Commentary on long Term Care Quality A Provider Perspective

1. Commentary on long Term Care QualityA Provider Perspective Bradley Shiverick Second National Medicaid Congress – June 14, 2007

2. A Brief Overview of Initiatives and Progress on Long Term Care Quality • Nursing Home Reform Act – 1987 • Prospective Payment Implications – 1999 • Quality First – 2002 • Nursing Home Quality Initiative – 2002 • Advancing Excellence – 2006 • Programs and Progress

3. IOM 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

4. First… 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

5. Regulation and Enforcement • ~ 150 Individual Requirements • Annual, Complaint and Incident Surveys • Cycle of Compliance • Scope and Severity – 1995 • Outcomes Focus (Double “G”) – 1999 • Revised Outcomes Focus – 2006 • Minimal Standards and Penalties

6. Prospective 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

7. Accidents Clinical Management Cognitive Patterns Elimination/Incontinence Infection Control Nutrition/Eating Behavior/Emotional Patterns Physical Functioning Psychotropic Drug Use Quality of Life Skin Care 1999 Nursing Home Quality Indicators24 QIs in 11 Domains www.medicare.gov/nhcompare

9. Quality 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)

10. Quality 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

11. Alliance for Quality Nursing Home CareQF Code of Conduct and Ethical Practices Commitment 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

12. Quality 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

13. Nursing Home Quality Improvement 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

14. Results • 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.

15. Select Results

16. Select Results

17. NHQI / 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].”

18. Quality First in Action Advancing Excellence - 2006

19. National Coalition Unprecedented Centers for Medicare and Medicaid Services – Survey Group Centers for Medicare and Medicaid Services --Quality Improvement Group National Citizens’ Coalition for Nursing Home Reform Service Employees International Union The Commonwealth Fund National Commission for Quality Long-term Care Agency for Healthcare Research and Quality Association of Health Facility Survey Agencies American Association of Nurse Assessment Coordinators American College of Health Care Administrators American 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 Care The Evangelical Lutheran Good Samaritan Society

20. Campaign Components • Meaningful Goals • Measures and Data Sources • Technical Assistance - Evidenced-based Protocols • National and State-based Infrastructure

21. Advancing Excellence - 2006 • 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

22. Clinical Goals Pressure Ulcers 68% Restraints 42% LTC Pain 53% PAC Pain 40% Process Goals Targets 29% Satisfaction 65% Retention 39% Assignment 31% Advancing Excellence5360 Enrolled LTC Providers

23. What Does it All Mean? • Are We Making Progress? • Do Negative Outcomes Matter? • Do Residents and Families Care? • Consumer Experience of Care

24. Any Progress? Source: 1987-1984 Schoeneman AHSR – 2003-2006 NHQI-STAR

25. Any Progress? Source: 2003-2006 NHQI-STAR

26. Any Progress? Source: 2003-2006 NHQI-STAR

27. Any Progress? Source: 2003-2006 NHQI-STAR

28. Customer Satisfaction • Satisfaction Largely Linked to Positive Outcomes and Experiences of Care

29. 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

30. Changing Population

31. Medicare Stability Historic and Projected SNF Medicare Per Diems 1998 - 2006 (p) Source: Alliance for Quality Nursing Home Care Database and the Muse & Associates Reality Baseline

32. Medicaid Underfunding BDO Seidman - 2006

33. Medicaid Shortfalls BDO Seidman - 2006

34. Medicaid 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.

35. Thank You