OECD Health Policy Studies

2074-319X (online)
2074-3181 (print)
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This series of publications analyses the organisation and performance of health systems, and factors explaining performance variations. Studies are conducted on such topics as co-ordination of care, pharmaceutical pricing, long-term care and disability, health workforce and international migration of health workers, information and communications technologies in health care, and the economics of prevention. 
Also available in French
A Good Life in Old Age?

A Good Life in Old Age?

Monitoring and Improving Quality in Long-term Care You do not have access to this content

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17 June 2013
9789264194564 (PDF) ;9789264194526(print)

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As ageing societies are pushing a growing number of frail old people into needing care, delivering quality long-term care services – care that is safe, effective, and responsive to needs – has become a priority for governments. Yet much still remains to be done to enhance evidence-based measurement and improvement of quality of long-term care services across EU and OECD countries. This book offers evidence and examples of useful experiences to help policy makers, providers and experts measure and improve the quality of long-term care services.

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  • Foreword

    More and more people reach an age where they have to live with declining functional and cognitive abilities and thus become dependent on the help of others in their daily life. Protecting the right to a life in dignity of frail older people is thus becoming a major policy challenge.

  • Glossary
  • Executive summary

    With the ageing populations and growing costs, ensuring and improving the quality of long-term care (LTC) services has become an important policy priority across OECD countries. The share of those aged 80 years and over is expected to increase from 4% in 2010 to nearly 10% in 2050, while in 2010 OECD countries allocated 1.6% of GDP to public spending on LTC, on average. The goal of good quality care is to maintain or, when feasible, to improve the functional and health outcomes of frail elderly, the chronically ill and the physically disabled, whether they receive care in nursing homes, assisted living facilities, community-based or home care settings. This report focuses on three aspects generally accepted as critical to quality care: effectiveness and care safety, patient-centredness and responsiveness and care co-ordination.

  • Assessment and recommendations

    There are good reasons why quality assurance for long-term care is on the policy agenda in many OECD countries. First, users of care services demand more voice and control over their lives. Expectations towards the quality of care of "baby boomers" are higher than those of their parents. Most recipients expect to live in a single room to maintain their privacy or expect care services to reflect their own individual needs and preferences. Quality LTC services can help frail and dependent persons being more autonomous and continue to take part in society, despite their conditions. Maintaining independence, autonomy and privacy have been shown to prevent depression and loss of interest in life.

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  • Expand / Collapse Hide / Show all Abstracts Measuring quality in long-term care

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    • Why the quality of long-term care matters

      Long-term care recipients are demanding greater flexibility, more choice, more autonomy and better service quality. These demands and public stories of inadequate standards of care pressure governments to increase transparency over the quality of care delivered to frail and disabled elderly. This chapter provides definitions and a framework for looking at long-term care quality in this report. Three key domains that are generally accepted as being critical factors underpinning care quality are considered: i) effectiveness and care safety; ii) patient-centredness and responsiveness; iii) care co-ordination. Three structural outcomes instrumental to delivering good quality care are also identified, namely: i) staffing and management; ii) care environment; iii) information and communication technology and other assistive devices.

    • Measuring quality in long-term care

      Quality is a difficult concept to define and operationalise for measurement purposes. A majority of countries do not systematically collect information on quality and many have not reached a national consensus regarding which indicators ought to be collected and reported regularly. The measurement of quality is held back by definitional and methodological challenges and the lack of a mandate to collect these data. This chapter discusses these challenges by documenting the approaches to measure long-term care quality in a selection of OECD countries, evaluates the advantages and limitations of the indicators used, and provides recommendations for the development of indicators to monitor LTC quality across OECD and EU countries.

    • Using interRAI assessment systems to measure and maintain quality of long-term care

      Rapidly ageing populations and increasing prevalence of chronic diseases present major challenges for policy makers. Populations as well as individuals have different prevalence of conditions related to ageing and chronic disease. This is compounded by cultural and institutional differences in care service provision, eligibility criteria and funding models. Comparing differences at population and individual level helps policy makers address the complexities of maintaining quality in long-term care. This chapter describes how evolution in development of needs assessment instruments has led to a way of producing high-quality data for policy makers. It describes in detail the interRAI system of standardised needs assessment instruments for routine care that generate aggregatable data. Data driven algorithms generate outcome scales, care planning support protocols, quality indicators, and a resource-use casemix system. The chapter then illustrates, with data from nine OECD countries and regions, how needs assessment data recorded at the point of care using the interRAI system can inform policy. It ends with a discussion of factors for consideration when implementing sophisticated needs assessment tools.

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  • Expand / Collapse Hide / Show all Abstracts Policies to drive quality in long-term care

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    • Regulation to improve quality in long-term care

      The complexity of care services means that identifying the most appropriate policy approaches to drive long-term care quality can be challenging. This chapter and the next two review the approaches and policies used by OECD and EU countries to promote care quality. Three approaches are identified: 1) imposing external regulatory controls to safeguard and control quality; 2) developing standards to standardise care practice and monitor indicators to ensure that care outcomes match desired levels; and 3) stimulating quality improvement through the use of market-based incentives directed at providers and users, including the use of performance-based financial incentives and competition among care providers. This chapter focuses on external regulatory controls such as the development of minimum standards, licensing or accreditation of facilities and training requirements for workers. Standardisation policies and the use of incentives to drive quality will be analysed in the next two chapters.

    • Standardisation and monitoring of care processes

      Setting standards that establish how to "do the right things" is one of the methods to make long-term care delivery safe and effective. Standardising needs assessment or care processes, and monitoring care processes or outcomes are effective tools to determine the needs of individuals, minimise variations in care for certain conditions and encourage providers to improve quality of care. This chapter reviews standardisation and monitoring approaches used by OECD and EU countries. It provides an overview of care needs assessment, looking specifically at the extent to which there is standardisation in the process of measuring and assessing care needs. It also reviews how information from needs assessment is used to formulate care plans, and the extent to which clinical guidelines and protocols are incorporated in care planning processes to drive good practices. The chapter concludes by reviewing care quality monitoring policies.

    • Incentives for providers and choice for consumers

      Many OECD countries are looking at ways to change providers’ and users’ behaviours by strengthening incentives for quality improvement and creating a quality "culture". This chapter discusses the use of incentives to deliver responsive, safe, and effective care, addressing four main issues: 1) consumer-based initiatives such as those leveraging consumer choice and centredness; 2) the impact of performance incentives to encourage and reward providers to deliver higher quality care; 3) incentives to encourage care co-ordination and integration, the lack of which can have important consequences for safety, responsiveness and care effectiveness; and 4) the role of information technology in promoting outcome improvements and independent living.

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  • Expand / Collapse Hide / Show all Abstracts Case studies: Europe and the United States

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    • Quality measurement and improvement in long-term care in Europe

      A large variety of approaches to reduce risks and improve performance can be observed in long-term care across and within countries, depending on the role of public, private for-profit and non-profit care providers, as well as on governance mechanisms at national, regional or local levels. The introduction of quasi-markets and public tendering has triggered the need to increase transparency of providers’ service quality towards public purchasers and users. This led to new types of supervising institutions and related instruments, such as performance measurement, public reporting and quality certification. These instruments and their rationales are not always compatible and contribute to tensions between stakeholders involved, for example concerning individual needs related to quality of life, dignity and self-determination. It is argued that internal quality management within and across organisations providing care services needs to be supported by enabling policies and mechanisms at the systems level to trigger a process of continual improvement. This entails further development of indicators that should be informed by evidence from multiple perspectives, to measure not only quality of clinical care, but in particular quality of life across care pathways. Ill designed quality assurance systems may hamper improvement processes and lead to bureaucracy, high administrative burdens and feelings of alienation of care workers.

    • Long-term care quality assurance in the United States

      The market for nursing home care and other long-term care services is one of the most heavily regulated sectors in the United States economy. The present quality assurance system boasts an extensive regulatory scheme, with a complex interplay of federal, state, and voluntary rules controlling and monitoring the quality of nursing homes and, to a lesser extent, other home and community-based service providers. This chapter describes the current approach to long-term care regulation in the United States focusing on three key areas: 1) the standards for provider participation; 2) the monitoring and enforcement of compliance; and 3) public reporting and other market-based approaches to improving quality. It focuses primarily on nursing home care, given the predominant focus of regulation and the surrounding literature on this sector. It concludes with a brief discussion of the current state and future of long-term care regulation as well as lessons based on the US experience.

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