Predicting Quality in Nursing Homes: What do the Stars Tell Us?

1. Predicting Quality in Nursing Homes: What do the Stars Tell Us? ARIF NAZIR MD, CMD President, Indiana Medical Directors Association Assistant Professor, Clinical Medicine Division of General Internal Medicine & Geriatrics Department of Medicine August 20, 2010

2. My colleagues and Mentors advice: • Don’t be too detailed • Don’t use Geriatric lingo • Bottom line: “Think of the time when you were a resident and think of what would you have want to know about nursing homes”

3. Objectives: By the end of this presentation, participants will be familiar with: • Nursing home compare and 5 Star rating system for nursing home quality • Other factors impacting nursing home quality • The role of an interdisciplinary team in nursing home discharges

4. You are attending this presentation because: • You see (or used to see) pts in nursing homes • You manage nursing home patients in hospital • Neither of above but interested in the topic • Someone said that there was free lunch

5. Why is this presentation important? • A significant proportion of older inpatients are discharged to nursing homes (NHs). • Not all NHs are similar and offer a wide spectrum of quality • Re-hospitalizations: Increasing consequences for hospitals and nursing homes • Reimbursement models are evolving with focus on “bundled payments” • A third of us will spend some time in a nursing home!

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7. Do you have a loved one in a nursing facility? • Yes • No Customize footer: View menu/Header and Footer

8. Regarding Nursing Home Quality of Care: • I have NO concerns • I am concerned • I am seriously concerned • Not sure Customize footer: View menu/Header and Footer

9. A Case • Mrs. Smith an 79 yo AAF with mild dementia admitted with pneumonia and intubated in the ICU • Survives and transferred to monitored floor but still very weak • Team assess for discharge options • Mrs. Smith lived alone with the help from a daughter and a son who live few miles away

10. Case…..cont’d • Physical therapy recommends a NH discharge for rehab • Mrs. Smith agrees BUT wants to: • ask Aunt Gina who “knows it all” • stay close to daughters house • Her son states, “Doc, since I read the newspaper articles, I am very concerned about care provided in nursing homes. Can you make sure that mom goes to the best facility in the town”

11. Case…..cont’d • Social worker provides a list of 6 “decent” NHs within 5 miles of daughter’s home • Next day son calls, “Doc, aunt Gina recommends these two homes, but I need your help to make the decision” Happy Meadows 4-STAR Rated Facility Sloppy Shadows 2 -STAR Rated Facility

12. How should the team respond? • Avoid saying much due to “patient choice act” • Help arrange visits to a couple nursing homes • Provide nursing home websites • Provide information on “Nursing Home Compare” and other resources • Consult with Aunt Gina

13. I discharge patients to nursing homes: • Frequently • Sometimes • Rarely • Never

14. Measuring Quality in NHs • Quality of long-term care is multidimensional. Ideally it should include: • Clinical care issues • Functional independence • Current Minimum Data Set records • Quality of life, and • Patients’ and families’ satisfaction Mor V, Berg K, Angelelli J, Gifford D, Morris J, Moore T. The quality of quality measurement in US nursing homes. Gerontologist 2003;43(Spec No 2):37– 46

15. Nursing Home Compare • A CMS website to help consumers choose a NH • Allows search for a NH by geography (state or county), by proximity (city or zip code), or by name. • Also provides a “Nursing Home Checklist,” • Provides the 5 Star rating for all facilities in the nation compared to other state facilities

16. Audience and Nursing Home Compare • I utilized the website for a loved one • I have visited the website • I have only heard of it • I just learned about it

17. 5 Star rating for Nursing Homes • Available thru Nursing Home Compare. • Bell shaped distribution: • - Ten percent 5- star and 20% 1- star • Ratings aggregate of three sources: • State survey results. • Staffing data. • Quality Measures. • Limitations Customize footer: View menu/Header and Footer https://www.cms.gov/CertificationandComplianc/Downloads/usersguide.pdf

18. 5 Star Rating System

19. State surveys

20. State survey process • Carry the heaviest weight in the 5-Star ratings • Unannounced every 9-15 months • Compares facility to standards in the Code of Federal Regulations(CFR) • A 3-5 surveyor team reviews records and interviews all parties as needed.

21. State survey process • Deficiencies or tags cited • “Plan of correction” • Repeat state survey • Publicly reported survey score for comparison Customize footer: View menu/Header and Footer

22. Indiana Report Cardhttp://www.in.gov/isdh/reports/QAMIS/ltc/repcard/search.htm

23. Issues with State Survey process Government Accountability Office (GAO; 2004) • Depends upon staff competency • Complex regulations • Inadequate state oversight of the survey process and predictable timing of surveys. • Variation in deficiency citation exists between and within states (Detection bias)

24. So the State Survey Process is…. - Well structured and quite broad in scope • Creates sense of accountability • Helps in quality improvement process • Provides the consumers a voice • Scores are publicly available for comparison • Not a perfect science

25. Carry the heaviest weight in 5 Star ratings • Scores are only available to the facility • Detection bias is a concern • Surveyors can interview anyone they chose

26. Nursing Home TriviaWhich of the following is FALSE about the State Surveys: • Carry the heaviest weight in 5 Star ratings • Scores are only available to the facility • Detection bias is a concern • Surveyors can interview anyone they chose

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28. NH Environment and Staffing • NHs are nursing homes and NOT “mini hospitals” • Administration (owner, administrator, Director of Nursing) • Nursing Staff: • - Registered Nurses (RNs) • - Licensed Practical Nurses • - Certified Nurses Assistants • Other departments

29. Staffing and Quality • Better nurse staffing ratios lead to better NH quality of care • Also higher quality related to: • Low staff turnover rates • Director of Nursing retention • Higher number of Licensed staff (RNs and LPNs) related to low probability of death and higher discharge to home • (Fish 2001; Unruh 2004; Schnelle2004; Bostick 2007)

30. Appropriate Staffing ratios • Measured in nursing hours per resident per day or per week: Abt Associates Inc. Appropriateness of Minimum Staffing Ratios in Nursing Home: Report to Congress Phase II Final. Executive Summary: Phase II Report . 2001;I(Contract # 500-0062/TO#3) Customize footer: View menu/Header and Footer

31. Quality Measures/Quality Indicators

32. Quality Measures/Quality Indicators Slow progression over time and belong to structure, process and outcomes categories

33. Current Assessments and Quality Data • Omnibus Budget Reconciliation Act (OBRA, 87) • Mandated comprehensive functional assessments for all residents called Minimum Data Set (MDS) • MDS information assists with: • Reimbursements • Survey processes • Generating quality data including indicators and measures

34. MDS and Quality Measures • MDS data summarized into a monthly Quality Indicator/measures report. • Quality measures (QMs): • percentages of residents in the facility with certain problems • Help in monitoring/tracking of care • Reported on Nursing Home Compare website • Carry least weight towards the 5 Star ratings

35. Sample Quality Measures • (O) Percent of long-stay residents who had a urinary tract infection/wt loss/ pressure ulcers • (O) Percent of long-Stay residents whose need for help with daily activities has increased • (O) Percent of long-stay residents who are more depressed or anxious • (P) Percent of long-stay residents who have/had a catheter inserted and left in their bladder • (P) Percent of short-stay residents who were assessed and given pneumococcal vaccination http://www.medicare.gov/NHCompare/Static/tabHelp.asp?language=English&activeTab=4&subTab=1

36. Limitations of Quality Measures • Present a cross-section of time • Staff dependent • Less beds may limit statistical power • Higher acuity facilities may have poor scores • Conservative Risk Adjustments: • Comorbidities • Cognition • Type of facility (Mor, Berg et al. 2003)

37. So the Quality Measures .…. - Are well balanced between processes and outcomes • Provide a cross section of quality • Are used for quality improvement and tracking care • Are publicly available and “point” to possible care issues • Have several limitations

38. Nursing Home Trivia 1 Customize footer: View menu/Header and Footer

39. Nursing Home TriviaWhich of the following is FALSE: 1. High staffing ratio improve quality in NHs 2. Quality measures originate from the state survey scores 3. Indiana NHs lag behind in their staffing ratios 4. Current quality measures represent a good balance of outcome and process measures

40. Nursing Home Compare Overview • Offers multiple resources including 5 Star ratings and NH checklist • Provides a snapshot of care in a facility • Facilities that utilize the scores for quality improvements tend to improve • A crucial but only an initial tool in the process of selecting a NH (Mr. Edward Mortimer)

41. Other Evidence Based predictors of Quality of Care and Life in NHs • Medical staffing patterns • Consistent nursing assignments • Profit/ non-for-profit status of the facility • Patient factors and co-morbidities • Patient and/or family Satisfaction Customize footer: View menu/Header and Footer

42. Patient Satisfaction

43. Quality Improvements in NH care • Use of MDS led to significant decrease in multiple measures (restraints, ulcers, pain etc) • CMS supported Advancing Excellence in Nursing Home Care Campaign • - Multiple successes in Indiana and nationwide • Achieving targets in multiple quality measures • Indiana Pressure Ulcer Reduction Initiative • Culture Change Movement (www.pioneernetwork.com)

44. Back to Mrs. Smith • What steps can the team take to help transition to a high quality facility • How much the team can say? • What responsibilities do they have?

45. For Physicians Who Discharge Patients to NHs • I only write the discharge orders • I also discuss NH options with the social worker • I use some tool to assess NH quality

46. Patient Choice in Discharge process • The Social Security Act guidance: • Appropriateness of the discharge setting • The availability of the discharge venue • Conflict of interest and not steer patients to a partner facility • The team is responsibility to assure that discharge venue is appropriate

47. Team’s Role in Discharging Mrs. Smith • Case Management Society of America (CMSA): Five Ethical Principles of Case Management • Non-Maleficence: Do no harm • Beneficence: Look out for patient benefit • Autonomy: Right to information and self determination with free and informed consent • Veracity:Truth telling and obligation to full honest disclosure • - Justice: Actions are consistent and transparent

48. Team’s Role in Discharging Mrs. Smith • Inquire preferences • NH Compare information to help assess quality (“weather” analogy) • Discuss other factors that may impact quality • Advise to visit facility using the NH checklist http://www.medicare.gov/nursing/checklist.pdf • Review any patient/ family satisfaction tools • Hospital relationships • Provide accurate discharge orders and summaries

49. So to Summarize….. • Nursing Home Compare and 5- star ratings can help patients in selecting the appropriate NH. • 5 Star rating and its components do have limitations and be used as an initial step in selecting a nursing home. • Several other factors impact quality of NH care • Inpatient teams should help patients to select high quality nursing homes.