Dementia-Specific NH Quality Indicators

1. Dementia-Specific NH Quality Indicators IDND Meeting May 2008 Greg Arling, Ph.D.

2. Dementia-Specific QI (D-QI) Project • Funded by the Alzheimer’s Association (Investigator-Initiated Research Grant) • October 2007 – September 2010 • Greg Arling (PI) and Malaz Boustani (Co-PI) -- IU Center for Aging Research • Christine Mueller (Co-PI) – U of Minnesota School of Nursing • Focus on nursing home care in Minnesota

3. D-QI Project Objectives • Form an advisory group to provide guidance for the project; • Identify current and new quality indicators (D-QIs) most relevant to dementia residents; • Assemble available data on clinical care and quality of life of nursing home residents; • Analyze available data to arrive at a final set of D-QIs for profiling nursing facilities and their residents; • Describe best practices in care of dementia residents through interviews with nursing home staff in high quality facilities (high D-QI scores). • Incorporate D-QIs into the Minnesota NH Report Card, P4P, and facility quality improvement efforts.

4. Minnesota NH Quality andPayment System • Multidimensional measures of nursing home quality • NH Report Card to inform consumer decisions • Facility reporting system and training sessions to promote quality improvement. • Provider Payment Incentive Program which funds quality improvement projects to foster innovation and organizational learning

5. Minnesota NH Quality Measures

6. NH Quality Indicators (QIs) • Based on Minimum Data Set (MDS) assessments • Standardized assessment of health and functional conditions • Administered to all residents by NH staff at admission and every 90 days thereafter • Transmitted monthly to the state in a standardized electronic format • 24 QIs representing care processes and outcomes • Binary variable (yes/no) at resident level • Prevalence or incidence rate at the facility level

8. Quality of Life & Resident Satisfaction • Annual survey carried out by professional survey organization involving face-to-face interviews with 14,000+ NH residents • Probability sample designed to yield facility-specific QoL rates for all 400 nursing homes. • 53 QoL and other items adapted from established instruments • Surveys conducted in 2005 – 2008

9. QoL/RS Dimensions(# of survey items)

12. Facility Quality Reports • Detailed QI and QoL/RS reports sent periodically to each facility • Most current QI and QoL/RS results • Tracking of QI or QoL/RS rates over time • Special training programs on priority areas identified through quality reports • Meaningful activities • Skin care • Psychotropic medications • Pain management

13. Provider Incentive Payment Program • Funding • $5 Million available in Year 1 (10/07-9/08) • $20 Million available in Year 2 (10/08-9/09) • Response to Request for Proposals • Over 200 applications received • 35 projects (75 facilities) funded • Variety of projects: Culture change Wound care Quality of life Employee retention Pressure ulcers Pain management Exercise CHF

14. D-QI Project • Advisory Committee Meeting in March 2008 • Front-line caregivers (e.g., medical directors, nurses, and nursing assistants) • Family members • State agency staff • Other local experts • Advances in Nursing Home Dementia Care (June 2008 Workshop, Minneapolis) • Wide audience of local experts – particularly front-line caregivers • Identify high priority D-QIs and recommend areas for application • Advances in Nursing Home Dementia Care (Fall 2008 Workshop, Indianapolis)

15. D-QI Initial List of Indicators • From Advisory Group Meeting • Brainstorm • Consider QIs • Currently measured or present in available data (MDS or QoL survey) • Need to be developed and possible new data collection • Refine D-QIs in subsequent meetings and data analysis

16. Resident-Centered Care • Consistent staffing • Flexibility • Individualized care plan and care • Knowledgeable and respectful staff • Good communication with residents • Staff have accessible/easy-to-use information about residents (e.g. needs, care) • Residents can engage in meaningful activity • Behavioral problems are handled effectively • Appropriated decisions about care – e.g., advanced directives and surrogate decision-making

17. Family Engagement and Support • Promotion of family involvement • Family-staff partnership/collaboration • Environment where • families can freely be advocates for their loved one • family’s perspective is welcomed/families are engaged with staff in addressing resident’s needs • Family participation • Family involved in assessment • Family input into caregiving plans and activities • Two-way communication between staff and family • Family participates/shares in caregiving according to their preferences and capabilities

18. Staff Capabilities and Empowerment • Staff learning/knowledge about dementia • Staff is empowered and empowering • respond to resident’s needs • can individualize • Staff given support to manage their own stress & avoid burnout • Teamwork • among front-line staff • across disciplines and staff types • Staff stability and Avoidance of turnover • Sufficient number of staff & Right skill mix and expertise • Staff adequately paid/compensated

19. Physical Environment • Make it home-like (familiar objects) • Intuitive layout • Safety and Security • unobtrusive ways of keeping people safe • appropriate security • Sensory aids – cues & labeling • Good physical design – flooring, lighting, & exercise/wandering areas • Stimulation sensitive • Effective use of color • Noise levels (not over stimulation) • Music-appropriate to individual/groups • Effective use of technology to ↓ noise stimulation • Sensory deprivation attended to

20. Organization and Management • Organizational culture • Learning community • Innovation seeking • Empowering & flexible • Organization of care • Unique programming • Activities-appropriate for dementia care (RC) • Unit types and resident mix • Intergenerational • Specialized dementia units or dementia residents mixed with others • Do residents get “placed” or “moved” based on clinical and cognitive needs? Debatable • Information Technology • IT (Integration) & other Technology Use • Electronic Medical/Health Record • Computer Decision Support

21. Clinical Care • Dementia expertise • Specialist in dementia involved in care (assessment and prescription) ongoing • Proficiency of Geriatric Clinical Provider • Diagnosis and assessment • Diagnosis for dementia and type • Fully assess needs • Identify triggers/causes of behavioral symptoms • Staging • Assessment should determine dementia stage • Care tailored to stage of dementia (need work on criteria for staging) • Delirium diagnosis and treatment • Assessment/diagnoses of delirium • Prevention and treatment strategies/interventions • Delirium treatment strategies/interventions • Delirium -- close observation, assessment & management

22. Clinical Care (Cont.) • Short stay dementia residents receiving appropriate/equal care (medical, clinical) • Discharge decisions • Rehabilitation decisions, rehabilitation attempted • Rehabilitation and functional outcomes • Physical Therapy/Occupational Therapy* • Successful rehabilitation outcomes • Maintaining/promoting function • Choice of Therapies Validation, vs. Orientation* Tx (Traction?) • Non-traditional Therapies • Pet therapy • Music therapy • Touch

23. Clinical Care (Cont.) • Clinical Issues • Delirium • Pain • Depression • Communication/speech • Feeding/ Nutrition • Tube Feeding • Weight • Continence • Skin care • Functional Decline • Vision and hearing • Medications • End of Life Care* • Hospice Care • Palliative Care