Long Term Quality Measurement for Older Adults

1. Long Term Quality Measurement for Older Adults Tamara L. Burket, MS, GCNS-BC, ACNS-BC, CCRN Fellow Geriatric Nursing Leadership Academy

2. Resources • http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/index.html?redirect=/NursingHomeQualityInits/

3. http://www.newschool.edu/ltcc/pdf/txBackground03-10-05FINAL.pdfhttp://www.newschool.edu/ltcc/pdf/txBackground03-10-05FINAL.pdf

4. Objective • Discuss valid quality measures and their application in diverse gerontological settings throughout the community.

5. Points of Emphasis • Enhanced QOL as prime directive • History: Alphabet soup!! ACOVE /IOM/ CMS/ QI/ OBQI/ RAI… 3. Nursing Home Compare 4. Where do I start?

6. Target Population • The Administration on Aging defines the older population as persons 65 and older (2004). • The U.S. Census Bureau defines the older adult as “elderly” and includes persons 65 years of age and older (2001).

7. Young old =65-75 • Old =75-85 • Old old= 85+ • Centurions are now the fastest growing age group

8. Target Population Statistics • According to the U.S. Census Bureau: 1 in 8 Americans were elderly in 1994 & 1in 5 or 20% will be elderly by the year 2030. • The U.S. Census Bureau predicts the fastest growing portion of the elderly population is the “oldest old” (individuals 85 years of age and older).

9. Population Age Projections2005 - 2050

10. Persons 65 and Over:- by age group - 1900-2000 - projected 2010-2050

11. Target Population: Complex Issues • The elderly are living longer and they place increasing demands on the healthcare system and on medical and social services (CDC, 2005). • Though we see the health of older Americans improving, many of these individuals are disabled or coping with chronic diseases/conditions (U.S. Census Bureau, 2006). • Older adults are dealing with chronic diseases, diminished quality of life, and increased costs of healthcare (CDC, 2005).

12. Socioeconomic Issues • 30%of the Medicare budget is spent on 6% of the Medicare population in the last year of life • Federal spending in the elderly has double since 1960 • Hospitals receive the majority of Medicare expenditures and nursing facilities receive the majority of Medicaid expenditures. • Following retirement, income drops 50% on the average

13. Minority Elderly • 15%- 65+ • 8% Black • 2% Asian or Pacific Islanders • 1% Native American • 4% Hispanic

14. 12% of Black population are elderly • 13% of those are over 85 • They are the fastest growing segment of the black population

15. Health Care Disparities http://www.census.gov/Press-Release /www/releases/archives/aging_population/006544.html http://www.agingstats.gov/chartbook2004/population.html http://www.census.gov/population/www/pop-profile/elderlypop.html

16. Vulnerable Elders • ACOVE: • “community dwelling elders aged 65 and older who are at greater risk of death or functional decline over a 2-year period.” • JAGS 55:S247-S252, 2007

17. Characteristics of Vulnerable Elders • Patient Safety Concerns • Deficits In Quality of Care • Particular Care Needs of Older Persons • JAGS 55:S247-S252, 2007 • Iatrogenic Cascade

18. Complicated by: • Multiple Medical Conditions • Chronicity • Ageism • Functional Status • Substantial Variation in Preferences • Diversity

19. Top 4 Major Chronic Illnesses in Older Adults • Asthma • Hypertension • Hearing Impairment • Heart Conditions Robinson, D., Kish, C. (2001) Advanced Practice Nursing. St. Louis, MO: Mosby, Inc., 570

20. Geriatric Care Priorities • Medical • Cognitive • Affective • Functional • Social support/care giver

21. Elements Of Geriatric Assessment • Economic • Environmental • Quality of life/well-being • Advance Directives SPICES Sleep PO Incontinence Confusion Evidence of falls Skin breakdown

22. Legislation • 1935-Social Security Act –Intended as “old-age” insurance • 1965-Older Americans Act established the foundation for the development of today’s senior centers. • 1981- Omnibus Budget Reconciliation Act (OBRA) reduced Medicaid eligibility for older Americans, care, set limits for health care services, established criteria for nursing home care • 1983-Prospective Payment System reduced reimbursement for home health services • 1990-OBRA provided direct reimbursement for NP’s and specialists in rural areas…

24. ...“NEVER” EVENTS • 2008- A list of 28 medical errors from the National Quality Forum: • Should never happen • Never getting paid • Among them: Death or disability related to • falls • use of restraints or bedrails • stage 3 or 4 pressure ulcers • suicide or attempted suicide • medication error • sexual or physical assault while being cared for in a healthcare facility

25. Healthy People 2010 • Physical activity • Overweight and obesity • Responsible sexual behavior • Injury and violence • Immunizations • Tobacco use • Substance abuse • Mental health • Environmental quality • Access to quality care

26. “10 KEYS” TO HEALTHY AGING(From Healthy People 2020) • Lower Systolic Blood Pressure • Stop Smoking • Participate in Cancer Screening • Get Immunized Regularly • Regulate Blood Glucose • Lower LDL Cholesterol • Be Physically Active • Prevent Bone Loss and Muscle Weakness • Maintain Social Contact • Combat Depression The Center for Healthy Aging University of Pittsburgh Graduate School of Public Health http://www.healthyaging.pitt.edu/home.html#

27. Process Measures

28. More Process Measures

29. Improvement Measures

30. Healthcare utilization measures

31. Impacting Quality Measures

32. Safety Evidence: Hospitals face mounting costs and decreased reimbursement based on indicators like injuries related to falls, pressure ulcers, and nosocomial infections. Nurses and other providers are challenged to define their contribution to patient safety in meeting regulatory requirements and standards. Teamwork Evidence: The Institute of Medicine (2008) supports interdisciplinary teamwork as evidenced in the review of 128 successful, innovative models for geriatric care.

33. TransdisciplinaryTeamwork • Population • Intervention • Comparison • Intervention • Plan • Do • Change • Assess

34. Advocacy Evidence: Nurses have multiple opportunities within their organizations and communities to advocate for timely and just dispersal of increasingly sparse resources in the care of older adults. Rounds Evidence: The Studer Group recommends “Rounding for Outcomes” and the use of rounding logs and care plans to support nursing intervention, care coordination, and reward and recognition as patient and staff goals are achieved.

35. SPICES Sleep PO Incontinence Confusion Evidence of falls Skin breakdown

36. PICO • P= Elder Trauma Victims over 65 years of age • I= Targeted Geriatric Rounding • C= Absence of targeted geriatric rounding • 0= Effects of intervention

37. Sample PICO Question: Will targeted geriatric rounds provide measurable outcome improvements in nursing care for victims of injury patients over 65 years old?

38. Potential Qualitative Outcome Measures • Nurse Satisfaction • Patient Satisfaction • Quality of life • Patient Safety/Compliance Data • Nurse Sensitive Quality Indicators Geriatric Syndromes & Vulnerabilities

39. Qualitative • “Each time, those who espouse only evidence—without narratives about real people—struggle to control the debate. Typically, they lose.” Jason Karlawish http://scienceprogress.org/2011/11/the-importance-of-narrative-in-communicating-evidence-based-science/

40. 10 Most Common Geriatric Consult Team Interventions 1. Confusion Assessment 2. Falls Assessment & Precautions 3. Polypharmacy Issues 4. Dehydration 5. Pain Management 6. Discharge Recommendations 7. Bowel Regimen 8. Blood Pressure Management 9. Urinary Sepsis Screening 10. Dysphagia Screening

41. Population of Nursing Care Plans Before & After Targeted Rounding

42. Examples:Nurse Satisfaction Data Before and After Rounding for Outcomes

43. Nurse Satisfaction Data Before and After Rounding for Outcomes

44. Patient Satisfaction Data KEY: Baseline: 3Q11 4Q11 1Q12

45. Quality Indicators per 1000 Patient/Device Days

46. FY11 BOOST Results 30-Day Related Cause Readmission Rates

47. Additional Resources Penn State Milton S. Hershey Medical Center and Penn State College of Medicine.(2011). FY11 Project BOOST results inform the FY12 Care Transitions Project. Crescent. Hershey, PA. Sept. 14, 2011. Institute of Medicine. (2008). Retooling for an aging America: building the health care workforce. Washington, DC. The National Academies Press. Resnick, B. (2010). Function of older adults in acute care: optimizing an opportunity. In M.D. Foreman, K Milison & T.T. Fulmer (Eds.), Critical Care Nursing of Older Adults: Best Practices (3rd ed., pp. 209-238). New York: Springer.

48. http://www.studergroup.com/dotCMS/knowledgeAssetDetail?inode=111088http://www.studergroup.com/dotCMS/knowledgeAssetDetail?inode=111088 • http://www.iom.edu/Global/News%20Announcements/Crossing-the-Quality-Chasm-The-IOM-Health-Care-Quality-Initiat • http://consultgerirn.org/searched?q=SPICESive.aspx