Beyond Olmstead: Community-Based Services for All People with Disabilities

Access & Quality

Presenters: Ann Lawthers, Sc.D., Assistant Professor, Center for Health Policy and Research, University of Massachusetts Medical School, Shrewsbury, MA. Steven J. Landkamer, Project Manager, Wisconsin Partnership Program, Center for Delivery Systems Development, Office of Strategic Finance, Wisconsin Department of Health and Family Services, Madison, WI.

Quality of care and patient safety have particular significance for people with disabilities. These factors challenge the health care system to deliver services that are appropriate, efficient, effective, and coordinated in such a way that the unique needs of very different populations are met. Topics addressed by the literature in this area include:

• Basics of quality.
• Patient safety.
• Access.
• Patient experience.
• Coordination.
• Communication.

Quality is multidimensional. According to the Institute of Medicine, quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes. For others, it is dependent upon how individuals view quality. The primary dimensions or domains of quality are:

• Clinical quality.
• Patient experience.
• Access.

Access is the ease with which health care can be obtained. Thus, access is a necessary condition for safe and timely care. Barriers to access have been studied and include:

• Geographical barriers (distance of travel or whether or not services can be reached).
• Financial barriers (the cost of getting to care and receiving it).
• Organizational barriers (lack of appointments, long waiting periods, or gatekeeping).
• Cultural barriers (different language or health care beliefs).

All the dimensions of quality mentioned are very important for persons with disabilities who may need extra resources and/or attention to ensure quality of care.

Accidental injury also increased by frequent contact with the health care system and/or the complexity of the individual's situation. For example, when more than one injury occurs, and one is related to the maintenance of a chronic condition, certain medical conditions may be ignored as a result.

Access becomes an issue when physical barriers preclude a patient's ability to receive care (e.g., a person is unable to get on the examination table because it is too high, remains seated rather than lying down on the table, resulting in the consumer not being examined properly).

Communication difficulties or attitudes get in the way of a patient's ability to receive care, because coordination is the glue that links all areas of quality for people with disabilities. Communication is essential because of the number of providers that are usually involved in the care of people with disabilities. Communication difficulties between physician and patient can also increase patient risk for accidental injuries and, therefore, decrease the quality of patients' experience.

The Wisconsin Partnership Program integrates Medicare and Medicaid acute and long-term care services for elders and people with disabilities. The Partnership was implemented to provide:

• Comprehensive health and long-term care to Medicaid-eligible people who meet nursing home eligibility.
• Improve functional and clinical outcomes.
• Allow consumers choice of primary care physician.
• Improve quality of life.

The Wisconsin program was designed to:

• Emphasize home-based and community-based services.
• Be responsive to consumer's preferences.
• Be driven by quality.

The design expects that the integration of Medicare and Medicaid services will be cost-effective by reducing the need for expensive emergency, acute, and institutional care. The program was developed through partnerships with:

• Building Health Systems for People with Chronic Illnesses Program, a program of the Robert Wood Johnson Foundation.
• The Center for Health Care Strategies.
• Individual consumers, their families, and providers.
• The Wisconsin Department of Health and Family Services.
• Centers for Medicare & Medicaid Services (CMS).

The Wisconsin program found that integration of acute, primary, and long-term care services was best accomplished through a team approach.

The State has shifted from the historic approach to quality (adherence to standards, process measures, and the assumption that good documentation equals good outcomes) to a multipronged effort that looks at:

• Contract monitoring.
• Outcome and performance measures.
• Targeted reviews.
• Consumer evaluation.
• External evaluation.
• Administrative performance.
• Quality improvement.

Using inpatient encounter data and data from nursing home admissions and emergency room visits that do not lead to hospitalization, State officials have focused on ambulatory-sensitive outcomes that could have been avoided. Ambulatory-sensitive conditions include:

• Asthma.
• Hypoglycemia.
• Gastroenteritis.
• Dental conditions.
• Bacterial pneumonia.
• Kidney and urinary tract infections.
• Pelvic inflammation disease.
• Congestive heart failure.
• Diabetes.
• Chronic obstructive pulmonary disease.
• Injury/poisoning.
• Convulsions.
• Sepsis.

Members are interviewed to determine if outcomes that lend to overall quality of life are being met. Care management teams are interviewed to determine if supports are being provided to help members achieve desired outcomes.

Additional Resources

Himmelstein J, Lawthers AG, Peterson LE, Pransky GS. Quality and patient safety: Issues for children and adults with disability. Boston (MA): Agency for Healthcare Quality and Research;2001 Mar.

The Wisconsin partnership program: An integrated care model for people who are elderly and for people with physical disabilities. Princeton (NJ): Wisconsin Department of Health and Family Services and the Center for Health Care Strategies;2001 Apr.

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