f o u t c o m e m e a s u r e m e n t s . C O N S U n a b l e t o a s s e s s t h e g e n e r a l i z -a b i l i t y t o l o n g - t e r m c a r e , a s m e a s u r e m e n t i n s t r u m e n t s w e r e n o t p r e s e n t e d ; N e e d t o b u i l d i n e f f i c i e n c y o b j e c t i v e s ; T i m e / e f f o r t r e q u i r e d o f m a n a g e r s a t a l l l e v e l s t o i m p l e m e n t ; H a s b e e n u s e d m a i n l y f o r i n t e r n a l m a n a g e m e n t - w o u l d h a v e t o a d a p t t o u s e a s a n e x t e r n a l m a n a g e m e n t a p p r o a c h e . g . g o v e r n m e n t f u n d e r s ; N e e d f o r r e g u l a t o r y c h a n g e s t o o b t a i n i n f o r m a t i o n f o r e x t e r n a l f u n d e r s - m a y b e r e s i s t a n c e b y f o r - p r o f i t p r o v i d e r s . A g a i n t h e m e a s u r e m e n t a p p r o a c h e s u s e d i n Z B B a r e n o t c l e a r l y i d e n t i f i e d a n d t h e a p p r o a c h h a s b e e n d e v e l o p e d e s s e n t i a l l y f o r i n t e r n a l m a n a g e m e n t . H o w e v e r , a s a c o n c e p t u a l f r a m e w o r k t h e a p p r o a c h c o u l d b e a d a p t e d t o p r o v i d e i n f o r m a t i o n o n e f f e c t i v e n e s s a n d c o s t s w h i c h w o u l d s u p p o r t e f f i c i e n c y s t u d i e s a n d / o r o u t c o m e - b a s e d r e i m b u r s e m e n t i n f a c i l i t y - b a s e d l o n g - t e r m c a r e . T h e p r o c e s s a s i t i s n o w e s t a b l i s h e d m a y b e t o o u n w i e l d y t o b e e a s i l y a d a p t e d f o r u s e b y e x t e r n a l f u n d e r s . O n t h e o t h e r h a n d , t h e r e i s p o t e n t i a l f o r u s e b y i n t e r n a l m a n a g e m e n t a s a b u d g e t a r y a p p r o a c h i n w h i c h e f f e c t i v e n e s s m e a s u r e s f o r l o n g - t e r m c a r e c o u l d d e v e l o p e d . CHAPTER IV - 89 -Recommendation: Encourage use as a conceptual framework, and by providers as an int e r n a l management approach i n long-term care. This w i l l provide more empirical experience i n determining what outcome measures can or should be used. CONCLUSIONS ABOUT THE USE OF GENERIC ORGANIZATIONAL EFFECTIVENESS APPROACHES Conceptually these outcome approaches ( p a r t i c u l a r l y MBO and Z B B ) f i t the c r i t e r i a for approaches to be used i n long-term f a c i l i t y care as they are based on: s e t t i n g objectives, allowing managers (providers) f l e x i b i l i t y i n how they achieve r e s u l t s and yet require accountability through measurable outcomes which w i l l provide information for decision makers (e.g. funders). These approaches allow for the use of a v a r i e t y of outcome measurements which could accommodate the m u l t i p l i c i t y of outcomes that may be necessary i n f a c i l i t y - b a s e d long-term care with i t s mixed provider system, and where there i s a need to consider the multidimensional needs and problems of the c l i e n t s . Although organizational effectiveness approaches i n i t i a l l y leaned more towards measurement of effectiveness, there has been a recent trend towards the i n c l u s i o n of e f f i c i e n c y measures. In outcome-based reimbursement measurement of both effectiveness and e f f i c i e n c y are required to balance the d i f f e r e n t responses or incentive motives of the f o r - p r o f i t and non-profit providers. However the lack of information on the design, methods and actual measurement instruments on which the reports are based C H A P T E R I V - 90 -m a k e s i t d i f f i c u l t t o a s s e s s t h e s c i e n t i f i c c r e d i b i l i t y , a c c e p t a b i l i t y a n d m e r i t o f t h e o r g a n i z a t i o n a l e f f e c t i v e n e s s a p p r o a c h e s r e v i e w e d . T h e i r l i m i t e d u s e i n h e a l t h c a r e , p a r t i c u l a r l y i n l o n g - t e r m c a r e , a n d t h e t i m e a n d c o s t t o i m p l e m e n t t h e m a l s o r a i s e q u e s t i o n s a b o u t t h e i r f e a s i b i l i t y . I n g e n e r a l i t w o u l d a p p e a r t h a t t h e s e a p p r o a c h e s a r e n o t y e t r e a d y f o r d i r e c t a p p l i c a t i o n i n a n o u t c o m e - b a s e d r e i m b u r s e m e n t s y s t e m f o r f a c i l i t y - b a s e d l o n g - t e r m c a r e . H o w e v e r , u s e o f t h e s e a p p r o a c h e s b y i n d i v i d u a l p r o v i d e r s w o u l d p r o v i d e a g r e a t e r e m p i r i c a l b a s e , a n d a t t h e v e r y l e a s t r a i s e p r o v i d e r s 1 c o n s c i o u s n e s s a b o u t t h e n e e d f o r o u t c o m e m e a s u r e s o f e f f e c t i v e n e s s a n d e f f i c i e n c y i n f a c i l i t y - b a s e d l o n g - t e r m c a r e . T h e s e l i m i t a t i o n s l e d t o a r e v i e w o f o r g a n i z a t i o n a l e f f e c t i v e n e s s m e a s u r e s a n d o u t c o m e m e a s u r e m e n t a p p r o a c h e s m o r e s p e c i f i c a l l y d e s i g n e d f o r h e a l t h c a r e u s e . ORGANIZATIONAL LEVEL APPROACHES - APPLICATIONS IN HEALTH CARE T h e d i s c u s s i o n o f o u t c o m e m e a s u r e m e n t i n b o t h h e a l t h a n d l o n g - t e r m c a r e r e v e a l s t h a t t h e r e i s a l a c k o f a g r e e m e n t a b o u t w h a t i s m e a n t b y a n o u t c o m e o f h e a l t h c a r e . S o m e a p p r o a c h e s p r o p o s e t h a t o u t c o m e s h o u l d b e m e a s u r e d a t a b r o a d , m a c r o o r o r g a n i z a t i o n a l l e v e l , s u c h a s t h e a c h i e v e m e n t o f o p e r a t i v e o r g a n i z a t i o n a l g o a l s ( e . g . g o a l s s u c h a s p r o v i d i n g c l i e n t c e n t e r e d c a r e , r e s o u r c e u t i l i z a t i o n g o a l s , p a t i e n t p e r c e p t i o n s C H A P T E R I V - 91 -a n d o p i n i o n s a b o u t t h e c a r e o r t h e e n v i r o n m e n t , o r d e c r e a s e d m o r t a l i t y r a t e s , i m p r o v e d d i s c h a r g e p a t t e r n s , e t c . ) . T h e s e o r g a n i z a t i o n a l o u t c o m e s a r e v i e w e d b y s o m e a s i n p u t s o r i n t e r m e d i a t e o u t p u t s a n d b y o t h e r s a s o u t c o m e s [ 2 5 : 2 6 , 2 7 ] . L u k e a n d M o d r o w [ 2 6 ] s u g g e s t t h a t w h a t i s m e a s u r e d o r e v a l u a t e d i s c o n t i n g e n t o n h o w a c c o u n t a b i l i t y i s p e r c e i v e d o r d e f i n e d , t h a t i s w h a t i s t h e s c o p e o r l i m i t o f o n e ' s o b l i g a t i o n s ? T h e y p r o p o s e t h a t t h e d e f i n i t i o n o f a c c o u n t a b i l i t y s h o u l d b e g i n w i t h t h e c o n c e p t u a l m o d e l , f r o m w h i c h i s d e v e l o p e d a n o p e r a t i o n a l d e f i n i t i o n a n d w h i c h i n t u r n i s m e a s u r e d i n s o m e w a y i n t h e e m p i r i c a l a p p l i c a t i o n [ 2 6 ] . I n t h i s c a s e , w h a t i s m e a s u r e d a r e t h e a c t i o n s ( o r r e s u l t s ) t a k e n t o m e e t t h e s e o b l i g a t i o n s . I n t h i s s t u d y f o r i n s t a n c e , t h e f u n d e r s o b l i g a t i o n i s t o e n s u r e t h e e f f e c t i v e a n d e f f i c i e n t e x p e n d i t u r e o f t h e p u b l i c f u n d s a l l o c a t e d f o r t h e c a r e p r o v i d e d i n l o n g - t e r m c a r e f a c i l i t i e s . I n o r d e r t o d e t e r m i n e t h e s c o p e o f t h e a c c o u n t a b i l i t y , L u k e a n d M o d r o w s u g g e s t t h e r e a r e " d e l i m i t e r s ' w h i c h c a n b e i d e n t i f i e d . T h e s e i n c l u d e : - t h e c o n t e n t o r c o n s t i t u e n t e l e m e n t s ( e . g . e f f e c t i v e n e s s a n d e f f i c i e n c y ; - t h e l e v e l o f f o c u s - i n d i v i d u a l o r p o p u l a t i o n ( e . g . a g g r e g a t i o n s o f f a c i l i t y r e s i d e n t s a t s p e c i f i c l e v e l s o f c a r e ; - a n d t h e e m p o w e r e d a g e n t ( e . g . g o v e r n m e n t f u n d e r s a n d r e g u l a t o r s ) . C H A P T E R I V - 9 2 -T h u s , i f a c c o u n t a b i l i t y i s d e f i n e d , t h e n t h e o u t c o m e s t o b e m e a s u r e d w i l l b e w i t h i n t h e l i m i t a t i o n s o f t h a t a c c o u n t a b i l i t y . V i e w e d f r o m a n o t h e r p e r s p e c t i v e , B a k e r [ 2 7 ] a n d W o y [ 2 8 ] i n t h e i r r e v i e w s o f t h e s i m i l a r i t i e s a n d d i f f e r e n c e s b e t w e e n Q u a l i t y A s s u r a n c e P r o g r a m s a n d p r o g r a m e v a l u a t i o n a p p r o a c h e s s h e d s o m e l i g h t o n t h e c o n f u s i o n a n d d i s a g r e e m e n t a b o u t t h e l e v e l a t w h i c h o u t c o m e s s h o u l d b e m e a s u r e d . Q u a l i t y A s s u r a n c e P r o g r a m s h a v e b e e n i n s t i t u t e d i n h e a l t h c a r e i n r e c e n t y e a r s t o a s s u r e a d e q u a t e q u a l i t y o f c a r e i s p r o v i d e d a n d i n a c o s t e f f e c t i v e m a n n e r . B a k e r a n d W o y b o t h s u g g e s t t h a t q u a l i t y a s s u r a n c e h a s p r i m a r i l y b e e n c l i e n t c e n t e r e d , w i t h a s s e s s m e n t c r i t e r i a d e r i v e d m a i n l y f r o m c l i n i c a l j u d g e m e n t s , a n a l y s e d b y p e e r r e v i e w , a n d u s e d f o r e v a l u a t i o n a n d c h a n g e i n t h e c l i n i c a l o r s e r v i c e s i t u a t i o n ; w h e r e a s p r o g r a m e v a l u a t i o n e m p h a s i z e s t h e t o t a l o r g a n i z a t i o n a l s y s t e m , e v a l u a t e s t h e w o r t h o r v a l u e o f a p r o g r a m , a n d p r o v i d e s i n f o r m a t i o n w h i c h i s u s e d b y m a n a g e m e n t l e v e l d e c i s i o n m a k e r s [ 2 7 : 1 5 2 - 5 7 ] . I n p r o g r a m e v a l u a t i o n , o u t c o m e s a r e u s e d i n t h e m e a s u r e m e n t o f t o t a l p e r f o r m a n c e ( e . g . e f f e c t i v e n e s s a n d e f f i c i e n c y ) . I n q u a l i t y a s s u r a n c e p r o g r a m s a s s e s s m e n t o f o u t c o m e s m a y b e u s e d o n l y a s a m e a s u r e o f q u a l i t y a c h i e v e m e n t ( e f f e c t i v e n e s s ) . T h e m a j o r d i f f e r e n c e i n t h e t w o a p p r o a c h e s a p p e a r s t o b e t h e l e v e l a t w h i c h d a t a a r e a g g r e g a t e d . W h e r e a s q u a l i t y a s s u r a n c e t r a d i t i o n a l l y c o n s i d e r s o u t c o m e s f o r i n d i v i d u a l c l i e n t s , p r o g r a m e v a l u a t i o n i s b a s e d o n d a t a a n a l y s i s a g g r e g a t e d a t t h e g r o u p C H A P T E R I V - 9 3 -l e v e l . S o m e a r g u e t h a t t h e l a t t e r i s t h e o n l y v a l i d a p p r o a c h b e c a u s e a c l i e n t - s p e c i f i c o u t c o m e i s a t t h e m e r c y o f t h e d i f f e r e n c e s i n c l i e n t r e s p o n s e a n d c o m p l i a n c e [ 2 7 : 1 5 2 - 5 5 ; 2 8 ] . T h e t e c h n i c a l m e t h o d s o f a n a l y s i s h a v e a l s o v a r i e d . Q u a l i t y A s s u r a n c e o f t e n r e l i e s o n m a n u a l c h a r t r e v i e w s , a n d u s e s c l i n i c a l l y o r i e n t e d a s s e s s o r s a n d / o r p e e r r e v i e w , a l o n g w i t h c l i n i c a l s t a n d a r d s f o r a n a l y s i s . W h i l e p r o g r a m e v a l u a t i o n o n t h e o t h e r h a n d t e n d s t o r e v i e w d a t a d e r i v e d f r o m a n i n f o r m a t i o n s y s t e m s d a t a b a s e , a n d u s e s c o m p u t e r g e n e r a t e d a n d r e l a t i v e l y s o p h i s t i c a t e d s t a t i s t i c a l a n a l y s i s a p p r o a c h e s [ 2 7 : 1 5 6 ] . B a k e r s u g g e s t s t h a t t h e r e s h o u l d b e a c o n v e r g e n c e o f t h e s e t w o t e c h n i q u e s t o m e e t t h e n e e d s a t a l l l e v e l s f o r m e a s u r e s o f o u t c o m e . T h i s c o n v e r g e n c e m o d e l a p p r o a c h a n d i t s p o t e n t i a l f o r o u t c o m e - b a s e d r e i m b u r s e m e n t i n f a c i l i t y - b a s e d l o n g - t e r m c a r e i s t h e f o c u s o f C h a p t e r 5 , b u t t h e i m p a c t o f q u a l i t y a s s u r a n c e p r o g r a m s o n t h e d e v e l o p m e n t o f i n d i v i d u a l a n d o r g a n i z a t i o n a l l e v e l o u t c o m e m e a s u r e s i s d i s c u s s e d n e x t , f o l l o w e d b y a r e v i e w o f m o r e s p e c i f i c h e a l t h c a r e a p p r o a c h e s QUALITY ASSURANCE AND THE USE OF OUTCOME MEASUREMENT T h e a s s e s s m e n t o f i n s t i t u t i o n a l c a r e , b o t h a c u t e a n d n u r s i n g h o m e c a r e , h a s e v o l v e d f r o m p r o t e c t i v e r e g u l a t i o n s w h i c h u t i l i z e d s t r u c t u r a l s t a n d a r d s [ 2 9 : 2 2 - 2 4 ; 3 0 ; 3 1 ; 3 2 ] , t o a c c r e d i t a t i o n p r o g r a m s w h i c h i n c l u d e d s t r u c t u r e a n d p r o c e s s s t a n d a r d s [ 2 9 : 2 5 ; 3 3 ; 3 4 ] , t o n e e d s a s s e s s m e n t a n d u t i l i z a t i o n r e v i e w s [ 3 5 ; 3 6 ] t o Q u a l i t y A s s u r a n c e p r o g r a m s w h i c h h a v e n o w b e e n i n c o r p o r a t e d a s a r e q u i r e m e n t o f a c c r e d i t a t i o n . C H A P T E R I V - 9 4 -S i n c e t h e 1 9 7 0 ' s , t h e r e h a s b e e n p r e s s u r e o n g o v e r n m e n t f u n d e r s f o r m o r e a c c o u n t a b i l i t y f o r t h e m o n i e s e x p e n d e d o n h e a l t h c a r e p r o v i s i o n , a s w e l l a s f o r t h e q u a l i t y o f t h e c a r e p r o v i d e d [ 2 9 ; 3 3 ; 3 7 ] . T h e r e w e r e c o n c e r n s b o t h a b o u t q u a l i t y f o r i t s o w n s a k e , a s w e l l a s a r e c o g n i t i o n t h a t p o o r q u a l i t y c a r e c o u l d a c t u a l l y i n c r e a s e t h e c o s t s o f p r o v i d i n g h e a l t h c a r e ( e . g . o v e r - u t i l i z a t i o n , u n n e c e s s a r y s u r g e r y , e t c . ) . Q u a l i t y A s s u r a n c e p r o g r a m s a r e t h e r e f o r e c u r r e n t l y p r o m o t e d a s o n e o f t h e m a j o r v e h i c l e s f o r a s s e s s i n g a n d m o n i t o r i n g t h e p r o v i s i o n o f c a r e i n t h e h e a l t h c a r e i n d u s t r y . M o n i t o r i n g t h e q u a l i t y o f c a r e h a s h a d a l o n g h i s t o r y i n h e a l t h c a r e [ 2 : 7 2 ] . H o w e v e r t h e r e c e n t i m p e t u s h a s c o m e f r o m t h e U n i t e d S t a t e s f e d e r a l g o v e r n m e n t M e d i c a i d A c t ( 1 9 6 6 ) w h i c h m a n d a t e d u t i l i z a t i o n r e v i e w s , a n d t h e 1 9 7 2 A c t w h i c h m a n d a t e d t h e e s t a b l i s h m e n t o f P r o f e s s i o n a l S t a n d a r d s R e v i e w O r g a n i z a t i o n s r e s p o n s i b l e f o r b o t h u t i l i z a t i o n ( c o s t c o n t a i n m e n t ) a n d q u a l i t y a s s u r a n c e [ 2 : 7 6 ; 3 8 : 3 8 1 ] . I n C a n a d a t h e i m p e t u s f o r Q u a l i t y A s s u r a n c e c a m e f r o m t h e r e q u i r e m e n t s f o r h o s p i t a l a n d l o n g - t e r m c a r e f a c i l i t y a c c r e d i t a t i o n r a t h e r t h a n s p e c i f i c l e g i s l a t i o n [ 3 9 ] . Q u a l i t y A s s u r a n c e p r o g r a m s w e r e t h u s l a u n c h e d , b u t n o t w i t h o u t s o m e u n c e r t a i n t y a b o u t w h e t h e r s u c h p r o g r a m s w e r e t o a n s w e r q u e s t i o n s o f a s s u r a n c e o r c o s t c o n t a i n m e n t o r b o t h [ 2 ; 3 3 : ] . Q u a l i t y a s s u r a n c e i s v a r i o u s l y r e f e r r e d t o a s q u a l i t y a u d i t , q u a l i t y a s s e s s m e n t a n d q u a l i t y r e v i e w , a l l o f w h i c h i m p l y C H A P T E R I V - 9 5 -m e a s u r e m e n t a n d m o n i t o r i n g o f c a r e p r o v i s i o n . Q u a l i t y a s s u r a n c e i s f u r t h e r d e f i n e d a s h a v i n g t w o b a s i c f u n c t i o n s : q u a l i t y a s s e s s m e n t w h i c h m e a s u r e s t h e l e v e l o r e f f e c t i v e n e s s o f c a r e p r o v i d e d ( i . e . i d e n t i f i e s t h e p r o b l e m ) a n d q u a l i t y a c h i e v e m e n t w h i c h s u g g e s t s p r o b l e m s o l v i n g o r i n t e r v e n t i o n f o r i m p r o v e m e n t [ 2 9 : 5 ; 3 7 : 1 2 6 - 7 ; 3 8 : 3 8 2 ] . T h e i m p l i c a t i o n s o f t h e l a t t e r i s t h a t p r o v i d e r b e h a v i o r m a y n e e d t o b e c h a n g e d t o i m p r o v e q u a l i t y . S l e e t a k e s t h e Q u a l i t y A s s u r a n c e c o n c e p t o n e s t e p f u r t h e r t o w a r d s o r g a n i z a t i o n a l l e v e l o u t c o m e s b y s u g g e s t i n g t h e u s e o f t h e t e r m q u a l i t y m a n a g e m e n t w h i c h r e f l e c t s t h e r e s p o n s i b i l i t y o f l i n e m a n a g e r s f o r t h e a c h i e v e m e n t o f q u a l i t y w i t h i n a n i n s t i t u t i o n [ 4 0 : 1 4 ] . H e r e c o m m e n d s a q u a l i t y a u d i t p r o c e s s s i m i l a r t o a f i n a n c i a l a u d i t , w h i c h r e s u l t s i n a " Q u a l i t y S t a t e m e n t " m u c h l i k e a f i n a n c i a l s t a t e m e n t . T h e q u a l i t y s t a t e m e n t c o u l d b e d e r i v e d b y d e v e l o p i n g a p r o f i l e o f t h e i n s t i t u t i o n ' s ( e . g . h o s p i t a l ' s ) p e r f o r m a n c e c o m p a r e d w i t h e s t a b l i s h e d p r o c e s s a n d o u t c o m e s t a n d a r d s o r a g a i n s t t h e p e r f o r m a n c e o f o t h e r i n s t i t u t i o n s ( p e e r c o m p a r i s o n ) [ 4 0 : 9 ] . T h i s c o u l d r e s u l t i n a " s y s t e m o f ' g r a d i n g ' o f h o s p i t a l s . . . m u c h a s f i n a n c i a l r a t i n g s a r e c o n s t r u c t e d . " [ 4 0 : 1 4 ] . S l e e e m p h a s i z e s t h e n e e d f o r m o r e m o v e m e n t t o w a r d s t h e d e v e l o p m e n t o f t h e a s s u r a n c e s i d e ( i . e . c h a n g i n g p r o v i d e r b e h a v i o r ) o f t h e q u a l i t y a s s u r a n c e e q u a t i o n t o b a l a n c e t h e r e s e a r c h d o n e o n t h e a s s e s s m e n t o r a u d i t s i d e [ 4 0 : 2 7 ] . CHAPTER IV - 96 -The main focus of q u a l i t y assurance to date has been the development of measurement c r i t e r i a u s i n g Donabedian's concept of measuring the q u a l i t y of care p r o v i s i o n through the measurement of the s t r u c t u r e , process and outcomes of care [41]. The i n i t i a l c o n c e n t r a t i o n was on measurement of the s t r u c t u r e s and process of c a r e , u s u a l l y developed from the p r o f e s s i o n a l p r o v i d e r s p e r s p e c t i v e ( i . e . medicine and l a t e r nursing) [33; 43]. However there was and c o n t i n u e s to be support f o r the use of outcome measurements i n Q u a l i t y Assurance programs [33; 34; 38:382; 43:33-47; 44]. Outcome measurement i s promoted because: - i t measures the end r e s u l t of care ( i . e . the e f f e c t i v e n e s s ) ; - the approach i s a m u l t i d i m e n s i o n a l concept which can be be used a t s e v e r a l l e v e l s ( o r g a n i z a t i o n a l , managerial, p r o f e s s i o n a l p r o v i d e r , c l i e n t , e t c . ) ; - more than j u s t the t e c h n i c a l v a r i a b l e s of h e a l t h care may be i n c l u d e d [2:35-36; 29:123-24; 33:857; 41:100-09; 42:262; 45:122-27]. However, as Ressner [29] p o i n t s out, c o n s i d e r a b l e c o g n i t i v e dissonance has been experienced w i t h Q u a l i t y Assurance programs due to: the acceptance, on the one hand, of the need to monitor q u a l i t y of care w h i l e on the other hand e x p e r i e n c i n g the d i f f i c u l t i e s i n d e v e l o p i n g a c c e p t a b l e ( v a l i d and r e l i a b l e ) measures to do the monitoring; the l a c k of knowledge of the c a u s a l l i n k s between process and outcome; the f a c t t h a t a measurement of h e a l t h s t a t u s does not n e c e s s a r i l y r e p r e s e n t the r e s u l t s (outcome) of the care p r o v i d e d ; and the l a c k of understanding of how to motivate change i n p r o v i d e r behavior i f CHAPTER IV - 9 7 -a d e f i c i t i n care i s found. With outcome measurement there i s a l s o the i s s u e of whether the expected outcomes should be determined by normative standards (those developed by a group of experts or peers of the p r o v i d e r s ) or comparative ( e m p i r i c a l l y developed) means [1:131]. To overcome some these problems the concept of u s i n g h e a l t h s t a t u s as outcome, based on a f a i r l y narrow d e f i n i t i o n ( i . e . t a r g e t e d to s p e c i f i c groups of i n d i v i d u a l s w i t h s p e c i f i c problems who are r e c e i v i n g c a r e ) , was proposed as the way to develop outcome measures [46]. Two of the major approaches to outcome measurement w i t h i n Q u a l i t y Assurance programs noted i n the l i t e r a t u r e are the approach developed by the J o i n t Commission on H o s p i t a l A c c r e d i t a t i o n known as the P a t i e n t E v a l u a t i o n Procedure f o r A u d i t i n g and improving P a t i e n t Care (PEP) [43], and the H e a l t h Accounting Approach developed by Wi l l i a m s o n [44]. Both of these approaches were based on a medical a u d i t approach i n which a s p e c i f i c group of diagnoses (types of cases) were s e l e c t e d , and the expected outcomes were i d e n t i f i e d . These cases were then used as a u d i t p o i n t s i n order to review the process of care which l e d to these outcomes. These outcome a u d i t approaches have been used mainly i n acute care s e t t i n g s ( a Q u a l i t y Assurance approach f o r long-term care i s d i s c u s s e d i n Chapter F i v e ) . In these i n s t a n c e s outcomes were used an an i n t e r m e d i a r y s t e p , to determine i f the process of care was e f f e c t i v e and to d i r e c t p r o v i d e r change, i f necessary. CHAPTER IV - 98 -These e s s e n t i a l l y process o r i e n t e d approaches are more h e l p f u l i n meeting the i n t e r n a l management requirements of an o r g a n i z a t i o n than f o r the more aggregate i n f o r m a t i o n r e q u i r e d by e x t e r n a l d e c i s i o n makers such as government funders and program pl a n n e r s . In the same timeframe there has been a move from the more t r a d i t i o n a l outcome measures of h e a l t h s t a t u s - m o r t a l i t y r a t e s and m o r b i d i t y r a t e s - to the more complex measurement approaches known as h e a l t h s t a t u s indexes. INDIVIDUAL LEVEL OUTCOMES: MEASUREMENT OF OUTCOMES AT THE LEVEL OF THE INDIVIDUAL IN HEALTH CARE In the h e a l t h care i n d u s t r y the product i s the care ( s e r v i c e s and programs) p r o v i d e d to i n d i v i d u a l s w i t h d i s e a s e or d i s a b i l i t y i n order to improve or mai n t a i n that i n d i v i d u a l ' s h e a l t h s t a t u s a t the hi g h e s t p o s s i b l e l e v e l . Over the years s e v e r a l types of measurement have been d e v i s e d to determine the impact of care. That i s , to determine what i s the h e a l t h s t a t u s of an i n d i v i d u a l or p o p u l a t i o n as a r e s u l t of ca r e . These measures are d e r i v e d from an assessment of an i n d i v i d u a l ' s h e a l t h s t a t u s which i s then aggregated to repr e s e n t l a r g e r p o p u l a t i o n groupings. The two major types of outcome measures, developed at l e a s t i n p a r t to determine the need f o r and the r e s u l t s of h e a l t h care i n t e r v e n t i o n s , are measures of m o r t a l i t y and m o r b i d i t y , and h e a l t h s t a t u s indexes. These measures were o r i g i n a l l y a p p l i e d CHAPTER IV - 99 -to d e s c r i b e the h e a l t h of the p o p u l a t i o n and subsequently the impact of care on acute and c h r o n i c i l l n e s s e s . The f o l l o w i n g s e c t i o n s d i s c u s s the f e a s i b i l i t y and a p p l i c a t i o n of these approaches i n f a c i l i t y - b a s e d long-term c a r e . MORBIDITY AND MORTALITY MEASUREMENTS M o r t a l i t y and m o r b i d i t y data a r e the t r a d i t i o n a l approaches to the measurement of h e a l t h s t a t u s and the impact of h e a l t h care s e r v i c e s [6:199-200; 46; 47; 48:423; 49:76-77]. Mortality data a re measures of the occurrence of death i n p o p u l a t i o n s . H i s t o r i c a l l y , i n f a n t m o r t a l i t y r a t e s and l i f e expectancy (a v a r i a n t of age-adjusted m o r t a l i t y ) were two of the major r a t e s used to d e s c r i b e the h e a l t h of a p o p u l a t i o n . However i n developed c o u n t r i e s , other than f o r i n t e r n a t i o n a l comparisons, there now appears to be more drawbacks than p o s i t i v e reasons f o r u s i n g m o r t a l i t y r a t e s e i t h e r to as s e s s the h e a l t h s t a t u s or the impact of h e a l t h care on p o p u l a t i o n s [6:199-200; 49:76-77; ]. That i s , as the i n f a n t m o r t a l i t y r a t e s d e c l i n e d t h i s measurement was c o n s i d e r e d l e s s r e l e v a n t and c h r o n i c i l l n e s s and d i s a b i l i t y , which are not w e l l expressed by m o r t a l i t y r a t e s , have now emerged as s i g n i f i c a n t e n t i t i e s [47:2-3] . F i g u r e 5 summarizes the pros and cons of u s i n g m o r t a l i t y r a t e s as a f e a s i b l e approach to outcome-based reimbursement i n f a c i l i t y - b a s e d long-term care. CHAPTER IV - 100 -Figure 5 : THE PROS AND CONS OF MORTALITY RATES AS AN OUTCOME MEASUREMENT APPROACH IN FACILITY-BASED LONG-TERM CARE PROS CONS Data a r e w i d e l y a v a i l a b l e Measure o n l y a n e g a t i v e end-p o i n t , e.g. d e a t h Data a r e o f t e n d i f f e r e n t i a t e d by age, s e x and geography Are dichotomous measures w h i c h do not r e f l e c t q u a l i t y o f l i f e I n f a n t m o r t a l i t y can be used as a p r o x y f o r the h e a l t h s t a t u s o f Too i n s e n s i t i v e , i n d e v e l o p e d the p o p u l a t i o n c o u n t r i e s t o r e f l e c t t h e impact of c a r e A l t h o u g h m o r t a l i t y r a t e s a r e w i d e l y a v a i l a b l e and th e d a t a a r e d i f f e r e n t i a t e d by age, s e x and g e o g r a p h i c g r o u p i n g s , t he d a t a a r e t o o i n s e n s i t i v e a measure t o use on t h e i r own as a measure o f e f f e c t i v e n e s s i n l o n g - t e r m c a r e . The m o r t a l i t y r a t e s may be o f some use as p a r t o f a br o a d e r s e t o f outcomes about the d i s c h a r g e s t a t u s o f r e s i d e n t s of l o n g - t e r m c a r e f a c i l i t i e s . Recommendation: Used a l o n e , m o r t a l i t y r a t e s a r e not a s u i t a b l e outcome approach f o r l o n g - t e r m c a r e . As m o r t a l i t y r a t e s d e c l i n e d , m o r b i d i t y r a t e s were c o n s i d e r e d an a l t e r n a t e f o r e x p l a i n i n g o r d e f i n i n g t h e h e a l t h s t a t u s o f p o p u l a t i o n s . M o r b i d i t y r a t e s measure the o c c u r r e n c e of d i s e a s e o r d i s a b i l i t y i n p o p u l a t i o n s . P a t r i c k n o t e s t h a t v a r i o u s m o r b i d i t y i n d e x e s have been d e v e l o p e d based on " d i s a b i l i t y , d y s f u n c t i o n , d i s c o m f o r t , o r o t h e r c l i n i c a l , s u b j e c t i v e o r b e h a v i o r a l c a t e g o r i e s " [49:77-78]. C H A P T E R I V - 101 -F i g u r e 6 s u m m a r i z e s t h e p r o s a n d c o n s o f u s i n g m o r b i d i t y r a t e s a s a f e a s i b l e a p p r o a c h t o o u t c o m e - b a s e d r e i m b u r s e m e n t i n f a c i l i t y - b a s e d c a r e . Figure 6: THE PROS & CONS OF MORBIDITY RATES AS AN OUTCOME MEASUREMENT APPROACH IN FACILITY-BASED LONG-TERM CARE P R O S C O N S D a t a a r e r e a d i l y a v a i l a b l e i n t h e f o r m o f d i a g n o s t i c c o d e s . T r a d i t i o n a l m o r b i d i t y i n d i c e s d o n o t a c c o u n t f o r m u l t i p l e o u t c o m e s o r d i f f e r e n c e s i n s e v e r i t y , d u r a t i o n o r i n t e n s i t y o r c h r o n i c d i s e a s e s t a t e s ; I n s e n s i t i v e t o t h e w e l l n e s s -i l l n e s s c o n t i n u u m ; O f t e n b a s e d o n i m p l i e d , n o t e x p l i c i t a s s u m p t i o n s a n d p r e f e r e n c e s a b o u t t h e r e l a t i v e v a l u e s o f v a r i o u s m o r b i d i t y s t a t e s ; P r o b l e m s w i t h r e l i a b i l i t y , c o m p l e t e n e s s , a n d r e l e v a n c e . T r a d i t i o n a l m o r b i d i t y r a t e s d o n o t l e n d t h e m s e l v e s t o t h e n e e d i n l o n g - t e r m c a r e t o m e a s u r e m u l t i p l e a t t r i b u t e s o f h e a l t h s t a t u s o r t h e n e e d t o r e c o g n i z e t h e g o a l s i n l o n g - t e r m c a r e o f p r o m o t i n g , s u p p o r t i n g o r m a i n t a i n i n g t h e p o s i t i v e ( i n d e p e n d e n t ) a s p e c t s o f t h e w e l l n e s s - i l l n e s s c o n t i n u u m : m o r b i d i t y i s u s u a l l y a n e g a t i v e m e a s u r e . I n a d d i t i o n , " q u a l i t y o f l i f e " w i t h i t ' s i m p l i e d n e e d t o c o n s i d e r s o c i e t a l v a l u e s i s b e i n g e x p r e s s e d a s a C H A P T E R I V - 1 0 2 -m a j o r r e q u i r e m e n t i n r e l e v a n t m e a s u r e m e n t a p p r o a c h e s i n l o n g -t e r m c a r e . M o r b i d i t y r a t e s d o n o t d i r e c t l y m e a s u r e " q u a l i t y o f l i f e " a s p e c t s . R e c o m m e n d a t i o n : T r a d i t i o n a l m o r b i d i t y m e a s u r e s a r e n o t s e n s i t i v e e n o u g h o u t c o m e m e a s u r e s e i t h e r o f t h e h e a l t h s t a t u s o f r e s i d e n t s o r o f t h e i m p a c t o f l o n g - t e r m c a r e i n w h i c h c a r e i s d i r e c t e d a t p o p u l a t i o n s w i t h h i g h r a t e s o f c h r o n i c d i s e a s e a n d d i s a b i l i t y f o r w h i c h t h e r e a r e m u l t i p l e o u t c o m e s . T h e i n a d e q u a c i e s o f t h e m o r t a l i t y a n d m o r b i d i t y r a t e s t o m e e t t h e a s s e s s m e n t n e e d s f o r p o p u l a t i o n s w i t h c h r o n i c d i s e a s e a n d d i s a b i l i t y h a s l e d t o t h e d e v e l o p m e n t o f t h e h e a l t h s t a t u s i n d e x a p p r o a c h . HEALTH STATUS INDEXES (HSI) H e a l t h s t a t u s i n d e x e s ( H S I s ) h a v e b e e n t h e m a j o r a p p r o a c h d e v e l o p e d i n r e c e n t y e a r s i n c o u n t r i e s s u c h a s t h e U n i t e d S t a t e s a n d C a n a d a t o s p e c i f i c a l l y a d d r e s s t h e n e e d f o r i n f o r m a t i o n t o s u p p o r t d e c i s i o n m a k i n g a b o u t t h e p o l i c y , p l a n n i n g , f u n d i n g a n d e v a l u a t i o n o f h e a l t h c a r e . I n f a c t , i n t h e U n i t e d S t a t e s , u n d e r t h e P l a n n i n g B i l l o f 1 9 7 5 , t h e u s e o f H S I s w a s m a n d a t e d a s a p a r t o f t h e p l a n n i n g p r o c e s s [ 5 0 : x i i i ] . T h e t e r m h e a l t h s t a t u s i n d e x r e f e r s t o t h e f o r m o f o u t c o m e m e a s u r e m e n t u s e d t o a s s e s s t h e s t a t e o f h e a l t h o f g r o u p s o r p o p u l a t i o n s , b a s e d o n i n d i c a t o r s w h i c h r e p r e s e n t s o m e d e f i n i t i o n o f h e a l t h a n d / o r s o c i a l w e l l b e i n g . T h e s e i n d i c a t o r s a r e s c a l e d , w e i g h t e d ( v a l u e d ) a n d a g g r e g a t e d i n t o a n i n d e x w h i c h i s s a i d t o r e p r e s e n t e i t h e r t h e h e a l t h o f a p o p u l a t i o n o r t h e i m p a c t o f a h e a l t h s e r v i c e [ 4 6 ; 5 1 : 7 1 - 7 3 ; 5 2 : 7 4 ] . CHAPTER IV - 103 -Boyle and Torrance p r o v i d e a more s p e c i f i c d e f i n i t i o n which r e f l e c t s the complexity of the s t a t e of h e a l t h : "A m u l t i a t t r i b u t e h e a l t h index i s a h e a l t h s t a t u s measure based on the n o t i o n of h e a l t h as a m u l t i a t t r i b u t e phenomenon." [53:1046]. Bergner d e f i n e s h e a l t h s t a t u s as c o n t a i n i n g "...those elements that are an i n t e g r a l p a r t of the person but exclude those that e x i s t and behave independently of the person." [54:698]. As an o p e r a t i o n a l concept Bergner has i d e n t i f i e d f i v e dimensions of h e a l t h s t a t u s which can serve as a guide f o r choosing h e a l t h s t a t u s instruments. These f i v e dimensions a r e : 1. Genetic f o u n d a t i o n or i n h e r i t e d c h a r a c t e r i s t i c s ; 2. B i o c h e m i s t r y , p h y s i o l o g i c and anatomic f e a t u r e s , i n c l u d i n g d i s e a s e and d i s a b i l i t y ; 3. F u n c t i o n a l c o n d i t i o n ; 4. Mental c o n d i t i o n ; 5. H e a l t h p o t e n t i a l - i n c l u d i n g l o n g e v i t y , f u n c t i o n a l p o t e n t i a l and p r o g n o s i s of the d i s e a s e or d i s a b i l i t y . Three areas have been suggested where h e a l t h s t a t u s indexes might be of use to d e c i s i o n makers: p o l i c y making ( p r i o r i t y s e t t i n g , r e s o u r c e a l l o c a t i o n ) ; p l a n n i n g (comparative a n a l y s i s of p o p u l a t i o n s , comparing v a r i a b l e s a s s o c i a t e d w i t h h e a l t h or h e a l t h care impact); and e v a l u a t i o n ( l o o k i n g a t the end r e s u l t s or outcomes, e s t i m a t i n g b e n e f i t s ) [4:246; 35:255-58; 46; 54; 55; 56:703-04]. CHAPTER IV - 104 -In the l i t e r a t u r e reviewed on HSIs the i n f o r m a t i o n was presented i n terms of both the h i s t o r i c a l development of HSIs and by u s i n g a c a t e g o r i c a l framework. Included i n the review were works such as the H e a l t h Status Indexes Conference of 1972 e d i t e d by Berg [35]; two c o m p i l a t i o n s on the s t a t e of the a r t e d i t e d by E l i n s o n et a l i n 1977 [36], and by E l i s o n and Seigmann i n 1979 [50]; and a compendium of s c a l e s and indexes by Reeder et a l [52]. A r t i c l e s of a g e n e r a l nature by Chen and Bryant [46], Sackett et a l [48], Boyle and Torrance [53], Bergner/85 [54], Bergner/77 [55], Sackett and Torrance [56], Ware [57], and Brooks and Lohr [89], as w e l l as s p e c i f i c p r o p o s a l s which might have r e l e v a n c e to long-term care were reviewed. The l a t t e r i n c l u d e d Bergner et a l ' s S i c k n e s s Impact P r o f i l e (SIP) [59; 60;]; Katz's F u n c t i o n a l S c a l e of A c t i v i t i e s of D a i l y L i v i n g (ADLs) [61; 62]; and the r e s e a r c h conducted by Bush, Fanshel and P a t r i c k on a F u n c t i o n a l H e a l t h Index [1; 63; 64] and Skinner's D e b i l i t y Index [65]. Much of the development of HSIs has been a c o l l a b o r a t i v e , m u l t i d i s c i p l i n a r y approach combining p e r s p e c t i v e s from economics, h e a l t h care systems and h e a l t h care management, psychology, medicine, and s o c i o l o g y . S c i e n t i f i c r e s e a r c h and s t a t i s t i c a l methodologies are used. Throughout t h e i r development there appears to have been a c o n f l i c t between meeting the needs of the s c i e n t i f i c r e s e a r c h e r to as Lerner s t a t e s " d i s c o v e r the 'true' nature of s o c i a l r e a l i t y " [47:3] and the needs of CHAPTER IV - 105 -a d m i n i s t r a t o r s f o r e m p i r i c a l l y t e s t e d f i n d i n g s t h a t can be used f o r d e c i s i o n making [4:251; 52:5-6]. A f u r t h e r c o n f l i c t or dilemma has been whether index development sh o u l d be d i r e c t e d towards measuring the h e a l t h of p o p u l a t i o n s or the impact of h e a l t h care s e r v i c e s , or both [35; 52:74]. Although much of the r e s e a r c h on HSIs has used the broad approach of measuring the h e a l t h of p o p u l a t i o n s , some of HSIs developed can be di s a g g r e g a t e d to i d e n t i f y subgroups [35; 59; 60]. Others have taken the narrower focus of the impact of h e a l t h care s e r v i c e s on s p e c i f i c t a r g e t groups [6; 48; 56]. A sm a l l percentage of the l a t t e r have been developed f o r t a r g e t p o p u l a t i o n s (or to e s t a b l i s h the impact of care) i n long-term care. For i n s t a n c e , there has been c o n s i d e r a b l e study and use of Katz's f u n c t i o n a l s c a l e of ADLs f o r a s s e s s i n g p o p u l a t i o n s of the c h r o n i c a l l y i l l and d i s a b l e d i n a v a r i e t y of s e t t i n g s , i n c l u d i n g i n s t i t u t i o n a l care s e t t i n g s [46:261; 61:127-63; 62:39-59]. Other indexes such as B e r g n e r 1 s S i c k n e s s Impact P r o f i l e [59:9-32; 60] and the F u n c t i o n a l H e a l t h Index [1; 63; 64] c o u l d , e i t h e r by d i s a g g r e g a t i o n or by s p e c i f i c a p p l i c a t i o n , be used to e s t a b l i s h HSIs f o r long-term care p o p u l a t i o n s . The SIP instrument has been used i n p o p u l a t i o n s w i t h a s p e c i f i c c h r o n i c d i s e a s e and w i t h home care c l i e n t s w i t h c h r o n i c d i s e a s e s [60]. S e v e r a l i n v e s t i g a t o r s have developed g u i d e l i n e s and standards f o r a s s e s s i n g the s c i e n t i f i c m e r it (e.g. v a l i d i t y and r e l i a b i l i t y ) of HSIs and f o r t h e i r s e l e c t i o n and use. These CHAPTER IV - 106 -i n v e s t i g a t o r s a l s o s t r e s s the importance of knowing the o r i g i n a l intended purpose and the u n d e r l y i n g assumptions of the index [4; 6; 46; 48; 53; 56]. Problems may be encountered and use may be l i m i t e d i f there are d i f f i c u l t i e s understanding the index, or i f the index does not meet the purpose (e.g. an inexpensive p l a n n i n g t o o l ) f o r which i t i s r e q u i r e d [4; 35; 46; 56; 66]. There may a l s o be problems w i t h implementation i f data c o l l e c t i o n and a n a l y s i s are too c o s t l y and/or too time consuming or complex [54]. The p r e s e n t a t i o n of HSIs i n the l i t e r a t u r e e s s e n t i a l l y met the s c i e n t i f i c assessment c r i t e r i a : the problems addressed and the o b j e c t i v e s of HSIs have been noted i n the i n t r o d u c t i o n t o t h i s s e c t i o n ; and the l i t e r a t u r e p r o v i d e d c o n s i d e r a b l e d e t a i l and d i s c u s s i o n on study designs and measurement methodologies i n c l u d i n g both t h e o r e t i c a l and conceptual concerns, as w e l l as the s p e c i f i c d e s i g n approaches used f o r the development of the s p e c i f i c indexes. I t was c l e a r t h at indexes have been developed f o r a wide v a r i e t y of groups and p o p u l a t i o n s , and from a number of o r i e n t a t i o n s . The f i n d i n g s were u s u a l l y c l e a r l y presented, the c o n c l u s i o n s were based on f i n d i n g s , and were u s u a l l y q u a l i f i e d w i t h recommendations f o r f u r t h e r r e s e a r c h . F i g u r e 7 summarizes the pros and cons of the e x i s t i n g methods of HSIs as approaches which might be a p p l i e d to outcome-based reimbursement i n f a c i l i t y - b a s e d long-term c a r e . CHAPTER IV - 107 -Figure 7: THE PROS & CONS OF HSIs AS AN OUTCOME MEASUREMENT APPROACH FOR FACILITY-BASED LONG-TERM CARE PROS Measures r e l e v a n t outcomes ( i . e . h e a l t h s t a t u s ) ; Recognizes the complexity of the h e a l t h care continuum; Recognizes other u t i l i t i e s i n a d d i t i o n to p r o d u c t i v i t y i n c o s t -b e n e f i t a n a l y s i s (e.g. q u a l i t y of l i f e i n non-income producing p o p u l a t i o n s such as e l d e r l y , d i s a b l e d ) ; Allows f o r v a l u e weighting, s c a l i n g and ag g r e g a t i o n of the m u l t i a t t r i b u t e s i n t o a s i n g l e numeric v a l u e ; I n c r e a s i n g consensus about the need f o r m u l t i a t t r i b u t e indexes which measure more than p h y s i o l o g i c or p h y s i c a l f u n c t i o n i n g (e.g. mental, s o c i a l or s a t i s f a c t i o n ) . CONS Three major problem a r e a s : i ) how to o p e r a t i o n a l i z e the d e f i n i t i o n of h e a l t h that w i l l v a l i d i t y r e f l e c t t h a t d e f i n i t i o n (e.g. w i t h a f u n c t i o n a l assessment what f u n c t i o n s should be assessed, what v a l u e s and weigh t i n g should be at t a c h e d and how to aggregate?) i i ) measurement and s c a l i n g problems - d e v e l o p i n g a p p r o p r i a t e s c a l i n g and v a l i d i t y t e s t i n g f o r the i n d i c a t o r s chosen. Some prog r e s s has been made w i t h r e l i a b i l i t y t e s t i n g , but v a l i d i t y t e s t i n g c o n t i n u e s to be a concern i i i ) a p p l i c a t i o n , use and implementation problems have been noted - should HSIs a p p l y t o the h e a l t h s t a t u s of p o p u l a t i o n s or the impact of h e a l t h ? what are the u n d e r l y i n g assumptions and o r i g i n a l intended purpose and do they f i t t h i s a p p l i c a t i o n ? what i s the c o s t , time and complexity of the data c o l l e c t i o n and a n a l y s i s process? To be u s e f u l f o r the purpose of more s p e c i f i c a l l y a l l o c a t i n g r e s o u r c e s , such as i n reimbursement, the outcomes of the impact of long-term care s e r v i c e s must be measured. As M i l l e r notes, HSIs used f o r comparison between groups and between time p e r i o d s f o r a g i v e n group (both of which may be r e q u i r e d by an outcome-based reimbursement system) have s p e c i a l requirements. That i s , there are both d i s t r i b u t i o n (prevalence) and p r o g n o s t i c (measures of t r a n s i t i o n a l p r o b a b i l i t y ) f a c t o r s t o be c o n s i d e r e d CHAPTER IV - 108 -and each may pose s i g n i f i c a n t m e t h o d o l o g i c a l problems [ 4 : 2 5 4 ] . More r e c e n t l i t e r a t u r e s u g g e s t s t h a t s u f f i c i e n t s i g n i f i c a n t p r o g r e s s has been made and t h a t h e a l t h c a r e r e s e a r c h e r s and h e a l t h c a r e p r o v i d e r s s h o u l d not use t h e s e m e t h o d o l o g i c a l c o n c e r n s as an excuse not t o pro c e e d w i t h more e m p i r i c a l t e s t i n g o f t h e s e i n d e x e s [53; 54; 57; 5 8 ] . I n f a c t , Bergner s t r o n g l y s u g g e s t s t h a t i t i s no l o n g e r t e n a b l e t o a v o i d t h e c o l l e c t i o n o f h e a l t h s t a t u s i n f o r m a t i o n about whole p o p u l a t i o n s o r p o p u l a t i o n sub-groups, and t h a t h e a l t h s t a t u s i n d e x e s s h o u l d be used more i n t h r e e a r e a s : t o e v a l u a t e the e f f e c t s o f c l i n i c a l t r e a t m e n t s ; t o a s s e s s t h e impact o f changes i n h e a l t h c a r e d e l i v e r y and f o r the p l a n n i n g o f h e a l t h c a r e d e l i v e r y [ 5 4 ] . As n o t e d e a r l i e r , t he SIP i n s t r u m e n t d e v e l o p e d by Bergner e t a l has been used w i t h l o n g - t e r m c a r e community c l i e n t s . RECOMMENDATION: That the use o f an H e a l t h S t a t u s Index be t h e method o f c h o i c e t o meet the outcome measurement o b j e c t i v e s o f an outcome-based reimbursement system f o r f a c i l i t y - b a s e d l o n g -term c a r e . F u r t h e r r e s e a r c h and e s p e c i a l l y e m p i r i c a l t e s t i n g w i l l be r e q u i r e d t o overcome the problems o f r e l i a b i l i t y , v a l i d i t y , s c a l i n g and v a l u i n g i n d e v e l o p i n g a g e n e r a l i z a b l e approach, as w e l l as the needs r e l a t e d t o b o t h d i s t r i b u t i o n and p r o g n o s t i c f a c t o r s . P r o g n o s t i c f a c t o r s must be c o n s i d e r e d when u s i n g HSIs f o r comparison between groups and between time p e r i o d s i n l o n g - t e r m c a r e . CONCLUSIONS ABOUT THE USE OF HEALTH CARE OUTCOME MEASURES The development o f Q u a l i t y A s s u r a n c e programs has r e s u l t e d from t h e i n c r e a s i n g c o n c e r n s i n r e c e n t y e a r s about the q u a l i t y o f h e a l t h c a r e and the impact o f q u a l i t y on c o s t s . As the use o f Q u a l i t y A s s u r a n c e Programs moved from a c u t e and am b u l a t o r y c a r e t o l o n g - t e r m c a r e the use o f outcome measures was promoted as a way t o a s s e s s the r e s u l t s o f c a r e p r o v i d e d by an o r g a n i z a t i o n . CHAPTER IV - 109 -A number of concerns have been r a i s e d about Q u a l i t y Assurance Programs. These i n c l u d e d concerns about the c o s t and time i n v o l v e d to develop and implement a program ;as w e l l as how to motivate p r o v i d e r change i f the q u a l i t y of care must be improved. There has been l i t t l e documented experience to date w i t h Q u a l i t y Assurance Programs i n f a c i l i t y - b a s e d long-term care. In a review of s p e c i f i c measurement approaches used i n the h e a l t h care i n d u s t r y one sees that the t r a d i t i o n a l approaches of m o r t a l i t y and m o r b i d i t y measures are not s u i t a b l e g i v e n the c o m p l e x i t i e s of the present day h e a l t h care system. T h i s i s p a r t i c u l a r l y so g i v e n the emergence of c h r o n i c d i s e a s e and d i s a b i l i t y as s i g n i f i c a n t e n t i t i e s i n western s o c i e t i e s and r e s u l t a n t need to p r o v i d e long-term care s e r v i c e s . The c o m p l e x i t i e s of t h i s type of longer term care has r e s u l t e d , a t l e a s t i n p a r t , i n an i n c r e a s e d emphasis on the development of HSIs to determine h e a l t h care needs and the impact of h e a l t h care on p o p u l a t i o n s . Development of HSIs has moved more and more towards measuring the f u n c t i o n a l s t a t u s or a b i l i t i e s of i n d i v i d u a l s , o f t e n along s e v e r a l dimensions: p h y s i c a l , s o c i a l and emotional. In f a c t r e c e n t l i t e r a t u r e p r e s e n t s a s t r o n g argument f o r c o n s i d e r i n g h e a l t h s t a t u s as m u l t i a t t r i b u t e phenomenon which must be measured by m u l t i a t t r i b u t e indexes. While some HSIs were developed f o r a p p l i c a t i o n to the g e n e r a l p o p u l a t i o n , t h e r e has been more recent r e s e a r c h u s i n g indexes which can be d i s a g g r e g a t e d to subgroups or are f o r s p e c i f i c a l l y t a r g e t e d C H A P T E R I V - 110 -p o p u l a t i o n s . T h e d e v e l o p m e n t a n d u s e o f H S I s h a s n o t b e e n w i t h o u t p r o b l e m s , i n c l u d i n g p r o b l e m s i n d e f i n i n g w h a t i s h e a l t h , p r o b l e m s r e l a t e d t o v a l i d i t y , r e l i a b i l i t y a n d a g g r e g a t i o n ( i n c l u d i n g v a l u e w e i g h t i n g ) , a n d p r o b l e m s o f r e l e v a n c e a n d i m p l e m e n t a t i o n . T h i s r e v i e w h a s s h o w n t h a t t h e r e h a s b e e n a s i g n i f i c a n t m o v e t o w a r d s a d d r e s s i n g t h e c o m p l e x p r o b l e m s o f o u t c o m e m e a s u r e m e n t i n - h e a l t h a n d l o n g - t e r m c a r e , t h r o u g h t h e u s e o f f u n c t i o n a l h e a l t h s t a t u s i n i t s b r o a d e s t s e n s e a s t h e m e a s u r e o f t h e i m p a c t o r r e s u l t o f c a r e . R e s e a r c h e r s s u c h a s B o y l e a n d T o r r a n c e , B e r g n e r , a n d B r o o k s a n d L o h r s u g g e s t t h a t t h e d e v e l o p m e n t o f H S I s i s s u f f i c i e n t l y w e l l d e v e l o p e d t o b e g i n u s e t h e m m o r e w i d e l y [ 5 3 ; 5 4 ; 5 8 ] . A l t h o u g h f u r t h e r e m p i r i c a l t e s t i n g i s r e q u i r e d , t h i s s h o u l d b e a p p r o a c h e d a s a j o i n t e f f o r t b e t w e e n t h e r e s e a r c h e r a n d t h e p r o v i d e r . R e c e n t a p p l i c a t i o n s o f t h e u s e o f h e a l t h s t a t u s i n d e x e s i n l o n g - t e r m c a r e l o o k p r o m i s i n g a n d t h e s e a p p l i c a t i o n s w i l l b e d i s c u s s e d i n C h a p t e r F i v e . A l t h o u g h s o m e a t t e m p t s h a v e b e e n m a d e t o c o n t r o l ( o r a t l e a s t c o m p a r e ) t h e c o s t o f c a r e t h r o u g h t h e s e a p p r o a c h e s , f e w c o n c r e t e r e s u l t s h a v e b e e n s e e n t o d a t e . SUMMARY AND CONCLUSIONS T h e s t u d i e s r e v i e w e d i n t h i s c h a p t e r s h o w t h a t a c c o u n t a b i l i t y i s a n o v e r - r i d i n g t h e m e i n m a n a g e m e n t p r a c t i c e t o d a y , p a r t i c u l a r l y a s i t r e l a t e s t o t h e e f f e c t i v e n e s s a n d e f f i c i e n c y o f t h e p r o d u c t i o n p r o c e s s . M e a s u r e m e n t o f t h e o u t c o m e s o f p r o d u c t i o n i s v i e w e d a s o n e w a y t o p r o v i d e e v i d e n c e CHAPTER IV - I l l -o f a c c o u n t a b i l i t y . An outcome measurement i s d e f i n e d as a measure of t h e e x t e n t t o w h i c h th e g o a l s and o b j e c t i v e s o f p r o d u c t i o n a r e a c h i e v e d . I n the h e a l t h c a r e system, e v i d e n c e of a c c o u n t a b i l i t y i s p r o v i d e d t h r o u g h outcome measures w h i c h show e v i d e n c e of the impact of the c a r e p r o v i d e d ( e f f e c t i v e n e s s ) , and a t what c o s t ( e f f i c i e n c i e s ) . I n b o t h the p r i v a t e and t h e p u b l i c s e c t o r t h e e a r l y f o c u s of a c c o u n t a b i l i t y was o r g a n i z a t i o n a l e f f e c t i v e n e s s approaches w h i c h s u p p o r t e d i n t e r n a l management r e q u i r e m e n t s . Use o f t h e s e approaches i n the p u b l i c s e c t o r has l e d t o some r e c o g n i t i o n o f t h e needs of f u n d e r s and r e g u l a t o r s f o r e v i d e n c e of a c c o u n t a b i l i t y o f t h e s e r v i c e p r o v i d e r s o p e r a t i n g (and funded) w i t h i n t h e i r j u r i s d i c t i o n s . The major t h r u s t o f t h e s e o r g a n i z a t i o n a l approaches was aimed a t p r o m o t i n g a c c o u n t a b i l i t y t h r o u g h the i n v o l v e m e n t of managers ( o r p r o v i d e r s ) a t a l l l e v e l s i n the o r g a n i z a t i o n , w i t h t h e i n t e n t o f m o t i v a t i n g changes i n manager ( p r o v i d e r ) b e h a v i o r where needed. From t h i s r e v i e w i t appears t h a t t h e s e o r g a n i z a t i o n a l approaches p r o v i d e a g e n e r a l framework f o r outcome measurement, but t h e i r o r i e n t a t i o n t o i n t e r n a l management and t h e i r l a c k o f c l a r i t y and s p e c i f i c i t y about the measurement approaches used make them l e s s t h a n u s e f u l a t t h i s time i n outcome-based reimbursement f o r f a c i l i t y - b a s e d l o n g - t e r m c a r e . Use by i n t e r n a l management, however, would r a i s e t h e g e n e r a l l e v e l o f CHAPTER IV - 112 -consciousness of the need f o r outcome measures of e f f e c t i v e n e s s and e f f i c i e n c y and p r o v i d e e m p i r i c a l e xperience. In h e a l t h care, the focus of outcome measurement has been to measure the impact or outcome of h e a l t h care i n t e r v e n t i o n s on i n d i v i d u a l s . The changing needs of the h e a l t h care s e c t o r to p r o v i d e longer term care to those w i t h c h r o n i c d i s e a s e and d i s a b i l i t y c o u l d not be p r e d i c t e d w i t h the t r a d i t i o n a l outcome measures of m o r t a l i t y and m o r b i d i t y . Measurement of the h e a l t h s t a t u s of i n d i v i d u a l s r e c e i v i n g care thus evolved and was assumed to be a proxy measurement f o r the outcome of h e a l t h care, and l a t t e r l y long-term c a r e . Both the o r g a n i z a t i o n a l l e v e l and i n d i v i d u a l l e v e l of outcome measurement approaches co n c e n t r a t e d h e a v i l y on e f f e c t i v e n e s s measures. Although e x p r e s s i n g a need f o r e f f i c i e n c y measures a c t u a l evidence about how t h i s i s done i s l i m i t e d . Given the t h r u s t s and trends of these many approaches, and the c o n s t r a i n t s on f e a s i b i l i t y of a p p l i c a t i o n i n long-term f a c i l i t y care i n B.C., i t seems that what i s needed i s a combination of o r g a n i z a t i o n a l and i n d i v i d u a l l e v e l approaches. Such an approach should i n v o l v e p r o v i d e r s and must motivate behavior changes to meet the e f f e c t i v e n e s s and e f f i c i e n c y i m p e r a t i v e s . I t a l s o must r e c o g n i z e the c o m p l e x i t i e s of the C H A P T E R I V - 113 -l o n g - t e r m c a r e s y s t e m a n d i t s c l i e n t s . T o a d d r e s s t h e s e c o m p l e x i t i e s r e q u i r e s a n a p p r o a c h w h i c h c a n d e t e r m i n e t h e i m p a c t o f c a r e o n c l i e n t s w i t h m u l t i p l e n e e d s a n d w i t h i n a t o t a l l i v i n g e n v i r o n m e n t . T h e f o l l o w i n g c h a p t e r r e v i e w s s o m e o f t h e a p p r o a c h e s d e v e l o p e d m o r e s p e c i f i c a l l y w i t h i n t h e f a c i l i t y - b a s e d l o n g - t e r m c a r e s y s t e m w h i c h h a v e m o v e d t o w a r d s a n a p p r o a c h w h i c h c o m b i n e s t h e o r g a n i z a t i o n a l a n d i n d i v i d u a l l e v e l a p p r o a c h e s t o o u t c o m e m e a s u r e m e n t . Chapter IV - 114 -REFERENCES 1. Fanshel, S. and Bush, J . W. "A H e a l t h Status Index and I t s A p p l i c a t i o n to H e a l t h S e r v i c e s Outcomes." Operations  Research 18 (1970):1021-67. 2. Greene, R i c h a r d . A s s u r i n g Q u a l i t y i n Medical Care: The S t a t e  of the A r t . Cambridge, Mass.: B a l l i n g e r P u b l i s h i n g Co., 1976. 3. Kaluzny, A r n o l d D.; Warner, D. M i c h a e l ; Warren, David G.; and Zelman, W i l l i a m N. Management of H e a l t h S e r v i c e s . 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" Q u a l i t y Assurance an A c c o u n t i b i l i t y Model." H e a l t h S e r v i c e s Research 1982. 27. Baker, Frank. " Q u a l i t y Assurance and Program E v a l u a t i o n " . E v a l u a t i o n and the H e a l t h P r o f e s s i o n s . 6 (September 1983):149-160. 28. Woy, R i c h a r d J . ; Lund, Donald A.; and A t t k i s s o n , C. C l f f o r d . " Q u a l i t y Assurance i n Human s e r v i c e Program E v a l u a t i o n . " In E v a l u a t i o n of Human S e r v i c e Programs, pp.411-44. E d i t e d by C C . A t t k i s s o n et a l . New York: Academic Press, 1978. 29. Brook, Robert H.; W i l l i a m s , Kathleen; and Avery, A l l y s o n D. " Q u a l i t y Assurance i n the 20th Century: W i l l I t Lead to Improved H e a l t h i n the 21st?" In Q u a l i t y Assurance i n H e a l t h  Care, pp.3-29. E d i t e d by R i c h a r d H. Egdahl and Paul M. Gertman. Germantown, Maryland: Aspen Systems Corp., 1976. 30. T a f t , C y n t h i a , and Levine, S o l . "Problems of F e d e r a l P o l i c i e s and S t r a t e g i e s to I n f l u e n c e the Q u a l i t y of Care." In Q u a l i t y Assurance i n H e a l t h Care, pp.31-57. E d i t e d by R i c h a r d Egdahl and Paul Gertman. Maryland: Aspen Systems Corp., 1976. 31. Dunlop, Burton David. The Growth of Nursing Home Care. Lexington, Mass.: Lexington Books, 1979. 32. Waldman, Saul "A L e g i s l a t i v e H i s t o r y of Nursing Home Care." In Long-Term Care: P e r s p e c t i v e s from Research and  Demonstrations, pp. 507-536. E d i t e d by R.J. Vogel and H. Palmer. U.S. Department of H e a l t h and Human S e r v i c e s , H e a l t h Care F i n a n c i n g A d m i n i s t r a t i o n , 1982. 33. I n s t i t u t e of Medicine. Report of a Study A s s e s s i n g Q u a l i t y  of Care: An E v a l u a t i o n . Washington, D.C: N a t i o n a l Academy of Science, 1976. 34. J o i n t Commission on A c c r e d i t a t i o n of H o s p i t a l s . A c c r e d i t a t i o n Manual f o r Long-Term Care F a c i l i t i e s . Chicago, I l l i n o i s : 1975. 35. Berg, Robert L., ed. H e a l t h Status Indexes:Conference  Proceedings. Chicago: H o s p i t a l Research and E d u c a t i o n a l T r u s t , 1973. 36. E l i n s o n , Jack; Mooney, Anne; and Siegmann, A t h i l i a E., eds. H e a l t h Goals and H e a l t h I n d i c a t o r s : P o l i c y , P l a n n i n g , and  E v a l u a t i o n , AAAS S e l e c t e d Symposium 2. Boulder, Colorado: Westview Press Inc., 1977. Chapter IV - 117 -37. Anderson, Odin W. and S h i e l d s , Mark C. " Q u a l i t y Measurement and C o n t r o l i n P h y s i c i a n D e c i s i o n Making: S t a t e of the A r t . " H e a l t h S e r v i c e s Research 17 (Summer 1982):125-155. 38. Kessner, David M. "Quality- Assessment and Assurance: E a r l y Signs of C o g n i t i v e Dissonance." The New England J o u r n a l of  Medicine 298 (February 18, 1978):381-386. 39. Canadian A c c r e d i t a t i o n of H o s p i t a l s . A c c r e d i t a t i o n Manual  f o r Long-Term Care F a c i l i t i e s . Chicago, I l l i n o i s : 1975. 40. S l e e , V i r g i l N. "The Q u a l i t y Management A u d i t . " Ann Arbor, Michigan: 1982. (Mimeographed.) 41. Donabedian, Avedis. E x p l o r a t i o n s i n Q u a l i t y Assessment and  M o n i t o r i n g Volume I: The D e f i n i t i o n s of Q u a l i t y and  Approaches to Assessment. Ann Arbor, Mich.: H e a l t h A d m i n i s t r a t i o n Press, 1980. 42. Bloch, D o r i s . " E v a l u a t i o n of Nursing Care i n Terms of Process and Outcome." Nursing Research 24 (July-August, 1975):256-263. 43. Jacobs, C h a r l e s M.; C h r i s t o f f e l , Tom H.; and Dixon, Nancy. Measuring the Q u a l i t y of P a t i e n t Care: The R a t i o n a l f o r  Outcome A u d i t . Cambridge, Mass.: B a l l i n g e r P u b l i s h i n g Co., 1976. 44. Williamson, John W. 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Sackett, D.L.; Chambers, L.W.; MacPherson, A.S.; Goldsmith, C.H.; and McAuley, M.D. "The Development and A p p l i c a t i o n of I n d i c e s of H e a l t h : General Methods and a Summary of R e s u l t s " . AJPH 67 (May, 1977):423-28 . 49. P a t r i c k , Donald. " C o n s t r u c t i n g S o c i a l M e t r i c s f o r H e a l t h S t a t u s Indexes." In S o c i o - M e d i c a l H e a l t h I n d i c a t o r s , pp. 75-88. E d i t e d by Jack E l i n s o n and A t h i l i a Siegmann. New York: Baywood P u b l i s h i n g Co. Inc. 1979. Chapter IV - 118 -50. E l i n s o n , Jack and Siegmann, A t h i l i a . Eds. S o c i o - M e d i c a l  H e a l t h I n d i c a t o r s . New York: Baywood P u b l i s h i n g Co Inc., 1979. 51. Kelman, Howard R. " E v a l u a t i o n of H e a l t h Care Q u a l i t y by Consumers." In S o c i o - M e d i c a l H e a l t h I n d i c a t o r s . E d i t e d by J . E l i n s o n and A. Siegmann. New York: Baywood P u b l i s h i n g Co. Inc., 1979. 52. Reeder, Leo G., Ramacher, Linda; and G o r l i n k , S a l l y , eds. Handbook of S c a l e s and I n d i c e s of H e a l t h Behavior. P a c i f i c P a l i s a d e s , C a l i f o r n i a : Goodyear P u b l i s h i n g Co. Inc., 1977 53. Boyle, Michael H. and Torrance, George W. "Developing M u l t i a t t r i b u t e H e a l t h Indexes." Medical Care. 22 (November 1985):1045-1057. 54. Bergner, M a r i l y n . "Measurement of H e a l t h S t a t u s . " Medical  Care 23 (May 1985):696-704. 55. Bergner, M a r i l y n . "Health S t a t u s I n d i c a t o r s as T o o l s f o r H e a l t h P l a n n i n g . " In H e a l t h Goals and I n d i c a t o r s : P o l i c y ,  P l anning, and E v a l u a t i o n , pp. 125-32. AAAS S e l e c t e d Symposium 2, E d i t e d by Jack E l i n s o n ; Anne Mooney; and A t h i l i a E. Siegmann. Boulder, Colorado: Westview Press Inc., 1977. 56. Sackett, D.L. and Torrance, G.W. "The U t i l i t y of D i f f e r e n t H e a l t h S t a t e s as P e r c e i v e d by the General P u b l i c . " J o u r n a l  of Chronic Disease, 31:697-704. 57. Ware, John E., J r . "Monitoring and E v a l u a t i n g H e a l t h S e r v i c e s . " Medical Care 23 (May 1985):705-709. 58. Brook, Robert H. and Lohr, Kathleen N. " E f f i c a c y , E f f e c t i v e n e s s , V a r i a t i o n s and Q u a l i t y : Boundary-Crossing Research." M e d i c a l Care 23 (May 1985):710-721. 59. Bergner, M a r i l y n and B o b b i t t , Ruth A. "The Sickness Impact P r o f i l e : Conceptual Formulation and Methodology f o r the Development of a H e a l t h Status Measure." In S o c i o - M e d i c a l  H e a l t h I n d i c a t o r s , pp. 9-32. E d i t e d by Jack E l i n s o n and A t h i l i a Siegmann. New York: Baywood P u b l i s h i n g Co. Inc. 1979. 60. Deyo, R i c h a r d A.; I n u i , Thomas S.; Leninger, J y l D. and Overman, Steven S. "Measuring F u n c t i o n a l Outcomes i n Chronic Disease: A Comparison of T r a d i t i o n a l S c a l e s and a S e l f -A d m inistered H e a l t h S t a t u s Q u e s t i o n n a i r e i n P a t i e n t s w i t h Rheumatoid A r t h r i t i s " . M e dical Care 21(February 1983):180-92 61. Katz, Sidney and Akpom, C.A. "A Measure of Primary S o c i o b i o l o g i c a l F u n c t i o n s . " In S o c i o - M e d i c a l H e a l t h  I n d i c a t o r s . E d i t e d by J . E l i s o n and A. Siegmann. New York: Baywood P u b l i s h i n g Co. Inc., 1979. Chapter IV - 119 -62. Katz, Sidney; Akpom, C.A.; P a p i s i d r o , J . A.; and Weiss, S.T. "Measuring the H e a l t h of P o p u l a t i o n s . " In He a l t h Status  Indexes, pp.39-58. E d i t e d by Robert L. Berg. Chicago: H o s p i t a l Research and E d u c a t i o n T r u s t , 1973. 63. P a t r i c k , Donald L; Bush, J.W. and Chen, M. K. "Toward an O p e r a t i o n a l D e f i n i t i o n of H e a l t h . " J o u r n a l of He a l t h and  S o c i a l Behavior 14 (March, 1973):16-21. 64. Reynolds, W. J e f f ; Rushing, W i l l i a m A. and M i l e s , David L. "The V a l i d a t i o n of a F u n c t i o n a l S t a t u s Index". J o u r n a l of  Hea l t h and S o c i a l Behavior 15 (December 1974):271-83. 65. Skinner, Douglas E. and Y e t t , Donald E. " D e b i l i t y Index f o r Long-Term Care P a t i e n t s . " In H e a l t h S t a t u s Indexes, pp.69-88. E d i t e d by Robert L. Berg. Chicago: H o s p i t a l Research and E d u c a t i o n a l T r u s t , 1973. 66. B i c e , Thomas W. "Comments on H e a l t h I n d i c a t o r s : M e t h o d o l o g i c a l P e r s p e c t i v e s . " In S o c i o - M e d i c a l H e a l t h  I n d i c a t o r s , pp. 185-96. E d i t e d by Jack E l i n s o n and A t h i l i a Siegmann. New York: Baywood P u b l i s h i n g Co. Inc. 1979. C H A P T E R V C U R R E N T A N D P R O P O S E D A P P R O A C H E S T O O U T C O M E M E A S U R E M E N T I N F A C I L I T Y - B A S E D L O N G - T E R M C A R E I N T R O D U C T I O N One sees from the review of outcome measurement approaches i n the p r e v i o u s chapter a t r e n d towards the use of outcome approaches i n both the p r i v a t e and p u b l i c s e c t o r , i n c l u d i n g the h e a l t h care i n d u s t r y . In long-term care the i n c r e a s i n g emphasis on measurement of e f f e c t i v e n e s s approaches has a r i s e n from two f a c t o r s - the changing government p e r c e p t i o n of i t s r e s p o n s i b i l i t i e s i n long-term care, and p u b l i c p r e s s u r e f o r a c c o u n t a b i l i t y i n the p r o v i s i o n of f a c i l i t y - b a s e d long-term care [1; 2 ], H i s t o r i c a l l y t h i s t r e n d to r e s p o n s i b i l i t y and a c c o u n t a b i l i t y can be seen as movement from: - the t r a d i t i o n a l l i c e n s u r e process w i t h r e g u l a t i o n s (based l a r g e l y on s t r u c t u r a l standards) intended to ensure p r o t e c t i o n and s a f e t y f o r dependent a d u l t r e s i d e n t s [3; 4] to; - d e l e g a t i o n of the r e s p o n s i b i l i t y to p r o f e s s i o n a l groups (medicine, nursing) f o r the establishment of standards of p r a c t i c e f o r t h e i r members. T h i s r e s u l t e d i n both s t r u c t u r a l and process standards intended to ensure the p r o v i s i o n of an adequate and a c c e p t a b l e q u a l i t y of care [5] ; - to a more recent t r e n d towards some form of i n s t i t u t i o n a l a c c o u n t a b i l i t y and the use of standards or r e g u l a t i o n s as the b a s i s f o r determining the e l i g i b i l i t y of i n s t i t u t i o n a l p r o v i d e r s to be reimbursed f o r the care p r o v i d e d [1; 5; 6; 7; 8; 9 ] , There i s a l s o a growing p r e s s u r e f o r and acceptance that outcome measures would one way to meet these a c c o u n t a b i l i t y requirements [10; 11; 12; 13]. CHAPTER V - 121 -To p r o v i d e f o r these a c c o u n t a b i l i t y requirements, a number of approaches to outcome measurement have been developed. Some of these approaches have t h e i r o r i g i n s i n the Q u a l i t y Assurance process noted i n Chapter Four. More r e c e n t l y these i n c l u d e an assessment of the h e a l t h s t a t u s of i n d i v i d u a l r e c i p i e n t s of long-term care, where h e a l t h s t a t u s i s assumed to be r e l a t e d to or a proxy f o r the outcomes of care. Other approaches have been developed more towards a program e v a l u a t i o n approach and are based on o r g a n i z a t i o n a l outputs or outcomes. T h i s chapter e x p l o r e s these two l e v e l s of outcome measurement as they have been developed and proposed f o r use i n f a c i l i t y - b a s e d long-term c a r e . OUTCOME MEASUREMENT AT THE ORGANIZATIONAL LEVEL IN LONG-TERM CARE As noted e a r l i e r f o r h e a l t h care, the d i s c u s s i o n of outcome measurement i n long-term care r e v e a l s that there i s a l a c k of agreement about what i s meant by outcome. While many recent approaches measure outcome at the l e v e l of the i n d i v i d u a l ( p a t i e n t ) f u n c t i o n i n g [13], other approaches propose t h a t outcome should be measured at a more macro l e v e l , such as the achievement of o p e r a t i v e o r g a n i z a t i o n a l g o a l s [14; 15; 16; 17; 18]. These o r g a n i z a t i o n a l outcomes are viewed by some as i n p u t s or i n t e r m e d i a t e outputs and by o t h e r s as outcomes. CHAPTER V - 122 -W i t h i n t h e l o n g - t e r m c a r e l i t e r a t u r e , measurement a t t h e o r g a n i z a t i o n a l l e v e l i s seen m o s t l y i n the many c o s t comparison s t u d i e s w h i c h have a t t e m p t e d t o measure c o s t - e f f e c t i v e n e s s o r e f f i c i e n c y o f f a c i l i t y - b a s e d c a r e as compared t o a l t e r n a t i v e community based l o n g - t e r m c a r e [ 1 9 ] . The o r g a n i z a t i o n a l l e v e l a pproach has a l s o been used i n s t u d i e s w h i c h have compared t h e outcomes of f o r - p r o f i t and n o n - p r o f i t l o n g - t e r m c a r e f a c i l i t i e s [20; 2 1 ] . Other s t u d i e s have compared t h e r e l a t i o n s h i p o f q u a l i t y and c o s t , where the q u a l i t y o f c a r e i s measured, a t l e a s t i n p a r t by outcome measures [22; 23; 24; 2 5 ] . A s t u d y o f the impact o f q u a l i t y on t h e c o s t o f f a c i l i t y -based l o n g - t e r m c a r e i n New York by Ullma n i s an example o f the l a t t e r [ 2 5 ] . The q u a l i t y of c a r e i n New York n u r s i n g homes i s de t e r m i n e d by a t h r e e - p r o n g s u r v e y assessment p r o c e s s - t h e r e a r e two s u r v e y s t o a s s e s s c o m p l i a n c e w i t h f e d e r a l - s t a t e r e g u l a t i o n s " c o n c e n t r a t e on s t r u c t u r e and p r o c e s s a s p e c t s o f f a c i l i t y q u a l i t y " , w h i l e the t h i r d s u r v e y , t h e P e r i o d i c M e d i c a l Review, "examines p r o c e s s and outcome o r i e n t e d measures ... th r o u g h d i r e c t o b s e r v a t i o n of each r e s i d e n t . . . " [25:294]. Except f o r s e e k i n g t o d e t e r m i n e i f t h e r e i s r e s i d e n t abuse o r n e g l e c t , i t i s not c l e a r what outcome measures a r e made [25:294] o r how the y a r e used. I t appears' t h a t t h i s approach may be s i m i l a r t o the Chambers approach i n w h i c h t h e outcomes measured a r e d i r e c t l y r e l a t e d t o e v a l u a t i o n o f the p r o c e s s ( c a r e ) a c t i v i t i e s r e q u i r e d t o a d d r e s s c a r e problems f r e q u e n t l y found i n l o n g - t e r m c a r e , such as i n c o n t i n e n c e [25:294; 2 6 ] . CHAPTER V - 123 -I n f o r m a t i o n from t h e s e t h r e e s u r v e y s t h e n form t h e b a s i s f o r a q u a l i t y r a t i n g p r o c e s s w h i c h r a t e s f a c i l i t y q u a l i t y i n a range from " v e r y good" t h r o u g h "needs improvement" t o " u n a c c e p t a b l e " . I t i s not c l e a r from t h e r e p o r t what impact the outcome measures have on t h e r a t i n g p r o c e s s [25:295]. Two o t h e r approaches d e v e l o p e d around t h e outcomes o f s p e c i f i c l o n g - t e r m c a r e problems a r e t h e " C r i t e r i a Mapping P r o c e s s " d e v e l o p e d by Chambers e t a l [ 2 6 ] , a Canadian group, and a t h r e e - p a r t i n c e n t i v e reimbursement p r o c e s s f o r l o n g - t e r m c a r e d e v e l o p e d by W e i s s e r t e t a l i n t h e U n i t e d S t a t e s [ 1 8 ] . These a r e s i m i l a r t o t h e C r i t e r i o n problem model n o t e d by Campbell e a r l i e r and may be c o n s i d e r e d as o r g a n i z a t i o n a l l e v e l approaches i n f a c i l i t y - b a s e d l o n g - t e r m c a r e . THE CRITERIA MAPPING MODEL The f o c u s o f the Chambers e t a l approach i s q u a l i t y a s s u r a n c e i n l o n g - t e r m c a r e f a c i l i t i e s . They r e f e r t o r e s i d e n t outcomes as the "measurement of t h e end r e s u l t o f r e s i d e n t c a r e . Examples ... i n c l u d e d e s c r i p t i o n s o f h e a l t h s t a t e s such as f e v e r r e d u c e d , d e c u b i t u s u l c e r h e a l e d . . . " [26:138]. They propose t h a t q u a l i t y a s s u r a n c e s t a n d a r d s can be anchored t o o b s e r v a b l e r e s i d e n t outcomes, and f u r t h e r propose t h a t outcomes may be i n f l u e n c e d by many f a c t o r s t h a t s h o u l d not be c o n s i d e r e d i n i s o l a t i o n from t h e p r o c e s s o f c a r e . The major emphasis o f t h i s a p proach i s t o p r o v i d e a v e h i c l e t o promote changes i n c a r e g i v e r b e h a v i o u r , t h a t i s t o c o r r e c t d e f i c i e n c i e s i n r e s i d e n t c a r e , i f r e q u i r e d . CHAPTER V - 124 -Chambers et a l have developed " c r i t e r i a maps" f o r f o u r h e a l t h care problems p r e v a l e n t i n long-term care - c o n s t i p a t i o n , d e c u b i t i , dehydration,and f a l l s . Each c r i t e r i a map o u t l i n e s e x p l i c i t process and outcome c r i t e r i a f o r the s e l e c t e d problem. The process and outcome c r i t e r i a used are based on minimal adequacy standards. A c h a r t review i s performed to determine the extent of achievement of the process and outcome c r i t e r i a [26:144]. I f expected outcome r e s u l t s are not achieved, then the process c r i t e r i a can be used to determine i f the outcome i s r e l a t e d to the process of care and what remediation, i f any, i s r e q u i r e d . In the a r t i c l e reviewed, a r e p o r t of the f e a s i b i l i t y study, o n l y process outcomes were s c o r e d u s i n g an "adequate or q u e s t i o n a b l e " r a t i n g as the s c o r e r e s u l t s [26:146]. A percentage (aggregation) s c o r e of the adequate outcomes i s derived, based on the extent of compliance w i t h the management (process) c r i t e r i a a c hieved by a l l r e s i d e n t s reviewed with a p a r t i c u l a r problem. In t h i s way an aggregate o r g a n i z a t i o n a l or f a c i l i t y l e v e l performance s c o r e s of "adequate q u a l i t y " can be developed [26:46]. I t i s assumed that outcome sc o r e s c o u l d be developed i n the same way. Another study i s planned by Chambers et a l to examine f u r t h e r the v a l i d i t y of t h i s approach and to present the outcome r e s u l t s . F i g u r e 8 summarizes the pros and cons of the C r i t e r i a Mapping Approach i n i t s a p p l i c a t i o n to outcome-based reimbursement i n f a c i l i t y - b a s e d long-term care. CHAPTER V - 125 -Figure 8 : THE PROS & CONS OF CRITERIA MAPPING AS AN OUTCOME MEASUREMENT APPROACH FOR FACILITY-BASED LONG-TERM CARE PROS Uses outcome measures s p e c i f i c t o f a c i l i t y - b a s e d l o n g - t e r m c a r e ; Can d e v e l o p an a g g r e g a t e d o r g a n i z a t i o n s c o r e of "adequate q u a l i t y " ; Has been used i n t h e Canadian l o n g - t e r m c a r e system; CONS Report on outcome r e s u l t s not y e t a v a i l a b l e ; A s s e s s e s o n l y a l i m i t e d number o f problems t o d e r i v e outcomes; Outcome measures may not be s e n s i t i v e enough t o use as s i n g l e measure o f e f f e c t i v e n e s s ; Focus i s Q u a l i t y A s s u r a n c e , not reimbursement. Recommendation: These outcome measures may not be s u f f i c i e n t o r s e n s i t i v e enough by themselves t o be used as a measure o f e f f e c t i v e n e s s f o r d i f f e r e n t l e v e l s o f c a r e , such as th e f i v e l e v e l s of c a r e p r o v i d e d i n l o n g - t e r m c a r e f a c i l i t i e s i n B.C. T h i s approach, however, may be u s e f u l i f used i n c o n j u n c t i o n w i t h o t h e r approaches t o outcome measurement o f e f f e c t i v e n e s s . The o t h e r o r g a n i z a t i o n a l l e v e l a pproach r e v i e w e d i s a more comprehensive i n c e n t i v e reimbursement model d e v e l o p e d by W e i s s e r t e t a l t o overcome problems of a c c e s s , i n a p p r o p r i a t e u t i l i z a t i o n and n o n - o p t i m a l c a r e i n l o n g - t e r m c a r e f a c i l i t i e s i n the U n i t e d S t a t e s [ 1 8 ] . The outcome measurement approach i n c o r p o r a t e d i n t h i s model p r o v i d e s t h e measures of e f f e c t i v e n e s s needed t o p r o v i d e an i n f o r m a t i o n base f o r t h e f i n a n c i a l i n c e n t i v e s t o overcome t h e problems o f n o n - o p t i m a l p r o v i s i o n o f c a r e f o r s e l e c t e d c a r e problems. CHAPTER V - 126 -THE INCENTIVE REIMBURSEMENT MODEL The nursing home payment system d e v e l o p e d i n the U n i t e d S t a t e s by W e i s s e r t e t a l , as proposed, has t h r e e i n c e n t i v e components d e s i g n e d t o improve b o t h the e f f e c t i v e n e s s and t h e e f f i c i e n c y o f t h e reimbursement system t o f o r - p r o f i t p r o v i d e r s o f f a c i l i t y - b a s e d l o n g - t e r m c a r e . The i n c e n t i v e s a r e aimed a t overcoming problems o f a c c e s s f o r M e d i c a i d p a t i e n t s "who a r e s e v e r e l y dependent" [18:42] and r e q u i r e more i n t e n s i v e c a r e t h a n the average r e s i d e n t ; i n a p p r o p r i a t e bed u t i l i z a t i o n by l i g h t e r c a r e c l i e n t s ; and a d d r e s s i n g the need t o encourage the use o f r e s o u r c e s towards m a i n t a i n i n g r e s i d e n t s ' independence [ 1 8 ] . These t h r e e i n c e n t i v e s a r e d i r e c t e d a t o r g a n i z a t i o n a l b e h a v i o u r change i n a system i n w h i c h a c c e s s and u t i l i z a t i o n problems a r e the r e s u l t o f f a c i l i t y c a r e p r o v i d e r s a c t i n g as the g a t e k e e p e r s f o r f a c i l i t y placement. The t h r e e i n c e n t i v e s i n c l u d e bonuses p a i d : f o r a d m i t t i n g p a t i e n t s c l a s s i f i e d as r e q u i r i n g c a r e more c o s t l y than the average p a t i e n t ; f o r s u c c e s s f u l d i s c h a r g e o f l o n g - t e r m c a r e p a t i e n t s ; and f o r a c h i e v i n g outcome g o a l s o f e i t h e r 'improvement o r maintenance o f h e a l t h s t a t u s f o r s p e c i f i e d h e a l t h c a r e problems w h i c h a r e c o s t l y t o p r o v i d e [ 1 8 ] . A l t h o u g h o n l y one of t h e s e i s s p e c i f i c a l l y i d e n t i f i e d as an outcome-based reimbursement i n c e n t i v e , g i v e n the g o a l s o f e f f e c t i v e n e s s and e f f i c i e n c y n o t e d by the a u t h o r s , one might c a t e g o r i z e t h e measured r e s u l t s o f a l l t h r e e i n c e n t i v e s as o r g a n i z a t i o n a l l e v e l outcomes. CHAPTER V - 127 -The admission i n c e n t i v e i s to be based on assessment of the r e s i d e n t ' s need f o r human a s s i s t a n c e and u n u s u a l / c o s t l y s e r v i c e s . The bonus i s s c a l e d to a f o u r t e e n l e v e l c l a s s i f i c a t i o n system based on the marginal c o s t s of care f o r those care l e v e l s and a d j u s t e d to the d a i l y reimbursement r a t e f o r the average p a t i e n t [18:44]. The d i s c h a r g e bonus i s to be p a i d f o r any long s t a y r e s i d e n t where there i s evidence of an a p p r o p r i a t e d i s c h a r g e p l a n and that the d i s c h a r g e has been maintained f o r at l e a s t 90 days at a lower l e v e l of care or i n the community. The bonus p a i d i s to cover the c o s t of d i s c h a r g e p l a n n i n g and case management f o r the f i r s t 90 days a f t e r d i s c h a r g e [18:46]. These two bonuses (admission and discharge) would p r o v i d e i n c e n t i v e s f o r o r g a n i z a t i o n a l l e v e l outcomes that demonstrate that p r o v i d e r s accept heavy care l e v e l r e s i d e n t s and r e l i n q u i s h more independent, l i g h t e r care r e s i d e n t s . The t h i r d i n c e n t i v e i s the outcome i n c e n t i v e to encourage p r o v i d e r s "to p r o v i d e r e s t o r a t i v e n u r s i n g care, d e v i c e s , a i d s and other s e r v i c e s that w i l l l e a d to achievement of s e l e c t e d care g o a l s " [18:48]. There are s i x h e a l t h care problems with g o a l s to e i t h e r improve or m a i n t a i n a h e a l t h s t a t u s or f u n c t i o n (e.g. maintenance of good s k i n c o n d i t i o n i n a comatose p a t i e n t ) . The bonus i s to be p a i d f o r p a t i e n t s w i t h any of the s i x h e a l t h care problems u n t i l improvement i s achieved or the problem i s maintained f o r a p e r i o d of time. CHAPTER V - 128 -To t e s t t h i s approach t o reimbursement f o r f a c i l i t y - b a s e d l o n g - t e r m c a r e , a s t u d y (18) was c a r r i e d out i n 36 p r o p r i e t a r y s k i l l e d n u r s i n g homes i n the San Diego a r e a o f C a l i f o r n i a ; e i g h t e e n o f the homes were t r e a t m e n t homes whi c h r e c e i v e d t h e i n c e n t i v e bonuses and e i g h t e e n d i d n o t . The number o f c l i e n t s s u r v e y e d i s not n o t e d . To-date the s t u d y r e s u l t s have not been p u b l i s h e d (based on a l i t e r a t u r e s e a r c h completed May 1986). F i g u r e 9 summarizes the p r o s and cons o f t h e I n c e n t i v e Reimbursement model as an approach w h i c h might be a p p l i e d t o outcome-based reimbursement i n f a c i l i t y - b a s e d l o n g - t e r m c a r e . F i g u r e 9: THE PROS & CONS OF THE INCENTIVE REIMBURSEMENT MODEL AS AN OUTCOME MEASUREMENT APPROACH FOR FACILITY-BASED LONG-TERM CARE PROS CONS Uses outcome measures s p e c i f i c t o f a c i l i t y - b a s e d l o n g - t e r m c a r e ; I n c l u d e s the reimbursement p e r s p e c t i v e ; P r o v i d e s measures o f e f f e c t i v e n e s s ; Has p o t e n t i a l f o r an a g g r e g a t e o r g a n i z a t i o n a l l e v e l s c o r e . Reimbursement i n c e n t i v e s based on problems found l a r g e l y i n t h e U n i t e d S t a t e s ; A s s e s s e s o n l y a l i m i t e d number o f problems t o d e r i v e outcomes; Outcome measures may not be s e n s i t i v e enough t o use as s i n g l e measure o f e f f e c t i v e n e s s ; Report on r e s u l t s not y e t a v a i l a b l e ; CHAPTER V - 129 -W h i l e c a r e p r o v i d e r s i n B r i t i s h Columbia a r e not t h e g a t e k e e p e r s o f the system, a t l e a s t not t o t h e e x t e n t t h e y a r e i n the U n i t e d S t a t e s , t h e r e i s t h e p o t e n t i a l f o r some of t h e problems n o t e d by W e i s s e r t e t a l . P r o v i d e r s i n B r i t i s h Columbia can a c c e p t r e s i d e n t s r e q u i r i n g d i f f e r e n t l e v e l s o f c a r e based on the case mix a l l o w e d under t h e i r o p e r a t o r s l i c e n s e . To t h a t e x t e n t , p r o v i d e r s may a c c e p t r e s i d e n t s whom th e y f e e l b e s t ' f i t ' t h a t mix. There has a l s o been some c o n c e r n i n B r i t i s h Columbia over the p o t e n t i a l f o r p r o v i d e r s t o r e t a i n r e s i d e n t s a t t h e more independent l e v e l s o f c a r e as t h e i r c o n d i t i o n improves [ 2 7 ] . The a c c e s s problems f o r i n d i v i d u a l s i n B r i t i s h Columbia, however, appear t o be more r e l a t e d t o bed s h o r t a g e s , o r an i n a p p r o p r i a t e mix o f beds i n the bed p o o l , o r t o a l a c k o f s u f f i c i e n t home c a r e r e s o u r c e s i n some a r e a s . T h i s has r e s u l t e d i n the ' b l o c k e d bed 1 phenomena b o t h w i t h i n l o n g - t e r m c a r e f a c i l i t i e s and a c u t e h o s p i t a l s , and the b l o c k a g e i s r e l a t e d t o the extended (heavy) c a r e l e v e l s [ 2 7 ] . As w i t h the Chambers e t a l model, the outcome measures used i n t h i s approach may not be s e n s i t i v e o r s p e c i f i c enough t o be used a t a l l l e v e l s o f c a r e o r as the s i n g l e measure of e f f e c t i v e n e s s . However, t h i s p r o p o s a l f o r a reimbursement i n c e n t i v e model i l l u s t r a t e s , i n t h e o r y a t l e a s t , the p o t e n t i a l f o r t h e use of a v a r i e t y of outcome measures t o m o t i v a t e p r o v i d e r b e h a v i o u r towards e f f e c t i v e n e s s and e f f i c i e n c y ; t h a t use o f a c o m b i n a t i o n o f r e s i d e n t l e v e l and o r g a n i z a t i o n a l l e v e l CHAPTER V - 130 -outcome o b j e c t i v e s i s p o s s i b l e ; and t h a t reimbursement can be l i n k e d t o the achievement o f th e s e o b j e c t i v e s . Recommendation: To the e x t e n t t h a t t h e r e a r e 'gatekeeper problems' the f i r s t two i n c e n t i v e s n o t e d i n t h i s model would have a p p l i c a t i o n i n the B.C. l o n g - t e r m c a r e payment system. The t h i r d outcome i n c e n t i v e might be o f use from a n o t h e r p e r s p e c t i v e . That i s , i f a g g r e g a t e d , the outcomes measured c o u l d p r o v i d e an o r g a n i z a t i o n a l o r f a c i l i t y l e v e l measure of e f f e c t i v e n e s s of c a r e ( a t l e a s t f o r some of the common f a c i l i t y -based l o n g - t e r m c a r e problems) o r t h e y may be used t o t e s t t h e v a l i d i t y of more e x t e n s i v e and s e n s i t i v e outcome measurement approaches such as H e a l t h S t a t u s Indexes. OUTCOME MEASUREMENT AT THE INDIVIDUAL/RESIDENT LEVEL The h i s t o r i c a l development o f outcome measurement i n l o n g -term c a r e , p a r t i c u l a r l y the assessments o f h e a l t h s t a t u s , has bo t h b e n e f i t t e d and s u f f e r e d from the e x p e r i e n c e i n the a c u t e c a r e s e c t o r of th e h e a l t h c a r e i n d u s t r y . Among t h e b e n e f i t s was the r e a l i z a t i o n t h a t the 'medical d i a g n o s t i c o r m o r b i d i t y model' was too l i m i t e d an approach f o r a s s e s s i n g i n d i v i d u a l s w i t h m u l t i p l e problems w h i c h have i n t e r a c t i v e e f f e c t s . T h i s r e a l i z a t i o n s t i m u l a t e d the movement towards d e v e l o p i n g f u n c t i o n a l and m u l t i d i m e n s i o n a l assessments, f o r example s p e c i f i c a l l y t a r g e t e d H e a l t h S t a t u s Indexes. Another b e n e f i t was the r e s e a r c h e f f o r t s toward d e v e l o p i n g r e l i a b l e and v a l i d measuring i n s t r u m e n t s . On t h e n e g a t i v e s i d e , development o f m u l t i d i m e n s i o n a l assessment i n s t r u m e n t s has o f t e n t a k e n the form of combining i n s t r u m e n t s o r i g i n a l l y d e v e l o p e d t o a s s e s s s i n g l e f u n c t i o n a l d i m e n s i o n s , w i t h o u t p a y i n g a t t e n t i o n t o the d i f f e r e n c e s i n the o r i g i n a l p urpose, i n t h e u n d e r l y i n g a s s u m p t i o n s , o r i n the o r i g i n a l t a r g e t p o p u l a t i o n [27:10-24]. CHAPTER V - 131 -As i n acute care, f u n c t i o n a l assessment i n long-term care has moved from a s s e s s i n g needs i n order to p l a n i n t e r v e n t i o n s , to p a t i e n t c l a s s i f i c a t i o n approaches f o r use i n determining a p p r o p r i a t e s t a f f u t i l i z a t i o n and work l o a d , to approaches f o r determining the e f f e c t i v e n e s s (or q u a l i t y ) of the care p r o v i d e d [27; 28:19-25). In a d d i t i o n , the long-term care i n d u s t r y now a l s o r e c o g n i z e s the need f o r assessment approaches which address and support a m u l t i d i s c i p l i n a r y approach to care and the ' q u a l i t y of l i f e ' i s s u e s [9; 27:140-200; 29]. The l i t e r a t u r e reviewed on i n d i v i d u a l assessment approaches i n long-term care i n c l u d e d s e v e r a l g e n e r a l overviews of approaches to a s s e s s i n g h e a l t h care i n which the assessment of long-term care was i n c l u d e d [30; 31; 32]. These reviews o f t e n focused on the e f f o r t s of a p a r t i c u l a r p r o f e s s i o n a l group (e.g. medicine or n u r s i n g ) ; u s u a l l y used the concepts of s t r u c t u r e -process-outcome as a way of d e f i n i n g and c a t e g o r i z i n g the approaches; and the assessment instruments were u s u a l l y developed w i t h i n the framework of Q u a l i t y Assurance programs. Other works reviewed assessment approaches s p e c i f i c a l l y developed f o r use i n the long-term care i n d u s t r y [13; 15; 16; 17; 27; 28; 33; 34]. These approaches were presented u s i n g e i t h e r the structure-process-outcome framework or used a c a t e g o r i c a l framework r e p r e s e n t i n g the f u n c t i o n a l dimensions assessed (e.g. p h y s i c a l , p s c h o - s o c i a l , e t c . ) . The f u n c t i o n a l assessment approaches i n c l u d e d both s i n g l e dimensional CHAPTER V - 132 -assessments of e i t h e r p h y s i c a l or mental or s o c i a l f u n c t i o n i n g and m u l t i d i m e n s i o n a l assessments which attempt to e v a l u a t e some combination of these f u n c t i o n a l dimensions. A d d i t i o n a l l y , the l a t t e r approaches o f t e n attempt to q u a n t i f y the i n f l u e n c e s of a dimension or dimensions through assessment of competency i n A c t i v i t i e s of D a i l y L i v i n g (ADL). ADLs are f e l t to be r e f l e c t i v e of the l e v e l of an i n d i v i d u a l ' s a b i l i t y f o r s e l f - c a r e or independent l i v i n g [27]. A growing t r e n d towards approaches that i n c l u d e measurement of the ' q u a l i t y of l i f e ' a s p e c t s of i n s t i t u t i o n a l care was a l s o noted [9; 17:342; 27:140-200; 35). ' Q u a l i t y of l i f e 1 i s g a i n i n g importance as an outcome v a r i a b l e i n i n s t i t u t i o n a l care as there i s an i n c r e a s i n g r e c o g n i t i o n t h a t placement i n a l o n g -term care f a c i l i t y f o r most i n d i v i d u a l s r e p r e s e n t s a permanent and f i n a l l i v i n g s i t u a t i o n and not j u s t a temporary care s i t u a t i o n . I t i s suggested that ' q u a l i t y of l i f e ' assessment c o u l d i n c l u d e a s p e c t s such as the ' f i t ' between the i n d i v i d u a l and the environment, s a t i s f a c t i o n w i t h care, e t c . [9; 17:305]. I t should be noted that approaches to the measurement of q u a l i t y of l i f e a s p e c t s are even more d i v e r g e n t than are f u n c t i o n a l measures. T H E E X P E C T E D O U T C O M E S A P P R O A C H A number of the r e c e n t l y developed approaches to outcome measurement at the i n d i v i d u a l l e v e l i n long-term care appear to be an a d a p t a t i o n of the g o a l attainment s c a l i n g approach [36]. CHAPTER V - 133 -T h i s a d a p t a t i o n might be l a b e l l e d the "expected versus the a c t u a l " outcome model. An expected outcome i s d e f i n e d (or p r e d i c t e d ) on the b a s i s of some form of c l i n i c a l p r o gnosis (and/ or p r e d i c t o r v a r i a b l e ( s ) ) developed e i t h e r through a normative or comparative p r o c e s s . At t h i s p o i n t the q u a l i t y of care i s assumed to be optimal and t h e r e f o r e i s constant. A f t e r a s t a t e d time p e r i o d , the a c t u a l outcome i s measured. Examination of the d i f f e r e n c e s between the expected ( p r e d i c t e d ) outcome and the a c t u a l (observed) outcome would then p r o v i d e i n f o r m a t i o n about the e f f e c t i v e n e s s of c a r e . I f the a c t u a l outcome i s d i f f e r e n t from what was expected such an approach might p r o v i d e d i r e c t i o n f o r managers as to areas which may need f u r t h e r i n v e s t i g a t i o n and/or change. T h i s a d a p t a t i o n of g o a l attainment s c a l i n g attempts to s t a n d a r d i z e the establishment of the expected outcomes, r a t h e r than the expected outcomes being n e g o t i a t e d between the p r o v i d e r and the i n d i v i d u a l c l i e n t [13; 14; 18]. The f l e x i b i l i t y and c o n s i d e r a t i o n of the uniqueness of the i n d i v i d u a l found i n the goal attainment s c a l i n g approach i s r e t a i n e d [36]. I d e a l l y , the prognoses or p r e d i c t o r v a r i a b l e s s hould be d e r i v e d from a knowledge about the expected course (or response to i n t e r v e n t i o n ) of i n d i v i d u a l s with a g i v e n combination of f u n c t i o n a l d i s a b i l i t i e s and d i s e a s e ( s ) . That i s , assuming that "optimal or t o t a l l y a p p r o p r i a t e c a r e " i s prov i d e d , what i s the expected response f o r i n d i v i d u a l s , g i v e n the unique c h a r a c t e r i s t i c s of t h e i r h e a l t h s t a t e [34]? Current knowledge, CHAPTER V - 134 -however, i s l i m i t e d about the r e l a t i o n s h i p of outcomes to the process of care, and even more l i m i t e d about the expected course (or response to i n t e r v e n t i o n ) f o r i n d i v i d u a l s w i t h v a r y i n g combinations of f u n c t i o n a l d i s a b i l i t y and d i s e a s e . But Zimmer notes that the measured f u n c t i o n a l l e v e l ( a b i l i t y ) of an i n d i v i d u a l i s o f t e n the s t r o n g e s t p r e d i c t o r of outcome [17]. Two methods have been used to develop the standards from which to e s t a b l i s h expected outcomes - i ) normative and i i ) comparative. With the normative approach expert o p i n i o n i s used to develop the c r i t e r i a which measure f u n c t i o n a l a b i l i t y and/or to i d e n t i f y the expected r e s u l t s of care i n t e r v e n t i o n s [13]. The problems w i t h t h i s approach i n c l u d e the f o l l o w i n g : - d i f f i c u l t y i n determining which experts w i t h what experience and p e r s p e c t i v e s should be c o n s u l t e d ; - e s t a b l i s h i n g what methodology should be used to v a l i d a t e the c r i t e r i a or even achieve consensus; - and whether the expert o p i n i o n a c t u a l l y r e p r e s e n t s these a c h i e v a b l e i n the e m p i r i c a l s i t u a t i o n . On the p o s i t i v e s i d e , the normative approach p r o v i d e s f o r the input of p r o v i d e r s and p r o f e s s i o n a l s who w i l l be u s i n g the instruments (promotes ownership), the expert o p i n i o n i s based on experience w i t h the l o c a l s i t u a t i o n and may be l e s s time consuming and c o s t l y than e m p i r i c a l t e s t i n g . In the comparative approach, the expected outcomes are developed from an e m p i r i c a l base through measurement of the c h a r a c t e r i s t i c s of the p o p u l a t i o n s or subgroups of i n d i v i d u a l s i n an a c t u a l care s i t u a t i o n s . The r e s u l t a n t outcomes are then assumed to r e p r e s e n t the expected outcomes f o r i n d i v i d u a l s w i t h CHAPTER V - 135 -s i m i l a r f u n c t i o n a l (or h e a l t h ) s t a t e s . These outcomes can then be used as the p r e d i c t o r s or prognoses f o r assessments of care i n other s i m i l a r p o p u l a t i o n s (e.g. another long-term care f a c i l i t y ) . One problem w i t h t h i s approach i s the need to assume th a t the q u a l i t y of care p r o v i d e d i s optimal and can be h e l d constant when d e v e l o p i n g the expected outcomes [34]. A combination of these two measurement approaches may be a p p l i e d i n the development of the expected outcomes. The normative approach c o u l d be used i n d e v e l o p i n g the c r i t e r i a or a t t r i b u t e s of the h e a l t h s t a t u s c l a s s i f i c a t i o n system and/or to s p e c i f y the prognoses. The normative approach should a l s o be used to determine which f a c i l i t i e s c u r r e n t l y p r o v i d e o p timal care ( i n order to de s i g n a t e f a c i l i t i e s f o r which q u a l i t y i s co n s i d e r e d to be h e l d constant w h i l e e s t a b l i s h i n g the comparative standards f o r h e a l t h s t a t u s or p r o g n o s i s ) . The normative instruments so developed would be used as standards t o assess, and l a t e r compare the outcomes found i n the e m p i r i c a l s i t u a t i o n . That i s the comparative approach c o u l d be used t o : - e s t a b l i s h both the expected and a c t u a l outcomes [13]; - compare the e m p i r i c a l r e s u l t s w i t h the normative p r o g n o s i s or w i t h the other types of comparatively d e r i v e d outcomes (e.g. death, d i s c h a r g e s of v a r i o u s types) [13; 14]; - compare the aggregate r e s u l t s of one group (e.g . one f a c i l i t y ) w i t h the aggregate data f o r s e v e r a l p o p u l a t i o n groups (e.g. a l l the f a c i l i t i e s i n a r e g i o n , or a peer group of f a c i l i t i e s ) [13; 17]. In a d d i t i o n to the problems and d i f f e r e n c e s noted when measures are developed through e i t h e r the normative or C H A P T E R V - 136 -c o m p a r a t i v e m e t h o d , o t h e r v a r i a t i o n s w e r e n o t e d a m o n g t h e t o o l s r e v i e w e d . T h e s e v a r i a t i o n s a p p e a r t o b e d u e c h i e f l y t o d i s a g r e e m e n t s a m o n g r e s e a r c h e r s a b o u t w h i c h m e t h o d o l o g i c a l a p p r o a c h e s t o u s e . T h e d i f f e r e n c e s s e e m t o b e r e l a t e d t o r e a l o r p e r c e i v e d d i f f e r e n c e s i n t h e p u r p o s e o r i n t e n t o f t h e a s s e s s m e n t t o o l a n d w e r e p a r t i c u l a r l y r e l a t e d t o t h e c o m p l e x i t y a n d m u l t i d i m e n s i o n a l i t y o f l o n g - t e r m c a r e a s s e s s m e n t s . ( S e e A p p e n d i x C f o r e x a m p l e s o f s o m e o f t h e q u e s t i o n s r a i s e d ) . A n u m b e r o f t h e s e i s s u e s m u s t b e a d d r e s s e d w i t h i n t h e c o n t e x t o f t h e p u r p o s e o f t h e a s s e s s m e n t : t h a t i s , i n t h i s s t u d y , w h a t a s p e c t s o f a c c o u n t a b i l i t y i s t h e a s s e s s m e n t p r o c e s s e x p e c t e d t o s u p p o r t ? T o m e e t a c c o u n t a b i l i t y r e q u i r e m e n t s s o m e m e a s u r e o f e f f e c t i v e n e s s o f t h e c a r e p r o v i d e d i n l o n g - t e r m c a r e f a c i l i t i e s i s r e q u i r e d . I f o n e a s s u m e s t h a t a s s e s s m e n t o f i n d i v i d u a l / r e s i d e n t o u t c o m e s p r o v i d e s , a t l e a s t i n p a r t , t h e i n f o r m a t i o n n e e d e d a b o u t a f a c i l i t y ' s e f f e c t i v e n e s s a n d t h a t t h e s e o u t c o m e s a r e t o b e u s e d i n a n o u t c o m e - b a s e d r e i m b u r s e m e n t s y s t e m , t h e f o l l o w i n g a s p e c t s w o u l d h a v e t o b e p a r t o f t h e a s s e s s m e n t m e t h o d . T h e a s s e s s m e n t s h o u l d b e : - a d m i n i s t e r e d b y e x t e r n a l a s s e s s o r s t o m a i n t a i n o b j e c t i v i t y , a n d t o a v o i d p r o v i d e r c o n f l i c t o f i n t e r e s t ; - b a s e d o n i n f o r m a t i o n s u p p l i e d b y s e l f - r e p o r t b y t h e r e s i d e n t a n d / o r i m m e d i a t e l y o b s e r v a b l e b e h a v i o r o r c o n d i t i o n s t o m a i n t a i n o b j e c t i v i t y a n d v a l i d i t y a n d t o r e d u c e t h e r e l i a n c e o n ( a n d r e q u i r e m e n t f o r ) f a c i l i t y r e c o r d k e e p i n g ; CHAPTER V - 137 -- comprehensive and m u l t i d i m e n s i o n a l , and which can be aggregated i n t o a s i n g l e s c o r e f o r an i n d i v i d u a l ; - and then f u r t h e r aggregated i n t o a f a c i l i t y s c o r e ; - which can be a p p l i e d i n a p r o s p e c t i v e reimbursement system. The assessment procedure w i l l be more a c c e p t a b l e i f the d e c i s i o n makers have input i n t o the v a l u i n g / w e i g h t i n g process p r i o r to a g g r e g a t i o n , e i t h e r by a c t u a l l y p r o v i d i n g the scheme ( i . e . how the v a r i o u s a s p e c t s of the assessment are v a l u e d w i t h i n t h e i r s p e c i f i c j u r i s d i c t i o n or a b i l i t y to fund), or by i d e n t i f y i n g whose p e r s p e c t i v e s they would want c o n s i d e r e d [13; 19]. D e c i s i o n makers should a l s o i d e n t i f y the extent to which q u a l i t y of l i f e v i s a v i s f u n c t i o n a l responses to care i s to be i n c l u d e d . The most c u r r e n t and developed example of an approach which attempts to meet many of these requirements i s the one developed by Kane and Kane [13; 33]. THE KANE MODEL The Kane Model i s a s p e c i f i c attempt to develop a reimbursement method based on a c h i e v a b l e outcomes [13]. An assessment t o o l has been developed and t e s t e d which measures an i n d i v i d u a l ' s s t a t u s i n s i x domains: f u n c t i o n a l s t a t u s (ADL); p h y s i c a l h e a l t h (e.g. p a i n , b l o o d p r e s s u r e ) ; c o g n i t i v e a b i l i t y ; a f f e c t i v e s t a t e ; s o c i a l a c t i v i t i e s ; and s a t i s f a c t i o n . In the i n i t i a l t e s t i n g of the model, assessments were c a r r i e d out i n four n u r s i n g homes (which by expert o p i n i o n p r o v i d e an a c c e p t a b l e q u a l i t y of care) i n f o u r waves (one approximately every 3 months) i n which approximately 250 CHAPTER V - 138 -r e s i d e n t s a r e a s s e s s e d each t i m e . The r e s u l t s o f t h e f i r s t wave were used as t h e p r e d i c t o r v a r i a b l e s f o r the e x p e c t e d outcomes i n subsequent waves. C l i n i c a l prognoses were a l s o made d u r i n g the f i r s t wave of t e s t i n g . The Kanes s t u d y found t h a t t h e r e s u l t s (outcomes) o f p r e v i o u s assessments d i d p r e d i c t f u t u r e performance i n each s c a l e , whereas c l i n i c a l prognoses d i d n o t . C l i n i c a l p r o g n o s e s , were b e t t e r p r e d i c t o r s o f the outcomes o f "death, d i s c h a r g e home, d i s c h a r g e t o h o s p i t a l o r remain i n t h e h o s p i t a l " [ 1 3 ] . A l t h o u g h s i n g l e s c o r e s have been dev e l o p e d f o r each domain, t o d a t e t h e s e s c o r e s have not been aggregated as t h e p r o c e s s o f w e i g h t i n g t h r o u g h v a l u e a t t a c h m e n t s ( p r e f e r e n c e s ) i s not complete. The Kanes s u g g e s t t h e v a l u i n g o f an assessment t o o l w h i c h i s t o be used by f u n d e r s has two components; one i s c o n s i d e r a t i o n o f the r e s o u r c e s r e q u i r e d f o r each outcome; and the second i s t h e p r e f e r e n c e s of i n d i v i d u a l s f o r d i f f e r e n t h e a l t h s t a t e s . The Kanes s u g g e s t t h a t the f i r s t component (needed r e s o u r c e s ) can e a s i l y be e s t i m a t e d on a d i r e c t t i m e / c o s t b a s i s w h i c h would r e f l e c t , a t l e a s t i n p a r t , the f u n d e r s p e r s p e c t i v e . H e a l t h economic t h e o r y however, s u g g e s t s t h a t v a r i a t i o n i n i n p u t s , t h e p o t e n t i a l f o r v a r i a t i o n i n t e c h n i c a l e f f i c i e n c i e s , and t h e e f f e c t s of e x t e r n a l f a c t o r s (e.g. p h y s i c i a n s ' p r a c t i c e modes) can make t h i s a r a t h e r c o m p l i c a t e d p r o c e s s (as n o t e d i n the c o s t i n g a s p e c t o f the CBA/CBE approaches - Chapter 4). CHAPTER V - 139 -I n t h e Kanes s t u d y , d a t a f o r the second component ( v a l u i n g ) i s b e i n g c o l l e c t e d from r e s i d e n t s , f a m i l i e s , p r o v i d e r s , o t h e r p r o f e s s i o n a l s and government d e c i s i o n makers. To d a t e t h e r e s u l t s from t h e s e groups have shown s i m i l a r t r e n d s among a l l t h e groups e x c e p t the f a m i l y [ 3 7 ] . When v a l u i n g and w e i g h t i n g i s a v a i l a b l e , a s i n g l e a g g r e g a t e d s c o r e c o u l d be d e v e l o p e d f o r each i n d i v i d u a l . I t i s not c l e a r y e t i f b o t h the h e a l t h s t a t u s assessment r e s u l t s and the outcomes r e f e r r e d t o as complex outcomes (e.g. d e a t h , d i s c h a r g e s t a t u s ) w i l l be i n c l u d e d as one outcome, and i f s o , w i t h what t r a d e - o f f s [13; 1 4 ] . Whatever th e f u t u r e r e f i n e m e n t s i n t h e Kane model, th e i n t e n t i o n i s t h a t the " a c t u a l 1 r e s u l t s w i l l be compared w i t h t h e "expected' ( p r e d i c t e d ) r e s u l t s t o d e t e r m i n e i f t h e outcome a c h i e v e d was b e t t e r , worse o r t h e same as e x p e c t e d . By-a s s i g n i n g t h e r e s u l t a number v a l u e (e.g. b e t t e r = 1.5; worse = .5; same = 1 ) , a f o r m u l a can be d e v e l o p e d f o r reimbursement w h i c h rewards (o r p e n a l i z e s ) c a r e p r o v i d e r s on t h e b a s i s o f t h i s f o r m u l a . The Kanes c a l l the number v a l u e the P r o g n o s t i c Adjustment F a c t o r (PAF). The f o r m u l a s u g g e s t e d by t h e Kanes i s : N u r s i n g Home Payment = (Cost x P r o g n o s t i c Adjustment F a c t o r ) The c o s t r e p r e s e n t s the "average c o s t " o f c a r i n g f o r an i n d i v i d u a l i n a f a c i l i t y . The Kane s t u d y does not c l a r i f y how CHAPTER V - 140 -the base cost should be determined but r a t h e r suggests that the base c o s t can be a p p l i e d u s i n g any c u r r e n t method of determining c o s t s or r a t e s . These i n v e s t i g a t o r s f e e l that p r o s p e c t i v e reimbursement systems w i t h t h e i r a l l e g e d p o t e n t i a l f o r p r o v i d e r s to s a c r i f i c e q u a l i t y i n order to achieve e f f i c i e n c y , may be the most u s e f u l p l a c e f o r t h i s approach. Depending on how the PAF i s s e t there may be no e f f e c t on the t o t a l c o s t to a system as the adjustments w i l l average out or the c o s t s can be c o n t r o l l e d by the share of the ' t r u e ' c o s t s the funder pays. I t i s suggested that i n the long run c o s t s would f a l l t o the extent that more e f f i c i e n t p r a c t i c e s emerge i n a l e s s s t r u c t u r a l l y r e g u l a t e d environment. I t i s perhaps s u r p r i s i n g t hat t h i s study assumes that use of t h i s approach w i l l l e a d to d e - r e g u l a t i o n (or w i l l be a p p l i e d i n a d e r e g u l a t e d environment) but other s t u d i e s have f a i l e d to s u b s t a n t i a t e the c o n n e c t i o n between i n c r e a s e d c o s t s and r e g u l a t o r y requirements [3; 20]. Other e f f e c t s on the system would be dependent on how the "average c o s t " i n the formula i s d e r i v e d (e.g. whether the PAF i s t i e d to an average c o s t u s i n g v a r i a b l e , or f i x e d , or t o t a l c o s t s ) . F i g u r e 10 summarizes the pros and cons of the Kane Model as an approach which might be a p p l i e d to outcome-based reimbursement i n f a c i l i t y - b a s e d long-term care. CHAPTER V - 141 -Figure 1 0 : THE PROS & CONS OF THE KANE MODEL AS AN OUTCOME MEASUREMENT FOR FACILITY-BASED LONG-TERM CARE PROS CONS Is outcome-based and developed s p e c i f i c a l l y for long-term care; Is linked to the reimbursement system; Would work well with prospective reimbursement system, such as proposed for B.C.; Dependent on how the PAF i s set, may be no additional cost to the system; Cost may f a l l i f e f f i c i e n c i e s are achieved; Meets the s c i e n t i f i c c r i t e r i a , given the current state of the art for HSIs. How to e s t a b l i s h 'cost' may be a problem; The system may be c o s t l y to implement and monitor as i t i s currently set up (e.g. time to do assessment, professional l e v e l of assessors, and the need to e s t a b l i s h funders values); S t i l l have considerable work to do to determine the generaliz-a b i l i t y to f a c i l i t y - b a s e d long-term care i n a l l j u r i s d i c t i o n s (e.g.. i n B.C.); Potential for promoting e f f i c i e n c i e s i s not clear (assumes w i l l come with de-regulation) ; Of the outcome measurement approaches reviewed, the Kane Model appears to best meet the c r i t e r i a established for measuring effectiveness and establishing an outcome-based reimbursement approach i n f a c i l i t y - b a s e d long-term care. It has been s p e c i f i c a l l y developed for long-term care and unlike the Weissert model, does not focus on the gatekeeper problems experienced i n the United States. It would therefore be more applicable i n Canada (B.C.). The strength of t h i s approach i s the measurement of the effectiveness side where the use of a multiattribute Health Status Index within the prognostic model CHAPTER V - 142 -allow s i t , t o g i v e c r e d i t f o r outcomes other than "improved h e a l t h s t a t u s " . The assumptions r e l a t e d to the co s t data and the s u p e r f i c i a l treatment of that aspect i n the model c o u l d be a problem i n d e v e l o p i n g the reimbursement component. Recommendation: That the f u n c t i o n a l assessment t o o l , based on a p r o g n o s t i c f a c t o r formula as developed by the Kanes, be g i v e n s e r i o u s c o n s i d e r a t i o n f o r use, a t l e a s t i n the e f f e c t i v e n e s s p a r t of a reimbursement formula f o r long-term f a c i l i t y c a re, and that f u r t h e r e m p i r i c a l t e s t i n g be done u s i n g t h i s or s i m i l a r assessment t o o l s i n a number of f a c i l i t y types ( s i z e , p r o v i d e r , l o c a t i o n , care l e v e l s ) to determine the g e n e r a l i z a b i l i t y of the assessment process based on an expected versus a c t u a l outcome approach. THE CONVERGENCE MODEL Although the pr e c e d i n g approaches are presented as examples of e i t h e r o r g a n i z a t i o n a l l e v e l or i n d i v i d u a l l e v e l approaches, each i n f a c t has i t s b a s i s i n both, or as Baker and Woy suggest the two approaches are converging [38; 39]. They i l l u s t r a t e t h i s concept by c o n s i d e r i n g the approaches used f o r i n d i v i d u a l l e v e l ( Q u a l i t y Assurance) and o r g a n i z a t i o n a l l e v e l (Program E v a l u a t i o n ) outcome measurement [38; 39]. With i n c r e a s i n g p r e s s u r e f o r a c c o u n t a b i l i t y from a l l s i d e s , Baker suggests there should be a planned movement towards convergence u s i n g a common conceptual framework which encourages an i n t e r a c t i o n of the s k i l l s and p e r s p e c t i v e s from each approach, and which develops and uses a common data base. He c a l l s such an approach "an i n t e g r a t e d program m o n i t o r i n g system" [38:157-59]. Goldberg [35:278-87] a l s o p r e s e n t s m o n i t o r i n g as an approach which can be used f o r both a c c o u n t a b i l i t y and e v a l u a t i o n . Such an approach on the one hand p r o v i d e s CHAPTER V - 143 -di s a g g r e g a t e d data as feedback to i n d i v i d u a l p r o v i d e r s or s m a l l groups, e n a b l i n g them to e v a l u a t e t h e i r own work and to document trends, w hile at the same time p r o v i d i n g aggregate data f o r p o l i c y d e c i s i o n makers which meets t h e i r p l a n n i n g , management and a c c o u n t a b i l i t y requirements. While d i s c u s s i n g i t s use i n community s o c i a l s e r v i c e s , Goldberg suggests such m o n i t o r i n g should be used f o r r e s i d e n t i a l care s e r v i c e s as w e l l [35:287]. In t h i s l i g h t , we can view approaches such as the proposed Kane model as a movement towards B a k e r 1 s convergence model s i n c e i t begins w i t h c l i e n t c entered data on f u n c t i o n a l s t a t u s , adds data about more g e n e r a l outcomes such as death and d i s c h a r g e p a t t e r n s , and attempts to aggregate the data to p r o v i d e some form of o r g a n i z a t i o n a l outcome data. Such data c o u l d be used i n a d i s a g g r e g a t e d form f o r q u a l i t y assurance f u n c t i o n s , or i n an aggregated form f o r program e v a l u a t i o n or as an a c c o u n t a b i l i t y measure f o r use i n e f f e c t i v e n e s s measurement and an outcome-based reimbursement system. Comparative analyses u s i n g l o n g i t u d i n a l a n a l y s i s to compare present w i t h past performance ( l i n k e d to a payment system i f d e s i r e d ) c o u l d be e s t a b l i s h e d or c r o s s - s e c t i o n a l a n a l y s i s c o u l d be used to compare the r e s u l t s among groups of p r o v i d e r s [10; 16; 17:342-43]. A l l of these p o s s i b l e outcome measurements are dependent on the o p e r a t i o n a l and a c c o u n t a b i l i t y g o a l s that are e s t a b l i s h e d . CHAPTER V - 144 -CONCLUSION T h i s chapter has co n s i d e r e d the s p e c i f i c models and approaches used (or proposed) f o r outcome assessment i n f a c i l i t y - b a s e d long-term care. The long-term care s e c t o r has reaped both p o s i t i v e and ne g a t i v e b e n e f i t s from the experience w i t h outcome measurement i n the acute care s e c t o r of the h e a l t h care i n d u s t r y . The f o l l o w i n g are some of the problems which have been noted i n the c u r r e n t approaches which would a f f e c t the f e a s i b i l i t y f o r use i n an outcome-based reimbursement system i n f a c i l i t y - b a s e d long-term care: - assessment g o a l s and o b j e c t i v e s which are not c l e a r l y i d e n t i f i e d , or a t l e a s t not from a funding p e r s p e c t i v e , as w e l l as the f a c t t h a t most o b j e c t i v e s f o r long-term care i d e n t i f y independence as an important g o a l of care, yet most measurement t o o l s measure l e v e l s or asp e c t s of dependence; and - c o n f l i c t or c o n f u s i o n over the d e f i n i t i o n of outcome, that i s should o r g a n i z a t i o n a l l e v e l measures be co n s i d e r e d i n p u t s , outputs, outcomes or i n t e r m e d i a t e outcomes, or should outcomes be a measure of what happens to i n d i v i d u a l r e c i p i e n t s of care, or both? - and i f outcomes are measured at the i n d i v i d u a l r e c i p i e n t l e v e l , t here are problems about what t o measure which w i l l r e f l e c t the outcomes of care (given the mu l t i d i m e n s i o n a l nature of most f a c i l i t y r e s i d e n t s ' problems) or the q u a l i t y of l i f e ( given the f a c t t h a t i n s t i t u t i o n a l placement r e p r e s e n t s a permanent l i v i n g s i t u a t i o n ) ; - v a l i d i t y and g e n e r a l i z a b i l i t y continue to be concerns, along w i t h the problems a s s o c i a t e d w i t h v a l u e weighting and the a g g r e g a t i o n of the m u l t i p l e measurements i n v o l v e d ; or the f u r t h e r a g g r e g a t i o n of the i n d i v i d u a l s c o r e s to rep r e s e n t the o v e r a l l r e s u l t s f o r a f a c i l i t y ; - t h a t a p a r t i c u l a r l y important aspect of v a l u i n g i s determ i n i n g the funders p e r s p e c t i v e about what they wish to support. CHAPTER V - 145 -Some of t h e s e problems c o u l d be a d d r e s s e d by c l a r i f y i n g t h e program's g o a l s and o b j e c t i v e s . D e c i s i o n s must a l s o be made about what l e v e l s o f achievement and/or c o m b i n a t i o n s of outcomes w i l l p r o v i d e t h e i n f o r m a t i o n about whether the g o a l s and o b j e c t i v e s have been met. Other problems a r e more r e l a t e d t o e s t a b l i s h i n g the s c i e n t i f i c c r e d i b i l i t y o f t h e outcome measurement t o o l s . T h i s i s i m p r o v i n g , but w i l l r e q u i r e more r e s e a r c h and more p a r t i c u l a r l y , more e m p i r i c a l t e s t i n g . I n t h i s r e g a r d , the d e v e l o p m e n t a l work done by t h e Kanes [13; 3 3 ] , the c o m p a r a t i v e work done by W e i s s e l as d e s c r i b e d by Kurow s k i and Shaughnessy [34:130-31), and Zimmer [ 1 7 ] , and t h e W e i s s e r t e t a l d e m o n s t r a t i o n p r o j e c t under way i n C a l i f o r n i a [18] as w e l l as the d i r e c t i o n p r o v i d e d by Bergner [40; 4 1 ] , and B o y l e and T o r r a n c e [42] i n h e a l t h s t a t u s measurement a r e a l l i m p o r t a n t s t e p s i n t h e attempt t o a d d r e s s b o t h t h e s c i e n t i f i c and a c c o u n t a b i l i t y i s s u e s from the f u n d e r s p e r s p e c t i v e . F u r t h e r r e s e a r c h i n t h i s a r e a s h o u l d r e s o l v e t h e q u e s t i o n s about t h e p o t e n t i a l f o r outcome-based measurement o f e f f e c t i v e n e s s and the r e s u l t i n g p o t e n t i a l f o r outcome-based reimbursement i n f a c i l i t y -based l o n g - t e r m c a r e . Some o f t h e l a t e r work i n l o n g - t e r m c a r e has a l s o a t t e m p t e d t o l i n k outcome measures o f e f f e c t i v e n e s s t o reimbursement, g i v e n t h e gro w i n g p r e s s u r e f o r a c c o u n t a b i l i t y i n a s s u r i n g b o t h the adequacy o f t h e c a r e p r o v i d e d ( e f f e c t i v e n e s s ) and the e f f i c i e n t use o f the funds expended f o r t h e p r o v i s i o n o f t h a t c a r e . What i s seen i n a l l i n s t a n c e s i s t h a t the measurement o f CHAPTER V - 146 -e f f e c t i v e n e s s must be i n p l a c e i n order to a pply a reimbursement scheme. With the e x c e p t i o n of Weissert et a l , the reimbursement s i d e appears l e s s w e l l developed than the e f f e c t i v e n e s s measurement s i d e . However, even w i t h Weissert the system problems t h a t formed the b a s i s of t h i s approach - p r o v i d e r s as gatekeepers - are much l e s s pronounced and/or have d i f f e r e n t u n d e r l y i n g causes i n B r i t i s h Columbia, making some asp e c t s of t h i s approach i n a p p r o p r i a t e . A more g l o b a l approach to e f f e c t i v e n e s s measurement i s needed i n the B r i t i s h Columbia system. In the Kane model, the e f f e c t i v e n e s s measures were q u i t e w e l l developed but l i m i t e d a t t e n t i o n was g i v e n to the payment s i d e . I t would appear that as Schlenker and Shaughnessy suggest, " i t may not [yet] be a p p r o p r i a t e to l i n k q u a l i t y [ e f f e c t i v e n e s s ] d i r e c t l y i n reimbursement" [24:61]. F i n a l l y , n o t w i t h s t a n d i n g the above concerns, there i s the q u e s t i o n of whether making i m p l i c i t v a l u e s and e x p e c t a t i o n s e x p l i c i t through an outcome measurement process i s a c c e p t a b l e or workable i n the l a r g e r p o l i t i c a l d e c i s i o n making arena. Can or should government meet the r i s i n g e x p e c t a t i o n f o r e x p l i c i t p u b l i c a c c o u n t a b i l i t y ? CHAPTER V - 147 -From t h i s Chapter one sees t h a t the p r o g r e s s towards f e a s i b l e outcome measurement approaches f o r use i n f a c i l i t y - b a s e d l o n g - t e r m c a r e has been c o n s i d e r a b l e . There a r e , however, s t i l l some problem a r e a s t o be r e s o l v e d , the f i r s t b e i n g the d e s i g n and methods i s s u e s i n t h e measurement approaches, w h i l e o t h e r s r e l a t e more t o t h e f e a s i b i l i t y a s p e c t s of a p p l i c a t i o n w i t h i n t h e p u b l i c and p o l i t i c a l environment. On the a s s u m p t i o n t h a t the s c i e n t i f i c problems w i l l , i n t i m e , be r e s o l v e d t h e f o l l o w i n g c h a p t e r e x p l o r e s the c o n d i t i o n s under w h i c h a outcome-based measures o f e f f e c t i v e n e s s may be a p p l i e d i n B r i t i s h Columbia. Chapter V - 148 -REFERENCES 1. T a f t , C y n t h i a , and Levine, S o l . "Problems of F e d e r a l P o l i c i e s and S t r a t e g i e s to I n f l u e n c e the Q u a l i t y of Care." In Q u a l i t y Assurance i n H e a l t h Care, pp.31-57. E d i t e d by R i c h a r d Egdahl and Paul Gertman. 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Boyle, Michael H. and Torrance, George W. "Developing M u l t i a t t r i b u t e H e a l t h Indexes." Medical Care. 22 (November 1985):1045-1057. C H A P T E R V I : M E A S U R I N G E F F E C T I V E N E S S I N F A C I L I T Y - B A S E D L O N G -T E R M C A R E : A N O U T C O M E - B A S E D P R O P O S A L F O R B R I T I S H C O L U M B I A I N T R O D U C T I O N The o v e r r i d i n g theme noted i n the l i t e r a t u r e r e v i e w e d i n t h i s s t u d y i s t h e need f o r a c c o u n t a b i l i t y . I t pervades a l l s e c t o r s of i n d u s t r y - p r i v a t e , p u b l i c , a c u t e and l o n g - t e r m h e a l t h c a r e . I n c r e a s i n g l y managers seek approaches t h a t w i l l s a t i s f y t h e need of e x t e r n a l f u n d e r s ( s h a r e h o l d e r s , government f u n d e r s , t a x p a y e r s ) t o ensure t h a t t h e funds expended on t h e i r b e h a l f have been managed e f f e c t i v e l y and e f f i c i e n t l y . I n i t i a l l y t h e s e approaches were h e a v i l y w e i g h t e d towards e f f e c t i v e n e s s ( q u a l i t y ) but l a t e r t h e i n c l u s i o n o f e f f i c i e n c y measures ( c o s t c o n t r o l ) was promoted. The c o n n e c t i o n , i f any, made between t h e s e two a s p e c t s of management was o f t e n tenuous i n t h e l i t e r a t u r e r e v i e w e d and i l l u s t r a t i o n o f e f f i c i e n c y measures was l i m i t e d . Yet t h e r e i s c o n t i n u e d e x t e r n a l p r e s s u r e on a l l s e c t o r s t o show a c c o u n t a b i l i t y f o r b o t h . The p r e s s u r e f o r a c c o u n t a b i l i t y has become i n c r e a s i n g l y s t r o n g i n the p u b l i c s e c t o r , p a r t i c u l a r l y i n h e a l t h c a r e . The n a t i o n a l commitment i n Canada t o a u n i v e r s a l h e a l t h i n s u r a n c e system w h i c h i s p u b l i c l y funded and a d m i n i s t e r e d draws i n c r e a s i n g p u b l i c a t t e n t i o n when h e a l t h c a r e e x p e n d i t u r e s make up a major p o r t i o n of a p r o v i n c i a l budget [ 1 ; 2; 3 ] . A c c o u n t a b i l i t y i n f a c i l i t y - b a s e d l o n g - t e r m c a r e i n B r i t i s h C olumbia (B.C.) i s b e g i n n i n g t o c o a l e s c e as t h e t r a d i t i o n a l r o l e s o f government f o r r e g u l a t i o n and f u n d i n g have begun t o move c l o s e r t o g e t h e r . R e s p o n s i b i l i t y f o r r e g u l a t i o n , program development and f u n d i n g a r e now a l l r e s p o n s i b i l i t i e s of the M i n i s t r y of H e a l t h . S i n c e the i n c e p t i o n of the Long-Term Care Chapter VI - 153 -Program i n 1978 the development of q u a l i t y of care standards which would promote e f f e c t i v e n e s s and an i n t e g r a t e d approach to reimbursement (with e f f i c i e n c y as one goal) have been ongoing concerns [4; 5; 6; 7]. As t h i s study progressed, i t became c l e a r that e f f e c t i v e n e s s measures must be developed and the impact of e f f e c t i v e n e s s on e f f i c i e n c y determined be f o r e a l i n k to reimbursement c o u l d be made. T h i s chapter proposes an o u t c o m e -b a s e d a p p r o a c h to the m e a s u r e m e n t of the e f f e c t i v e n e s s of f a c i l i t y - b a s e d l o n g - t e r m c a r e i n B r i t i s h C o l u m b i a . The p r o p o s a l p r o v i d e s funders i n B r i t i s h Columbia w i t h an a c c o u n t a b i l i t y approach to ensure that an adequate q u a l i t y of care i s p r o v i d e d ( e f f e c t i v e n e s s ) and i n c l u d e s some d i s c u s s i o n about the r e l a t i o n s h i p of these e f f e c t i v e n e s s measures to e f f i c i e n c y . C O M P O N E N T S O F E F F E C T I V E N E S S I N F A C I L I T Y - B A S E D L O N G - T E R M C A R E : HOW A R E T H E Y M E T I N B R I T I S H C O L U M B I A ? In t h i s study i t i s assumed that the three components of e f f e c t i v e n e s s i n f a c i l i t y - b a s e d long-term care: a body of knowledge which assures e f f i c a c y ; a p p r o p r i a t e r e s o u r c e s ; and a p p r o p r i a t e placement are s u f f i c i e n t l y i n p l a c e the long-term care system i n B r i t i s h Columbia to make p o s s i b l e the measurement of e f f e c t i v e n e s s . T h i s assumption i s based on the f o l l o w i n g f a c t o r s . Body of Knowledge: - A c c r e d i t a t i o n and other q u a l i t y assurance standards which have been e s t a b l i s h e d f o r long-term care f a c i l i t i e s i n Canada [8; 9] and the r a p i d l y i n c r e a s i n g amount of r e s e a r c h and experience i n gero n t o l o g y and g e r i a t r i c s , p r o v i d e a growing body of knowledge about how to meet the care needs of r e s i d e n t s of long-term care f a c i l i t i e s . Chapter VI - 154 -- The three major u n i v e r s i t i e s i n B.C. support r e s e a r c h d i r e c t e d towards f a c i l i t y care and there are a l s o numerous t r a i n i n g and e d u c a t i o n programs o f f e r e d s p e c i f i c a l l y f o r p r o f e s s i o n a l and a u x i l i a r y s t a f f p r o v i d i n g care i n long-term care f a c i l i t i e s [10]. - The i n c r e a s i n g l o n g e v i t y and l e n g t h of s t a y of r e s i d e n t s i n long-term care f a c i l i t i e s may a l s o be i n d i c a t i v e of the i n c r e a s i n g understanding and c a p a b i l i t y of f a c i l i t i e s to p r o v i d e e f f e c t i v e care [11]. F a c i l i t y Resources - L e g i s l a t i v e r e g u l a t i o n s , program standards and funding a l l o c a t i o n s i n B. C. a l l r e c o g n i z e that r e s i d e n t s r e q u i r e d i f f e r e n t l e v e l s of care and that r e s o u r c e s must be a l l o c a t e d d i f f e r e n t l y based on the l e v e l of care r e q u i r e d [12; 13; 14]. - As a r e s i d e n t ' s l e v e l of dependency i n c r e a s e s there a re d i f f e r e n t ( u s u a l l y more) s t a f f i n g r esources a l l o c a t e d to pr o v i d e that care adequately [4; 15; 16]. Ap p r o p r i a t e Placement of C l i e n t s : - The s i n g l e p o i n t of e n t r y a l l o w s the program to l i m i t a ccess to the system to o n l y those r e s i d e n t s of B r i t i s h Columbia i n need of ca r e . At the p o i n t of e n t r y the a p p l i c a n t i s assessed as to what type and l e v e l of care i s needed, i f any, and then r e f e r r a l i s made to the a p p r o p r i a t e community support s e r v i c e or long-term care f a c i l i t y . Emphasis i s on care i n the home (where p o s s i b l e ) so t h a t o n l y those i n need of i n s t i t u t i o n a l care are r e f e r r e d to a long-term care f a c i l i t y [12; 13], - The esta b l i s h m e n t of the f i v e l e v e l s of long-term care: P e r s o n a l Care (P.C.), three l e v e l s of Intermediate Care (IC) and Extended (EC) al l o w s f o r a continuum of placement o p t i o n s [12; 13; 14]. - One i n d i c a t o r t h a t the c u r r e n t assessment process i s p r o v i d i n g a p p r o p r i a t e placements i s a r e d u c t i o n i n the placement of persons at the PC l e v e l of care i n t o f a c i l i t i e s and the r e s u l t i n g i n c r e a s e i n the p r o p o r t i o n of persons a t the higher Intermediate and Extended Care l e v e l s . I t i s f e l t t h a t , f o r the most p a r t , the former (PC l e v e l c l i e n t s ) can be maintained w i t h home and community supports and that f a c i l i t y care i s a p p r o p r i a t e o n l y f o r persons r e q u i r i n g Intermediate or Extended Care [17] • Chapter VI - 155 -However a word o f c a u t i o n about t h e r e l i a b i l i t y o f t h e c u r r e n t placement p r o c e s s must be r a i s e d . A t e s t o f r e l i a b i l i t y o f c a r e d e c i s i o n s f o r a s s e s s i n g l e v e l s o f c a r e i n t h e B r i t i s h C olumbia system completed i n 1978 showed " e x c e l l e n t " r e l i a b i l i t y f o r placement d e c i s i o n s a t the PC and EC l e v e l s but o n l y " f a i r " f o r the IC l e v e l s [ 1 8:9-10]. These r e s u l t s s u ggest p o t e n t i a l problems i n the assessment o f e f f e c t i v e n e s s i f i t can not be assumed t h a t the r i g h t c l i e n t i s i n the r i g h t p l a c e . A number o f s t u d i e s i n o t h e r j u r i s d i c t i o n s have a l s o n o t e d problems w i t h i n a p p r o p r i a t e placements [18:3; 19:38-39]. T h i s may be l e s s o f a problem i n B r i t i s h Columbia, g i v e n more e x p e r i e n c e w i t h the program. Or, a b e t t e r assessment t o o l may be r e q u i r e d (e.g. m u l t i a t t r i b u t e H e a l t h S t a t u s I n d e x ) . R e l i a b i l i t y t e s t i n g o f the c u r r e n t placement assessment t o o l s h o u l d be r e p e a t e d p r i o r t o f u l l i m p l e m e n t a t i o n o f an outcome-based e f f e c t i v e n e s s measurement approach. N o t w i t h s t a n d i n g t h e s e q u a l i f i c a t i o n s , t he components f o r e f f e c t i v e f a c i l i t y - b a s e d l o n g - t e r m c a r e a r e i n p l a c e i n B.C., but t h e measurement o f e f f e c t i v e n e s s , p a r t i c u l a r l y from an outcome-based p e r s p e c t i v e i s n o t . AN OUTCOME-BASED APPROACH TO THE MEASUREMENT OF EFFECTIVENESS IN FACILITY-BASED LONG-TERM CARE IN BRITISH COLUMBIA G i v e n t h e d i r e c t i o n of t h e new i n t e g r a t e d reimbursement system f o r t h e f a c i l i t y - b a s e d l o n g - t e r m c a r e i n B r i t i s h Columbia and t h e i n t e n t t o d e v e l o p and a p p l y q u a l i t y o f c a r e s t a n d a r d s , i t would seem the time i s r i g h t t o c o n s i d e r moving towards the Chapter VI - 156 -goal that at l e a s t p a r t of the reimbursement w i l l be based on measures of e f f e c t i v e n e s s and e f f i c i e n c y . A f i r s t and necessary s t e p towards that goal i s to e s t a b l i s h outcome measures of e f f e c t i v e n e s s . The f o l l o w i n g s e c t i o n s present the elements c o n s i d e r e d necessary to develop and implement an outcome-based approach to the measurement of e f f e c t i v e n e s s i n f a c i l i t y - b a s e d long-term care i n B r i t i s h Columbia. Using the "expected versus a c t u a l outcome model", the development and implementation of such an approach would i n c l u d e the f o l l o w i n g s t e p s : 1. I d e n t i f y i n g the r e l e v a n t v a l u e s and assumptions about f a c i l i t y - b a s e d long-term care i n B.C. and c o n f i r m i n g and/or s e t t i n g program g o a l s and o b j e c t i v e s f o r e f f e c t i v e n e s s ; 2. D e v i s i n g an outcome measurement approach and e s t a b l i s h i n g a p r o t o c o l f o r measuring the outcomes of care; 3. A p p l y i n g the r e s u l t s of the outcome measure i n the m o n i t o r i n g and e v a l u a t i o n of the e f f e c t i v e n e s s of the care p r o v i d e d by f a c i l i t i e s ; and/or Ap p l y i n g the outcome r e s u l t s i n e f f i c i e n c y s t u d i e s ; and/or A p p l y i n g the outcome r e s u l t s i n a reimbursement formula once the r e l a t i o n s h i p between e f f e c t i v e n e s s and e f f i c i e n c y has been e s t a b l i s h e d . B u i l d i n g on the known f e a t u r e s of the c u r r e n t system, the f o l l o w i n g s e c t i o n s d e s c r i b e how these steps might be a t t a i n e d i n i n B r i t i s h Columbia. Chapter VI - 157 -1 . IDENTIFYING THE RELEVANT VALUES, ASSUMPTIONS, GOALS AND OBJECTIVES The o v e r a l l o b j e c t i v e of f a c i l i t y - b a s e d long-term care i n B r i t i s h Columbia i s to promote or maintain the independence of i n d i v i d u a l s , to the extent p o s s i b l e , g i v e n the h e a l t h - r e l a t e d problems f o r which they r e q u i r e care [11; 12]. I t would seem that e f f e c t i v e n e s s t h e r e f o r e should be measured i n terms of how w e l l the i n d i v i d u a l ' s h e a l t h s t a t u s i s maintained, based on a p r e d i c t i o n of what c o u l d be expected g i v e n h i s / h e r unique combination of problems, and assuming that adequate care i s r e c e i v e d . T h i s p r o p o s a l f o r the measurement of e f f e c t i v e n e s s i n f a c i l i t y - b a s e d long-term care i n B r i t i s h Columbia i s based on the f o l l o w i n g v a l u e s and assumptions: - that the C o n t i n u i n g Care Program w i l l continue to have a s i n g l e p o i n t of e n t r y f o r b e n e f i c i a r i e s of long-term care, p r o v i d i n g a continuum of care o p t i o n s to meet h e a l t h care and s o c i a l support needs; - that the C o n t i n u i n g Care Program w i l l c o n t r o l access through a needs assessment and admission of o n l y those i n need of care; - that the f a c i l i t y - b a s e d s e c t o r of the long-term care system w i l l continue to be p u b l i c l y a d m i n i s t e r e d and funded by government; - that i n d e v e l o p i n g the r e v i s e d standards of care f o r long-term care f a c i l i t i e s , outcome standards w i l l be i n c l u d e d ; - t hat government w i l l continue to support a mixed p r o v i d e r system of f o r - p r o f i t and n o n - p r o f i t p r o v i d e r s , and that there w i l l be o n l y one system of reimbursement f o r both types of p r o v i d e r s . Chapter VI - 158 -P r i o r to embarking on an outcome-based approach to the measurement of e f f e c t i v e n e s s , these v a l u e s and assumptions should be re-confirmed a g a i n s t the e x i s t i n g s i t u a t i o n . As t h i s study sees i t , the f o l l o w i n g should be the four major g o a l s f o r the Long-Term Care Program i n B r i t i s h Columbia and which an outcome-based approach to the measurement of e f f e c t i v e n e s s i n f a c i l i t y - b a s e d must support: "PROPOSED" PROGRAM GOALS 1. To fund f a c i l i t y care o n l y f o r those i n need of i t , w i t h the o b j e c t i v e of f a c i l i t y care being the promotion of independence to the extent p o s s i b l e g i v e n the l i m i t a t i o n s of the i n d i v i d u a l and the f a c i l i t y s e t t i n g ; 2. To ensure adequate care i s provided; 3. To ensure optimum use of the funds a l l o c a t e d f o r f a c i l i t y - b a s e d long-term care ; 4. To ma i n t a i n an arms-length r e l a t i o n s h i p with the p r o v i d e r s of f a c i l i t y - b a s e d long-term care. Goals 2 and 4 cou l d , at l e a s t i n p a r t , be accomplished through an outcome-based approach which determines e f f e c t i v e n e s s . The f o l l o w i n g are "proposed" program o b j e c t i v e s which i d e n t i f y how, as t h i s study sees i t , these g o a l s might be achieved. "PROPOSED" PROGRAM OBJECTIVES 1. To c o n t r o l e n t r y to the program through assessment and admission of i n d i v i d u a l s to the most a p p r o p r i a t e s e r v i c e s , g i v i n g f i r s t c o n s i d e r a t i o n to home based supports and s e r v i c e s (supports Goal 1 as e f f e c t i v e n e s s i s dependent on a p p r o p r i a t e placement). Chapter VI - 159 -2. To monitor and fund the care p r o v i d e d by f a c i l i t i e s through a system which al l o w s p r o v i d e r s to determine how they w i l l p r o v i d e care (with the e x c e p t i o n of meeting some s a f e t y s t a n d a r d s ) , but that r e q u i r e s them to demonstrate the e f f e c t ( r e s u l t s ) of the care p r o v i d e d , that i s what outcomes are achieved (meets Goal 2 & 4); 3. More s p e c i f i c a l l y , to measure the effectiveness of the care p r o v i d e d at each of the f i v e l e v e l s of care, based on e s t a b l i s h e d (expected) e f f e c t i v e n e s s outcomes, u s i n g a p r o g n o s t i c or p r e d i c t o r model which r a t e s achievement (outcomes) on whether the a c t u a l outcomes were B e t t e r , the Same or Worse than the p r e d i c t e d outcome (meets Goal 2). Once e f f e c t i v e n e s s measures had been implemented other outcome r e l a t e d g o a l s might i n c l u d e : 4. To measure the c o s t - e f f e c t i v e n e s s and e f f i c i e n c y w i t h which funds are expended to p r o v i d e care (meets Goal 3) ; 5. To e s t a b l i s h an outcome-based reimbursement system which r e c o g n i z e s the extent to which expected outcomes are met and uses the r e s u l t s to determine the t o t a l reimbursement p a i d or to determine an i n c e n t i v e reimbursement which motivates p r o v i d e r s to meet the , e f f e c t i v e n e s s and e f f i c i e n c y standards e s t a b l i s h e d (meets Goal 2 and 3). 2. D E V I S I N G A N O U T C O M E - B A S E D E F F E C T I V E N E S S M E A S U R E M E N T A P P R O A C H Methodology and f e a s i b i l i t y i s s u e s f o r outcome measurement approaches as they have been developed to date were noted i n Chapters Three, Four and F i v e . D e s p i t e some of the concerns noted, there i s an i n c r e a s i n g r e c o g n i t i o n of the need f o r comprehensive and aggregated h e a l t h s t a t u s indexes f o r use by h e a l t h care r e s e a r c h e r s , and h e a l t h p l a n n i n g and p o l i c y a n a l y s t s which i s encouraging [20:702-03; 21:706]. The Kanes 1 outcome-based model (reviewed i n Chapter F i v e ) i s an attempt to meet t h i s need i n long-term care and the experiment conducted i n C a l i f o r n i a , u s i n g that model should p r o v i d e some answers to the Chapter VI - 160 -f e a s i b i l i t y and implementation concerns [22; 24]. F u r t h e r refinements i n the use of the m u l t i a t t r i b u t e assessment t o o l s developed f o r by the Kanes and i n Bergner's Sickness Impact P r o f i l e (SIP) i l l u s t r a t e attempts to overcome these concerns [24; 25]. The progress i n the development and use of m u l t i a t t r i b u t e H e a l t h Status Indexes appears to be s u f f i c i e n t f o r t h i s i n v e s t i g a t i o n to recommend that the M i n i s t r y of H e a l t h i n B r i t i s h Columbia begin to develop an outcome-based approach to the measurement of e f f e c t i v e n e s s of the care p r o v i d e d i n l o n g -term care f a c i l i t i e s . The development (or s e l e c t i o n ) of an e f f e c t i v e n e s s measurement t o o l c o u l d proceed as p a r t of the development of q u a l i t y of care standards which are to be t e s t e d i n the near f u t u r e i n B r i t i s h Columbia [ 7 ] . T H E PROPOSED MODEL As noted i n Chapter F i v e , the h e t e r o g e n e i t y of the r e s i d e n t s of long-term care f a c i l i t i e s , and the complexity of the h e a l t h - r e l a t e d problems experienced by r e s i d e n t s makes a h e a l t h s t a t u s measurement approach based on an e x p e c t a t i o n of improved h e a l t h s t a t u s u n s u i t a b l e . T h i s study t h e r e f o r e proposes that a p r e d i c t o r or p r o g n o s t i c assessment model, which can accommodate outcomes other than improved h e a l t h , be used to measure e f f e c t i v e n e s s a t the i n d i v i d u a l c l i e n t l e v e l i n f a c i l i t y - b a s e d long-term care i n B r i t i s h Columbia. Chapter VI - 161 -To do t h i s , assessment data from a m u l t i a t t r i b u t e H e a l t h S t a t u s Index would be used to c a l c u l a t e an expected outcome f o r each r e s i d e n t . The expected outcome would then be compared w i t h the a c t u a l outcome as assessed at the next p o i n t i n time. The r e s u l t of the comparison would p r o v i d e the l e v e l of ac h i e v e d e f f e c t i v e n e s s f o r that r e s i d e n t [22]. .To o b t a i n a s i n g l e numeric value f o r these comparisons of the outcomes of e f f e c t i v e n e s s f o r each r e s i d e n t , the a t t r i b u t e areas measured must be value-weighted p r i o r to t h e i r a g g r e g a t i o n . The aggregated numeric r e s u l t s can then be used to determine whether the outcome f o r an i n d i v i d u a l r e s i d e n t was B e t t e r , Worse or the Same as Expected ( p r e d i c t e d ) . These p r e d i c t o r s c o r e s , a t t a i n e d f o r the i n d i v i d u a l s assessed a t each of the f i v e l e v e l s of care (PC through to EC), c o u l d then be aggregated. T h i s would p r o v i d e a f a c i l i t y - l e v e l ( o r g a n i z a t i o n a l ) e f f e c t i v e n e s s outcome s c o r e f o r each l e v e l of care p r o v i d e d by a f a c i l i t y . These aggregated f a c i l i t y s c o r e s c o u l d then be used f o r comparison a c r o s s time and amongst groups of f a c i l i t i e s . The p r o g n o s t i c model developed by the Kanes i s an example of what i s needed i n t h i s type of approach [22; 24]. The use of a p r e d i c t o r model approach would a l l o w c o n s i d e r a t i o n of the range of p o t e n t i a l outcomes that may occur amongst long-term care r e s i d e n t s r a t h e r than a more l i m i t e d focus which uses l e v e l s of f u n c t i o n a l dependency [26], or di s c h a r g e outcomes/mortality [22; 24; 27], or the outcomes of a l i m i t e d s e t of h e a l t h care problems common to r e s i d e n t s of lon g -Chapter VI - 162 -term care f a c i l i t i e s [26; 28]. Options such as the l a t t e r two may be u s e f u l i n determining u n d e r l y i n g causes i f an adequate l e v e l of e f f e c t i v e n e s s i s not achieved. SELECTION AND DEVELOPMENT of an EFFECTIVENESS MEASURE The f o l l o w i n g s t e p s would be r e q u i r e d to develop and implement the outcome-based e f f e c t i v e n e s s measures. I t i s suggested that a l l these i n i t i a l phases be completed as a j o i n t h e a l t h s e r v i c e s r e s e a r c h and c l i n i c a l a p p l i c a t i o n approach, that i s , u s i n g a demonstration p r o j e c t approach. The f i r s t s t e p would be to s e l e c t a m u l t i a t t r i b u t e h e a l t h s t a t u s measurement instrument f o r use w i t h i n the p r e d i c t o r model. For i n s t a n c e , the m u l t i a t t r i b u t e t o o l developed by the Kanes [22; 24] may be a p p r o p r i a t e f o r a p p l i c a t i o n i n B r i t i s h Columbia, but other instruments, such as the Sickness Impact P r o f i l e (SIP) [29] may be as a p p r o p r i a t e . In order to make the s e l e c t i o n , a normative process u s i n g expert r e p r e s e n t a t i v e s from p r o v i d e r s groups and other h e a l t h p r o f e s s i o n a l s and e m p i r i c a l t e s t i n g i n f a c i l i t i e s w i l l be r e q u i r e d . B e r g n e r 1 s f i v e dimensions of a H e a l t h Status Index should be co n s i d e r e d as a guide f o r s e l e c t i o n to ensure that the instrument has s u f f i c i e n t scope [20]. More s p e c i f i c a l l y , normative means should be used to s e l e c t the a t t r i b u t e s to be measured and to develop the instrument. Once t h i s i s completed, comparative means should be used to t e s t the instrument f o r v a l i d i t y and r e l i a b i l i t y , and to e s t a b l i s h the expected outcomes. Chapter VI - 163 -I t i s important to s e l e c t a t t r i b u t e s which d u r i n g the s c a l i n g and a g g r e g a t i o n process can be d e f i n e d i n t o l e v e l s ( i . e . which r e f l e c t a stepwise p r o g r e s s i o n f o r each a t t r i b u t e between good and poor h e a l t h or f u n c t i o n i n g ) [30]. T h i s p r o g r e s s i o n may a l s o become v e r y important l a t e r , when a p p l y i n g the index a t the f i v e l e v e l s of c a r e . For i n s t a n c e , i f a r e s i d e n t ' s h e a l t h s t a t u s i s at the f i r s t (good h e a l t h ) s t e p , f u r t h e r assessment would not be r e q u i r e d . T h i s would reduce the time needed f o r assessment and/or f o r a g g r e g a t i o n a c t i v i t i e s . An i n t e r m e d i a t e process may a l s o be r e q u i r e d to reduce the amount of data to be c o n s i d e r e d (and assessment time) b e f o r e s c a l i n g the instrument f o r a g g r e g a t i o n [30]. Boyle and Torrance suggest two ways to approach data r e d u c t i o n : one i s to i d e n t i f y and e l i m i n a t e those a t t r i b u t e s which are c o n s i d e r e d unimportant to l i f e q u a l i t y . The other i s to combine a t t r i b u t e s which are c o n c e p t u a l l y r e l a t e d [30:1049]. Boyle and Torrance c a u t i o n that "data r e d u c t i o n by f a c t o r a n a l y s i s i s not a s u i t a b l e way of t e s t i n g f o r ordered responses and should not be used to reduce the number of a t t r i b u t e s . " [30:1059]. In f a c t o r a n a l y s i s the s o l u t i o n s depend on c o v a r i a t i o n or o r d e r i n g , and might r e s u l t i n e l i m i n a t i o n of r a r e l y o c c u r r i n g items which are important i n d i c a t o r s of good or poor h e a l t h [30:1059). S i m i l a r concerns were expressed as a r e s u l t of a study completed i n 1981 i n B.C. u s i n g v a r i a b l e s from the c u r r e n t l o n g -term care assessment form. A m u l t i v a r i a t e s t a t i s t i c a l a n a l y s i s of the data elements was done i n an attempt to reduce the Chapter VI - 164 -v a r i a b l e s needed to a l l o w c o n s i s t e n t placement d e c i s i o n s [31:2]. The r e s u l t s showed that u s i n g a s e t of j u s t s i x v a r i a b l e s , about 60 percent of c l i e n t s were c o r r e c t l y c l a s s i f i e d and another 20 per cent were w i t h i n one l e v e l (out of 5 l e v e l s ) [31:6]. However these r e s e a r c h e r s were r e l u c t a n t to recommend the use of t h i s s m a l l s e t of v a r i a b l e s . T h i s r e l u c t a n c e was due to the m u l t i p l e use of the assessment form and the concern that l o s s of data, such as those r e l a t e d to behaviour problems, c o u l d cause d i f f i c u l t i e s i n d e c i d i n g on the s e r v i c e needs of an i n d i v i d u a l or i n u s i n g the assessment as a r e c o r d a g a i n s t which to e v a l u a t e change i n c o n d i t i o n [31:7]. Once the a t t r i b u t e s have been s e l e c t e d , value weighting and s c a l i n g approaches would have to be determined and a p p l i e d as a b a s i s f o r a g g r e g a t i n g or "mapping" the a t t r i b u t e s and c r i t e r i a l e v e l s of the s e l e c t e d instrument i n t o a s i n g l e numeric s c a l e [30:1046]. Boyle and Torrance p r o v i d e a comprehensive review and a d v i c e on the s e l e c t i o n of the s c a l i n g techniques needed to a s s i g n numeric v a l u e s [30]. As with t h i s study, (see Chapter Three - v a l u i n g ) Boyle and Torrance a l s o emphasize the importance of "the i n c o r p o r a t i o n of s o c i a l p r e f e r e n c e s " i n t o the s c a l i n g process [30:1050]. The amount of instrument development r e q u i r e d w i l l be dependent on the H e a l t h Status Index s e l e c t e d and the extent to which i t has been t e s t e d i n long-term care s e t t i n g s , p a r t i c u l a r l y i n f a c i l i t y - b a s e d c a r e . The aim of the experiment w i t h the Kane instrument i n C a l i f o r n i a ( d e s c r i b e d i n Chapter Chapter VI - 165 -F i v e ) was to r e s o l v e many of the methodological and f e a s i b i l i t y concerns noted above. Depending how w e l l t h e i r g o a l s were achieved, the Kane instrument may w e l l be q u i t e s u i t a b l e i n B r i t i s h Columbia. But i t should be remembered that i t was a p p l i e d o n l y i n l a r g e s k i l l e d n u r s i n g homes (which p r o v i d e care to r e s i d e n t s s i m i l a r to those a t the h e a v i e r IC and EC l e v e l s i n B.C.). Examination and t e s t i n g of the va l u e weighting aspect of the Kanes' model would be important to see i f r e s i d e n t s , f a m i l i e s , p r o v i d e r s , other p r o f e s s i o n a l s and government d e c i s i o n makers i n B.C. have s i m i l a r v a l u e s to those found i n C a l i f o r n i a . I f not, changes would have to be made. I t should be noted that the a t t r i b u t e s (or domains) measured i n the Kane instrument a re s i m i l a r t o the broad areas of v a r i a b l e s i n c l u d e d i n the c u r r e n t long-term care assessment form i n B r i t i s h Columbia. The major divergence i n the B.C. t o o l appears to be a l a c k of a d i r e c t measure of s a t i s f a c t i o n [22; 31:1], along w i t h l e s s s t r i n g e n t measurement c r i t e r i a and no a b i l i t y to s c a l e or aggregate the v a r i a b l e s i n t o a numeric s c o r e . I f the Kane instrument was found not to be a c c e p t a b l e t o funders and p r o v i d e r s i n B r i t i s h Columbia, the Sickness Impact P r o f i l e (SIP), although not developed s p e c i f i c a l l y f o r long-term care, i s another H e a l t h Status Index which might be c o n s i d e r e d [29]. As Bergner et a l s t a t e , the SIP "was developed t o p r o v i d e a measure of p e r c e i v e d h e a l t h s t a t u s that i s s e n s i t i v e enough to de t e c t changes or d i f f e r e n c e s i n h e a l t h s t a t u s that occur over Chapter VI - 166 -time or between groups ... I t was designed to be br o a d l y a p p l i c a b l e a c r o s s types and s e v e r i t i e s of i l l n e s s ... and i s intended to p r o v i d e a measure of the e f f e c t s or outcomes of h e a l t h care that can be used f o r e v a l u a t i o n , program p l a n n i n g and p o l i c y f o r m u l a t i o n . " [32:787]. The go a l s i n d e v e l o p i n g the instrument were to develop an index that was m e t h o d o l o g i c a l l y sound and p r a c t i c a l , and f e a s i b l e to a d m i n i s t e r . The index has been w e l l t e s t e d f o r r e l i a b i l i t y and v a l i d i t y and has been used w i d e l y i n a v a r i e t y of s e t t i n g s , i n c l u d i n g use with i n d i v i d u a l s with c h r o n i c d i s e a s e s and w i t h home care c l i e n t s with c h r o n i c i l l n e s s . An example of the use of the SIP instrument i n n u r s i n g homes was not found i n the l i t e r a t u r e reviewed, but not a l l a p p l i c a t i o n s were s p e c i f i c a l l y noted. Of the a p p l i c a t i o n s reviewed, the acceptance of SIP has been h i g h [29; 25; 32]. The instrument can be s e l f - a d m i n i s t e r e d by the c l i e n t or admi n i s t e r e d by an i n t e r v i e w e r w i t h the c l i e n t or c l i e n t s u b s t i t u t e (e.g. f a m i l y c a r e g i v e r ) . A d m i n i s t r a t i o n has been found to take between 20 to 30 minutes which i s comparable to the time f o r use of the Kane instrument. There has been some sug g e s t i o n , based on e m p i r i c a l t e s t i n g t h a t some t e s t items c o u l d be e l i m i n a t e d f o r some groups. T h i s might be the case f o r the d i f f e r e n t l e v e l s of f a c i l i t y care i n B.C. [25,-29,-32]. The wide f i e l d t e s t i n g and a p p l i c a t i o n of t h i s instrument may g i v e i t some c u r r e n t advantage over the Kane t o o l . A l s o the SIP t o o l has items that c o u l d apply to c l i e n t s on a home care program Chapter VI - 167 -which may be an advantage f o r B.C V i f a s i m i l a r e f f e c t i v e n e s s measurement process were to be i n c o r p o r a t e d i n t o the standards f o r home care. In t h i s s e c t i o n some of the a c t i v i t i e s that are r e q u i r e d to s e l e c t and develop a h e a l t h s t a t u s index f o r the outcome e v a l u a t i o n of the e f f e c t i v e n e s s of care p r o v i d e d i n long-term care f a c i l i t i e s i n B r i t i s h Columbia have been i d e n t i f i e d . The amount of development and t e s t i n g r e q u i r e d w i l l v ary depending on the extend of p r e v i o u s use of the index i n f a c i l i t y - b a s e d long-term care e v a l u a t i o n and the extent to which i t i s g e n e r a l i z a b l e to f a c i l i t y care i n B.C. Two instruments have been suggested as p o s s i b i l i t i e s - the Kane and the SIP h e a l t h s t a t u s indexes [22; 29]. In e i t h e r case i n f o r m a t i o n about the r e s u l t s of t h e i r most recent a p p l i c a t i o n s would be needed, s p e c i f i c a l l y those i n long-term care. Some t e s t i n g f o r a p p l i c a b i l i t y i n B.C., p a r t i c u l a r l y i n the va l u e weighting would be necessary. DEVELOPMENT OF PROTOCOLS FOR TESTING AND APPLYING OUITCOME MEASURES Once the i n i t i a l a c t i v i t i e s i n the s e l e c t i o n of a h e a l t h s t a t u s instrument are completed, e m p i r i c a l t e s t i n g i n long-term care f a c i l i t i e s would be r e q u i r e d . T h i s c o u l d be accomplished through an experimental or demonstration p r o j e c t i n which the s e l e c t e d instrument i s developed and t e s t e d f o r r e l i a b i l i t y and v a l i d i t y i n long-term care f a c i l i t i e s i n B.C. The p r o t o c o l s f o r t h i s development should proceed i n two st a g e s . For the i n i t i a l Chapter VI - 168 -t e s t i n g , f a c i l i t i e s which are known to p r o v i d e q u a l i t y c a r e should be s e l e c t e d to develop and t e s t the expected outcomes. Once the expected outcomes are determined (assuming v a l i d i t y and r e l i a b i l i t y ) f o r each l e v e l of care, a second p r o t o c o l f o r a p p l i c a t i o n of the f u l l p r e d i c t o r model approach would need to be d e v i s e d and t e s t e d . During t h i s phase, l o n g -term care f a c i l i t i e s s h ould be s e l e c t e d that would be r e p r e s e n t a t i v e of the s i z e range, case mix and p r o v i d e r types found a c r o s s the p r o v i n c e i n B.C. D e c i s i o n s r e l a t e d to the implementation p r o t o c o l would i n c l u d e : how or whether to i n c o r p o r a t e the e f f e c t i v e n e s s assessment w i t h the annual u t i l i z a t i o n reviews; whether the same s t a f f should be used; whether the new instrument should r e p l a c e or augment the c u r r e n t assessment used i n the l e v e l of care form (LTC-1); how o f t e n or at what i n t e r v a l s would h e a l t h s t a t u s assessments be made (every s i x months, a n n u a l l y ) ; and who would have access to the r e s u l t s of the e f f e c t i v e n e s s measures, i n what form (aggregated or disaggregated) and f o r what purposes (program p l a n n e r s , standards managers, funders, p r o v i d e r s ) . Other e v a l u a t i o n concerns would i n c l u d e the c o s t to implement the approach, the impact on e x i s t i n g l e g i s l a t i o n and r e g u l a t i o n s , and the whether there i s the p o l i t i c a l w i l l to move towards d e c i s i o n making based on more e x p l i c i t v a l u e s and outcomes. OTHER OPTIONS FOR OUTCOME MEASUREMENT OF EFFECTIVENESS Two other more g l o b a l or o r g a n i z a t i o n a l l e v e l approaches to outcome-based e f f e c t i v e n e s s measurement i n long-term care have been proposed i n the l i t e r a t u r e . One i s based on d i s c h a r g e Chapter VI - 169 -outcomes, u s u a l l y u s i n g four or f i v e c a t e g o r i e s (e.g. death, d i s c h a r g e to h o s p i t a l , d i s c h a r g e to another long-term care f a c i l i t y , d i s c h a r g e home, remains i n f a c i l i t y ) of outcomes [22; 26; 27]. Conceivably, d i s c h a r g e data c o u l d r e p r e s e n t outcomes of care at a s p e c i f i c l e v e l and c o u l d be used as p r e d i c t o r (expected) outcomes to be measured a g a i n s t a c t u a l performance. In one study, these outcomes were l i n k e d to reimbursement i n c e n t i v e s i n an e f f o r t to dis c o u r a g e i n a p p r o p r i a t e d i s c h a r g e of heavy care r e s i d e n t s [26]. Another approach i s to assess the outcome of commonly o c c u r r i n g h e a l t h care problems (e.g. i n c o n t i n e n c e , bed s o r e s , e t c . ) [26; 28]. In t h i s approach, as proposed by Weissert e t a l , reimbursement i n c e n t i v e s are as s i g n e d to each of a s p e c i f i e d l i s t of care problems. Payments are then made, dependent on the r e s u l t s of the expected outcomes ( i . e . improvement or maintenance) [26]. In the Chambers et a l approach, four h e a l t h problems have been s e l e c t e d based on knowledge of the e f f i c a c y of the a p p r o p r i a t e i n t e r v e n t i o n s (process of care) and both the processes and outcome of care are assessed [28]. T h i s study proposes that e i t h e r of these l a t t e r outcome approaches c o u l d be used as an a d d i t i o n a l source of outcome measures. Or they c o u l d p r o v i d e one source of c o n s t r u c t v a l i d a t i o n f o r the p r o g n o s t i c model w i t h i t s m u l t i a t t r i b u t e h e a l t h s t a t u s index. Alone these approaches would not be s u f f i c i e n t nor s e n s i t i v e enough to develop o r g a n i z a t i o n a l l e v e l outcome e f f e c t i v e n e s s s c o r e s , p a r t i c u l a r l y f o r each of the f i v e l e v e l s of c a r e . Chapter VI - 170 -3. APPLYING THE RESULTS Use of a m u l t i a t t r i b u t e h e a l t h s t a t u s index would p r o v i d e data i n a d i s a g g r e g a t e d form which c o u l d be used by p r o v i d e r s and a s s e s s o r s as needed i n p l a n n i n g care, as w e l l as by the l o c a l r e g i s t r y to e s t a b l i s h l e v e l s of c a r e . Aggregated data c o u l d be used f o r e f f e c t i v e n e s s m o n i t o r i n g and e v a l u a t i o n , and f o r p o l i c y , p l a n n i n g and/or funding d e c i s i o n s . For i n s t a n c e aggregated (or some l e v e l s of disaggregated) data c o u l d become pa r t of the c e n t r a l r e g i s t r y ' s computer data base and used i n comparative s t u d i e s and t r e n d a n a l y s i s . With the e x c e p t i o n of a n a l y s e s examining the p o t e n t i a l f o r r e d u c i n g the v a r i a b l e s necessary to make a c c u r a t e l e v e l s of care d e c i s i o n s , data based on the c u r r e n t assessment form have not r o u t i n e l y been u t i l i z e d f o r program and p o l i c y p l a n n i n g . The m u l t i a t t r i b u t e h e a l t h s t a t u s approach would p r o v i d e the i n f o r m a t i o n to do so. Once an approach to measure e f f e c t i v e n e s s i s e s t a b l i s h e d , the c o s t s r e l a t e d to the p r o v i s i o n of adequate and e f f e c t i v e care must be determined. Numerous recent s t u d i e s i n the U n i t e d S t a t e s have approached the c o s t i n g of f a c i l i t y - b a s e d long-term care, u s i n g p a t i e n t l e v e l and case-mix approaches, along w i t h attempts to determine the impact of q u a l i t y on c o s t s [33; 34; 35; 36; 37; 38; 39; 40]. Experience gained from these s t u d i e s , along w i t h the c u r r e n t undertakings r e l a t e d to cost assessment i n B.C. should p r o v i d e the i n f o r m a t i o n sources to develop the needed c o s t r e l a t e d i n f o r m a t i o n . Once the c o s t s and t h e i r i n t e r r e l a t i o n s h i p to the e f f e c t i v e n e s s of care have been determined an outcome-based reimbursement system f o r f a c i l i t y -Chapter VI - 171 -based care i n B r i t i s h Columbia may be developed. I n i t i a l l y the measures of e f f e c t i v e n e s s may be used i n c o s t - e f f e c t i v e n e s s and e f f i c i e n c y s t u d i e s . CONCLUSION T h i s study has o u t l i n e d the present f a c i l i t y - b a s e d l o n g -term care system i n B r i t i s h Columbia, n o t i n g c u r r e n t problems w i t h m o n i t o r i n g the adequacy of the care p r o v i d e d and some of the problems experienced w i t h the reimbursement system. The study has a l s o reviewed the assumptions, v a l u e s and o r g a n i z a t i o n a l s t r u c t u r e s which u n d e r l i e the long-term care system i n Canada and B r i t i s h Columbia. These i n c l u d e the s o c i a l p o l i c y , c o n s t i t u t i o n a l and economic environment, and the s o c i o -demographic v a r i a b l e s which have a f f e c t e d i t s development. These v a r i a b l e s were used as r e f e r e n c e p o i n t s i n a comparison of the seemingly s i m i l a r systems of f a c i l i t y - b a s e d long-term care i n Canada and the Un i t e d S t a t e s , n o t i n g p a r t i c u l a r l y the i m p l i c a t i o n s i f outcome-based approaches to e v a l u a t e care developed i n the United S t a t e s are c o n s i d e r e d f o r use i n Canada. Se v e r a l f a c t o r s were noted as p r o v i d i n g the st i m u l u s f o r c o n s i d e r a t i o n of an outcome-based approach: the h e t e r o g e n e i t y of the r e s i d e n t s of long-term care f a c i l i t i e s which makes i t d i f f i c u l t to determine at an o r g a n i z a t i o n a l l e v e l which s t r u c t u r e and process standards p r o v i d e the best care r e s u l t s ; the c o n t i n u i n g concern that s t r u c t u r e and process standards i n and of themselves do not assure e f f e c t i v e and adequate care; and Chapter VI - 172 -the funders goal of an arms-length r e l a t i o n s h i p w i t h p r o v i d e r s . These f a c t o r s have l e d funders to the p o s i t i o n t h at p r o v i d e r s should have the f l e x i b i l i t y and r e s p o n s i b i l i t y to determine t h e i r own approaches to care, as long as the outcomes demonstrate that the care p r o v i d e d was e f f e c t i v e and that funds were expended e f f i c i e n t l y . From the funders p e r s p e c t i v e , i f the outcomes are s a t i s f a c t o r y i n terms of e f f e c t i v e n e s s , how these outcomes are achieved need not be a concern. The e x c e p t i o n may be r e t e n t i o n of b a s i c s a f e t y standards. Approaches to outcome measurement and outcome-based approaches l i n k e d to reimbursement as used (or proposed f o r use) i n p r i v a t e i n d u s t r y , the p u b l i c s e c t o r , the h e a l t h care system i n g e n e r a l and the f a c i l i t y - b a s e d long-term care s e c t o r i n p a r t i c u l a r were reviewed and c r i t i q u e d . The purpose of the review was to assess the f e a s i b i l i t y of these approaches f o r use i n conducting outcome-based assessments of the e f f e c t i v e n e s s of care and the p o t e n t i a l , i f any, of l i n k i n g the measurement of e f f e c t i v e n e s s to reimbursement i n f a c i l i t y - b a s e d long-term care i n B r i t i s h Columbia. T h i s study proposes that the time i s r i g h t to begin to develop outcome measures of the e f f e c t i v e n e s s of the care p r o v i d e d i n long-term care f a c i l i t i e s i n B r i t i s h Columbia, as the f i r s t s t e p towards an outcome-based reimbursement system. The study has concluded that e f f e c t i v e n e s s measures must be i n p l a c e b e f o r e e f f i c i e n c y s t u d i e s can be p r o p e r l y undertaken and/or outcome-based reimbursement e s t a b l i s h e d . Chapter VI - 173 -The use of a comprehensive, m u l t i a t t r i b u t e h e a l t h s t a t u s index w i t h i n the framework of a p r e d i c t o r model has been s e l e c t e d as the approach of c h o i c e to measure the outcome of the e f f e c t i v e n e s s of the care p r o v i d e d i n long-term care f a c i l i t i e s i n B r i t i s h Columbia. T h i s approach was chosen as i t was f e l t , t h a t d e s p i t e some p o s s i b l e methodological concerns, i t would pr o v i d e the most comprehensive and most s e n s i t i v e assessment of e f f e c t i v e n e s s i n a system which r e c o g n i z e s f i v e l e v e l s of care and a l l o c a t e s r e s o u r c e s on a case-mix b a s i s u s i n g those l e v e l s of c a r e . T h i s assessment approach a l s o appears to be the c l o s e s t and most u s e f u l a l t e r n a t i v e t o the c u r r e n t assessment process c u r r e n t l y i n use and g i v e n the multi-purpose nature of the form. Four d i f f e r e n t sources make use of the i n f o r m a t i o n on the c u r r e n t assessment form: the c e n t r a l r e g i s t r y , the l o c a l r e g i s t r y , the p r o v i d e r and the a s s e s s o r . The p r e d i c t o r model approach to measuring e f f e c t i v e n e s s proposed i n t h i s chapter i s one attempt a t an outcome-based approach which would a s s i s t government funders i n meeting the need f o r a c c o u n t a b i l i t y f o r e f f e c t i v e and e f f i c i e n t p r o v i s i o n of f a c i l i t y - b a s e d long-term care i n B r i t i s h Columbia. The r e a d i n e s s of the B.C. f a c i l i t y - b a s e d system f o r such an approach was Chapter VI - 174 -noted, as w e l l as the f a c t t h at there s t i l l some i s s u e s r e l a t e d to methodology and f e a s i b i l i t y . In r e l a t i o n to the l a t t e r concerns, i t has been recommended that any development and implementation of an e f f e c t i v e n e s s measurement approach be undertaken as a j o i n t p r o j e c t i n v o l v i n g both h e a l t h s c i e n c e s r e s e a r c h e r s and p r o v i d e r s . T h i s w i l l p r o v i d e the e m p i r i c a l b a s i s r e q u i r e d to f u r t h e r develop t h i s approach f o r use i n f a c i l i t y -based long-term care i n B r i t i s h Columbia and to a l l o w f o r on-going e v a l u a t i o n . REFERENCES 1. Bennett, James, and Krasney, Jacques. H e a l t h Care i n Canada: A S e r i e s on the Nations H e a l t h . The F i n a n c i a l  Post. March 26 - May 7, 1977. 2. Government of Canada. F i s c a l F e d e r a l i s m i n Canada: Report  of the Pa r l i a m e n t a r y Task Force i n F e d e r a l - P r o v i n c i a l  F i s c a l Arrangements. Ottawa 1981. 3. H a l l , Emmett. 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"Care f o r the C h r o n i c a l l y 111: Nursing Home I n c e n t i v e Payment Experiment." H e a l t h Care F i n a n c i n g  Review, V o l . 5, No. 2 (Winter 1983):41-49. 27. L i n n , Margaret W.; G u r e l , Lee; and Li n n , Bernard S. " P a t i e n t Outcome as a Measure of Q u a l i t y of Nursing Home Care." AJPH ( A p r i l , 1977):337-342. 28. Chambers, L a r r y W. et a l . "A S e l f - M o n i t o r i n g Method of Resident Care: Q u a l i t y Assurance i n Long term care F a c i l i t i e s . " Canadian J o u r n a l on Aging 2:3(Autumn 1983) :137-51. 29. Bergner, M a r i l y n and B o b b i t t , Ruth A. "The Sick n e s s Impact P r o f i l e : Conceptual Formulation and Methodology f o r the Development of a He a l t h Status Measure." In So c i o - M e d i c a l  H e a l t h I n d i c a t o r s , pp. 9-32. E d i t e d by Jack E l i n s o n and A t h i l i a Siegmann. New York: Baywood P u b l i s h i n g Co. Inc. 1979 . 30. Boyle, Michael H. and Torrance, George W. "Developing M u l t i a t t r i b u t e H e a l t h Indexes." Medical Care. 22:11(November 1985):1045-1057. 31. Gutman, G l o r i a ; Stark, Annette J . and Kliewer, E r i c h . Placement D e c i s i o n s : Attempts at Reducing V a r i a b l e s to a  Manageable Set. Paper Presented at the 33rd Annuak S c i e n t i f i c Meeting of the G e r o n t o l o g i c a l S o c i e t y of North America, San Diego, C a l i f o r n i a . November 1980. 32. Bergner, M a r i l y n ; B o b b i t t , Ruth A.; C a r t e r , W i l l i a m B. and G i l s o n , B e t t y S. "The Sick n e s s Impact P r o f i l e : Development and F i n a l R e v i s i o n of a He a l t h Status Measure." Medical Care XIX(August 1981):787-805. 33. H a r r i n g t o n , Charlene, and Swan, James H. "Medicaid Nursing Home Reimbursement P o l i c i e s , Rates and Expenditures." H e a l t h Care F i n a n c i n g Review. 6 : l ( F a l l 1984):39-49. 34. Schlenker, Robert E.; Shaughnessy, Peter W. "Case Mix, Q u a l i t y and Cost r e l a t i o n s h i p s i n Colorado Nursing Homes." He a l t h Care F i n a n c i n g Review 6:2(Winter 1984):61-71. 35. Smits, Helen L. " I n c e n t i v e s i n Case-Mix Measures f o r Long-Term Care." H e a l t h Care F i n a n c i n g Review 6:2(Winter 1984) :53-59. 36. Meiners, Mark R. "An Economic A n a l y s i s of the Major Determinants of Nursing Home Costs i n the United S t a t e s . " Medical Care 16(1982):887-898. 37. Shaughnessy, Peter W., and Kurowski, B e t t i n a . " Q u a l i t y Assurance Through Reimbursement." H e a l t h S e r v i c e s Research 17 (Summer 1982 ):157-183. Chapter VI - 178 -38. Buchanan, Robert J . H e a l t h Care Finance: an A n a l y s i s of  Cost and U t i l i z a t i o n Issues. Toronto: Lexington Books, 1981. 37. F o t t l e r , Myron, Smith, Howard L., and James, W i l l i a m L. 9 P r o f i t s and P a t i e n t Care Q u a l i t y i n Nursing Homes: Are They Compatible?" The G e r o n t o l o g i s t , 21(1981) 5:532-538. 40. R u c h l i n , H i r s c h S.; Levy, Samuel; and Mullen, C h a r l o t t e . "The Long-Term Care Marketplace: A n a l y s i s of D e f i c i e n c i e s and P o t e n t i a l Reform by Means of I n c e n t i v e Reimbursement." Medical Care XIII (December, 1975): 979-991. APPENDIX A SCIENTIFIC AND FEASIBILITY CRITERIA I. SCIENTIFIC CRITERIA TO ASSESS OUTCOME APPROACHES II. CRITERIA TO ASSESS THE FEASIBILITY OF OUTCOME MEASUREMENT APPROACHES III . CRITERIA FOR NEW APPROACHES TO REIMBURSEMENT APPENDICES - 180 -I. SCIENTIFIC CRITERIA TO ASSESS OUTCOME APPROACHES STUDY PROBLEM - Has th e problem been a d e q u a t e l y i d e n t i f i e d ? - Does the f o r m a t i o n of the problem i n d i c a t e t he t h e o r y , the r e l a t e d r e s e a r c h and the f a c t o r s r e l a t e d t o t h e p r e s e n t s i t u a t i o n ? - Does t h e s t u d y show adequate awareness o f o t h e r r e l a t e d work? OBJECTIVES - Do the o b j e c t i v e s f l o w from t h e problem, and a r e th e y c o n s i s t e n t w i t h the problem s t a t e m e n t ? - Do the o b j e c t i v e s s t a t e what the s t u d y / a p p r o a c h e f f o r t proposes t o a c c o m p l i s h ? DESIGN AND METHODS - Does t h e s t u d y / a p p r o a c h l i n k t he t h e o r y and methodology from the r e l a t e d l i t e r a t u r e t o the p r e s e n t s t u d y ? - Are t h e methods a p p r o p r i a t e t o the o b j e c t i v e s o f t h e stu d y ? - I s the s e t t i n g and the methodology c l e a r l y s p e c i f i e d t o f a c i l i t a t e r e p l i c a t i o n ? - Are t h e d a t a s o u r c e s i d e n t i f i e d , and were t h e y d e v e l o p e d s p e c i f i c a l l y f o r the s t u d y , from p r e - e x i s t i n g management d a t a , o r a n o t h e r s t u d y ? - Does the s t u d y c l e a r l y d e f i n e the p o p u l a t i o n s t u d i e d ? LIMITATIONS - Are the l i m i t a t i o n s of t h e methodology used a d e q u a t e l y noted? - Are t h e l i m i t a t i o n s a d e q u a t e l y d i s c u s s e d i n the a n a l y s i s and c o n c l u s i o n s ? - I s the scope of the s t u d y broad enough t o a c c o m p l i s h the o b j e c t i v e s of the s t u d y and narrow enough t o complete w i t h i n the r e s o u r c e c o n s t r a i n t s ? FINDINGS - Are t h e f i n d i n g s c l e a r l y p r e s e n t e d w i t h p r o p e r use o f t a b l e s and t e c h n i c a l f o o t n o t e s ? - Are the f i n d i n g s p r o p e r l y i n t e r p r e t e d i n r e l a t i o n t o t h e o b j e c t i v e s ? APPENDICES - 181 -CONCLUSIONS - Are the c o n c l u s i o n s based on the f i n d i n g s ? - Do the c o n c l u s i o n s adequately r e l a t e the f i n d i n g s t o the the study o b j e c t i v e s and study problem? - Are the c o n c l u s i o n s p r o p e r l y q u a l i f i e d ? RECOMMENDATIONS - Are the recommendations d e r i v e d from the f i n d i n g s and c o n c l u s i o n s ? - Are the recommendations r e l a t e d to the study problem? - Do the recommendations p r o v i d e a f i r m b a s i s f o r d e c i s i o n making? I I . CRITERIA TO ASSESS THE FEASIBILITY OF OUTCOME MEASUREMENT APPROACHES STUDY PROBLEM - Was the problem studied/approach r e l a t e d to outcome measurement, p r o d u c t i v i t y , and/or reimbursement, and i n p r i v a t e i n d u s t r y , p u b l i c s e c t o r , h e a l t h care or l o n g -term care? - Are the assumptions of the study e x p l i c i t or i m p l i c i t , and a re they s i m i l a r to or r e l a t e d to the g e n e r a l g o a l s of outcome based reimbursement f o r the long-term care i n d u s t r y ? OBJECTIVES - Do the o b j e c t i v e s r e l a t e to outcome measurement, p r o d u c t i v i t y , and/or reimbursement? - Do the o b j e c t i v e s of the study/approach come from a sh a r e h o l d e r s or funders p e r s p e c t i v e ? - W i l l the i n f o r m a t i o n sought p r o v i d e support to d e c i s i o n makers e x t e r n a l to the p r o d u c t i o n ( f a c i l i t y ) managers? - Does the study i n c l u d e c o n s i d e r a t i o n of at l e a s t one of the f o l l o w i n g types of outcome measurement? i . p rocess outcomes ( c l i e n t outcomes r e l a t e d to process i n t e r v e n t i o n s i i . h e a l t h s t a t u s outcomes (measure outcomes or h e a l t h s t a t e ) i i i . a d m i n i s t r a t i v e outcomes (measures of e f f i c i e n c y , eg. u n i t c o s t of s e r v i c e s ) i v . economic outcomes (cos t b e n e f i t , cost e f f e c t i v e n e s s , c o s t u t i l i t y ) APPENDICES - 182 -DESIGN AND METHODS - Does the study/approach consider the need for multi-dimensional measurement approaches and/or multi-dimensional outcomes? - Have the measurement instruments been tested for v a l i d i t y and r e l i a b i l i t y , across raters and over time? - Does the sampling technique recognize the population variance expected i n long-term care f a c i l i t i e s , and the co r r e l a t i o n relationship, i f any, of the dependent variable of outcome to the independent variables of s i z e , case mix, etc. LIMITATIONS - Would the li m i t a t i o n s noted preclude the application i n long-term care? - Would the l i m i t a t i o n s noted preclude the g e n e r a l i z a b i l i t y across a l l types of long-term care f a c i l i t i e s ? - Would the resources necessary to implement the approaches be a l i m i t i n g factor eg. need for professional judgement, analysis design, costs to support the study or approach, time for administration. - Is the study/approach capable of handling a large number of c l i e n t s and f a c i l i t i e s within a s p e c i f i c time frame, eg. a f i s c a l year? - Is the assessment approach capable of being administered c e n t r a l l y or on a decentralized basis? - Are there l i m i t a t i o n s related to the sources of data, eg. provider inter e s t s , stamina of c l i e n t s , etc. FINDINGS - Do the findings r e f l e c t any ef f e c t the outcome measurements studied/proposed have on current or future regulation? - Do the findings i d e n t i f y the impact on c l i e n t s of the measurement process studied? - Are any unanticipated findings discussed, including impact implication? - Does the measurement instrument res u l t i n scores that can be aggregated to produce an ov e r a l l performance score for the production process ( f a c i l i t y care)? - Is the measurement process studied predictive of the production process, eg. the adequacy of care and not of other variables, eg. case mix, siz e of f a c i l i t y , etc.? CONCLUSIONS - Do the conclusions relate to the findings about outcome measurement, productivity, or reimbursement? - Are the approaches developed to support funding decisions c l e a r l y i d e n t i f i e d , eg. incentives, competition, the extent of the basis for reimbursement. APPENDICES - 183 -- Are i s s u e s such as the q u a l i t y of l i f e , the r e l a t i o n s h i p of outcome to s t r u c t u r e and process noted, the need f o r f u r t h e r study, and/or implementation i s s u e s mentioned? RECOMMENDATIONS - Are there recommendations made f o r c o r r e c t i v e a c t i o n , i f what are they and by whom? - Are these recommendations a p p l i c a b l e and g e n e r a l i z a b l e f o r f a c i l i t y care i n Canada? I I I . CRITERIA FOR NEW APPROACHES TO REIMBURSEMENT A s p e c i a l p r o j e c t e s t a b l i s h e d address approaches to overcome the c u r r e n t problems i n reimbursement system i n B r i t i s h Columbia, to adapt to the o r g a n i z a t i o n a l s t r u c t u r e and to meet the funders o b j e c t i v e s of e f f i c i e n c y and e f f e c t i v e n e s s proposed t h a t changes to the reimbursement system i n B r i t i s h Columbia must be ev a l u a t e d a g a i n s t the f o l l o w i n g c r i t e r i a 11; 25). The proposed system must: - p r o v i d e s u f f i c i e n t compensation to enable the p r o v i s i o n of adequate care ( i e . e f f e c t i v e care r e l a t i v e to r e s i d e n t need and the care l e v e l mix; - p r o v i d e i n c e n t i v e s f o r e f f i c i e n t o p e r a t i o n of a f a c i l i t y ( i e . a l l o w f o r m a n i p u l a t i o n of input combinations, and t e c h n i c a l e f f i c i e n c i e s ) ; - p r o v i d e f o r f a i r and e q u i t a b l e reimbursement acr o s s . f a c i l i t i e s , g i v e n d i f f e r e n c e s i n type ( p r o f i t / n o n -p r o f i t ) , s i z e , l o c a t i o n , l e v e l s of care and programs pr o v i d e d and f i x e d and v a r i a b l e c o s t s ; - p r o v i d e a mechanism (eg. a management i n f o r m a t i o n system) to monitor and assess p r o v i d e r performance i n terms of e f f i c i e n c y and e f f e c t i v e n e s s ; - be a d m i n i s t r a t i v e l y f e a s i b l e ( i e . f i t budget c o n s t r a i n t s , r e q u i r e minimal manpower and other r e s o u r c e s to e s t a b l i s h and maintain, b u i l d on or i n c o r p o r a t e the cu r r e n t data base, comply wi t h c u r r e n t or f u t u r e l e g i s l a t i o n ) ; - p r o v i d e f o r an arms-length r e l a t i o n s h i p between the government d e c i s i o n makers and the p r o v i d e r s ; - p r o v i d e f l e x i b i l i t y to promote expansion or r e d u c t i o n of the p r o v i n c i a l bed i n v e n t o r y . Based on i n f o r m a t i o n i n Bo l t o n , P a t r i c i a "Reimbursement f o r Long-Term Care i n B r i t i s h Columbia" C l e r k s h i p Report. B r i t i s h Columbia M i n i s t r y of Hea l t h . September 1983. (Mimeograph) APPENDIX B EXCERPTS FROM THE FACILITY REIMBURSEMENT SYSTEM REPORT BRITISH COLUMBIA MINISTRY OF HEALTH LONG TERM CARE PROGRAM, CONTINUING CARE DIVISION JANUARY 1985 APPENDICES - 185 -E x c e r p t s from the F a c i l i t y Reimbursement System Report, B r i t i s h Columbia, M i n i s t r y of Health. Long Term Care Program, C o n t i n u i n g Care D i v i s i o n . January 1985. The g o a l s of the p r o j e c t were: 1) To have a s i n g l e e f f i c i e n t , e f f e c t i v e and e q u i t a b l e system of reimbursement f o r a l l f a c i l i t i e s . 2) T m a i n t a i n a two s e c t o r i n d u s t r y i n which the competing f o r c e s of c o s t and q u a l i t y c o u l d be c l e a r l y i d e n t i f i e d and a u d i t e d . In a d d i t i o n , the new reimbursement system was seen as a v e h i c l e to ensure e f f i c i e n t , e f f e c t i v e and e q u i t a b l e s e r v i c e d e l i v e r y . F i n a l l y , a major s h o r t term c o n s i d e r a t i o n was to minimize the number of f a c i l i t i e s which might make excess p r o f i t s from the new reimbursement system or, c o n v e r s e l y , have d i f f i c u l t y m a i n t a i n i n g o p e r a t i o n s . I t was f e l t that the above g o a l s c o u l d be achieved u s i n g the f o l l o w i n g methods: 1) Apply the same standard reimbursement formula to p r i v a t e and n o n p r o f i t o p e r a t o r s u s i n g i n d u s t r y c o s t standards. T h i s would reduce the spread i n per diem c o s t s , f a i r l y reimburse the p r i v a t e o p e r a t o r s and r e q u i r e cost c o n t r o l among n o n p r o f i t o p e r a t o r s . 2) Introduce d e t a i l e d and t i m e l y f i n a n c i a l a c c o u n t i n g by both p r o f i t and n o n p r o f i t o p e r a t o r s , thus e n s u r i n g c o m p a r a b i l i t y and e f f e c t i v e Government c o n t r o l of c o s t s . 3) Introduce the m o n i t o r i n g of q u a l i t y of care to ensure an adequate standard i s maintained w i t h i n the p r i v a t e s e c t o r , and that q u a l i t y i s not compromised as c o s t s come under c o n t r o l i n the n o n p r o f i t s e c t o r . 4) Review the n o n p r o f i t s t a f f i n g g u i d e l i n e s to determine what c o n s t i t u t e s an adequate l e v e l of s t a f f i n g i n f a c i l i t i e s . 5) Review the method of c a p i t a l reimbursement to see i f one method can be developed to apply to both s e c t o r s . APPENDIX C METHODOLOGICAL QUESTIONS IN LONG TERM CARE ASSESSMENT APPENDICES - 187 -From the l i t e r a t u r e reviewed on assessment i n long term care the f o l l o w i n g are some of the qu e s t i o n s r a i s e d about which methodological approaches to use: - should assessments be based on s e l f - r e p o r t e d data or observed b e h a v i o r a l data? - should assessments be completed i n t e r n a l l y by s t a f f / r e s i d e n t s or by e x t e r n a l a s s e s s o r s ? - should assessments measure s i n g l e or m u l t i p l e f u n c t i o n a l dimensions? - i f the assessment i s m u l t i d i m e n s i o n a l , should i t i n c l u d e a s p e c t s which r e f l e c t o n l y the r e s u l t s of care or should i t i n c l u d e a q u a l i t y of l i f e p e r s p e c t i v e , or both ? - what are the outcomes which re p r e s e n t the q u a l i t y of l i f e p e r s p e c t i v e (e.g. l i f e s a t i s f a c t i o n , morale, p r i v a c y , o p p o r t u n i t y f o r c h o i c e or r i s k , i n d i v i d u a l to environment ' f i t ' ) ? - i f u s i n g a m u l t i d i m e n s i o n a l ( m u l t i a t t r i b u t e ) approach, should the assessment r e s u l t i n simply a p r o f i l e of the i n d i v i d u a l s t a t u s i n each of the dimensions measured, or should there be an ag g r e g a t i o n or the outcomes from each dimension i n t o a s i n g l e s c o r e or index? - i f the r e s u l t s are aggregated, how should the i n d i v i d u a l dimensions be value weighted w i t h i n the ag g r e g a t i o n (e.g. should the v a l u i n g be based on the p r e f e r e n c e s of the r e s i d e n t , or the f a m i l y , or the p r o v i d e r , or the funder)? - f u r t h e r , i f the assessment of an i n d i v i d u a l r e s u l t s i n a s i n g l e aggregated s c o r e or index, can the sc o r e s f o r a group of i n d i v i d u a l s be f u r t h e r aggregated to re p r e s e n t some o v e r a l l h e a l t h care index f o r a f a c i l i t y , and how cou l d t h i s be done? - should the assessment process be completed c o n c u r r e n t l y (at the time the care i s provided) or r e t r o s p e c t i v e l y ( i . e . at some s t a t e d f o l l o w i n g care p r o v i s i o n ) ? 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