Quality Improvement in the Nursing Home Setting

1. Quality Improvement in the Nursing Home Setting Assoc Prof Samuel Scherer

2. EXAMPLES OF CURRENT QI PROCESSES AMONG PROVIDER ORGANISATIONS IN SINGAPORE • Quality Department and Quality Manager • ISO 9001:2008 framework • Structured Induction and Orientation programme for new staff • Quality Objectives focused on: • Clinical Governance (MAB; M&M meetings) • Clinical measures (eg aim for ZERO NH acquired Pressure Ulcers) • Internal and External Quality Audits (Quantitative) • Quality Service Performance Monitoring (Qualitative) • PFG Meetings; Written & verbal feedback • Service quality (Customer satisfaction); • Training Programs • Develop and involve staff in QI • Communication; mutual trust; manage and communicate adverse events • Quality Circles; Staff Suggestion Scheme; Quality Improvement Workgroups • Nursing Quality Assurance Activities; Quarterly Meetings; Quality Projects Very similar frameworks and initiatives in Australia

3. OUTLINEQuality Improvement in the Nursing Home Setting • A framework for QI • The NH in the 21st Century • QI for the NH of the 21st Century • Putting it together

4. DOMAINS OF QUALITY AND SAFETY http://www.health.vic.gov.au/clinrisk/publications/clinical_gov_policy.htm • Consumer participation • Clinical effectiveness • An effective workforce • Risk management These Domains provide a conceptual framework for strategies to enhance the delivery of care in all settings Within each Domain there are a number of quality and safety management functions that require attention Under these Domains all of the required principles of clinical governance and QI should be addressed

5. SCIENCE VALUES SYSTEMS CONSCIOUSNESS http://www.health.vic.gov.au/clinrisk/publications/clinical_gov_policy.htm

6. SCIENCE The US Institute of Medicine has defined quality health care as: • "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

7. Assessment Outcome Measurement Scales Care planning Protocols (RAP, CAP) Eligibility & Placement Screening Resource UseRUG Quality Indicators INTERRAI MDS ASSESSMENT SYSTEM Minimum Data Set (Carpenter 2003)

8. CLINICAL PRACTICE GUIDELINES Medical capacity to deliver & role of nurse practitioners

10. Risk-adjusted indicators of quality of care : intervention vs control residential care facilities over six-months (Boorsma 2011)

11. QI’s traditionally conceptualized as interventions (discrete changes) separated from their surroundings in order to assess whether they cause changes –eg patient outcomes. If the change is an improvement, the assumption is they can be repeated elsewhere to achieve the same outcome • However in QI nothing ever happens for one reason or cause. It would be convenient to package changes as a QI which could work anywhere, like an effective drug. But to change social systems, a number of factors influence implementation and success • Some useful knowledge can be generated using medical treatment research designs like RCT’s but we also require non-experimental naturalistic methods that are more often used in the social sciences (Øvretveit J, BMJ Qual Saf 2011) • “The Quality Improvement field is still emerging, still relies a great deal on trial and error, and lacks a strong theory and empirical base.” (Leviton L, BMJ Qual Saf 2011)

12. EVIDENCE TO PRACTICE TRANSLATIONAL IN LTC A randomised controlled trial of staff education to improve the quality of life of people with dementia living in residential care facilities: the Dementia In Residential care: Education intervention Trial (DIRECT) study. Christopher Beer1,2*, Barbara Horner3, Leon Flicker1,2, Samuel Scherer5, Nicola T Lautenschlager1,4,6, Nick Bretland7, Penelope Flett8, Frank Schaper9, Osvaldo P Almeida1,4

13. SYSTEMS: HUMAN RESOURCES • Create positive working conditions for nursing home practitioners with attractive career development opportunities, recognition, and similar rewards enjoyed by health care workers in comparable roles within the acute care services • Effective leadership structures include an expert physician (medical director), an expert registered nurse (nursing director), and skilled administrator

14. SYSTEMS: HUMAN RESOURCES AT ALL LEVELS TEAMS

15. LEVELS WITHIN QI HIERARCHY THE CARE TEAM Patient Centered Multidisciplinary Nurse Doctor Patient Resident Therapists Care Staff

16. HEALTH CARE QI IN LTC - AUSTRALIAN “SYSTEM” INITIATIVES Report Of Ministerial Reference Group (2002) “GP's & hospitals are reluctant to be involved with aged care services and as a result the provision of basic medical services to people in residential care is poor” Response strategies: • Sponsored innovation program s (eg “EBPAC”) and guidelines • New programs and funding incentives for GP’s • “Telehealth” • Hospital-based “Inreach” and Substitution Programs • Decrease reliance on doctors alone/increase support for doctors • Nursing and Nurse Practitioner initiatives – education, career structure, funding • Allied health funding and career streams • eg Royal Freemasons - Chief Nurse, Geriatrician, AH Coordinator  • (External, Internal or Regional Models for Medical Service?)

17. ALLIED HEALTH RESOURCES FOR LTC?

18. VALUES The US Institute of Medicine has defined quality health care as: • "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” The Department of Health and Human Services in the US says: • “quality health care means doing the right thing at the right time, in the right way for the right person and getting the best possible results.” Ethical Principles • Autonomy • Beneficence • Distributive Justice

19. Projected success of alternative model of health care versus the current model Braithwaite MJA2011

20. BraithwaiteMJA2011

21. A CONSENSUS ON MINIMUM GERIATRICS COMPETENCIES FOR GRADUATING MEDICAL STUDENTS. (Academic Medicine, Vol. 84, No. 5 2009) Include Inter Alia, to be able to: • Define and differentiate among types of code status, health care proxies, and advance directives • Accurately identify clinical situations where life expectancy, functional status, patient preference, or goals of care should override standard recommendations for screening tests in older adults • Accurately identify clinical situations where life expectancy, functional status, patient preference, or goals of care should override standard recommendations for treatment in older adults

22. CONSCIOUSNESS • Knowhow • Intention • Attention • Empathy • Confidence • Integrity • Compassion • Application • Professional Identity • Personal Identity • Experience • Courage • Sense of reward • Privilege • Gratefulness “Whether ye be the taker or giver of care, Is naught but a trick of time”

23. OUTLINEQuality Improvement in the Nursing Home Setting • A framework for QI • The NH in the 21st Century • QI for the NH of the 21st Century • Putting it together

24. WHY DO WE NEED NURSING HOMES? Disability Ageing Overlapping Concepts Frailty Disease

25. AGEING, FRAILTY, DISEASE AND DISABILITY Ferruci 2001

26. 2.5 2 1.5 Prevalence rate 1 0.5 0 75 78 81 84 87 90 93 Age Other Systemic Peripheral Vascular Disease Chronic Lung Disease* Stroke Obesity Heart Disease Arthritis PREVALENCE OF SYSTEMIC DISEASES WITH AGE (N=522. Age trends: * p < 0.05) Sydney Older Persons Study Creasey 2001;Broe 2004

27. 3.5 3 2.5 2 1.5 1 0.5 0 75 78 81 84 87 90 93 Age Parkinsonism** Dementia** Gait Slowing (Excl. Park)** Cognitive Impairment ** Vision** Ataxia** PREVALENCE OF NEURODEGENERATIVE DISEASES WITH AGE Prevalence Rate (N=522. Age Trends: * P < 0.05; ** P< 0.01) Sydney Older Persons Study Creasey 2001;Broe 2004

28. MEDICAL CHARACTERISTICS OF LTC POPULATIONS (Scherer 2001)

30. THE NURSING HOME OF THE 21st CENTURY

31. LENGTH OF STAY IN NURSING HOMES AT THE END OF LIFE (Kelly et al JAGS 2010) • Median LOS to death 5 months • Men 3 months • Women 8 months • Average LOS 14 months • Shorter LOS if married • Shorter LOS if wealthy • 65% died within 1 year • 53% died within 6 months • Australian data:~ 35% of total • high plus low care population • die within 6 months • ~ 50% HC die within 6 months • 19% stay 5y+

32. COMMON TRAJECTORIES OF DECLINE AND DEATH #1. SHORT DECLINE • Primarily • Somatic. • Not typically, but • sometimes in NH’s High Mostly cancer PALLIATIVE GROUP Trajectory #1 Possible hospice enrollment Function Death Low Time Often a few years Decline usually few months Onset of incurable cancer (Murray 2005)

33. TRAJECTORY #2: LONG TERM LIMITATIONS WITH INTERMITTENT SEVERE EPISODIC DECLINE High • Primarily • Somatic. • Typically • admitted to NH • late in course of • illness when functional • decline is severe. • “End stage” in terms of response to therapy PALLIATIVE GROUP Trajectory #2 Mostly heart & lung disease Function Emergency hospitalisations Low Death Time ~ 2-5 years, death may be “sudden” Profound decline in weeks or months Hospital use (Murray 2005)

34. TRAJECTORY #3: PROLONGED DWINDLING FRAILTY GROUP Trajectory #3b) Mostly Dementia & Frailty High DEMENTIA GROUP Trajectory #3a) #3a) Dementia Group: Often admitted to NH earlier in course of (physical) functional decline • #3b) Frailty Group: • Primarily • Somatic (or mixed) • Admitted to NH • later in course of • functional • decline Function Likely NH admission Low Death Onset Time Variable ++: ~ 6-8 + years (from dementia onset) (Murray 2005 modified)

35. TRAJECTORY #4: STABLE +/- RESTORATIVE POTENTIAL Eg: Stroke; Musculoskeletal; Psychosocial; ABI; Ageing ID High • Stable/Restorative Group(s): • Somatic or Cognitive • Longer life expectancy • Death from new event or illness STABLE GROUP Trajectory #4 Function Likely NH admission Low Death Onset Time Life Expectancy Variable ++

36. OUTLINEQuality Improvement in the Nursing Home Setting • A framework for QI • The NH in the 21st Century • QI for the NH of the 21st Century • Putting it together

37. WORKING DEFINITION OF QUALITY IMPROVEMENT: “The totality, at any point in time, of an interaction of multiple dynamic (evolving) concepts, structures and processes” Need To Align: 1. Patient Focused Goals • Enhance outcomes for a particular patient • Life expectancy • Function • QOL • Symptom control 2. System Focused Goals • Match the level and type of resources provided to particular goals • Effectively • Efficiently • Economically

38. STABLE GROUP Trajectory #4 “SPECIALISATION” Somatic vs Dementia • NH’s (Clustering) • Units/Wings ( “ ” ) • Programs/Teams/ “Champions” (only) Restorative vs Maintenance vs Palliative Programs • NH’s , Units/Wings, Programs/Teams • (If programs – define on admission) Method for transition to Palliative Status FRAILTY GROUP Trajectory #3b) DEMENTIA GROUP Trajectory #3a) PALLIATIVE GROUP Trajectories #1,2

39. Fig. 1 THE TRANSITION FROM ROUTINE CARE TO END-OF-LIFE CARE IN A NURSING HOME FRAILTY GROUP Trajectory #3b) STABLE GROUP Trajectory #4 DEMENTIA GROUP Trajectory #3a) Source:Deborah P. Waldrop, LMSW, PhD and Kathy Nyquist, GCS, NHA JAMDA 2011; 12:114-120 (DOI:10.1016/j.jamda.2010.04.002 )

40. INTEGRATION OF PALLIATIVE CARE AND AGED CARE • A palliative approach • Dignity and quality of life • Advance care planning • Advanced dementia • Physical symptom assessment and management • Psychological support • Family and social support, intimacy and sexuality • Cultural and spiritual issues, including Aboriginal issues • Volunteer, staff support • End of life care • Bereavement • Developing a team http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/pc29.pdf

41. HOW CAN THESE GUIDELINES BE INTRODUCED? • Ethical issues: • capacity to care, philosophy • Introducing to Boards of Management • Liaising with palliative care services • Preventing unnecessary hospitalisation • Encouraging GP participation

42. AN ETHICAL FRAMEWORK FOR INTEGRATING PALLIATIVE CARE PRINCIPLES INTO THE MANAGEMENT OF ADVANCED CHRONIC OR TERMINAL CONDITIONS CLINICAL INTEGRITY REQUIRES: 1. Best available continuing and integrated treatment and care as health care needs change 2. Responsible health professionals undertake a specific review of a person’s treatment, care options and wishes 3. People are referred in timely and transparent ways to the most appropriate health professionals 4. Health professionals communicate and collaborate with each other in a timely and regular way 5. Review by multidisciplinary health teams is available when needed http:// www.nhmrc.gov.au

43. HOW CAN THESE GUIDELINES BE INTRODUCED? - MACRO LEVEL INITIATIVES PROVIDE DEVELOP EDUCATION & POLICIES & TRAINING PROCEDURES MANAGEMENT RESPONSIBILITIES WITHIN THE LEGISLATIVE FRAMEWORK PROMOTE COMMUNICATION CONSULTATION & NETWORKING PROVIDE STAFF SUPPORT

44. 75% of respondents said loved ones had not discussed care preferences with them

45. HOW CAN THESE GUIDELINES BE INTRODUCED? - MICRO LEVEL INITIATIVES • Implementing a palliative approach in NH’s can reduce the potential distress to residents and their families caused by a transfer to an acute setting • A palliative approach can be provided in the resident’s familiar surroundings if adequately skilled care is available • Providing information about a palliative approach may help residents and their families to consider a palliative approach as active care rather than withdrawal of treatment care plans Flow charts Policies

46. A multidisciplinary team that promotes goal setting in collaboration with the family is critical to the success of a palliative approach • This approach decreases discomfort for residents, saves valuable resources and improves satisfaction levels for the family when they recall the care provided IMPLEMENTING A PALLIATIVE APPROACH Self Directed Learning Package http://agedcare.palliativecare.org.au/Default.aspx?tabid=1765

47. Self Directed Learning Packages for Staff and Doctors http://agedcare.palliativecare.org.au/Default.aspx?tabid=1765 http://www.palliativecare.org.au/Portals/46/Factsheet%20-%20online%20education%20-%20palliative%20care%20in%20aged%20care%20homes.pdf

48. PROCESS OF END OF LIFE DECISION MAKING

49. (C Stirling; S Andrews; F McInerney; C Toye; M Ashby; A Robinson 2011)

50. OUTLINEQuality Improvement in the Nursing Home Setting • A framework for QI • The NH in the 21st Century • QI for the NH of the 21st Century • Putting it together