11

Commentary on long Commentary on long Term Care QualityTerm Care Quality

A Provider PerspectiveA Provider Perspective

Bradley ShiverickSecond National Medicaid Congress

– June 14, 2007

22

A Brief Overview of Initiatives A Brief Overview of Initiatives and Progress on Long Term and Progress on Long Term

Care QualityCare Quality

Nursing Home Reform Act – 1987Prospective Payment Implications –

1999Quality First – 2002Nursing Home Quality Initiative –

2002Advancing Excellence – 2006Programs and Progress

33

IOM Study 1986IOM Study 1986

1986 Institute of Medicine ReportImproving the Quality of Care in Nursing

Homes

Recommendations– Stronger Federal Role in LTC Quality– Strengthening of Performance

Standards– Training Standards for Staff– Improved Resident Assessment– Strengthened Regulatory Process

44

First… There was OBRAFirst… There was OBRA

Minimum Regulatory Standards for LTC

Process Standards for:– Quality of Life– Quality of Care– Support for Activities of Daily Living– Resident Rights– Resident Assessment– Physical and Chemical Restraints– Regulatory Process and Remedies

55

Regulation and Regulation and EnforcementEnforcement

~ 150 Individual RequirementsAnnual, Complaint and Incident

SurveysCycle of ComplianceScope and Severity – 1995Outcomes Focus (Double “G”) –

1999Revised Outcomes Focus – 2006 Minimal Standards and Penalties

66

Prospective PaymentProspective Payment

1998 – 1999 Prospective Payment System(Medicare)– RUGS – III System – 44 Utilization Groups– 10% of all US Nursing Homes Under

Bankruptcy Protection– Five of Top 7 LTC Firms Under

Bankruptcy– Significant Pressure on Resources– Quality Indicators Introduced Nationally

77

1999 Nursing Home Quality 1999 Nursing Home Quality IndicatorsIndicators

24 QIs in 11 Domains24 QIs in 11 Domains Accidents Clinical Management Cognitive Patterns Elimination/

Incontinence Infection Control Nutrition/Eating

Behavior/Emotional Patterns

Physical Functioning Psychotropic Drug

Use Quality of Life Skin Care

www.medicare.gov/nhcompare

88

99

Quality First Pledge - 2002Quality First Pledge - 2002

Strategic Alliance Between Major Provider Groups to Improve Quality– American Health Care Association

(AHCA)– American Association of Homes and

Services for the Aging (AAHSA)– Alliance for Quality Nursing Home

Care (AQNHC)

1010

Quality First - 2002Quality First - 2002

Seven Core Principles– Continuous Quality Assurance and

Quality Improvement – Public Disclosure and Accountability – Patient/Resident and Family Rights – Workforce Excellence – Public Input and Community

Involvement– Ethical Practices– Financial Stewardship

1111

Alliance for Quality Nursing Home Alliance for Quality Nursing Home CareCare

QF Code of Conduct and Ethical QF Code of Conduct and Ethical PracticesPracticesCommitment to Patient Well-Being

Through Quality Care Leadership Commitment to Quality – Continuous Quality Improvement – Quality Improvement Goals – Uniform Measures of Quality

Public Disclosure and Accountability – Patient and Family Rights Workforce Excellence –

Employee Recruitment, Assessment. Employee Training. Commitment to Employees

Public Input on Quality:Ethical Practices Financial Stewardship

1212

Quality First Pledge - 2002Quality First Pledge - 2002

Expected Outcomes– Compliance with Federal

Regulations– Financial Integrity and Reduction in

Fraud– Improvements in Abuse and Neglect– Improvements in Clinical Outcomes– Customer Satisfaction– Employee Retention

1313

Nursing Home Quality Nursing Home Quality Improvement Initiative - 2002Improvement Initiative - 2002

CMS Led Initiative to Improve Quality– Regulation and Enforcement– Consumer Information on Quality of Care

Improved Quality Measures

– Community Based Quality Improvement QIO Role

– Assistance with Clinical Processes– Clinical Collaboratives– Culture Change Initiatives

– Collaboration and Partnership Federal and State Agencies QIOs / Providers / Advocates

1414

ResultsResults Nearly 50% drop from 1999 to 2005 in

the “number of nursing homes with serious quality problems" (GAO, January 2006)

Decrease in facilities receiving G or above deficiencies from 2002 – 2004 (AHCA OSCAR data)

Marked improvement in compliance with abuse and neglect standards since Quality First began in 2002. (AHCA)

Since the inception of Quality First, the U.S. Department of Labor has pledged to work with the profession. They declared that 2006 is the Year of Long Term Care.

1515

Select ResultsSelect Results

1616

Select ResultsSelect Results

1717

NHQI / Quality FirstNHQI / Quality First

Secretary Tommy Thompson (12/04): “…it has worked better than we

could have hoped for… we are pleased that nursing home residents are now receiving better care compared to just two years ago… we stabilized the funding in the last two years and improved [care quality].”

1818

Quality First in Action

Advancing Excellence - 2006Advancing Excellence - 2006

1919

National CoalitionNational Coalition

Centers for Medicare and Medicaid Services – Survey GroupCenters for Medicare and Medicaid Services --Quality Improvement Group

National Citizens’ Coalition for Nursing Home Reform Service Employees International UnionThe Commonwealth FundNational Commission for Quality Long-term CareAgency for Healthcare Research and QualityAssociation of Health Facility Survey AgenciesAmerican Association of Nurse Assessment Coordinators American College of Health Care AdministratorsAmerican Medical Directors Association National Association of Health Care Assistants

American Association of Homes and Services for the Aging (AAHSA)American Health Care Association (AHCA)The Alliance for Quality Nursing Home CareThe Evangelical Lutheran Good Samaritan Society

2020

Campaign ComponentsCampaign Components

Meaningful Goals Measures and Data Sources Technical Assistance -

Evidenced-based Protocols National and State-based

Infrastructure

2121

Advancing Excellence - Advancing Excellence - 20062006

Clinical Outcome Goals– High Risk Pressure Ulcers– Physical Restraints– Chronic Care Pain– Post Acute Care Pain

Process (Organizational Improvement Goals)– Setting Clinical Targets– Customer Satisfaction– Staff Retention– Consistent Staffing

2222

Advancing ExcellenceAdvancing Excellence5360 Enrolled LTC Providers5360 Enrolled LTC Providers

Clinical Goals– Pressure

Ulcers 68%– Restraints 42%– LTC Pain 53%– PAC Pain 40%

Process Goals– Targets 29%– Satisfaction

65%– Retention 39%– Assignment

31%

2323

What Does it All Mean?What Does it All Mean?

Are We Making Progress?Do Negative Outcomes Matter?Do Residents and Families Care? Consumer Experience of Care

2424

0%

5%

10%

15%

20%

25%

30%

35%

40%

1987 1994 2003 2004 2005 2006

Restraint Use in US Nursing Homes

Restraint Use

Any Progress?Any Progress?

Source: 1987-1984 Schoeneman AHSR – 2003-2006 NHQI-STAR

2525

3%

4%

4%

5%

5%

6%

6%

7%

7%

2003 2004 2005 2006

Pain in US Nursing Home (LT) Residents

Chronic Pain

Any Progress?Any Progress?

Source: 2003-2006 NHQI-STAR

2626

11%

12%

12%

13%

13%

14%

14%

2003 2004 2005 2006

Pressure Ulcers in Nursing Home (LT) Residents

Pressure Ulcers

Any Progress?Any Progress?

Source: 2003-2006 NHQI-STAR

2727

16%

16%

17%

17%

18%

18%

19%

19%

20%

20%

2004 2005 2006

Pressure Ulcers in US Nursing Home (ST) Residents

Pressure Ulcers

Any Progress?Any Progress?

Source: 2003-2006 NHQI-STAR

2828

Customer SatisfactionCustomer Satisfaction

Satisfaction Largely Linked to Positive Outcomes and Experiences of Care

2929

Continued Progress?Continued Progress?

The Road Ahead– Population Change / Role of PAC– Nursing Shortage / Aging Workforce– Medicare Stability / Medicaid

Shortfalls– Electronic Medical Records– Person Centered Care“A culture of aging that is life-

affirming, satisfying, humane and meaningful.”

Pioneer Network Vision

3030

3.5

3.55

3.6

3.65

3.7

3.75

3.8

3.85

3.9

3.95

4

1998 1999 2000 2001 2002 2003 2004 2005

ADL Dependence

Changing PopulationChanging Population

3131

Historic and Projected SNF Medicare Per Diems1998 - 2006

Source: Alliance for Quality Nursing Home Care Database and the Muse & Associates Reality Baseline

Medicare Stability

$287

$323$330

$321

$301

$325

$312

$276

$367

$250

$270

$290

$310

$330

$350

$370

$390

1998 1999 2000 2001 2002 2003 2004 2005 2006

(p)

3232

Medicaid UnderfundingMedicaid Underfunding

BDO Seidman - 2006

3333

Medicaid ShortfallsMedicaid Shortfalls

BDO Seidman - 2006

3434

Medicaid ShortfallsMedicaid Shortfalls

It’s Only $13…– Times 100 Residents = $1300 / day– Times 365 Days = $474,500

Is That a Lot?– At $12/hour = $25,000/year– Equivalent Shortfall = 19 FTEs.

3535

Thank You