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11
Commentary on long Term Commentary on long Term Care QualityCare Quality
A Provider PerspectiveA Provider Perspective
Bradley ShiverickSecond National Medicaid Congress
–
June 14, 2007
22
A Brief Overview of Initiatives and A Brief Overview of Initiatives and Progress on Long Term Care QualityProgress on Long Term Care Quality
Nursing Home Reform Act – 1987
Prospective Payment Implications – 1999
Quality First – 2002
Nursing Home Quality Initiative – 2002
Advancing Excellence – 2006
Programs and Progress
33
IOM Study 1986IOM Study 1986
1986 Institute of Medicine ReportImproving the Quality of Care in Nursing Homes
Recommendations–
Stronger Federal Role in LTC Quality
–
Strengthening of Performance Standards
–
Training Standards for Staff
–
Improved Resident Assessment
–
Strengthened Regulatory Process
44
FirstFirst…… There was OBRAThere was OBRA
Minimum Regulatory Standards for LTCProcess Standards for:–
Quality of Life
–
Quality of Care–
Support for Activities of Daily Living
–
Resident Rights–
Resident Assessment
–
Physical and Chemical Restraints–
Regulatory Process and Remedies
55
Regulation and EnforcementRegulation and Enforcement
~ 150 Individual Requirements
Annual, Complaint and Incident Surveys
Cycle of Compliance
Scope and Severity – 1995
Outcomes Focus (Double “G”) – 1999
Revised Outcomes Focus – 2006
Minimal Standards and Penalties
66
Prospective PaymentProspective Payment
1998 – 1999 Prospective Payment System(Medicare)–
RUGS –
III System –
44 Utilization Groups
–
10% of all US Nursing Homes Under Bankruptcy Protection
–
Five of Top 7 LTC Firms Under Bankruptcy
–
Significant Pressure on Resources
–
Quality Indicators Introduced Nationally
77
1999 Nursing Home Quality Indicators1999 Nursing Home Quality Indicators 24 QIs in 11 Domains24 QIs in 11 Domains
Accidents Clinical Management Cognitive Patterns Elimination/Incontinence Infection ControlNutrition/Eating
Behavior/Emotional Patterns Physical FunctioningPsychotropic Drug UseQuality of LifeSkin Care
www.medicare.gov/nhcompare
99
Quality First Pledge Quality First Pledge --
20022002
Strategic Alliance Between Major Provider Groups to Improve Quality–
American Health Care Association (AHCA)
–
American Association of Homes and Services for the Aging (AAHSA)
–
Alliance for Quality Nursing Home Care (AQNHC)
1010
Quality First Quality First --
20022002
Seven Core Principles–
Continuous Quality Assurance and Quality Improvement
–
Public Disclosure and Accountability
–
Patient/Resident and Family Rights
–
Workforce Excellence
–
Public Input and Community Involvement
–
Ethical Practices
–
Financial Stewardship
1111
Alliance for Quality Nursing Home CareAlliance for Quality Nursing Home Care QF Code of Conduct and Ethical PracticesQF Code of Conduct and Ethical Practices
Commitment to Patient Well-Being Through Quality CareLeadership Commitment to Quality –Continuous Quality Improvement –Quality Improvement Goals –Uniform Measures of Quality
Public Disclosure and Accountability –Patient and Family Rights Workforce Excellence –
Employee Recruitment, Assessment.Employee Training.Commitment to Employees
Public Input on Quality:Ethical Practices Financial Stewardship
1212
Quality First Pledge Quality First Pledge --
20022002
Expected Outcomes–
Compliance with Federal Regulations
–
Financial Integrity and Reduction in Fraud
–
Improvements in Abuse and Neglect
–
Improvements in Clinical Outcomes
–
Customer Satisfaction
–
Employee Retention
1313
Nursing Home Quality Nursing Home Quality Improvement Initiative Improvement Initiative --
20022002
CMS Led Initiative to Improve Quality–
Regulation and Enforcement
–
Consumer Information on Quality of CareImproved Quality Measures
–
Community Based Quality ImprovementQIO Role
–
Assistance with Clinical Processes–
Clinical Collaboratives–
Culture Change Initiatives
–
Collaboration and PartnershipFederal and State AgenciesQIOs / Providers / Advocates
1414
ResultsResultsNearly 50% drop from 1999 to 2005 in the “number of nursing homes with serious quality problems" (GAO, January 2006)Decrease in facilities receiving G or above deficiencies from 2002 – 2004 (AHCA OSCAR data)Marked improvement in compliance with abuse and neglect standards since Quality First began in 2002. (AHCA)Since the inception of Quality First, the U.S. Department of Labor has pledged to work with the profession. They declared that 2006 is the Year of Long Term Care.
1717
NHQI / Quality FirstNHQI / Quality First
Secretary Tommy Thompson (12/04):
“…it has worked better than we could have hoped for…
we are pleased that nursing
home residents are now receiving better care compared to just two years ago…
we
stabilized the funding in the last two years and improved [care quality].”
1818
Quality First in Action
Advancing Excellence Advancing Excellence --
20062006
1919
National CoalitionNational Coalition
Centers for Medicare and Medicaid Services – Survey GroupCenters for Medicare and Medicaid Services --Quality Improvement Group
National Citizens’ Coalition for Nursing Home Reform Service Employees International UnionThe Commonwealth FundNational Commission for Quality Long-term CareAgency for Healthcare Research and QualityAssociation of Health Facility Survey AgenciesAmerican Association of Nurse Assessment Coordinators American College of Health Care AdministratorsAmerican Medical Directors Association National Association of Health Care Assistants
American Association of Homes and Services for the Aging (AAHSA)American Health Care Association (AHCA)The Alliance for Quality Nursing Home CareThe Evangelical Lutheran Good Samaritan Society
2020
Campaign ComponentsCampaign Components
Meaningful Goals
Measures and Data Sources
Technical Assistance - Evidenced-based Protocols
National and State-based Infrastructure
2121
Advancing Excellence Advancing Excellence --
20062006
Clinical Outcome Goals–
High Risk Pressure Ulcers
–
Physical Restraints–
Chronic Care Pain
–
Post Acute Care PainProcess (Organizational Improvement Goals)–
Setting Clinical Targets
–
Customer Satisfaction–
Staff Retention
–
Consistent Staffing
2222
Advancing ExcellenceAdvancing Excellence 5360 Enrolled LTC Providers5360 Enrolled LTC Providers
Clinical Goals–
Pressure Ulcers 68%
–
Restraints 42%
–
LTC Pain 53%
–
PAC Pain 40%
Process Goals–
Targets 29%
–
Satisfaction 65%
–
Retention 39%
–
Assignment 31%
2323
What Does it All Mean?What Does it All Mean?
Are We Making Progress?
Do Negative Outcomes Matter?
Do Residents and Families Care?
Consumer Experience of Care
2424
0%
5%
10%
15%
20%
25%
30%
35%
40%
1987 1994 2003 2004 2005 2006
Restraint Use in US Nursing Homes
Restraint Use
Any Progress?Any Progress?
Source: 1987-1984 Schoeneman
AHSR –
2003-2006 NHQI-STAR
2525
3%
4%
4%
5%
5%
6%
6%
7%
7%
2003 2004 2005 2006
Pain in US Nursing Home (LT) Residents
Chronic Pain
Any Progress?Any Progress?
Source: 2003-2006 NHQI-STAR
2626
11%
12%
12%
13%
13%
14%
14%
2003 2004 2005 2006
Pressure Ulcers in Nursing Home (LT) Residents
Pressure Ulcers
Any Progress?Any Progress?
Source: 2003-2006 NHQI-STAR
2727
16%
16%
17%
17%
18%
18%
19%
19%
20%
20%
2004 2005 2006
Pressure Ulcers in US Nursing Home (ST) Residents
Pressure Ulcers
Any Progress?Any Progress?
Source: 2003-2006 NHQI-STAR
2828
Customer SatisfactionCustomer Satisfaction
Satisfaction Largely Linked to Positive Outcomes and Experiences of Care
2929
Continued Progress?Continued Progress?
The Road Ahead–
Population Change / Role of PAC
–
Nursing Shortage / Aging Workforce
–
Medicare Stability / Medicaid Shortfalls
–
Electronic Medical Records
–
Person Centered Care
“A culture of aging that is life-affirming, satisfying, humane and meaningful.”
Pioneer Network Vision
3030
3.5
3.55
3.6
3.65
3.7
3.75
3.8
3.85
3.9
3.95
4
1998 1999 2000 2001 2002 2003 2004 2005
ADL Dependence
Changing PopulationChanging Population
3131
Historic and Projected SNF Medicare Per Diems1998 - 2006
Source: Alliance for Quality Nursing Home Care Database and the Muse & Associates Reality Baseline
Medicare Stability
$287
$323$330
$321
$301
$325$312
$276
$367
$250
$270
$290
$310
$330
$350
$370
$390
1998 1999 2000 2001 2002 2003 2004 2005 2006
(p)
3434
Medicaid ShortfallsMedicaid Shortfalls
It’s Only $13…–
Times 100 Residents = $1300 / day
–
Times 365 Days = $474,500
Is That a Lot?–
At $12/hour = $25,000/year
–
Equivalent Shortfall = 19 FTEs.