Long Term Quality Long Term Quality Measurement for Measurement for Older Adults Older Adults

Tamara L. Burket, MS, GCNS-Tamara L. Burket, MS, GCNS-BC, ACNS-BC, CCRNBC, ACNS-BC, CCRN

Fellow Geriatric Nursing Fellow Geriatric Nursing Leadership AcademyLeadership Academy

ResourcesResources

http://www.cms.gov/Medicare/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Quality-Initiatives-Patient-Assessment-Instruments/Assessment-Instruments/NursingHomeQualityInits/NursingHomeQualityInits/index.html?redirect=/index.html?redirect=/NursingHomeQualityInits/NursingHomeQualityInits/

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http://www.newschool.edu/ltcc/pdf/http://www.newschool.edu/ltcc/pdf/txBackground03-10-05FINAL.pdftxBackground03-10-05FINAL.pdf

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ObjectiveObjective

–Discuss valid quality measures and their application in diverse gerontological settings throughout the community.

Points of EmphasisPoints of Emphasis1.Enhanced QOL as prime

directive

2.History: Alphabet soup!!ACOVE /IOM/ CMS/ QI/ OBQI/ RAI…

3. Nursing Home Compare

4. Where do I start?55

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Target PopulationTarget Population

The Administration on Aging The Administration on Aging defines the older population as defines the older population as persons 65 and older (2004).persons 65 and older (2004).

The U.S. Census Bureau defines the The U.S. Census Bureau defines the older adult as “elderly” and older adult as “elderly” and includes persons 65 years of age includes persons 65 years of age and older (2001).and older (2001).

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Young old =65-Young old =65-7575

Old =75-85Old =75-85 Old old= 85+Old old= 85+ Centurions are Centurions are

now the fastest now the fastest growing age growing age groupgroup

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Target Population StatisticsTarget Population Statistics

According to the U.S. Census Bureau: According to the U.S. Census Bureau: 1 in 8 Americans were elderly in 1994 & 1in 1 in 8 Americans were elderly in 1994 & 1in 5 or 20% will be elderly by the year 2030.5 or 20% will be elderly by the year 2030.

The U.S. Census Bureau predicts the fastest The U.S. Census Bureau predicts the fastest growing portion of the elderly population is the growing portion of the elderly population is the “oldest old” (individuals 85 years of age and “oldest old” (individuals 85 years of age and older).older).

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Population Age ProjectionsPopulation Age Projections 2005 - 20502005 - 2050

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Persons 65 and Over:Persons 65 and Over:- by age group- by age group- 1900-2000 - 1900-2000

- projected 2010-2050 - projected 2010-2050

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Target Population: Target Population: Complex Issues Complex Issues

The elderly are living longer and they The elderly are living longer and they place increasing demands on the place increasing demands on the healthcare system and on medical and healthcare system and on medical and social services (CDC, 2005).social services (CDC, 2005).Though we see the health of older Though we see the health of older Americans improving, many of these Americans improving, many of these individuals are disabled or coping with individuals are disabled or coping with chronic diseases/conditions (U.S. chronic diseases/conditions (U.S. Census Bureau, 2006).Census Bureau, 2006).Older adults are dealing with chronic Older adults are dealing with chronic diseases, diminished quality of life, diseases, diminished quality of life, and increased costs of healthcare and increased costs of healthcare (CDC, 2005).(CDC, 2005).

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Socioeconomic IssuesSocioeconomic Issues

30%of the Medicare budget is spent on 6% 30%of the Medicare budget is spent on 6% of the Medicare population in the last year of the Medicare population in the last year of lifeof life

Federal spending in the elderly has double Federal spending in the elderly has double since 1960 since 1960

Hospitals receive the majority of Medicare Hospitals receive the majority of Medicare expenditures and nursing facilities receive expenditures and nursing facilities receive the majority of Medicaid expenditures. the majority of Medicaid expenditures.

Following retirement, income drops 50% on Following retirement, income drops 50% on the average the average

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Minority ElderlyMinority Elderly

15%- 65+15%- 65+– 8% Black8% Black– 2% Asian or 2% Asian or

Pacific Pacific IslandersIslanders

– 1% Native 1% Native AmericanAmerican

– 4% Hispanic4% Hispanic

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12% of Black 12% of Black population are population are elderlyelderly

13% of those are 13% of those are over 85over 85

They are the They are the fastest growing fastest growing segment of the segment of the black population black population

Health Care Health Care DisparitiesDisparities

http://www.census.gov/Press-Release http://www.census.gov/Press-Release /www/releases/ /www/releases/ archives/aging_population/006544.htmlarchives/aging_population/006544.html

http://www.agingstats.gov/chartbook2004/population.html

http://www.census.gov/population/www/pop-profile/elderlypop.html

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Vulnerable EldersVulnerable Elders

ACOVE:ACOVE:– ““community dwelling elders aged 65 community dwelling elders aged 65

and older who are at greater risk of and older who are at greater risk of death or functional decline over a 2-death or functional decline over a 2-year period.”year period.”

– JAGS 55:S247-S252, 2007JAGS 55:S247-S252, 2007

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Characteristics of Characteristics of Vulnerable EldersVulnerable Elders

Patient Safety ConcernsPatient Safety Concerns Deficits In Quality of CareDeficits In Quality of Care Particular Care Needs of Older Particular Care Needs of Older

PersonsPersons– JAGS 55:S247-S252, 2007JAGS 55:S247-S252, 2007

Iatrogenic CascadeIatrogenic Cascade

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Complicated by:Complicated by:

Multiple Medical ConditionsMultiple Medical Conditions ChronicityChronicity AgeismAgeism Functional StatusFunctional Status Substantial Variation in Substantial Variation in

PreferencesPreferences– DiversityDiversity

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Top 4 Major Chronic Top 4 Major Chronic Illnesses in Older Illnesses in Older AdultsAdults AsthmaAsthma HypertensionHypertension Hearing ImpairmentHearing Impairment Heart ConditionsHeart Conditions

Robinson, D., Kish, C. (2001) Advanced Practice Nursing. St. Louis, MO: Mosby, Inc., 570

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Geriatric Care PrioritiesGeriatric Care Priorities

MedicalMedical CognitiveCognitive AffectiveAffective FunctionalFunctional Social support/care giverSocial support/care giver

Elements Of Geriatric Elements Of Geriatric AssessmentAssessment

EconomicEconomic EnvironmentalEnvironmental Quality of Quality of

life/well-beinglife/well-being Advance Advance

DirectivesDirectives

SPICESSPICESSSleepleep

POPO

IIncontinencencontinence

CConfusiononfusion

EEvidence of fallsvidence of falls

SSkin breakdownkin breakdown

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LegislationLegislation

• 1935-Social Security Act –Intended as “old-age” insurance1935-Social Security Act –Intended as “old-age” insurance• 1965-Older Americans Act established the foundation for 1965-Older Americans Act established the foundation for

the development of today’s senior centers. the development of today’s senior centers. • 1981- Omnibus Budget Reconciliation Act (OBRA) 1981- Omnibus Budget Reconciliation Act (OBRA)

reduced Medicaid eligibility for older Americans, care, set reduced Medicaid eligibility for older Americans, care, set limits for health care services, established criteria for limits for health care services, established criteria for nursing home carenursing home care

• 1983-Prospective Payment System reduced 1983-Prospective Payment System reduced reimbursement for home health servicesreimbursement for home health services

• 1990-OBRA provided direct reimbursement for NP’s and 1990-OBRA provided direct reimbursement for NP’s and specialists in rural areas…specialists in rural areas…

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...“NEVER” EVENTS...“NEVER” EVENTS 2008- A list of 28 medical errors from the 2008- A list of 28 medical errors from the

National Quality Forum:National Quality Forum:– Should never happenShould never happen– Never getting paidNever getting paid

Among them: Death or disability related toAmong them: Death or disability related to– falls falls – use of restraints or bedrailsuse of restraints or bedrails– stage 3 or 4 pressure ulcersstage 3 or 4 pressure ulcers– suicide or attempted suicidesuicide or attempted suicide– medication errormedication error– sexual or physical assaultsexual or physical assault

while being cared for in a healthcare facilitywhile being cared for in a healthcare facility

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Healthy People 2010Healthy People 2010 Physical activityPhysical activity Overweight and obesityOverweight and obesity Responsible sexual behaviorResponsible sexual behavior Injury and violenceInjury and violence ImmunizationsImmunizations Tobacco useTobacco use Substance abuseSubstance abuse Mental healthMental health Environmental qualityEnvironmental quality Access to quality careAccess to quality care

““10 KEYS” TO HEALTHY AGING10 KEYS” TO HEALTHY AGING

(From Healthy People (From Healthy People 2020)2020)• Lower Systolic Blood PressureLower Systolic Blood Pressure• Stop SmokingStop Smoking• Participate in Cancer ScreeningParticipate in Cancer Screening• Get Immunized RegularlyGet Immunized Regularly• Regulate Blood GlucoseRegulate Blood Glucose• Lower LDL CholesterolLower LDL Cholesterol• Be Physically ActiveBe Physically Active• Prevent Bone Loss and Muscle WeaknessPrevent Bone Loss and Muscle Weakness• Maintain Social ContactMaintain Social Contact• Combat DepressionCombat Depression

2626The Center for Healthy AgingUniversity of Pittsburgh Graduate School of Public Healthhttp://www.healthyaging.pitt.edu/home.html#

Process MeasuresProcess Measures

Timely initiation of careHow often the home health team began their patients’ care in a timely manner.

Influenza immunization received for current flu season

How often the home health team determined whether patients received a flu shot for the current flu season.

Pneumococcal polysaccharide vaccine ever received

How often the home health team determined whether their patients received a pneumococcal vaccine (pneumonia shot).

Heart failure symptoms during short-term episodes

How often the home health team treated heart failure (weakening of the heart) patients’ symptoms.

Diabetic foot care and patient education implemented during short-term episodes of care

For patients with diabetes, how often the home health team got doctor’s orders, gave foot care, and taught patients about foot care.

Pain assessment conductedHow often the home health team checked patients for pain.

Pain interventions implemented during short-term episodes

How often the home health team treated their patients’ pain.

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More Process More Process MeasuresMeasures

Depression assessment conductedHow often the home health team checked patients for depression.

Drug education on all medications provided to patient/caregiver during short-term episodes

How often the home health team taught patients (or their family caregivers) about their drugs.

Multifactor fall risk assessment conducted for patients 65 and over

How often the home health team checked patients’ risk of falling.

Pressure ulcer risk conductedHow often the home health team checked patients for the risk of developing pressure sores (bed sores).

Pressure ulcer prevention included in the plan of care

How often the home health team included treatments to prevent pressure sores (bed sores) in the plan of care.

Pressure ulcer prevention implemented during short term episodes of care

How often the home health team took doctor-ordered action to prevent pressure sores (bed sores).

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Improvement Improvement MeasuresMeasures

 

Improvement in ambulationHow often patients got better at walking or moving around.

Improvement in bed transfer How often patients got better at getting in and out of bed.

Improvement in pain interfering with activity

How often patients had less pain when moving around.

Improvement in bathingHow often patients got better at bathing.

Improvement in management of oral medications

How often patients got better at taking their drugs correctly by mouth.

Improvement in dyspneaHow often patients’ breathing improved.

Improvement in status of surgical woundsHow often patients’ wounds improved or healed after an operation.

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Healthcare utilization Healthcare utilization measuresmeasures

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Acute care hospitalizationsHow often home health patients had to be admitted to the hospital.

Emergency department use without hospitalization

How often patients receiving home health care needed any urgent, unplanned care in the hospital emergency room – without being admitted to the hospital.

Impacting Quality Impacting Quality MeasuresMeasures

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SSafetyafety

Evidence: Hospitals face mounting costs and decreased reimbursement based on indicators like injuries related to falls,

pressure ulcers, and nosocomial infections. Nurses and other providers are challenged

to define their contribution to patient safety in meeting regulatory requirements

and standards.

TTeamworkeamwork

Evidence: The Institute of Medicine (2008) supports interdisciplinary

teamwork as evidenced in the review of 128 successful, innovative models for

geriatric care.

TransdisciplinaryTransdisciplinaryTeamworkTeamwork PopulationPopulation InterventionIntervention ComparisonComparison InterventionIntervention

PlanPlan DoDo ChangeChange AssessAssess

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AAdvocacydvocacy

Evidence: Nurses have multiple opportunities within their organizations and communities to advocate for timely and just dispersal of increasingly sparse

resources in the care of older adults.

RRoundsounds

Evidence: The Studer Group recommends “Rounding for Outcomes” and the use of rounding logs and care plans to support nursing intervention, care coordination,

and reward and recognition as patient and staff goals are achieved.

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SPICESSleepPOIncontinenceConfusionEvidence of fallsSkin breakdown

PICOPICO

P= Elder Trauma Victims over 65 P= Elder Trauma Victims over 65 years of ageyears of age

I= Targeted Geriatric RoundingI= Targeted Geriatric Rounding C= Absence of targeted geriatric C= Absence of targeted geriatric

roundingrounding 0= Effects of intervention0= Effects of intervention

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Will targeted geriatric Will targeted geriatric rounds provide rounds provide measurable outcome measurable outcome improvements in nursing improvements in nursing care for victims of injury care for victims of injury patients over 65 years patients over 65 years old? old?

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Sample PICO Question:

Potential Qualitative Potential Qualitative Outcome MeasuresOutcome Measures

Nurse SatisfactionNurse Satisfaction Patient Patient

SatisfactionSatisfaction Quality of lifeQuality of life Patient Patient

Safety/CompliancSafety/Compliance Data e Data

Nurse Sensitive Nurse Sensitive Quality IndicatorsQuality Indicators

Geriatric Geriatric Syndromes & Syndromes &

VulnerabilitiesVulnerabilities

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QualitativeQualitative

““Each time, those who Each time, those who espouse only evidence—espouse only evidence—without narratives about real without narratives about real people—struggle to control people—struggle to control the debate. Typically, they the debate. Typically, they lose.” lose.”

Jason Karlawish Jason Karlawish

http://scienceprogress.org/2011/11/the-importance-of-http://scienceprogress.org/2011/11/the-importance-of-narrative-in-communicating-evidence-based-science/narrative-in-communicating-evidence-based-science/

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10 Most Common Geriatric 10 Most Common Geriatric Consult Team InterventionsConsult Team Interventions

1. Confusion 1. Confusion AssessmentAssessment

2. Falls Assessment & 2. Falls Assessment & PrecautionsPrecautions

3. Polypharmacy 3. Polypharmacy IssuesIssues

4. Dehydration4. Dehydration

5. Pain Management5. Pain Management

6. Discharge 6. Discharge RecommendationsRecommendations

7. Bowel Regimen7. Bowel Regimen

8. Blood Pressure 8. Blood Pressure ManagementManagement

9. Urinary Sepsis 9. Urinary Sepsis ScreeningScreening

10. Dysphagia 10. Dysphagia ScreeningScreening

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Population of Nursing Care Population of Nursing Care Plans Before & After Targeted Plans Before & After Targeted RoundingRounding

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Examples:Examples:Nurse Satisfaction Data Before and Nurse Satisfaction Data Before and After Rounding for OutcomesAfter Rounding for Outcomes

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Nurse Satisfaction Data Before Nurse Satisfaction Data Before and After Rounding for and After Rounding for OutcomesOutcomes

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Patient Satisfaction Patient Satisfaction DataData

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KEY: Baseline: 3Q11 4Q11 1Q12

Quality Indicators per Quality Indicators per 1000 Patient/Device 1000 Patient/Device DaysDays

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FY11 BOOST ResultsFY11 BOOST Results

30-Day Related Cause Readmission 30-Day Related Cause Readmission RatesRates

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ComparisoComparison Groupsn Groups FY10FY10 FY11FY11 11 Jul-Dec11 Jul-Dec

11 Jan-11 Jan-JuneJune

OrganizatiOrganizationon 5.25.2 5.185.18 5.265.26 5.095.09

Internal Internal MedicineMedicine 3.483.48 4.534.53 4.864.86 4.254.25

Family & Family & Comm Comm Med.Med. 4.24.2 4.914.91 5.685.68 4.084.08

Additional ResourcesAdditional Resources

Penn State Milton S. Hershey Medical Center and Penn State Penn State Milton S. Hershey Medical Center and Penn State College of Medicine.(2011). FY11 Project BOOST results inform College of Medicine.(2011). FY11 Project BOOST results inform the FY12 Care Transitions Project. the FY12 Care Transitions Project. Crescent.Crescent. Hershey, PA. Sept. Hershey, PA. Sept. 14, 2011.14, 2011.

Institute of Medicine. (2008). Institute of Medicine. (2008). Retooling for an aging America: Retooling for an aging America: building the health care workforce.building the health care workforce. Washington, DC. The Washington, DC. The National Academies Press.National Academies Press.

Resnick, B. (2010). Function of older adults in acute care: Resnick, B. (2010). Function of older adults in acute care: optimizing an opportunity. In M.D. Foreman, K Milison & T.T. optimizing an opportunity. In M.D. Foreman, K Milison & T.T. Fulmer (Eds.), Critical Care Nursing of Older Adults: Best Fulmer (Eds.), Critical Care Nursing of Older Adults: Best Practices (3rd ed., pp. 209-238). New York: Springer. Practices (3rd ed., pp. 209-238). New York: Springer.

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http://www.studergroup.com/dotCMS/http://www.studergroup.com/dotCMS/knowledgeAssetDetail?inode=111088knowledgeAssetDetail?inode=111088

http://www.iom.edu/Global/Newshttp://www.iom.edu/Global/News%20Announcements/Crossing-the-%20Announcements/Crossing-the-Quality-Chasm-The-IOM-Health-Care-Quality-Chasm-The-IOM-Health-Care-Quality-InitiatQuality-Initiat

http://consultgerirn.org/searched?http://consultgerirn.org/searched?q=SPICESive.aspxq=SPICESive.aspx

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