As the pilot enters its second quarter, staff and residents are helping shape practical improvements designed to fit each community.
In May, we shared the story of the Wisconsin Initiative for Long-term Care Quality Advancement and Leadership (WiLQAL), the pilot program designed to help assisted living communities (ALCs) improve quality. Led by MetaStar in partnership with Leading Age Wisconsin, the Wisconsin Center for Assisted Living (WiCAL), the Wisconsin Assisted Living Association (WALA), the Disability Service Provider Network (DSPN), the Wisconsin Coalition for Collaborative Excellence in Assisted Living (WCCEAL) at the University of Wisconsin, and the Wisconsin Department of Health Services (WI DHS), the pilot is now in its second quarter.
WiLQAL has two goals: help change the culture around quality improvement and create sustainable changes within the 40 participating ALCs. These communities have often been left to navigate quality improvement on their own. WiLQAL offers hands-on support shaped around each community, its staff, and its residents.
After completing gap assessments, Jenna Heim and Penny Clary, long-term care project specialists in MetaStar’s Healthcare Transformation department, have been visiting participating ALCs to meet the leadership, direct care staff, and residents. While the second quarter data are still being analyzed, the response so far has been encouraging. “The reaction [from ALCs] has been positive from all aspects,” Heim said. “Direct care staff feels like their voice is being heard.”
Each ALC chooses measurable clinical outcomes to improve. Two of the most common are reducing medication errors and preventing falls.
“We’re finding a lot of struggles with medication timing as well as psychotropic medication administration,” Heim said. At one WiLQAL community, direct care staff must call and speak with a nurse whenever a PRN psychotropic medication is being administered. Rather than applying a generic solution, Heim used the LOCK model described in our previous article to build an intervention around that community’s actual workflow:
First, she Looks for the bright spots—things that are going well. She then uses those examples and the ALC’s own policies and procedures to create targeted training. “We know a big change is not going to be sustainable,” Heim explained. “We’ve Kept it simple by picking a very specific problem and an intervention to match.” Training is reinforced through Collaborating in huddles.
When Heim returns, she will Observe whether the change is sticking and whether the ALC needs additional training, policy changes, or other adjustments.
“We’re with the ALC until we’ve found the right solution that is sustainable for them,” said Emily Nelson, vice president of Healthcare Transformation at MetaStar. That ongoing support is central to WiLQAL. Rather than handing over a list of corrections and walking away, the team stays involved, which makes them different from consultants. “It’s implementation until it sticks,” said Nelson.
The same individualized approach can be applied to fall prevention.
At another ALC, root-cause analysis was not happening in real time. Nurses completing incident reports later often lacked enough information to determine what caused a fall, making it harder to choose an effective intervention.
Drawing upon her years of experience in skilled nursing facilities (SNFs), Heim suggested a simple addition to the incident report: a box where staff could draw the scene. Was a walker too far away? Did a resident become tangled in oxygen tubing? “It was a small change, but a huge help in finding effective interventions tailored to specific residents,” said Heim.
On-site visits to ALCs also allow Heim and Clary to see the environment themselves. At one adult family home, a resident regularly used steep stairs at the back door to go outside. This was where most of the resident’s falls happened. The intervention was simple: use the front door where those environmental hazards were not present.
Again, the answer was not a broad fall-prevention rule. It was a small change for that resident in that home.
“Going into this program, we felt very passionate about the need for improved quality in assisted living communities,” said Heim. However, the team quickly realized some communities need help not only with clinical outcomes but also with the structure of quality improvement itself.
As a result, WiLQAL’s change packages are evolving. “We’re diving deeper into policies, procedures, and development of the quality program itself,” Heim explained.
Other ALCs are starting from the opposite place: they may be using a quality improvement program created for an affiliated SNF or hospital. As the regulations for ALCs are a few pages compared to hundreds for an SNF, these ALCs can be asked to do much more than is required of them with less staff support. More focused policies and procedures “can better help them focus and prioritize,” said Heim.
Since Wisconsin has such few regulations for ALCs, some communities with fewer established systems may struggle to determine how to interpret the regulations for their particular situation.
“Nursing homes have guardrails that are really long because there are a lot of regulations,” Nelson explained. “While there’s a burden to that, there’s also a challenge to having few or no guardrails to guide an ALC.” WiLQAL aims to help reduce the administrative burden of changing regulations, interpretation, and application as appropriate for each ALC.
Being in the pilot stage has not stopped WiLQAL from looking at the goals and challenges that await them in the future. One challenge is that residents are entering ALCs with increasingly complex medical needs. “Skilled nursing facilities are turning into what hospitals used to be, and ALCs are turning into what SNFs used to be,” Heim said.
At the same time, ALCs are homes. Supporting higher-acuity residents cannot mean simply importing every feature of a hospital or nursing facility. “We can start adding alarms and fall pads, but we need to strike that balance,” Nelson said. The challenge is to provide the right level of care without losing the sense of home that makes assisted living different.
For Heim, one early visit captures why the work WiLQAL does matters. She and Clary were visiting a two-person ALC in Milwaukee. While speaking with the leader of the home, a resident joined them for an interview. During the interview, the woman starting singing gospel music she had learned living in the South.
“It was beautiful and heartwarming,” Heim said. “This is where I need to be, in this environment, seeing how happy this woman is, listening to her sing, and making a difference.”
WiLQAL’s work is about systems, policies, data, and measurable outcomes. But it is also about the people inside those systems. By listening to leaders, direct care staff, and residents, the program is helping ALCs find changes that fit their communities and can last. Because in assisted living, one size does not fit all. The best solutions begin by listening to the voices of the people who live and work there.
Jenna Heim, Long-Term Care Project Specialist, has been with MetaStar for 3 ½ years. As a Director of Nursing, one small change I made that made a big difference was eliminating the use of all fall alarms in the facility. Instead of relying on alarms as a standard first response intervention, the elimination required staff to think more deeply. Once they identified the root cause, they could develop individualized, person-centered interventions. This shifted our focus from a routine response to a more effective, evidence-based approach to fall prevention.
Emily Nelson is the Vice President of Healthcare Transformation at MetaStar and has been with the organization for 11 years. Her small-but-impactful change is an act of self-care before busy workdays: a large coffee and a large fountain Diet Coke ready at her desk. These beverages make her days a little brighter (and more caffeinated) while helping her keep things rolling at work.
Kate Schultz is a freelance writer who has been working with MetaStar for over two years. In her previous life as a high school teacher, she was often frustrated by the sound of sniffling noses during cold and flu season and the associated germs being spread around her classroom. She bought a big box of nice, soft tissues and a large bottle of hand sanitizer. For about $10, she helped her students stay healthier and germ-free.