Implementation and Sustainabiliy of Quality Improvement (QI) in Home and Community-Based Service (HCBS) Settings

Monday, 31 July 2017: 10:15 AM

Kathleen Abrahamson, PhD
School of Nursing, Purdue University, West Lafayette, IN, USA
Heather Davila, MPA
Center on Aging, University of Minnesota, Minneapolis, MN, USA
Christine Mueller, PhD
School of Nursing, University of Minnesota, Minneapolis, MN, MN, USA
Greg Arling, PhD
School of Nursing, Purdue University School of Nursing, West Lafayette, IN, USA


Home and community-based services (HCBS), defined as receipt of support services in one’s own home or other community setting, have been expanding rapidly since the 1980s, when the United States (US) Congress enacted section 1915(c) of the Social Security Act. Continued growth and expansion of HCBS and efforts to better integrate health and social services have sparked national interest in improving the quality of community-based services. Increasingly, QI processes are promoted by US agencies seeking to improve the quality “value” received from monetary investment. Within healthcare, the majority of QI efforts have taken place within hospitals, nursing facilities, and other institution-based care delivery environments. Across settings, nurses are often involved in leading QI efforts. Little is known about the implementation of QI in HCBS settings and it remains unclear whether QI principles can be effective within the variable, diffuse, individual-focused organizations that comprise the HCBS delivery network.

The objective of this study was to explore HCBS providers’ perspectives of organizational readiness for QI in regards to motivation, structure, capabilities and QI experiences early in the project implementation phase. Additionally, follow-up data was collected from HCBS providers six-months after project completion to gather provider perceptions of project impact, sustainability, and availability of resources to maintain improved processes and outcomes.

Multiple models of innovation uptake and change processes note organizational readiness as a key component in the success of organizational change efforts. The current analyses examine readiness at the organizational level using the constructs of organizational readiness: motivational readiness (perceived need for improvement and training, pressure to change from internal or external forces); institutional resources (adequacy of space, staffing, training and technology); staff attributes (efficacy, influence, adaptability and desire for growth among employees); and organizational climate (clarity of mission, staff cohesiveness, autonomy, stress, openness to change and open communication).


The sample for this study were participants (52 respondents within 27 provider organizations) in a state-sponsored QI program, the Minnesota Home and Community-Based Services Performance-Based Incentive Payment Program (HCBS PIPP), which funded QI projects developed by HCBS providers. The number of respondents per organization ranged from 1-4, with a mode of 2 per organization. Projects that were selected for funding through HCBS PIPP aimed to improve the quality of life of older adults and people with disabilities in a measureable way; improve the quality of services in a measurable way; and/or deliver good quality services more efficiently. Fifty-eight agencies applied for HCBS PIPP support and 27 projects were funded. Funded agencies varied considerably, ranging from large home care agencies with a wide consumer base to small social service agencies serving a narrowly defined population. Projects were funded initially for one year; 17 agencies completed their work in one year and the remainder received extensions of 3 to 12 months. The HCBS PIPP provided a unique opportunity to examine provider perspectives of organizational readiness for QI within a diverse set of HCBS organizations.

A pencil and paper survey addressing 17 domains of QI capacity, readiness, implementation and impact was administrated to participants attending a conference for HCBS PIPP participants in January, 2015 (about 6 months after the HCBS PIPP-funded QI projects started). The survey was designed to capture a comprehensive view of HCBS PIPP providers’ perspectives of their organization’s capacity for QI. Each of the 17 domains contained multiple survey items. Survey items were presented in Likert-scale format. At least 6 months after project completion a follow-up survey was delivered on-line to HCBS-PIPP funded organizations. This latter survey addressed perceptions of project impact, sustainability, and factors that were barriers and/or facilitators to project success.

Descriptive statistics and frequencies were calculated for each survey item. Independent t-tests were used to determine significant differences in means based on organizational characteristics. A p-value of ≤ 0.05 was considered to be significant. For purposes of analysis, organizations were coded based on five major characteristics: residential services delivery (versus non-residential services), population served (older adults versus not specifically older adults), amount or level of prior experience with QI, structure (multiple participating sites versus a single site), and project size (>100 consumers or < 100 consumers affected or served by the project). Analyses were performed using SPSS version 23.


The three factors most frequently noted as essential for QI participation were support from top leadership, having someone to write the HCBS-PIPP proposal, and having someone available to lead project planning. Top apprehensions surrounding participation in HCBS PIPP were choosing the right area for QI, coming up with a “really good” project, measuring quality, meeting project goals, and sustaining the project after funding. Primary resources needed by respondents to support QI included staff members who are trained in QI techniques and processes, as well as existing structures within the organization to manage QI implementation. Almost half of respondents reported making good progress in areas that were not yet fully established in their organization such as having a written description of their QI program (46%), and having a means to obtain consumer input (47%). Conversely, only 17% of respondents reported using a QI model such as the PDSA cycle or LEAN to guide their QI efforts and only 23% had a fully established evaluation plan for their QI project. It is notable that three fourths of respondents reported not having an established evaluation plan despite the HCBS PIPP projects being underway at the time of initial survey administration.

Respondents from organizations that provided residential services reported significantly less experience with QI implementation, greater use of root cause analysis, and increased use of internally-generated data reports to aid QI efforts than respondents from organizations providing only non-residential services. Respondents from organizations that served primarily older adults reported significantly more experience with QI implementation, greater use of root cause analysis, higher average organizational designation of someone with responsibility for QI, and less established identification of a set of quality areas that the organization wanted to monitor than those serving younger consumers. Additionally, respondents from organizations that served more than 100 consumers reported significantly more experience with implementing QI and more frequent designation of someone with responsibility for QI. Representatives from larger organizations (those serving > 100 consumers) noted connecting with other organizations to share ideas as a significant weakness and meeting the basic needs of consumers so there is more time to think about QI as a significant strength, in comparison to smaller organizations.

The follow-up survey addressing project sustainability, administered at least 6 months after project completion, revealed that most projects used project funds to hire a project coordinator, additional staff members, or to purchase/rent equipment. Most providers perceived significant improvements in quality within the project focus area, consumer quality of life, and consumer satisfaction. Although most noted that most of the project remained intact after completion of HCBS funding, funding project coordinator time and additional staff was a challenge. Turnover of staff and training newly hired staff was an additional concern. Those who were able to sustain parts of the project noted budgetary support from top leadership and redirection of resources toward the project to be successful strategies.


Internal resources available to support QI varied widely between participating organizations, with differences observed between smaller and larger agencies, as well as between provider types and populations served. Project funds were often used to provide additional staff, staff training and equipment. Directing funds toward tangible items became a challenge to project sustainability when funding concluded. Providers listed multiple innovative approaches to sustaining QI impacts after funding, and these approaches will be discussed in the presentation. Although implementing QI was perceived by respondents to have some sustained positive impact on organizational processes, follow-up research could explore the impact of QI implementation on the capacity of organizations for ongoing QI, as well as the influence on organizational climate in order to inform and direct future HCBS QI initiatives.