comprehensive assessment of nursing home quality fall research conference -- regenstrief center for...
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Comprehensive Comprehensive Assessment of Assessment of Nursing Home Nursing Home
QualityQualityFall Research Conference -- Fall Research Conference --
Regenstrief Center for Healthcare Regenstrief Center for Healthcare Engineering, Purdue UniversityEngineering, Purdue University
Greg Arling, Ph.D.Greg Arling, Ph.D.Indiana University Center for Aging Indiana University Center for Aging
ResearchResearch
Minnesota NH Quality Minnesota NH Quality Assessment & Payment Assessment & Payment
ProjectProject Sponsored by Minnesota Department of Sponsored by Minnesota Department of
Human Services (DHS)Human Services (DHS) Multidisciplinary Research TeamMultidisciplinary Research Team
Robert L Kane, MD, Christine Mueller, RN Robert L Kane, MD, Christine Mueller, RN PhD, & Julie Bershadsky, University of PhD, & Julie Bershadsky, University of MinnesotaMinnesota
Greg Arling, PhD, Indiana University Center Greg Arling, PhD, Indiana University Center for Aging Researchfor Aging Research
Valerie Cooke, Robert Held, and Teresa Lewis Valerie Cooke, Robert Held, and Teresa Lewis Minnesota Department of Human ServicesMinnesota Department of Human Services
GoalsGoals Develop comprehensive measures of Develop comprehensive measures of
nursing home qualitynursing home quality Apply the measuresApply the measures
Informing consumer decisions Informing consumer decisions Guiding nursing home quality improvementGuiding nursing home quality improvement Offering financial incentives for better careOffering financial incentives for better care
Engage consumers and providers in Engage consumers and providers in efforts to achieve better qualityefforts to achieve better quality
Continue to refine the quality Continue to refine the quality assessment system and evaluate its assessment system and evaluate its impactimpact
Guiding PrinciplesGuiding Principles ComprehensiveComprehensive – contains process and outcome – contains process and outcome
indicators, quality of care and quality of lifeindicators, quality of care and quality of life Mutually Reinforcing --Mutually Reinforcing -- quality measurement quality measurement
and application proceeds iteratively and are and application proceeds iteratively and are mutually reinforcingmutually reinforcing
RelevantRelevant – taps dimensions of care that are – taps dimensions of care that are important to consumers and providersimportant to consumers and providers
CredibleCredible – has strong research base – has strong research base UnderstandableUnderstandable – effectively presented to – effectively presented to
different audiencesdifferent audiences ActionableActionable – informs consumer decision-making – informs consumer decision-making
and provider quality improvementand provider quality improvement TransparentTransparent – methods are well described, in – methods are well described, in
the public domain, and open to scrutiny by the public domain, and open to scrutiny by stakeholders and the research communitystakeholders and the research community
Comprehensive Quality Comprehensive Quality MeasuresMeasures
Direct care staffing level (salary and Direct care staffing level (salary and CM adjusted HPRD), employee CM adjusted HPRD), employee retention rate, & use of permanent retention rate, & use of permanent (non-contract) staff(non-contract) staff
Clinical Quality Indicators (QI)Clinical Quality Indicators (QI) Quality of Life and Resident Quality of Life and Resident
Satisfaction (QoL/RS) SurveySatisfaction (QoL/RS) Survey State Inspection (NH Survey) State Inspection (NH Survey)
ResultsResults
MN Nursing Home QIsMN Nursing Home QIs
Based on MDS assessmentsBased on MDS assessments 35,000 residents in 400 facilities per calendar 35,000 residents in 400 facilities per calendar
quarterquarter 24 QIs representing care processes and 24 QIs representing care processes and
outcomesoutcomes Dimensions (# of QIs)Dimensions (# of QIs)
Psychosocial (4)Psychosocial (4) Accidents (2)Accidents (2)
Restraints (1)Restraints (1) Nutrition (1)Nutrition (1)
Continence (6)Continence (6) Pain (1)Pain (1)
Infections (2)Infections (2) Skin Care (2)Skin Care (2)
Functioning (5)Functioning (5) Drugs (1)Drugs (1)
Quality of Life & Resident Quality of Life & Resident SatisfactionSatisfaction
Annual survey carried out by professional Annual survey carried out by professional survey organization involving face-to-face survey organization involving face-to-face interviews with 14,000 NH residentsinterviews with 14,000 NH residents
53 QoL and other items adapted from 53 QoL and other items adapted from established instrumentsestablished instruments
Dimensions (# of survey items)Dimensions (# of survey items)Comfort (4)Comfort (4) Autonomy (5)Autonomy (5)Environmental (4)Environmental (4) Individuality (3)Individuality (3)Privacy (3)Privacy (3) Security (3)Security (3)Dignity (4)Dignity (4) Relationships (3)Relationships (3)Meaningful Activity (3)Meaningful Activity (3) Satisfaction with Care (7)Satisfaction with Care (7)Food Enjoyment (3)Food Enjoyment (3) Mood (9)Mood (9)
MN Nursing Facilities QoL/RS Scores(2006 Survey)
0.500.550.600.650.700.750.800.850.900.951.00
Comfo
rt
Environ
men
t
Privacy
Activi
ties
Food
Autono
my
Indivi
duali
ty
Securit
y
Relations
hips
Satisfa
ction
Grade
Mood
Domain
Sco
re
Mean
Bottom 10%
Top 10%
Adjustment & EstimationAdjustment & Estimation Hierarchical General Linear Models Hierarchical General Linear Models
(HLM 6.0)(HLM 6.0) QIs risk adjustersQIs risk adjusters
Age and genderAge and gender Diagnoses (e.g, stroke, hip fracture, end-stage)Diagnoses (e.g, stroke, hip fracture, end-stage) functional status (e.g., ADL, cognitive status)functional status (e.g., ADL, cognitive status) health conditions (e.g., hemiplegia, sensory loss)health conditions (e.g., hemiplegia, sensory loss)
QoL/RS score risk adjustersQoL/RS score risk adjusters Resident gender, ADL, age, cognitive status & LOSResident gender, ADL, age, cognitive status & LOS Facility location and average LOSFacility location and average LOS
Empirical Bayes estimates of facility QI Empirical Bayes estimates of facility QI or QoL/RS ratesor QoL/RS rates
ApplicationApplication Nursing Home Consumer Report CardNursing Home Consumer Report Card
Facilities receive 1-5 Stars on each quality Facilities receive 1-5 Stars on each quality measuremeasure
1,800 internet users/month1,800 internet users/month Detailed QI and QoL Reports sent Detailed QI and QoL Reports sent
periodically to facilitiesperiodically to facilities Quality Add-on (2.4%) to Medicaid Quality Add-on (2.4%) to Medicaid
Payment RatesPayment Rates Pay for Performance Quality InitiativesPay for Performance Quality Initiatives
Facilities develop quality improvement Facilities develop quality improvement projectsprojects
Tied to quality measure outcomesTied to quality measure outcomes $30 Million allocated for 2007-2008$30 Million allocated for 2007-2008
Nursing Home Report Nursing Home Report CardCard
Transparency to consumersTransparency to consumers Make better LTC choicesMake better LTC choices Advocate for care improvementAdvocate for care improvement
Provider benchmarking and quality Provider benchmarking and quality improvementimprovement
Nursing homes selected by Nursing homes selected by geographical areasgeographical areas
Facility assigned 1-5 stars on each of Facility assigned 1-5 stars on each of seven dimensionsseven dimensions
Consumer ResponseConsumer Response
Use of Report CardUse of Report Card 26,000 “hits” the first week26,000 “hits” the first week 1,800/month since then1,800/month since then
Consumer feedback on Report CardConsumer feedback on Report Card 87% rate “easy” or “pretty easy” to use87% rate “easy” or “pretty easy” to use 55% “definitely” would use in selecting 55% “definitely” would use in selecting
a nursing home a nursing home 36% “probably” would use in selecting 36% “probably” would use in selecting
a nursing homea nursing home
Feedback from Report Card Feedback from Report Card Users Users (N=108,000)(N=108,000)
Quality DimensionQuality Dimension % Giving it Top % Giving it Top PriorityPriority
Quality of Quality of Life/Resident Life/Resident SatisfactionSatisfaction
84%84%
State NH Survey State NH Survey ResultsResults
61%61%
NH Quality NH Quality IndicatorsIndicators
59%59%
Staffing Level Staffing Level (HPRD)(HPRD)
38%38%
Staff RetentionStaff Retention 16%16%
Use of Pool StaffUse of Pool Staff 6%6%
Facility Quality ReportsFacility Quality Reports
Detailed QI and QoL/RS reports sent Detailed QI and QoL/RS reports sent periodically to each facilityperiodically to each facility Most current QI and QoL/RS resultsMost current QI and QoL/RS results Tracking of QI or QoL/RS rates over timeTracking of QI or QoL/RS rates over time
Special training programs on priority Special training programs on priority areas identified through quality reportsareas identified through quality reports Meaningful activitiesMeaningful activities Skin careSkin care Psychotropic medicationsPsychotropic medications Pain managementPain management
Trends in QI RatesTrends in QI Rates
Total Improvement in Risk-Adjusted QIs (July 2004 - Dec 2006)
-0.01
0.00
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08Decline Improvement
Quality Adjustment to Quality Adjustment to Payment RatePayment Rate
Bonus added annually to Medicaid per diem Bonus added annually to Medicaid per diem payment rate -- proportional to Quality Scorepayment rate -- proportional to Quality ScoreQuality ScoreQuality Score Bonus (% of PD Rate)Bonus (% of PD Rate)
0-400-40 0.0%0.0%41-9941-99 0.1% to 2.3%0.1% to 2.3%100100 2.4%2.4%
Quality score also used to adjust Medicaid Quality score also used to adjust Medicaid cost limitscost limits ReducesReduces rates for rates for high costhigh cost & & low qualitylow quality
facilitiesfacilities IncreasesIncreases rates for rates for low costlow cost and and high qualityhigh quality
facilitiesfacilities
Performance-Based Performance-Based IncentivesIncentives
Facilities propose a new program to:Facilities propose a new program to: Improve quality outcomesImprove quality outcomes Increase efficiencyIncrease efficiency Re-balance long-term care (e.g., community Re-balance long-term care (e.g., community
discharges)discharges) Facilities receive a 5% rate increase IF they:Facilities receive a 5% rate increase IF they:
Implement the program effectivelyImplement the program effectively Achieve outcome objectivesAchieve outcome objectives
Most projects linked to improvement in QIs, Most projects linked to improvement in QIs, QoL/RS, and other quality measuresQoL/RS, and other quality measures
Response to Performance-Response to Performance-Based IncentivesBased Incentives
155 applications received, 19 projects 155 applications received, 19 projects and 32 facilities approved in first yearand 32 facilities approved in first year
Focus of projects:Focus of projects:Culture changeCulture change Wireless call systemsWireless call systems
QoL for dementia residentsQoL for dementia residents Employee Employee retentionretention
Pressure ulcersPressure ulcers Pain managementPain management
ExerciseExercise CHFCHF
Overall Provider Overall Provider ResponseResponse
Even modest financial incentives have Even modest financial incentives have stirred considerable provider intereststirred considerable provider interest
Providers have asked for more frequent Providers have asked for more frequent and detailed QI and QoL/RS reportsand detailed QI and QoL/RS reports
Providers have been supportive of QI and Providers have been supportive of QI and QoL/RS risk adjustment with some calling QoL/RS risk adjustment with some calling for expanded adjustersfor expanded adjusters
State-sponsored quality improvement State-sponsored quality improvement training programs have been attended by training programs have been attended by 100’s of nursing home staff100’s of nursing home staff
Continued ResearchContinued Research Improve validity and reliability of quality Improve validity and reliability of quality
measuresmeasures Track trends in quality over timeTrack trends in quality over time Facilitate consumer decision-makingFacilitate consumer decision-making Develop better provider reportsDevelop better provider reports Identify effective management practicesIdentify effective management practices Evaluate quality improvement strategiesEvaluate quality improvement strategies Build a business case for better qualityBuild a business case for better quality
Expand Quality MeasuresExpand Quality Measures
QI or QoL/RS measures designed QI or QoL/RS measures designed specifically for dementia residentsspecifically for dementia residents
Post-acute QIsPost-acute QIs Family satisfaction surveyFamily satisfaction survey Community discharge/NH Community discharge/NH
transitionstransitions Re-hospitalization ratesRe-hospitalization rates Refined scoring of NH inspection Refined scoring of NH inspection
resultsresults
Stress Value and Cost-Stress Value and Cost-EffectivenessEffectiveness
Wide variation in nursing home per diem Wide variation in nursing home per diem prices & qualityprices & quality
Information about NH prices and their Information about NH prices and their relationship to quality is not publicly relationship to quality is not publicly availableavailable
Many consumers are receiving very poor Many consumers are receiving very poor value for their long-term care dollarsvalue for their long-term care dollars
Need to focus on connection between Need to focus on connection between price and quality – greater value and cost-price and quality – greater value and cost-effectivenesseffectiveness
Improve ReportingImprove Reporting
Track quality measures over timeTrack quality measures over time Trends in QI rates (quarterly)Trends in QI rates (quarterly) Changes in annual QoL/RS scoresChanges in annual QoL/RS scores
Drill down capabilityDrill down capability Dimension scoresDimension scores Individual survey items or QIsIndividual survey items or QIs
Decision support toolsDecision support tools
Build a Business Case for Build a Business Case for QualityQuality
Increase quality adjustment of Increase quality adjustment of payment ratepayment rate Reward high qualityReward high quality Discourage poor qualityDiscourage poor quality
Expand funding for Performance-Based Expand funding for Performance-Based Incentive projectsIncentive projects Emphasize organizational change Emphasize organizational change
and technologyand technology Encourage provider collaboration Encourage provider collaboration
and diffusion of best practicesand diffusion of best practices