Developing standards to enhance

the quality of life of senior citizens

TATA EDUCATION AND DEVELOPMENT TRUST

Study Conducted by Samarth, Delhi & Technically Supported by UNFPA, Delhi

New Delhi
10th November, 2017
VISION, MISSION

To improve the quality of life of elderly people by decreasing their dependency and maintaining their
dignity, through caregiving, social and economic opportunities and an empathetic ecosystem

Deliver medical care and end of Provide access to affordable and

life care services Health Care reliable products and services;
and Wellness support R&D for innovative
solutions
Ecosys E
L
tem D Happy
Buildin E Ageing
g R
L Propagate and support the idea of
Y
Facilitate an elderly friendly happy ageing by improving
ecosystem by involving all Advocacy and awareness and providing avenues for
stakeholders Regulations engagement

Advocate standardized practices and regulatory mechanism in the caregiving sector

Longevity to not cause deterioration in the Quality of life or loss of Dignity

TATA TRUSTS
 Gap in Senior Living Facilities

GDP per Capita PPP

TATA TRUSTS
 List of experts & stakeholders met / interviewed
OAH OWNERS / MANAGERS GOVERNMENT OFFICIALS
(Interviewed 13 OAH owners / managers) (Spoke to 7 senior level government officials)
• Dr. Aastha Randev, Clinical Psychiatrist, • Mrs. Latha Krishna Rao, Secretary, MSJE
Hope Care India • Mrs. Ghazala Minai, Jt. Secretary
• Col. Achal Sreedharan, Managing Director, Social Defence & Media, MSJE
Covai Property Center India Pvt. Ltd. • Dr. K. Manivasan, Principal Secretary,
• Mr. Ankur Gupta, Joint Managing Director, Social Justice, Govt. of Tamil Nadu
Ashiana Housing Ltd • Ms. Geeta Kamthe, Jt. Director
• Ms. Neelam Mohan, Founder, Directorate of Social Justice, M.P. Govt.
Panchvati Old Age Home, Delhi • Mr. M. Jagadeeshwar, Secretary,
• Dr. P.C. Raju, Director, Women Development & Child Welfare, Telangana govt.
Arogya Kudumbam, Coimbatore • Ms. V. Nirmala, Jt. Sec. to Telangana Govt.
• Mr. Pankaj Kumar, Manager , Dept for Women, Child, Disabled & Elders
Har-Mit Old Age Home, Delhi • Mr. V. J. Dharmadhikari, Chairperson
• Mr. R. Thakur , Manager, Varisht Nagarik Kalyan Aayog, Madhya Pradesh
Rana Old Age Home, Delhi
• Mr. Saumyajit Roy, Antara Senior Living
• Ms. Suchismita Panda, Manager,
The Golden Estate, Gurgaon
47SENIOR
stakeholders met / interviewed and
LIVING FACILITIES
(Visited 18 senior living facilities)
• Mr. Edward Esguerra, Manager,
Autumn Grove, Texas 18 senior living
• Aarogya facilities
Kudumbam, Coimbatore / developments visited
• Antara Senior living, Dehradoon
• Ms. Kristen S. Kima, Administrator,
• Ashiana Housing, Bhiwadi
Apex Oaks, Texas
• Covai Care, Coimbatore
• Ms. Lynn A. Gillespie, Administrator,
• Epoch Assisted Living, Delhi
St. Dominic Village, Texas
• Melanie Heathcock, Director, • F.S. Parukh Dharamshala, Mumbai
• Har-Mit Old Age Home, Delhi
Autumn Leaves Memory Care OAH, Texas
• Hope Care India, Delhi
• Justice H. K. Chainani Elder’s Home, Mumbai
• Panchvati Old Age Home, Delhi
MEMBERS OF SENIOR CITIZEN • Rana Old Age Home, Delhi
ASSOCIATION • Sandhya Old Age Home, Delhi
• Mr. D. N. Chapke, Secretary General (AISCCON) • Salvation Army Old Age Home, Mumbai
• Mr. J.R.Gupta, President, • The Golden Estate, Gurgaon
Senior Citizens Council of Delhi • Apex Oaks Assisted Living and Memory Care, Texas, US
• Mr. Mohan Gulrajani, President, • Autumn Grove Katy Cottage, Texas, US
DLF City Senior Citizen Council • Autumn Leaves Memory care OAH, Cinco Ranch, Texas, US
• St. Dominic Village, Texas, US
EXPERTS & ACADEMICIANS
(Interviewed 24 national and international experts)
• Dr. Aarati Saxena, Asso. Prof. , Delhi University
• Dr. Anil Jauhri, CEO, NABCB
• Dr. Biranchi Jena, Adjunct Prof.,
Symbiosis Inst. Of Health Sciences, Pune
• Mr. Dev Bharat, Director, Sanctus Healthcare
• Dr. Gayatri Vyas Mahindroo, Director, NABH
• Dr. Harish Nadkarni, CEO, NABH
• Mr. Mathew Cherian, CEO, Helpage India
• Dr. Murlidhara C P, AGM – Senior Living
Operations, Ashiana Housing Ltd.
• Dr. R. Gambhir, University of Pune
• Dr. S. Siva Raju, TISS Hyderabad
• Mr. S. Premkumar Raja, Director (Admin),
Nightingales Home Health Services Pvt. Ltd.
• Ms. Annette Betz, Administrator, The Medallion
Assisted Living Facility, Texas
• Dr. Carmen Castro, Houston-area Managing
Ombudsman, Texas
• Mr. Calvin Green, Director, Regulatory Policy,
Rules and Curriculum Development, Texas
• Mr. Gary Jones, CEO, Age-UK Camden
• Prof. Martin Green, CEO, Care England
• Ms. Lakshmi Kaul, India advisor to British
Parliamentarian
• Mr. Mark Kendall, Regional Director for Regulatory
Services, Texas
• Ms. Melissa, Administrator at Tuscany Villas
Assisted Living Facility
• Ms. Patty Ducayet, State Long-term Care
Ombudsman, Texas
• Mr. Robert Ochoa, Administrator, DADS, US
• Dr. Rohit Verma, Professor and Executive
Director, Cornell Institute for Healthy Futures,
Cornell University
• Mr. Sun Kai, PhD scholar, Renmin Univ. of China
• Dr. Zuo Meiyun, Member of National Committee of
Ageing, Beijing, China

2
 Key activities this
Methodology week

• Collection of secondary data and review of facilities in various parts of

India
• Comparative study of standards in UK, USA, China, Singapore,
Hongkong, Mexico and Malaysia
Data
• Discussion with key stakeholders-OAH owners/managers, senior
Collection
housing project developers, senior citizen associations, academics,
experts and government officials Hypo-
thesis
• Comparative analysis of standards in OAHs based on sampling
• Selection of design principles, themes and, frameworks for
Analysis and implementation of standards
Inference • Identification of organizations that can play a role in regulating standards

• Development of detailed hypothesis with definition of minimum

standards with a specified grading system Report
Interpretation
• Validation of minimum standards with a sample of senior living facilities
Validation
• Operationalisation plan for administering the standardst
Integration

3
 Learnings for defining standards

Policies are focused on desired outcomes, ensuring independence and empowerment of elders

Process oriented system with performance based compensation

Mandatory compliance for licensing from state government, enforced by Ombudsmen

Heavily subsidized
Infrastructure oriented standards enforced by government

Mandatory minimum standards

Strictly enforced by government through random inspections

Strictly regulated licence to operate

Enforced through random inspections by government body and heavy penalty for non compliance

Policy of discouraging institutionalization of elders.

Focus on disease prevention, active aging in place, ensuring financial independence and trained staff

6
 Summary of key themes adopted internationally

Theme UK US China Hong Singapore Mexico Malaysia Tamil Nadu

Kong

Choice & - -
Information

Health &
Personal Care

Daily Life and -

social activities

Complaints and - - -
Protection

Infrastructure &
Environment

Staffing

Management &
Administration

Exceptionally emphasized Moderately emphasized Weakly emphasized - Not emphasized

5
 Interviews – Key takeaways

“Keep the “Use a blended model of

system simple” • Standards must go beyond infrastructure to include safety, implementation.
Community involvement
hygiene and dignity of elders will be helpful”

• Standards must be designed to ensure physical,

psychological and social empowerment of elders “Make accreditation
Standards are very critical
–The sector is entering a mandatory for all
OAHs”
high-demand phase and
need to ensure quality
• Government must be a key partner in implementation of
care standards
“Design a graded
• Standards/guidelines should be created considering different system but have
minimum standards for
categories of OAHs existing today all OAHs”
“Create legislation to
implement standards”
• Affordability needs to be a consideration in defining the
minimum requirements to operate
“Senior citizen groups
should be nodal • Standards should be easily quantifiable and input oriented – “Emphasize on
recruitment system and
agencies for easy to implement training of staff”
implementation”
 Sampling and Inferences
Gathering insights on present conditions of OAHs through surveys and
Chandigarh stakeholder interviews
List of OAH surveyed:
Delhi NCT region
• Rana Senior Citizen Home
• Sandhya Old Age Home
• Har-Mit Senior Citizen Home
Delhi NCR • Panchvati Old Age Home
• Epoch Assisted Living
• Hope Care India
Chandigarh (Sangrur)
• Apna Ghar (All India Pingalwara Charitable Society)
Coimbatore
• Vishvanathan Chettiar home for the aged
• Aarogya Kudumbam, Mangarai
• Covai care – multiple facilities
Bhopal Mumbai
• Salvation Army Old Age Home
• F.S. Parekh Dharamshala (run by Bombay Parsi Punchayet)
Hyderabad • Justice H.K.Chainani Elders Home
Kolkata
• St. Joseph’s Old Age Home
Indore
• Aastha Vridh Seva Ashram
Kolkata Pune
• Missionaries of Charity Old Age Home
Mumbai
Indore Survey criteria:
• Registered under Society Registration Act : Yes / No
Pune • Type of accommodation: Single, Double, Dormitory
• Govt. Aided: Yes / No
• Type of ownership: Govt. / NGO / Private
• Type of food: Veg, Non-Veg or Both
• Price point: Low/Mid income, Luxury
Coimbatore • Capacity >50 residents: Yes / No
• Type of medical services provided:
Doctor on call / Special needs / Rehabilitation facilities / Tie-up with hospitals
• Type of stay: Day-care / short-term / long-term stay
 Importance of qualitative aspects in elder care

Epoch Assisted Living (Gurgaon) Har-Mit senior citizen home (New Delhi)

A set of 12 high end apartments boasting modern
infrastructure and amenities with 24 x 7
attendant. Medical care is provided by Medanta
hospital and billed separately.
Rent: INR 1.5 lacs per month (approx.)
A closely knit group of 12 residents, basic well
maintained infrastructure with complete autonomy
and customized care plans.
Rent: INR 30,000 per month

In spite of providing an ultra-modern infrastructure in Epoch Assisted Living, the relatively

happier residents of Har-Mit senior citizen home underscores the statement of Prof. Martin
Green (CEO–Care England), that standards in OAHs must go beyond the infrastructure
to include qualitative aspects like safety and dignity of elders as the cornerstones of
elder care policy
 Framework for developing a system of standards
The following three components are critical to the framework:

What should the standards be?

Qualitative vs quantitative
Objective vs subjective
Detailed descriptions

Who should be responsible for monitoring, implementation and

accreditation?
Government
Independent regulator
Industry body
Civil Society

How should OAHs participate?

Mandatory
Voluntary
Hybrid
 Our Hypothesis - STANDARDS

Study of elder care

standards in different
• Ask six core questions:
countries and analyzing the
pros & cons 1. Is it safe?
2. Are physical needs met?
3. Are emotional needs met?
Discussion with experts,
central and state 4. Is it caring?
government officials 5. Is it well managed?
6. Is it responsive?
Interviews with Old Age
Home operators,
attendants and • Combine outcome oriented and input based standards
management • Define minimum standards required for basic yet effective elder
care which are mandatory for Economy and Luxury. Give time for
Shelters to upgrade to minimum standards
Consultation with senior
citizen groups • Detail standards over 4 levels for a ratings based system
 Preliminary insights from field testing

Commonly met standards

• Food, wheel chair and first aid are provided
18 24 • Have tie ups with ambulance service providers
senior reviewers • The manager is able to handle old age related issues
living from the • Financial records are kept updated in a verifiable condition
facilities community • Maintains atleast 50% occupancy
mapped

Common gaps
• Lack of social activities, community connect etc Gaps easy to fill
10 14 cities • Lack of sensitization in staff and awareness of resident’s rights with cost effective
interventions like
states
across
• No provisions for abuse prevention, registering complaint awareness, and
tiers • Lack of hygiene in sleeping area / kitchen / toilets guidance
• Lack of relevant registrations and verifiable records
• No grab rails and lack of safe drinking water
• No gender separation of sleeping area / toilets
Adherence to recommended

100
minimum standard (in %)

80
60
40
20
0
Is it safe Are physical Are emotional Is it caring Is it well Is it responsive
needs met needs met managed
SLF 1 SLF 2 SLF 3 SLF 4 SLF 5 SLF 6 SLF 7
 Insights from other sectors

Healthcare ISO
1. Accreditation is voluntary 1. Accreditation is voluntary
2. Standards are monitored by 3rd party 2. Key stakeholders are: Industry
accreditor, NABH (looking for compliance), Auditors
3. Variations in compliance across urban (implementing the standards) and
and rural India as well as public and Consultants (helping to create
private healthcare providers standards)

Hospitality Higher Education

1. Accreditation is 1. Accreditation is mandatory within
voluntary six months of establishment
2. Industry follows a hybrid 2. Accreditation is linked to receiving
model of mandatory and central and state government
voluntary standards grant-in-aid
3. Strict enforcement by 3. Different bodies for accreditation
3rd party monitoring and regulation e.g.
body like HACCP • Accreditation: NAAC, National
4. Rating system for Board of Accreditation etc
service quality • Regulation: UGC, AICTE etc

Strong role of a separate 3rd party accreditor to ensure implementation of standards

 Our Hypothesis - IMPLEMENTATION

• Mandatory Registration and compliance with MINIMUM standards along with annual self-
declaration
 Better compliance with minimum standards
 Information transparency and availability to public and users
• Third-party for accreditation
 Publicly accountable
• Accreditation mandatory for receiving government and private aid/donations
 Encourage and incentivize compliance
 Assists donor/aiding organizations
• Monitor standards through local ombudsmen (volunteers）
 Involves civil society meaningfully
 Accessible and inexpensive
 Quick and direct conciliation
• Ombudsmen program, training of ombudsmen to be run through accreditation body
 Maintaining an effective long-term care ombudsman program
• Training & certification of sector workers and professionals
 Build capacity which is sorely missing
 Achieve uniform quality of care over time
• Establishment of model OAHs
 Laboratory and experiential learning opportunity, open-source processes and practices
 Implementation Road Map
No Initiative Responsible for implementation
Relevant Ministry (Central government);
1 Notification for creation of standards & accreditation system
adopted by State Governments
2 Appointment of an accreditation agency/board Relevant Ministry (Central government)
Accreditation agency (with support from a
3 Detail and translate the recommended set of standards into auditable format
sector expert group as needed)
4 Develop audit guidelines for facilities as well as auditors (like the NABH manual for accreditation standard) Accreditation agency
Relevant Ministry (Central government);
5 Notification for operationalizing the standards and accreditation system
adopted by State Governments
6 Establish a timeline for compliance to the recommended minimum standards Relevant Ministry (Central government)
7 Appoint auditors/accreditation partners as per plan Accreditation agency
Create a portal for self-reporting and filing of information by senior living facilities for voluntary accreditation
8 Designated expert agency
and star rating, followed by workshops for effective self-reporting
9 Initiate process for inviting application for accreditation Accreditation agency
10 Initiate the process for inviting application for local care “Ombudsmen” Accreditation agency
11 Develop training modules and model documents for ombudsmen and auditors Designated expert Agency
12 Initiate accreditation process for volunteered facilities Accreditation agency
13 Monitor the accredited facilities Ombudsmen
Develop model programs for senior living facilities. These programs will be customized to the facilities opting
14 for it and will help in upgrading their service qualities to meet the mandatory minimum standards. The Sector Expert Agency
program will also assist the facilities to apply for voluntary accreditation and get rated suitably
15 Develop and initiate e-learning module to train staff for effective implementation of standards Sector Expert Agency

Establish a model senior living facility implementing the recommended standards and providing experiential
16 living for residents. This will act as a case study for other facilities across the country, learning from the best Sector Expert Agency* & Tata Trusts
practices, customizing the insights to their needs and scaling up the impact.
17 Increase the scope of accreditation standards to include all 9 formats of senior living facilities in India Sector Expert Agency

18 Extend to cover other formats of senior living facilities such as hospices, nursing homes etc.
THANK YOU
 Minimum Standards: Is it safe EXAMPLE

Key Result Performance Area Minimum Standards / 1 Star (Mode of verification)*

Area
1.1.Fall and accident A. Provides grab-rails in bathrooms, corridors, stairs and other relevant locations (O)
Is it safe?

prevention aids B. Has provisions to prevent skidding in wet areas (O)

C. Provides at least 1 wheelchair in a well maintained working condition (I)

1.2.Hygiene and A. Ensures safe drinking water for all residents (O)
infection control B. Establishes and maintains infection control procedures designed to help provide a safe and sanitary environment and to help prevent the
development and transmission of disease (O + I)
C. Hand washing facilities are prominently located (O)
D. Provides closed bin for garbage collection (O)
E. Provides measures for mosquito control (O)
F. Maintains a checklist of cleanliness and infection control procedures (O)

1.3. Medication control A. Has a safe, lockable space for storage of medicines (O)
B. Ensures medicines and supplies for emergency first-aid are easily accessible (O)

1.4.Fire protection A. Emergency evacuation plan for the facility is documented and displayed with instructions written in language(s) understood by resident (O)
and emergency B. All the staff are familiar with the evacuation process (I)
evacuation
C. Residents are familiarized with evacuation process on admission and periodically (I)
D. At least emergency light is operational in case of power breakdown (O)
E. Designated person is available at all times to assist any resident who is not physically fit to evacuate independently (O + I)

1.5.Protection against A. A policy for protection of residents against all forms of abuse (physical, financial, material, psychological and sexual) is available and displayed (I)
abuse (a model policy could be drafted)
B. Displays prominently the rights of residents in language(s) understood by residents (a model bill of right could be drafted) (O)
C. Has an appointed committee, with atleast one external member, to address any issues of abuse; contact numbers, email-ids for complaint are
displayed and provided to the residents and their family members through facility information booklet (O + I)
D. Ensures all staff and workers (whether permanent or on contract) are police-verified (I)
 Minimum Standards: Are physical needs met
Key Result Performance Area
Area
2.1.Food
Are physical needs met ?
(this standard should be
applicable to facilities where
residents are required/
dependent to take food
compulsorily from the facility)
2.2.Sleeping space
2.3.Toilet and bathing
facilities
2.4.Other spaces and
facilities
2.5.Premises
2.6.Health services
EXAMPLE
Minimum Standards / 1 Star (Mode of verification)*
A. Week-wise menu is displayed for three meals a day (O)
B. Provides food (nutrition and hydration) that meets minimum daily calorie requirement of an average senior citizen of that age and gender (I)
C. Food meets basic requirements of hygiene and health (I)
D. Kitchen, if on premises, is kept clean, ventilated, hygienic and free of pests & rodents (O)
E. Appropriate utensils for preparing and serving food are available (O)
A. Keeps the room clean, well-lit and ventilated which is enclosed and covered (O)
B. Provides clean mattress, pillow and cover/blanket (O)
C. Provides gender separation of sleeping facilities (O)
D. Ensures the following standards for sleeping space (O)
-Provides atleast 6 sq.m of space per resident for single-occupancy room
-Provides atleast 4 sq.m of space per resident for multiple occupancy room
-Ensures that there is atleast 2m space between walls of the room
-Ensures that there is atleast 2.5m space between the floor and ceiling of the room
A. Toilets are cleaned and functional 24X7 (O)
B. Has separate facilities for men and women (O)
C. Toilet and bathing areas are well lit (O)
A. There is a common space for residents to congregate for dining and/or other activities (O)
A. Is accessible by wheel chair (O)
B. Entrance is well lit and marked; Entry and exit is secured/controlled with automatic devices or a security guard (O)
A. General practitioner is available on call in case of emergency (I)
B. Has an identified hospital for meeting emergency and other hospital care needs of the residents (I)
C. Emergency ambulance is available on call 24X7 (I)
D. Maintains record of age, allergies, pre-existing medical conditions, weight, and blood group at time of admission and key health related events
of residents thereafter (O)
E. Has a documented protocol for informing the family member in case of health emergencies (I)
 Minimum Standards: Are emotional needs met
EXAMPLE

Key Result Performance Area Minimum Standards / 1 Star (Mode of verification)*

Area
3.1.Recreational A. Space is provided for recreation within the facility, or arrangements are made for residents to engage in exercise and recreation activities in the
Are emotional needs met ?

facilities vicinity every day (O + I)

3.2.In-home activities A. Some social engagement activities are organized on a periodic basis (atleast once in 3 months) for the residents (I)
and outings

3.3.Enabling family A. Has a policy to promote interaction with community (I)

and community
connect

3.4.Psychological NA
support
 Minimum Standards: Is it caring
EXAMPLE

Key Result Performance Area Minimum Standards / 1 Star (Mode of verification)*

Area
4.1.Caring and A. List of do’s and don’ts for the staff is articulated and displayed (O)
Is it Caring?

supportive staff B. Has a policy of monthly briefing on treating senior citizens with care and respect (I)

4.2.Privacy and A. Has a clearly defined procedure for handling situations of death (I)
dignity B. Allow residents to exercise independence and choice in ADLs as far as possible (O + I)
 Minimum Standards: Is it well managed EXAMPLE

Key Result Performance Area Minimum Standards / 1 Star (Mode of verification)*

Area
5.1.Staffing A. Has a designated manager/in-charge available during normal working hours who supervises the following activities supported by staff:
Is it well managed?

-Communicate effectively with the residents (I)

-Maintain procedures and policies applicable to the facility (I)
-Administer and execute occupational ADLs (cleaning, dusting, cooking, gardening and yard work) (I)
-Support self-care ADLs (grooming, bathing, dressing, oral-care and eating) with gender considerations (I)
-Provide first-aid and basic health -related assistance (I)
B. Has policy for recognizing performance of staff and managing consequences (I)
C. Clearly communicates roles and responsibility to the staff (I)
D. Facility manager/in-charge is conversant with age-related issues, and physically capable of dealing with the residents (I)

5.2.Record keeping A. Keeps verifiable records of the following (O)

-policies & procedures
-staff and staff roster
-medical events for residents
-financial transactions with residents
-death
-food menu
-sourcing of food items (milk, grains etc) for residents
-visitors
-feedback and complaints

5.3.Transparent A. Provides clear terms and conditions detailing services provided and cost to residents and their families which are documented in an agreement/
documentation and form (can have a model agreement) (O)
information
B. Displays the charter of residents’ rights prominently (O)
availability
C. Files information annually as statutorily required (I)

5.4.Advisory board NA
 Minimum Standards: Is it well managed EXAMPLE

Key Result Performance Area Minimum Standards / 1 Star (Mode of verification)*

Area
5.5.Financial condition A. Attains atleast 30% occupancy rate within 5 years of establishment and maintains that minimum thereafter (applicable only if the facility receives
Is it well managed?

and occupancy any aid or concession in any form) (O)

rate

5.6.Essential utilities A. Facility has regular connections for electricity and water (I)

5.7.Competence of A. Ensures that the designated manager is of good character, physically and mentally fit, and is literate and educated to deal with the residents. A
manager minimum 10th pass education is desirable (I)

5.8.Quality NA
assurance
 Minimum Standards: Is it responsive EXAMPLE

Key Result Performance Area Minimum Standards / 1 Star (Mode of verification)*

Area
6.1. Complaints A. Must have a formal procedure for reporting, handling and responding to complaints and feedback related to service and infrastructure (I)
Is it responsive?

redressal B. Must maintain records of action taken and timelines (O)

6.2.Personalised care NA

6.3.Residents’ A. All residents are informed of decisions and information relating to changes affecting food, living area and staff (I)
participation in
decision making

*Where,
(O) = By means of observation, ( I ) = Through interview of stakeholders / asking questions, NA = Not Applicable
BACKUP
Operating model: UK
Evolution of elder care system
• The Care Quality Commission is the independent regulator of health and adult
social care in England.
• In 2009, three separate commissions: the Commission for Social Care Inspection
(for social care services), the Healthcare Commission and the Mental Health Act
Commission were merged and CQC (Care Quality Commission) was established
• UK Govt’s Care Act Legislation proposed that no one will have to pay any more for
their eligible elder care needs to be met once they have spent a total of £72,000
(Lifetime cap on elder care costs) and that anyone with less than £118,000 in
savings will in future be entitled to at least some financial support to help pay their
care costs if they need to enter an elder care home
Implementation
• Health and Social Care Act 2008 mandates all elder care service providers to
register with the CQC and meet a set of minimum service quality standards
• The CQC recently embarked on a special programme of 250 unannounced
inspections of elder care services in senior living facilities
• CQC implements through a team of 3 chief inspectors and 4 deputy chief
inspectors each leading a team of approx 200 inspectors.
• The elder care policy is resident-centered, requires expert inspection, and is
supplemented by star ratings from RDB
Key Initiatives
• The National Adult Social Care Survey has used ASCOT to survey all facility
users. ASCOT is a tool designed to capture information about elder care outcomes
focusing on items such as cleanliness and comfort, good nutrition, safety, control
over daily life, social interaction, occupation, accommodation and dignity.
• A 2009 national project named “Action on Elder Abuse”, tasked safeguarding
teams in local councils with responsibilities for raising alerts in case of abuse. The
team consists of Civic mayor, Councilor elected by community and council officers
• In 2011, the “Statement of Government Policy on Adult Safeguarding” set a new
framework for elderly protection, based on six principles: protection,
empowerment, prevention, proportionality, partnership and accountability
• The 2012 White Paper “Caring for Our Future: Reforming Care and support”
clarifies legal responsibilities by requiring each local authority to establish a
Safeguarding Adults Board (SAB)
• CQC recently discontinued star rating ranking care providers/facilities. Care homes
now pay independent bodies like RDB, PQR and Assured Care for rating them
• CQC now assesses care providers/facilities simply as compliant or non-compliant
with the essential standards, and no organization provides information on the
quality of care beyond this. CQC is also warning the facilities against getting rated
by independent bodies.
 Operating model: China (Beijing)

Evolution of elder care system

• In 1984, Beijing established the Committee for Aged People to
Ministry of Civil Affairs of PRC develop elder care policies that later became Committee of Service
OAHs for Aged People in 2000.
• In 1996, Leadership group for Aged People was established to
develop elder care system focused on infrastructure and incentives
• In 1999, China National Committee on Ageing was created to
● Certification implement elder care standards and monitor the same
● Protection of the Elderly Law Bureau of Civil Affairs (3 years) Implementation
● Measures for Licensing/ (State/Municipalities) ● Awards • In 1999 the Ministry of Civil Affairs released the Provisional Measures
Administration/ Regulating OAHs for the Management of Social Welfare Institutions; the elder care
regulatory structure based on three major policy documents - Code
for Design of Buildings for Elderly Persons jointly developed by
Ministry of Housing and Urban-Rural Development and the Ministry of
Civil Affairs, Basic Standards for Social Welfare Institutions for the
Bureau of Civil Elderly and National Occupational Standards for Old-Age Care
● Regulation on Service Charges Rate Workers drafted by the Ministry of Civil Affairs and approved by the
● Code of Practice Affairs (District) Ministry of Labor and Social Security
● Star-rating Standards • Elder care policy is focused on “3 No’s” i.e. people with no children,
5 star
no income, and no relatives, who are eligible for the “5 Guarantees”-
food, clothing, housing, medical care, burial expenses
4 star • Implementation happens across three tiers : home-based care as the
“basis,” community-based services as “backing,” and institutional care
Register Implementation Inspection Rating 3 star as “support.”
Key Initiatives
2 star • In 2011, Govt. implemented “9064” framework for elder care
development plan i.e. 90% elders expected to live with own families,
6% expected to get support from community and 4% expected to live
Bureau of
● Assessing documents ● Capacity 1 star in senior living facilities
Quality and ● Utility
● Onsite inspection • Govt delivered a coupon worth US$ 15 per month to 80+ population
Technical ● Infrastructure
● Survey to elderly ● Staffing ensuring 5 basic services; daily care, housekeeping, recovery care,
Supervision
education and mental support
• Govt started to appraise and incentivize 10000 people and 1000
companies annually for exemplary elder care
Incentives • Extended 11 preferential treatments for elderly like free transport,
OAHs - Awards healthcare, legal services, entertainment etc
- Pricing • National policy initiatives attempted to develop community-based
elder care services e.g. the Starlight Program, under which the Govt.
invested US $2.1 billion to build 32,000 Starlight Senior Centers
nationwide.
• More recently, Virtual Elder Care Home or Elder Care Home without
Walls, has gained popularity in China; a triage system where services
are initiated by phone calls to a local government–sponsored
information and service center, which then directs a qualified service
provider to the elder’s home.
 Operating model: USA
Evolution of elder care system
• The present elder care system was developed in 1986 after the
establishment of Omnibus Budget Reconciliation Act of 1987 (OBRA ’87)
• Most significant high-level change was the shift toward resident-focused,
outcome-oriented, performance based standards.
Statues • A five-star quality rating system has been added since Dec 2008.
Statues Standards • The 2010 PPACA health reform law included provisions to make filing
Federal State complaints easier for residents
Implementation
government government • Standards are governed by federal statutory requirements and regulations,
Rating metrics but the task of monitoring compliance with these standards falls on the
Rating metrics states
Stakeholders • Accreditation is done by the Joint Commission, a non-profit standard-setting
(Companies, and accrediting entity
• Ombudsmen act as advocates of old people and makes complaint
users etc.) redressal faster, more effective
Key Initiatives:
• The mandatory implementation and submission of the Minimum Data Set
Rating based on reports (MDS) is one of the most crucial quality requirements set by the OBRA ’87
• Nineteen quality measures, generated out of the Minimum Data Set (MDS),
are used for public reporting, highlighting things such as ADL change,
Licensing with mobility change, high-risk pressure ulcers, long-term catheters, physical
State restraints, urinary tract infections, and pain
mandatory OAHs • The Centers for Medicare and Medicaid Services launched a website,
government implementation Home Health Compare, in fall 2003 that publishes 11 quality measures
(ADL management, pain and pressure ulcer treatment; preventing harms
and preventing unplanned care)
• Medicaid agencies have implemented performance-based compensation in
Inspection and enforcement: their reimbursement of Medicaid-certified facilities
Ombudsmen - Frequent and unannounced • In 2015, Texas Health and Human Services (HHS) began a reorganization
(Independent entity) visit (4-10 times/year) to produce a more efficient, effective, and responsive system. The goal of
- Talking with residents the transformation was to create a system that is easier to navigate for
people who need information, benefits, or services and breaking down
operational silos for better service integration. As part of this initiative,
Texas Department of Aging and Disability Services (DADS) function has
been moved to HHS effective Sept 2017
 Operating model: Joint Commission, USA
Joint Commission’s Accreditation Process:
The Joint Commission’s accreditation process seeks to help facilities identify risks to quality and resident safety — including risk previously unknown to the facility— by
conducting a meaningful assessment, and to inspire them to improve their care and services.

Standards development process: The Joint Commission’s standards set expectations for facility’s performance that are reasonable, achievable and surveyable
The standards development process includes the following steps:
• Emerging quality and safety issues suggesting the need for additional or modified requirements are identified through the scientific literature or discussions with The
Joint Commission’s standing committees and advisory groups, accredited organizations, professional associations, consumer groups or others.
• The Joint Commission prepares draft standards using input from technical advisory panels, focus groups, experts and other stakeholders.
• The draft standards are distributed nationally for review and made available for comment on the Joint Commission website.
• After any necessary revisions, standards are reviewed and approved by executive leadership.
• The survey process is enhanced, as needed, to address the new standards requirements, and pilot testing of the survey process is conducted.
• Surveyors are educated about how to assess compliance with the new standards.
• The approved standards are published for use by the field.
• Once a standard is in effect, ongoing feedback is sought for the purpose of continuous improvement.

Survey process: Joint Commission surveys are unannounced, except initial surveys. During the on-site survey, Joint Commission surveyors evaluate an organization’s
performance of functions and processes aimed at continuously improving outcomes. They do this by tracing the care delivered to residents served, reviewing information
and documentation provided by the facility and observing / interviewing staff as well as residents. A facility can have an unannounced survey between 18 and 36 months
after its previous full survey. The survey agenda includes activities such as:
• Survey-planning session
• Opening conference and orientation to the organization
• Leadership session
• Tracer methodology. The cornerstone of The Joint Commission survey, the tracer methodology uses actual residents served as the framework for assessing
standards compliance.
• Individual tracers follow the experience of care for individuals through the entire care process
• System tracers evaluate the integration of related processes and the coordination and communication among disciplines and departments in those
processes. The system tracers are specific time slots devoted to in-depth discussion and education regarding the use of data in performance
improvement (as in core measure performance and the analysis of staffing), medication management, infection control and other topics of interest
• Competence assessment process
• Environment of care session, which includes an infrastructure observation tour
• Exit conference, during which the survey team presents a written summary of the survey findings

Post Survey process: The survey findings are posted on the Joint Commission’s extranet. If no requirements for improvement (RFIs), then the accreditation decision
becomes official at the same time that the facility’s summary report is available, and is effective the day after the completion of the survey. If a facility receives RFIs, then
the accreditation decision is made after the submission of an acceptable evidence of standards compliance (ESC) report