raising theb ar onq uality of are in nursingh omes - global health care… · 2011. 6. 23. ·...

© Pittsburgh Regional Health Initiative 2011 1

RAISING THE BAR ON QUALITY OF CARE IN NURSING HOMES

Keith T. Kanel, MD MHCM FACP Chief Medical Officer

Na;onal Medicaid Congress

Washington, DC June 15, 2011


Accountable Care Organiza;on (Ideal)

HOSPITAL

PHYSICIAN PRACTICE

PHYSICIAN PRACTICE

PHYSICIAN PRACTICE

PHYSICIAN PRACTICE

PHYSICIAN PRACTICE

PHYSICIAN PRACTICE

PHYSICIAN PRACTICE


Accountable Care Organiza;on (in Reality)

HOSPITAL

PHYSICIAN PRACTICE

PHYSICIAN PRACTICE

PHYSICIAN PRACTICE

PHYSICIAN PRACTICE

PHYSICIAN PRACTICE

PHYSICIAN PRACTICE

PHYSICIAN PRACTICE

PHYSICIAN PRACTICE PHYSICIAN

PRACTICE

SKILLED NURSING FACILITY



LONG-‐TERM CARE FACILITY



PERSONAL CARE HOME

RETAIL CLINIC

RETAIL CLINIC

RETAIL CLINIC RETAIL

CLINIC

RETAIL CLINIC



Nursing Homes as a Physician Concern in Building Accountable Care

“The thing we need help with most are the nursing home pa4ents. They bounce back to our EDs with incomplete informa4on, and we have to bring them in to sort it out.”

-‐  Primary Care Physician in PRHI ACO focus group


Nearly Half of all Nursing Home Transfers for Emergency Department Evalua;on are AdmiXed

Percent of ED Visits ResulBng in HospitalizaBon, 2008


Nursing Homes Generate More ED Visits Than Other Parts of the Community

45.4 37.9

167.8

37.5

72.8

0

20

40

60

80

100

120

140

160

180

Total (Northeast)

From Private Residences

From Nursing Homes

From Other InsBtuBons

Homeless

Source: CDC NaBonal Hospital Medical Care Survey: 2008 Emergency Department Summary Tables; h]p://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed2008.pdf

Emergency Department Visits (Number per 100 persons per year, 2008)


Quality Improvement in Nursing Homes

•  Regulatory efforts: •  Nursing Home Reform Act (1987) •  CMS Nursing Home Compare (2002) •  Pennsylvania Pa;ent Safety Authority (Act 52)

•  Current measures of quality: 1.  Minimum Data Set (MDS) Quality Measure Indicator

Report 2.  Online Survey, Cer;fica;on, and repor;ng (OSCAR)

System


Evolu;on of Quality Improvement in Healthcare Facili;es

Historical Approach to Quality

RegulaBon

InspecBon

Risk Management

Progressive Approach to Quality

Reward (e.g., Pay-‐for-‐Performance)

RecogniBon (e.g., Leapfrog, BTE)

Transparency (e.g., public reporBng

System-‐Based Improvement (e.g, Lean, Six-‐Sigma)


Barriers to QI Programs in Nursing Homes

•  Difficulty engaging pa;ents •  Minimal involvement of commercial payers •  Absence of compelling outcome measures •  No electronic health records •  Staff turnover •  Documenta;on demands


Administra;ve Priori;es May Not Be Clinically Determined in Nursing Homes

“Quality improvement is focused so much on compliance with federal and state regula4ons.”

-‐ Nursing Home Administrator


Nursing Home Data Collec;on Tool

•  Minimum Data Set (MDS) 3.0

•  37 page data collec;on instrument

•  Completed at days 5, 14, 21, 30, 90, then quarterly

•  Comple;on takes 1-‐2 hours

•  Federal tool shared with state regulatory agencies

•  Generates CMS Nursing Home Compare


“Long term care is the most regulated industry in the country, exceeding the Nuclear Regulatory Commission and the Transporta4on Safety Authority.”


Using Regional Data Sets to Drive Quality Improvement

COHORT •  11 coun;es of SW Pa •  2.6 million popula;on •  32 Hospitals •  149 Nursing Homes

–  54% for-‐profit

•  2000 primary care MDs

HOSPITAL ADMISSION (n=813,896)

NURSING HOME

TRANSFER (n=112,799)

HOSPITAL READMISSION (n=27,557)

PENNSYLVANIA HEALTH CARE COST CONTAINMENT COUNCIL

•  Independent agency created by state legislature 1986

•  Hospitals must report discharge data within 90 days

•  Unique, all-‐payer database offering one of most complete sources of data in US

TWO-‐YEAR DATA SAMPLE (October 2007 – September 2009)


Distribu;on of Hospitals by 30-‐day Readmission Rates Following Discharge

to Nursing Facili;es


30-‐Day Readmission Rates from Skilled Nursing Facili;es Are Highest

Kind of Discharge # of Admits Share of Admits

30-Day Readmit Rate

To Home 466,226 57% 14%

To Home Health Service in Anticipation of Covered Skilled Care 141,309 17% 21%

To Skilled Nursing Facility 112,799 14% 24%

To Rehabilitation, Long-Term, or Critical care Facility 57,018 7% 21%

Source: Pennsylvania Health Care Cost Containment Council, October 2007 – September 2009 (24-‐month sample), an all-‐payer database. Data is for the 11-‐county region of southwestern Pennsylvania (813,896 discharges).


Readmissions from Nursing Homes are Highest with Medicaid

Medicaid Medicare Dual Eligible

Commercial TOTAL

Home

14.4% 16.3% 21.4% 9.4% 14.0%

Home with Home Health

20.7% 20.8% 26.9% 15.9% 21.0%

Nursing Home

29.4% 23.3% 25.4% 22.4% 24.0%

Source: Pennsylvania Health Care Cost Containment Council, October 2007 – September 2009 (24-‐month sample), an all-‐payer database. Data is for the 11-‐county region of southwestern Pennsylvania (813,896 discharges).


What Drives High Transfer, Admission, and Readmission Rates?

•  Pa;ents complexity and frailty •  PCPs may be less involved in care •  Unavailability of medical informa;on at point-‐of-‐care •  Unavailability of off-‐hour lab tes;ng and radiography •  Nursing home staffing •  Liability concerns


Ranked Diagnoses in Hospital Readmissions from Nursing Homes

ICD-‐9 Code for Principal Diagnosis Percent

Infec;on: Unspecified sep;cemia (0389)* 6.7% Infec;on: Pneumoni;s due to inhala;on of food or vomitus (5070) * 4.8% Conges;ve heart failure, unspecified (4280) 3.8% Unspecified acute renal failure (5849) * 3.5% Infec;on: Pneumonia, organism unspecified (486) * 3.4% Acute respiratory failure (51881) * 3.1% Infec;on: Urinary tract infec;on, site not specified (5990) * 3.0% Infec;on: Intes;nal infec;ons due to clostridium difficile (00845) * 2.5% TOTAL READMISSIONS 27,557 Source: Pennsylvania Health Care Cost Containment Council, October 2007 – September 2009 (24-‐month sample), an all-‐payer database. Data is for the 11-‐county region of southwestern Pennsylvania (813,896 discharges).


Ranked Diagnoses in Hospital Readmissions from Nursing Homes

ICD-‐9 Code for Principal Diagnosis Percent

Infec;on: Unspecified sep;cemia (0389)* 6.7% Infec;on: Pneumoni;s due to inhala;on of food or vomitus (5070) * 4.8% Conges;ve heart failure, unspecified (4280) 3.8% Unspecified acute renal failure (5849) * 3.5% Infec;on: Pneumonia, organism unspecified (486) * 3.4% Acute respiratory failure (51881) * 3.1% Infec;on: Urinary tract infec;on, site not specified (5990) * 3.0% Infec;on: Intes;nal infec;ons due to clostridium difficile (00845) * 2.5% TOTAL READMISSIONS 27,557 Source: Pennsylvania Health Care Cost Containment Council, October 2007 – September 2009 (24-‐month sample), an all-‐payer database. Data is for the 11-‐county region of southwestern Pennsylvania (813,896 discharges).

49% of readmissions from nursing homes have “infecBon or complicaBon” as their principle diagnosis!


Discharge Diagnoses Before Nursing Home Transfer

ICD-‐9 Code for Principal Diagnosis Percent Readmit Rate

Infec;on: Urinary tract infec;on, site not specified (5990) 3% 20.7% Infec;on: Unspecified sep;cemia (0389) 3% 29.8% Infec;on: Pneumonia, organism unspecified (486) 3% 24.5% Infec;on: Pneumoni;s due to inhala;on of food or vomitus (5070) 3% 26.6% Localized osteoarthrosis not specified whether primary or secondary, lower leg (71536)

3% 8.1%

Unspecified acute renal failure (5849) 3% 27.9% Other specified rehabilita;on procedure (V5789) 2% 19.9% Conges;ve heart failure, unspecified (4280) 2% 29.2%

Total Number of Admissions 112,799 23.8% Source: PRHI Analysis of PHC4 all-payer discharge data, 10/1/07-9/30/09

Are we propaga;ng a “non-‐virtuous cycle”?


Effect of Select Diagnoses on Readmission Rate, LOS, and Charges in Pa;ents Coming from

Nursing Homes Primary or Secondary Diagnoses on Admission

No. of Admits

RaBo 30-‐Day Readmit Rate

RaBo Length of Stay

RaBo Total Charges

Disorders of fluid electrolyte and acid-‐base balance

28,421 1.13 (p<0.001)

1.05 (p<0.001)

0.98 (Not Significant)

MRSA 3,715 1.17 (p<0.001)

1.28 (p<0.001)

1.21 (p<0.001)

Clostridium Difficile 4,356 1.42 (p<0.001)

1.60 (p<0.001)

1.50 (p<0.001)

Decubitus Ulcer 8,199 1.25 (p<0.001)

1.23 (p<0.001)

0.96 (Not Significant)

Broken Hip 5,951 0.72 (p<0.001)

0.82 (p<0.001)

0.94 (p=0.007)


Infec;on Control in Nursing Homes

•  What to do about UTIs? •  Restrict use of urinary catheters •  Hand hygiene protocols (staff and residents) •  Adherence to modified contact precau;ons •  Immuniza;on (staff and residents) •  BeXer (and earlier) communica;on •  Infec;on control prac;;oners


Risk Management Drivers: The Prevalence of Falls and Pressure Ulcers

Studdert DM. NEJM 2011;364:1243-‐50.


Percep;ons About Nursing Home Quality Priori;es Differ

What the DATA would suggest:1

What RISK-‐MANAGERS would suggest:2

What NURSING HOME ADMINISTRATORS would suggest:3

1. Infec;ons 2. Readmissions

1. Falls 2. Pressure Ulcers

1. Regulatory Compliance 2. Individual Family Concerns

1Based on Pennsylvania Health Care Cost Containment data set, 2007-‐9. 2Based on Studdert N Engl J Med 2011;364:1243-‐50. 3Based on interviews by inves;gators.


Skilled Nursing Con;nues to Generate Strong Gains

Source: MedPAC Report to Congress, March 2011 Courtesy of N. Kane, Harvard School of Public Health


The Majority of Nursing Home Care is Funded by Medicaid

Private Insurance, 7%

Other Private, 4%

Medicaid, 43%

Medicare, 17% Other Public, 2%

Out-‐of-‐Pocket, 26%

NURSING HOME EXPENDITURES, 2006

Source: Kaiser Commission on Medicaid facts, es;mates based on CMS Na;onal Expenditure Data Set, February 2009.


Many Nursing Home Pa;ents Do Not Have Advance Direc;ves

Percentage of home health paBents, nursing home residents, and discharged hospice care paBents with any advance

direcBve: United States, 2004 and 2007.

Home and Hospice Care Survey, Adapted from NCHS Data Brief, No. 54, January 2011. Sources: CDC/NHCS, Na;onal Nursing Home Survey 2004, and Na;onal 2007.


Future Steps: Quality in Nursing Homes

•  Predic;ve risk modeling using EHRs

•  CMS Nursing Home Value-‐Based Demonstra;on (2009) •  3 year study in Arizona, Wisconsin, New York

•  Domains: staffing, appropriate hospitaliza;ons, MDS scores, survey deficiencies

•  CMS “Partnership for Pa;ents” Ini;a;ve (2011) •  Keep paBents from genng injured or sicker. By the end of 2013, preventable

HAIs would decrease by 40% compared to 2010.

•  Help paBents heal without complicaBon. By the end of 2013, preventable complica;ons during a transi;on from one care setng to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.


Raising the Bar on Quality of Care in Nursing Homes

1.  Standardize communica;on (e.g., SBAR)

2.  Develop standing orders

3.  Ensure basic diagnos;c capabili;es at all hours

4.  Consider adding an infec;on control prac;;oner

5.  Regard hospital transfer as a last resort

6.  Establish advance direc;ves

7.  Train staff in system-‐based quality improvement (e.g., Lean) – establish an ins;tu;onal “culture of quality”


Crea;ng a Culture of Quality in Nursing Homes


Lean Transforma;on at Asbury Heights Nursing Home

•  Unit-‐based Lean staff training and ongoing coaching

•  “5-‐S” restructuring of equipment rooms and service areas to improve staff efficiency

•  Standardized communica;on of good ideas


Asbury Heights – Early Projects

§  Occupancy Rates §  Increased occupancy rates from

55 to 93%

§  Café Profitability §  Deficit of $15,000 in one year

turned into a $30,000 profit the next year

§  Podiatry Clinic §  End of 2009, 95% of pa;ents

were on ;me for their appointments

§  PAC A]ack §  Responded to every sugges;on

made on their new sugges;on form

§  Kilowa] Killers §  Savings in the first year

amounted to 100,000 kWh and $8,500 in one building alone


Asbury Heights – Recent Projects

Pressure Ulcer Preven;on •  60% reduc;on in decubitus ulcers

within 6-‐months of unit-‐based protocol.

Readmissions Reduc;on •  Unplanned hospital admissions

among residents with chronic condi;ons reduced to zero over a 12-‐month period.

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12

% Po

pulat

ion

Month

Nursing % Population Transferred

% census

raising theb ar onq uality of are in nursingh omes - global health care… · 2011. 6. 23. ·...

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