Comprehensive Comprehensive Assessment of Assessment of Nursing Home Nursing Home

QualityQualityFall Research Conference -- Fall Research Conference --

Regenstrief Center for Healthcare Regenstrief Center for Healthcare Engineering, Purdue UniversityEngineering, Purdue University

Greg Arling, Ph.D.Greg Arling, Ph.D.Indiana University Center for Aging Indiana University Center for Aging

ResearchResearch

Minnesota NH Quality Minnesota NH Quality Assessment & Payment Assessment & Payment

ProjectProject Sponsored by Minnesota Department of Sponsored by Minnesota Department of

Human Services (DHS)Human Services (DHS) Multidisciplinary Research TeamMultidisciplinary Research Team

Robert L Kane, MD, Christine Mueller, RN Robert L Kane, MD, Christine Mueller, RN PhD, & Julie Bershadsky, University of PhD, & Julie Bershadsky, University of MinnesotaMinnesota

Greg Arling, PhD, Indiana University Center Greg Arling, PhD, Indiana University Center for Aging Researchfor Aging Research

Valerie Cooke, Robert Held, and Teresa Lewis Valerie Cooke, Robert Held, and Teresa Lewis Minnesota Department of Human ServicesMinnesota Department of Human Services

GoalsGoals Develop comprehensive measures of Develop comprehensive measures of

nursing home qualitynursing home quality Apply the measuresApply the measures

Informing consumer decisions Informing consumer decisions Guiding nursing home quality improvementGuiding nursing home quality improvement Offering financial incentives for better careOffering financial incentives for better care

Engage consumers and providers in Engage consumers and providers in efforts to achieve better qualityefforts to achieve better quality

Continue to refine the quality Continue to refine the quality assessment system and evaluate its assessment system and evaluate its impactimpact

Guiding PrinciplesGuiding Principles ComprehensiveComprehensive – contains process and outcome – contains process and outcome

indicators, quality of care and quality of lifeindicators, quality of care and quality of life Mutually Reinforcing --Mutually Reinforcing -- quality measurement quality measurement

and application proceeds iteratively and are and application proceeds iteratively and are mutually reinforcingmutually reinforcing

RelevantRelevant – taps dimensions of care that are – taps dimensions of care that are important to consumers and providersimportant to consumers and providers

CredibleCredible – has strong research base – has strong research base UnderstandableUnderstandable – effectively presented to – effectively presented to

different audiencesdifferent audiences ActionableActionable – informs consumer decision-making – informs consumer decision-making

and provider quality improvementand provider quality improvement TransparentTransparent – methods are well described, in – methods are well described, in

the public domain, and open to scrutiny by the public domain, and open to scrutiny by stakeholders and the research communitystakeholders and the research community

Comprehensive Quality Comprehensive Quality MeasuresMeasures

Direct care staffing level (salary and Direct care staffing level (salary and CM adjusted HPRD), employee CM adjusted HPRD), employee retention rate, & use of permanent retention rate, & use of permanent (non-contract) staff(non-contract) staff

Clinical Quality Indicators (QI)Clinical Quality Indicators (QI) Quality of Life and Resident Quality of Life and Resident

Satisfaction (QoL/RS) SurveySatisfaction (QoL/RS) Survey State Inspection (NH Survey) State Inspection (NH Survey)

ResultsResults

MN Nursing Home QIsMN Nursing Home QIs

Based on MDS assessmentsBased on MDS assessments 35,000 residents in 400 facilities per calendar 35,000 residents in 400 facilities per calendar

quarterquarter 24 QIs representing care processes and 24 QIs representing care processes and

outcomesoutcomes Dimensions (# of QIs)Dimensions (# of QIs)

Psychosocial (4)Psychosocial (4) Accidents (2)Accidents (2)

Restraints (1)Restraints (1) Nutrition (1)Nutrition (1)

Continence (6)Continence (6) Pain (1)Pain (1)

Infections (2)Infections (2) Skin Care (2)Skin Care (2)

Functioning (5)Functioning (5) Drugs (1)Drugs (1)

Quality of Life & Resident Quality of Life & Resident SatisfactionSatisfaction

Annual survey carried out by professional Annual survey carried out by professional survey organization involving face-to-face survey organization involving face-to-face interviews with 14,000 NH residentsinterviews with 14,000 NH residents

53 QoL and other items adapted from 53 QoL and other items adapted from established instrumentsestablished instruments

Dimensions (# of survey items)Dimensions (# of survey items)Comfort (4)Comfort (4) Autonomy (5)Autonomy (5)Environmental (4)Environmental (4) Individuality (3)Individuality (3)Privacy (3)Privacy (3) Security (3)Security (3)Dignity (4)Dignity (4) Relationships (3)Relationships (3)Meaningful Activity (3)Meaningful Activity (3) Satisfaction with Care (7)Satisfaction with Care (7)Food Enjoyment (3)Food Enjoyment (3) Mood (9)Mood (9)

MN Nursing Facilities QoL/RS Scores(2006 Survey)

0.500.550.600.650.700.750.800.850.900.951.00

Comfo

rt

Environ

men

t

Privacy

Activi

ties

Food

Autono

my

Indivi

duali

ty

Securit

y

Relations

hips

Satisfa

ction

Grade

Mood

Domain

Sco

re

Mean

Bottom 10%

Top 10%

Adjustment & EstimationAdjustment & Estimation Hierarchical General Linear Models Hierarchical General Linear Models

(HLM 6.0)(HLM 6.0) QIs risk adjustersQIs risk adjusters

Age and genderAge and gender Diagnoses (e.g, stroke, hip fracture, end-stage)Diagnoses (e.g, stroke, hip fracture, end-stage) functional status (e.g., ADL, cognitive status)functional status (e.g., ADL, cognitive status) health conditions (e.g., hemiplegia, sensory loss)health conditions (e.g., hemiplegia, sensory loss)

QoL/RS score risk adjustersQoL/RS score risk adjusters Resident gender, ADL, age, cognitive status & LOSResident gender, ADL, age, cognitive status & LOS Facility location and average LOSFacility location and average LOS

Empirical Bayes estimates of facility QI Empirical Bayes estimates of facility QI or QoL/RS ratesor QoL/RS rates

ApplicationApplication Nursing Home Consumer Report CardNursing Home Consumer Report Card

Facilities receive 1-5 Stars on each quality Facilities receive 1-5 Stars on each quality measuremeasure

1,800 internet users/month1,800 internet users/month Detailed QI and QoL Reports sent Detailed QI and QoL Reports sent

periodically to facilitiesperiodically to facilities Quality Add-on (2.4%) to Medicaid Quality Add-on (2.4%) to Medicaid

Payment RatesPayment Rates Pay for Performance Quality InitiativesPay for Performance Quality Initiatives

Facilities develop quality improvement Facilities develop quality improvement projectsprojects

Tied to quality measure outcomesTied to quality measure outcomes $30 Million allocated for 2007-2008$30 Million allocated for 2007-2008

Nursing Home Report Nursing Home Report CardCard

Transparency to consumersTransparency to consumers Make better LTC choicesMake better LTC choices Advocate for care improvementAdvocate for care improvement

Provider benchmarking and quality Provider benchmarking and quality improvementimprovement

Nursing homes selected by Nursing homes selected by geographical areasgeographical areas

Facility assigned 1-5 stars on each of Facility assigned 1-5 stars on each of seven dimensionsseven dimensions

Consumer ResponseConsumer Response

Use of Report CardUse of Report Card 26,000 “hits” the first week26,000 “hits” the first week 1,800/month since then1,800/month since then

Consumer feedback on Report CardConsumer feedback on Report Card 87% rate “easy” or “pretty easy” to use87% rate “easy” or “pretty easy” to use 55% “definitely” would use in selecting 55% “definitely” would use in selecting

a nursing home a nursing home 36% “probably” would use in selecting 36% “probably” would use in selecting

a nursing homea nursing home

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

Quality DimensionQuality Dimension % Giving it Top % Giving it Top PriorityPriority

Quality of Quality of Life/Resident Life/Resident SatisfactionSatisfaction

84%84%

State NH Survey State NH Survey ResultsResults

61%61%

NH Quality NH Quality IndicatorsIndicators

59%59%

Staffing Level Staffing Level (HPRD)(HPRD)

38%38%

Staff RetentionStaff Retention 16%16%

Use of Pool StaffUse of Pool Staff 6%6%

Facility Quality ReportsFacility Quality Reports

Detailed QI and QoL/RS reports sent Detailed QI and QoL/RS reports sent periodically to each facilityperiodically to each facility Most current QI and QoL/RS resultsMost current QI and QoL/RS results Tracking of QI or QoL/RS rates over timeTracking of QI or QoL/RS rates over time

Special training programs on priority Special training programs on priority areas identified through quality reportsareas identified through quality reports Meaningful activitiesMeaningful activities Skin careSkin care Psychotropic medicationsPsychotropic medications Pain managementPain management

Trends in QI RatesTrends in QI Rates

Total Improvement in Risk-Adjusted QIs (July 2004 - Dec 2006)

-0.01

0.00

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08Decline Improvement

Quality Adjustment to Quality Adjustment to Payment RatePayment Rate

Bonus added annually to Medicaid per diem Bonus added annually to Medicaid per diem payment rate -- proportional to Quality Scorepayment rate -- proportional to Quality ScoreQuality ScoreQuality Score Bonus (% of PD Rate)Bonus (% of PD Rate)

0-400-40 0.0%0.0%41-9941-99 0.1% to 2.3%0.1% to 2.3%100100 2.4%2.4%

Quality score also used to adjust Medicaid Quality score also used to adjust Medicaid cost limitscost limits ReducesReduces rates for rates for high costhigh cost & & low qualitylow quality

facilitiesfacilities IncreasesIncreases rates for rates for low costlow cost and and high qualityhigh quality

facilitiesfacilities

Performance-Based Performance-Based IncentivesIncentives

Facilities propose a new program to:Facilities propose a new program to: Improve quality outcomesImprove quality outcomes Increase efficiencyIncrease efficiency Re-balance long-term care (e.g., community Re-balance long-term care (e.g., community

discharges)discharges) Facilities receive a 5% rate increase IF they:Facilities receive a 5% rate increase IF they:

Implement the program effectivelyImplement the program effectively Achieve outcome objectivesAchieve outcome objectives

Most projects linked to improvement in QIs, Most projects linked to improvement in QIs, QoL/RS, and other quality measuresQoL/RS, and other quality measures

Response to Performance-Response to Performance-Based IncentivesBased Incentives

155 applications received, 19 projects 155 applications received, 19 projects and 32 facilities approved in first yearand 32 facilities approved in first year

Focus of projects:Focus of projects:Culture changeCulture change Wireless call systemsWireless call systems

QoL for dementia residentsQoL for dementia residents Employee Employee retentionretention

Pressure ulcersPressure ulcers Pain managementPain management

ExerciseExercise CHFCHF

Overall Provider Overall Provider ResponseResponse

Even modest financial incentives have Even modest financial incentives have stirred considerable provider intereststirred considerable provider interest

Providers have asked for more frequent Providers have asked for more frequent and detailed QI and QoL/RS reportsand detailed QI and QoL/RS reports

Providers have been supportive of QI and Providers have been supportive of QI and QoL/RS risk adjustment with some calling QoL/RS risk adjustment with some calling for expanded adjustersfor expanded adjusters

State-sponsored quality improvement State-sponsored quality improvement training programs have been attended by training programs have been attended by 100’s of nursing home staff100’s of nursing home staff

Continued ResearchContinued Research Improve validity and reliability of quality Improve validity and reliability of quality

measuresmeasures Track trends in quality over timeTrack trends in quality over time Facilitate consumer decision-makingFacilitate consumer decision-making Develop better provider reportsDevelop better provider reports Identify effective management practicesIdentify effective management practices Evaluate quality improvement strategiesEvaluate quality improvement strategies Build a business case for better qualityBuild a business case for better quality

Expand Quality MeasuresExpand Quality Measures

QI or QoL/RS measures designed QI or QoL/RS measures designed specifically for dementia residentsspecifically for dementia residents

Post-acute QIsPost-acute QIs Family satisfaction surveyFamily satisfaction survey Community discharge/NH Community discharge/NH

transitionstransitions Re-hospitalization ratesRe-hospitalization rates Refined scoring of NH inspection Refined scoring of NH inspection

resultsresults

Stress Value and Cost-Stress Value and Cost-EffectivenessEffectiveness

Wide variation in nursing home per diem Wide variation in nursing home per diem prices & qualityprices & quality

Information about NH prices and their Information about NH prices and their relationship to quality is not publicly relationship to quality is not publicly availableavailable

Many consumers are receiving very poor Many consumers are receiving very poor value for their long-term care dollarsvalue for their long-term care dollars

Need to focus on connection between Need to focus on connection between price and quality – greater value and cost-price and quality – greater value and cost-effectivenesseffectiveness

Improve ReportingImprove Reporting

Track quality measures over timeTrack quality measures over time Trends in QI rates (quarterly)Trends in QI rates (quarterly) Changes in annual QoL/RS scoresChanges in annual QoL/RS scores

Drill down capabilityDrill down capability Dimension scoresDimension scores Individual survey items or QIsIndividual survey items or QIs

Decision support toolsDecision support tools

Build a Business Case for Build a Business Case for QualityQuality

Increase quality adjustment of Increase quality adjustment of payment ratepayment rate Reward high qualityReward high quality Discourage poor qualityDiscourage poor quality

Expand funding for Performance-Based Expand funding for Performance-Based Incentive projectsIncentive projects Emphasize organizational change Emphasize organizational change

and technologyand technology Encourage provider collaboration Encourage provider collaboration

and diffusion of best practicesand diffusion of best practices