Comprehensive Assessment of Nursing Home Quality

1. Comprehensive Assessment of Nursing Home Quality Fall Research Conference -- Regenstrief Center for Healthcare Engineering, Purdue University Greg Arling, Ph.D. Indiana University Center for Aging Research

2. Minnesota NH Quality Assessment & Payment Project • Sponsored by Minnesota Department of Human Services (DHS) • Multidisciplinary Research Team • Robert L Kane, MD, Christine Mueller, RN PhD, & Julie Bershadsky, University of Minnesota • Greg Arling, PhD, Indiana University Center for Aging Research • Valerie Cooke, Robert Held, and Teresa Lewis Minnesota Department of Human Services

3. Goals • Develop comprehensive measures of nursing home quality • Apply the measures • Informing consumer decisions • Guiding nursing home quality improvement • Offering financial incentives for better care • Engage consumers and providers in efforts to achieve better quality • Continue to refine the quality assessment system and evaluate its impact

4. Guiding Principles • Comprehensive – contains process and outcome indicators, quality of care and quality of life • Mutually Reinforcing -- quality measurement and application proceeds iteratively and are mutually reinforcing • Relevant – taps dimensions of care that are important to consumers and providers • Credible – has strong research base • Understandable – effectively presented to different audiences • Actionable – informs consumer decision-making and provider quality improvement • Transparent – methods are well described, in the public domain, and open to scrutiny by stakeholders and the research community

5. Comprehensive Quality Measures • Direct care staffing level (salary and CM adjusted HPRD), employee retention rate, & use of permanent (non-contract) staff • Clinical Quality Indicators (QI) • Quality of Life and Resident Satisfaction (QoL/RS) Survey • State Inspection (NH Survey) Results

6. MN Nursing Home QIs • Based on MDS assessments • 35,000 residents in 400 facilities per calendar quarter • 24 QIs representing care processes and outcomes • Dimensions (# of QIs) Psychosocial (4) Accidents (2) Restraints (1) Nutrition (1) Continence (6) Pain (1) Infections (2) Skin Care (2) Functioning (5) Drugs (1)

8. Quality of Life & Resident Satisfaction • Annual survey carried out by professional survey organization involving face-to-face interviews with 14,000 NH residents • 53 QoL and other items adapted from established instruments • Dimensions (# of survey items) Comfort (4) Autonomy (5) Environmental (4) Individuality (3) Privacy (3) Security (3) Dignity (4) Relationships (3) Meaningful Activity (3) Satisfaction with Care (7) Food Enjoyment (3) Mood (9)

10. Adjustment & Estimation • Hierarchical General Linear Models (HLM 6.0) • QIs risk adjusters • Age and gender • Diagnoses (e.g, stroke, hip fracture, end-stage) • functional status (e.g., ADL, cognitive status) • health conditions (e.g., hemiplegia, sensory loss) • QoL/RS score risk adjusters • Resident gender, ADL, age, cognitive status & LOS • Facility location and average LOS • Empirical Bayes estimates of facility QI or QoL/RS rates

11. Application • Nursing Home Consumer Report Card • Facilities receive 1-5 Stars on each quality measure • 1,800 internet users/month • Detailed QI and QoL Reports sent periodically to facilities • Quality Add-on (2.4%) to Medicaid Payment Rates • Pay for Performance Quality Initiatives • Facilities develop quality improvement projects • Tied to quality measure outcomes • $30 Million allocated for 2007-2008

12. Nursing Home Report Card • Transparency to consumers • Make better LTC choices • Advocate for care improvement • Provider benchmarking and quality improvement • Nursing homes selected by geographical areas • Facility assigned 1-5 stars on each of seven dimensions

14. Consumer Response • Use of Report Card • 26,000 “hits” the first week • 1,800/month since then • Consumer feedback on Report Card • 87% rate “easy” or “pretty easy” to use • 55% “definitely” would use in selecting a nursing home • 36% “probably” would use in selecting a nursing home

15. Feedback from Report Card Users (N=108,000)

16. 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

17. Trends in QI Rates Decline Improvement

18. Quality Adjustment to Payment Rate • Bonus added annually to Medicaid per diem payment rate -- proportional to Quality Score Quality ScoreBonus (% of PD Rate) 0-40 0.0% 41-99 0.1% to 2.3% 100 2.4% • Quality score also used to adjust Medicaid cost limits • Reduces rates for high cost & low quality facilities • Increases rates for low cost and high quality facilities

19. Performance-Based Incentives • Facilities propose a new program to: • Improve quality outcomes • Increase efficiency • Re-balance long-term care (e.g., community discharges) • Facilities receive a 5% rate increase IF they: • Implement the program effectively • Achieve outcome objectives • Most projects linked to improvement in QIs, QoL/RS, and other quality measures

20. Response to Performance-Based Incentives • 155 applications received, 19 projects and 32 facilities approved in first year • Focus of projects: Culture change Wireless call systems QoL for dementia residents Employee retention Pressure ulcers Pain management Exercise CHF

21. Overall Provider Response • Even modest financial incentives have stirred considerable provider interest • Providers have asked for more frequent and detailed QI and QoL/RS reports • Providers have been supportive of QI and QoL/RS risk adjustment with some calling for expanded adjusters • State-sponsored quality improvement training programs have been attended by 100’s of nursing home staff

22. Continued Research • Improve validity and reliability of quality measures • Track trends in quality over time • Facilitate consumer decision-making • Develop better provider reports • Identify effective management practices • Evaluate quality improvement strategies • Build a business case for better quality

23. Expand Quality Measures • QI or QoL/RS measures designed specifically for dementia residents • Post-acute QIs • Family satisfaction survey • Community discharge/NH transitions • Re-hospitalization rates • Refined scoring of NH inspection results

24. Stress Value and Cost-Effectiveness • Wide variation in nursing home per diem prices & quality • Information about NH prices and their relationship to quality is not publicly available • Many consumers are receiving very poor value for their long-term care dollars • Need to focus on connection between price and quality – greater value and cost-effectiveness

25. Improve Reporting • Track quality measures over time • Trends in QI rates (quarterly) • Changes in annual QoL/RS scores • Drill down capability • Dimension scores • Individual survey items or QIs • Decision support tools

26. Build a Business Case for Quality • Increase quality adjustment of payment rate • Reward high quality • Discourage poor quality • Expand funding for Performance-Based Incentive projects • Emphasize organizational change and technology • Encourage provider collaboration and diffusion of best practices