Physician Practice in the Nursing Home: Measuring Performance and Assuring Quality Care

1. Physician Practice in the Nursing Home: Measuring Performance and Assuring Quality Care Paul R. Katz, MD, CMD Professor of Medicine Department of Geriatrics College of Medicine Florida State University

2. Understand the Context • Interdisciplinary care is the underpinning of quality in the nursing home (NH) • Nurses contribute the majority of “person hours” of care in the NH • In addition to nurses, physicians are among the key players in the interdisciplinary team • Nurse practitioners and physician assistants are also important contributors to medical care delivery in the NH

3. Choosing a Nursing Home • Families often don’t get an informed choice • Placement driven by: • Medical needs • Psychiatric/behavioral needs • Payment source • Location of nursing home • Relationships between nursing home and hospital • Hospital and nursing home bed supply • Family advocacy • Hospital clinicians often unaware of nursing home capacity and quality

4. Choosing a Nursing Home • Evidence based considerations • Nurse staffing ratios • Survey deficiencies • Performance on publically reported quality measures • Administrator/Director of Nursing leadership style and turnover rates • For profit v not-for profit • Philosophy of care (i.e. person centered/culture change) • Focus on quality improvement (i.e. INTERACT)

5. Is There a Doctor in the House? • The link between physician care and NH quality • Approaches to measuring physician performance • Setting a research agenda

6. Nursing Homes (NH) • 1.4 million residents in US • 46% chance of being admitted to a NH after the age of 65 • Post-acute patients receiving SNF care account for 20% of total NH days (US) • New payment models focus on enhanced care coordination and transitions of care with reduced re-hospitalization rates

7. Nursing Home Physicians in North America (historical) • In the U.S. only one in five primary care physicians engages in the care of nursing home residents (JAGS 45: 911, 1997) • The majority spend 2 hours or less per week in NH care • In Ontario (2005), 1190 physicians engage in NH care out of 10,317 (12%); of these 628 (53%) cared for 90% of all residents. • Between 1990 and 2000 there was a 5% decline in proportion of general practitioners providing services to LTC homes (CMAJ 19:429, 2002)

8. Teno JM et al. Research Letter: Temporal Trends in the Number of Skilled Nursing Facility Specialists from 2007 through 2014. Published online: July 10, 2017.doi:10.1001/jamainternmed.2017.2136

9. Ryskina KL, Polsky D, Werner RM. Research Letter: Physicians and advanced practitioners specializing in nursing home care, 2012-2015. JAMA Nov 28, 2017 Vol 318 (20)

10. Baseline and Projected Geriatrician National Supply and Demand, 2013 and 2025 • US DHHS, HRSA-Bureau of Health Workforce, April 2017 • Estimated supply 2013: 3590 • New entrants 2013-2025: 2640 • Attrition 2013-2025: -690 • Change in average work hours: -20 • Projected supply: 6230

11. Baseline and Projected Geriatrician National Supply and Demand, 2013 and 2025 • Demand: • Estimated demand 2013: 22,940 • Changing demographic impact: 10,260 • Insurance coverage impact: ------- • Projected demand: 33,200 • Projected supply minus demand: -26,980

13. Credibility GapJ Am Med Dir Assoc 14(2):83-84, 2013 • Physicians practicing in NHs have low credibility/respect compared to their peers • Skill set not recognized or appreciated • Acute care is the center of the health care universe reflecting predominance of the medical model • Disease focused • Cure at all costs • Technology

14. Is this Assumption True? • Optimal physician practice translates into desirable outcomes: • Clinical quality • Efficiency/cost effectiveness • Patient and family satisfaction • Quality of life

15. A Model for Nursing Home Physicians: Linking Practice to Quality Ann Intern Med 2009; 150:411-413 Three critical dimensions… Commitment conceptualized as percentage of the physician's practice devoted to NH care and the amount of time, on average, spent per NH patient encounter. Physician NH practice competency defined by specialized training and experience necessary to handle the complex medical care in a highly regulated, interdisciplinary care context that is the contemporary NH. Organizational structure reflects the cohesive integration of the medical providers into the culture of the facility.

21. Nursing Home Medical Staff Organization • Clinical and Nonclinical Factors Associated with Potentially Preventable Hospitalizations Among Nursing Home Residents in New York State (JAMDA 12: 364-371, 2011) • 147 randomly selected NHs • Outcomes derived from DON survey, MDS and SPARCS (patient level data related to hospitalizations) 2007-8

22. Nursing Home Medical Staff Organization • Results • Four factors significantly associated with reduction in ambulatory care sensitive (ACS) conditions • Nursing staff trained to effectively communicate with physicians regarding a resident’s condition • Physicians treat residents within the nursing home and admit to hospital as a last resort • NHs that provide better information and support to nurses and aides surrounding end-of-life care • Easy access to stat lab results in <4hrs on weekends

23. Treatment of Pain in European Nursing Homes: Results from the SHELTER StudyJAMDA online: www.jamda.com/article/S1525-8610(13)00250-8/fulltext • Cross sectional study of pharmacological and non-pharmacological pain management involving 4156 residents • Assessed with interRAI instrument for LTCF • 7 countries involved: Czech Republic, England, Finland, France, Germany, Italy, Netherlands and Israel • High turnover of regular staff and low to moderate physician availability were negatively associated with pharmacological pain management

24. Organizational Factors Associated with Inappropriate Neuroleptic Drug Prescribing In Nursing Homes (J Am Med DirAssoc 2015;16:590-597) • 6275 residents of 175 nursing homes included as part of larger IQUARE study in southwestern France • The number of GPs working at each home varied from 1 to 42 with mean of 13.8 • Residents in NHs with 20 GPs or more/100 beds had more inappropriate prescribing than in NHs with less than10 GPs/100 beds (OR 1.8)

25. Organizational Determinants of Transfers from Residential Aged Care Facilities • Unplanned transfer to emergency departments for frail elderly residents of aged care facilities: A review of patient and organizational factors (J Am Med DirecAssoc 2015;16:551-562): • Literature review of observational studies (N=78) • Meta-analysis not possible given heterogeneity of studies • 36% of studies included some prospective data • 54% from US;12% Australia;10% Canada

26. Organizational Determinants of Transfers from Residential Aged Care Facilities • Lower rates of hospitalizations if: • Greater involvement of medical staff through full time appointments • Greater availability of facility medical director • Greater availability of primary care physicians • Increased physician hours per resident • More formal structured appointment process for physician

27. Impact of NH Specialists on Postacute Care Outcomes and Cost • Rysinka KL, Yuan Y, Werner RM. Health Serv Res. 2019;1-11. • Data sources: Medicare claims and NH assessments for 2,118.941 hospital discharges to 14,526 SNFs Jan 2012-October 2014 • Nursing home specialist’s (MD/NP) patients were: • Less likely to be rehospitalized (14.71% v 16.23%) • More likely to be successfully discharged to community (56.33% v 55.49%) • Nursing home specialists had higher 60-day Medicare payments ($31,628 v $31,292)

28. If Physician practice relates to quality then…… • What metrics do we use to measure physician performance? • Should they be based on productivity and financial performance OR • Should they be based on measures that exemplify a special skill set and it’s application at the bedside?

29. Metrics to measure physician performance • Measures of productivity and financial performance, while important, DO NOT necessarily measure good clinical care • The skill set necessary to practice high quality care is defined by attending physician competencies specific to the nursing home

30. Competencies for Physicians Practicing in the NH: Rationale Nursing Home practice demands a unique skill set Competencies linked to relevant clinical outcomes/quality Credibility of physicians predicated, in large part, on specialization Impetus to set the bar independently or allow government to determine performance metrics Helps inform new curriculum development

31. National Academy of Medicine Priorities “Preparing for Better Health for an Aging Population” (nam.edu/VitalDirections) • Physician and nurse training in all settings where older adults receive care, including nursing homes, assisted-living facilities, and patients’ homes. • Demonstration of competence in the care of older adults as a criterion for all licensure, certification, and maintenance of certification for health care professionals. • Enhanced reimbursement for clinical services delivered by practitioners who have a certification of special expertise in geriatrics

32. Competencies for Post-Acute and LTC Attending Physicianshttp://www.amda.com/strategic-initiatives/competencies.cfm • Foundational (ethics, professionalism and communications) • Medical Care Delivery Process • Systems • Nursing Home Medical Knowledge • Personal QAPI (quality assurance and professional improvement)

33. Domain I: Foundation (Ethics, Professionalism and Communication) • Module 1.1 Application of Ethical Principles in Clinical Decision-Making • Module 1.2 Clinical Implications of Legal and Regulatory Requirements • Module 1.3 Recognizing and Adapting to Patient Limitations and Impairments • Module 1.4 Optimizing Communication with Patients and Families • Module 1.5 Culturally Sensitive Interactions with Patients, Families and Staff • Module 1.6 Elements of Appropriate and Timely Practitioner Performance

34. Domain II: Medical Care Delivery Process • Module 2.1 Applying the Care Delivery Process to Patient Care • Module 2.2 Developing a Person-Centered Evidence-Based Medical Care Plan • Module 2.3 Identifying and Incorporating Prognosis into Care Decisions • Module 2.4 Principles of Palliative and End-of-Life Care • Module 2.5 Developing Effective Palliative and End-of-Life Care Plans

35. Domain III: Systems • Module 3.1 Providing Prudent and Minimally Disruptive Care • Module 3.2 Using Patient Databases in Clinical Practice • Module 3.3 Determining Appropriate Levels of Care • Module 3.4 Optimal Management of Care Transitions • Module 3.5 Working Effectively with the Interdisciplinary Care Team • Module 3.6 Understanding and Explaining the Impact of Finances on Care Decisions

36. Domain IV: Medical Knowledge • Module 4.1 Identifying and Managing Changes in Condition • Module 4.2 Formulating a Pertinent and Adequate Differential Diagnosis • Module 4.3 Identifying and Developing a Person-centered Medical Plan • Module 4.4 Minimizing Risk and Optimizing Patient Safety • Module 4.5 Managing Pain Safely and Effectively • Module 4.6 Prescribing Medications Prudently and Effectively

37. Domain V: Personal Professional Development in PA-LTC • Module 5.1 Developing a Personal Professional Development Plan • Module 5.2 Utilizing Quality-Related Information to Improve Care • Module 5.3 Using Patient Outcomes to Improve Practice

38. Competencies Curriculum Online Course • Web-based • Asynchronous • Case studies • Pre- and post-test questions • Evaluations • Certificates

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40. Metrics to measure physician performance (Castle N, Ferguson JC. The Gerontologist 50: 426, 2010) • Donabedian conceptualized quality along 3 dimensions: • Structure (organizational characteristics) • Process (what is done in practice) • Outcome (the final product) • Logic: • Good structure (i.e. high nurse staffing ratios) facilitates good process (i.e performing medication reconciliation) • Good process facilitates good outcomes(i.e. reduced rates of re-hospitalization)

41. Provision of Care in the Nursing Home Process Outcomes Structure • Steps of care • provided by • Nursing aides • LVNs • Registered Nurses • Therapists • Physicians • Nurse Practitioner • Pharmacists • Policy • Implementation • NH Staff • - Training • - Number • - Stability • Organization • NH layout • Policies • NH Ownership • - Profit • - Not-for-profit • Expenditures • Fall rates • Rates of • restraint use • Functional • decline • Deficiencies RAND Health

42. Metrics to measure physician performance (Castle N, Ferguson JC. The Gerontologist 50: 426, 2010) • Pro • Structure: Data available and easy to measure • Process: Describes what is done to the resident • Outcome: The desired state for the resident • Con • Structure: Variable link to quality of care (“necessary but not sufficient”) • Process: Does not necessarily describe appropriateness of what is done; documentation vs actual care; often requires chart review • Outcome: Dependent on multiple inputs and often inevitable in frail NH residents (majority of MDS measures)

43. Development of Quality Indicators for NH Primary Care Providers (Phase I) • Grant support from the Morris Justein Family Charitable Foundation • Focus on PROCESS measures that operationalize the AMDA competencies • Identifythestepsofcarethatareinfluencedbytheprimary careprovider(physicianor advancepracticenurse/PA). • Mitigates need for complicated risk adjustments • Allows for more “discipline specific” focus • Ideally reflects best practices

44. TEAMMEMBERS UCLA BorunCenter FORGERONTOLOGICALRESEARCH

45. Methodology • Reviewed and adapted existing indicators • ACOVE3QualityIndicators2007 • NHQualityIndicators2004 • NHResidentialCareQualityIndicators(2002) • AGS/AMDAChoosingWisely • TheEuropeanHeartRhythmAssociationguidelines • SGIM-AMDA-AGS Consensus Best Practice Recommendations for Care Transitions

46. Methodology • Technical expert panel convened • Modified Delphi Process (Rand) • Pre-meeting ratings • In-person discussion (June 2017) • Goalisclarification • Notforcingagreement • Re-rateafterdiscussion

47. INSTRUCTIONS • MostoftheQIsareconstructedasIFandTHENstatements: • “IF”statementdescribestheresidentstowhomtheindicator applies • “THEN”statementdescribestheprocessofcarethatshouldor shouldnotbeappliedunderthesecircumstances • Ratethevalidityandfeasibilityofindicatorsona1-9pointscale where9=mosthighlyvalidand1=notatallvalid • 1-3=notvalid;notfeasibletoimplement • 4-6=variationinvalidity;variationinfeasibility • 7-9=valid;feasibletoperformtheprocess • Wheretherearemultipleoptions,voteeachindependently.

48. VALIDITY • We defineanindicatortobevalidif: • Thequalityindicatorisclearandexplicit. • Adequatescientificevidenceorprofessionalconsensusexiststosupportastronglinkbetweentheperformanceofspecifiedcareandoutcomes.Improvedqualityoflifeis consideredanoutcome. • Aproviderwithsignificantlyhigherratesofadherenceto anindicatorwouldbeconsideredahigherqualityprovider. • Amajorityoffactorsthatdetermineadherencetoan indicatorareundertheinfluenceoftheprovider(oraresubjecttoinfluence,suchassupportofcaregivers).

49. FEASIBILITY Feasibilityofimplementationshouldberatedbasedonan averagenursinghometryingtodeliverhighqualitycare. Considerstaffingresources,physicianresources,expense.

50. NH Quality Measure • IF the NH staff attempts to contact the PCP by phone or pager for an acute change in a nursing home resident (NHR),THEN there should be documentation that the PCP returned the call within 60 minutes. • (Note: acute change in condition includes a critical lab)