Comprehensive Assessment of Nursing Home Quality Fall Research Conference -- Regenstrief Center for Healthcare Engineering, Purdue University Greg Arling, Ph.D. Indiana University Center for Aging Research

Minnesota NH Quality Assessment & Payment Project Sponsored by Minnesota Department of Human Services (DHS) Sponsored by Minnesota Department of Human Services (DHS) Multidisciplinary Research Team Multidisciplinary Research Team Robert L Kane, MD, Christine Mueller, RN PhD, & Julie Bershadsky, University of Minnesota Robert L Kane, MD, Christine Mueller, RN PhD, & Julie Bershadsky, University of Minnesota Greg Arling, PhD, Indiana University Center for Aging Research Greg Arling, PhD, Indiana University Center for Aging Research Valerie Cooke, Robert Held, and Teresa Lewis Minnesota Department of Human Services Valerie Cooke, Robert Held, and Teresa Lewis Minnesota Department of Human Services

Goals Develop comprehensive measures of nursing home quality Develop comprehensive measures of nursing home quality Apply the measures Apply the measures Informing consumer decisions Informing consumer decisions Guiding nursing home quality improvement Guiding nursing home quality improvement Offering financial incentives for better care Offering financial incentives for better care Engage consumers and providers in efforts to achieve better quality Engage consumers and providers in efforts to achieve better quality Continue to refine the quality assessment system and evaluate its impact Continue to refine the quality assessment system and evaluate its impact

Guiding Principles Comprehensive – contains process and outcome indicators, quality of care and quality of life Comprehensive – contains process and outcome indicators, quality of care and quality of life Mutually Reinforcing -- quality measurement and application proceeds iteratively and are mutually reinforcing Mutually Reinforcing -- quality measurement and application proceeds iteratively and are mutually reinforcing Relevant – taps dimensions of care that are important to consumers and providers Relevant – taps dimensions of care that are important to consumers and providers Credible – has strong research base Credible – has strong research base Understandable – effectively presented to different audiences Understandable – effectively presented to different audiences Actionable – informs consumer decision-making and provider quality improvement Actionable – informs consumer decision-making and provider quality improvement Transparent – methods are well described, in the public domain, and open to scrutiny by stakeholders and the research community Transparent – methods are well described, in the public domain, and open to scrutiny by stakeholders and the research community

Comprehensive Quality Measures Direct care staffing level (salary and CM adjusted HPRD), employee retention rate, & use of permanent (non-contract) staff Direct care staffing level (salary and CM adjusted HPRD), employee retention rate, & use of permanent (non-contract) staff Clinical Quality Indicators (QI) Clinical Quality Indicators (QI) Quality of Life and Resident Satisfaction (QoL/RS) Survey Quality of Life and Resident Satisfaction (QoL/RS) Survey State Inspection (NH Survey) Results State Inspection (NH Survey) Results

MN Nursing Home QIs Based on MDS assessments Based on MDS assessments 35,000 residents in 400 facilities per calendar quarter 35,000 residents in 400 facilities per calendar quarter 24 QIs representing care processes and outcomes 24 QIs representing care processes and outcomes Dimensions (# of QIs) Dimensions (# of QIs) Psychosocial (4)Accidents (2) Restraints (1)Nutrition (1) Continence (6)Pain (1) Infections (2)Skin Care (2) Functioning (5)Drugs (1)

Quality of Life & Resident Satisfaction Annual survey carried out by professional survey organization involving face-to-face interviews with 14,000 NH residents Annual survey carried out by professional survey organization involving face-to-face interviews with 14,000 NH residents 53 QoL and other items adapted from established instruments 53 QoL and other items adapted from established instruments Dimensions (# of survey items) Dimensions (# of survey items) Comfort (4)Autonomy (5) Environmental (4)Individuality (3) Privacy (3)Security (3) Dignity (4)Relationships (3) Meaningful Activity (3)Satisfaction with Care (7) Food Enjoyment (3)Mood (9)

Adjustment & Estimation Hierarchical General Linear Models (HLM 6.0) Hierarchical General Linear Models (HLM 6.0) QIs risk adjusters QIs risk adjusters Age and gender Age 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 adjusters QoL/RS score risk adjusters Resident gender, ADL, age, cognitive status & LOS Resident gender, ADL, age, cognitive status & LOS Facility location and average LOS Facility location and average LOS Empirical Bayes estimates of facility QI or QoL/RS rates Empirical Bayes estimates of facility QI or QoL/RS rates

Application Nursing Home Consumer Report Card Nursing Home Consumer Report Card Facilities receive 1-5 Stars on each quality measure Facilities receive 1-5 Stars on each quality measure 1,800 internet users/month 1,800 internet users/month Detailed QI and QoL Reports sent periodically to facilities Detailed QI and QoL Reports sent periodically to facilities Quality Add-on (2.4%) to Medicaid Payment Rates Quality Add-on (2.4%) to Medicaid Payment Rates Pay for Performance Quality Initiatives Pay for Performance Quality Initiatives Facilities develop quality improvement projects Facilities develop quality improvement projects Tied to quality measure outcomes Tied to quality measure outcomes $30 Million allocated for $30 Million allocated for

Nursing Home Report Card Transparency to consumers Transparency to consumers Make better LTC choices Make better LTC choices Advocate for care improvement Advocate for care improvement Provider benchmarking and quality improvement Provider benchmarking and quality improvement Nursing homes selected by geographical areas Nursing homes selected by geographical areas Facility assigned 1-5 stars on each of seven dimensions Facility assigned 1-5 stars on each of seven dimensions

Consumer Response Use of Report Card Use of Report Card 26,000 “hits” the first week 26,000 “hits” the first week 1,800/month since then 1,800/month since then Consumer feedback on Report Card Consumer feedback on Report Card 87% rate “easy” or “pretty easy” to use 87% rate “easy” or “pretty easy” to use 55% “definitely” would use in selecting a nursing home 55% “definitely” would use in selecting a nursing home 36% “probably” would use in selecting a nursing home 36% “probably” would use in selecting a nursing home

Feedback from Report Card Users (N=108,000) Quality Dimension % Giving it Top Priority Quality of Life/Resident Satisfaction 84% State NH Survey Results 61% NH Quality Indicators 59% Staffing Level (HPRD) 38% Staff Retention 16% Use of Pool Staff 6%

Facility Quality Reports Detailed QI and QoL/RS reports sent periodically to each facility Detailed QI and QoL/RS reports sent periodically to each facility Most current QI and QoL/RS results Most current QI and QoL/RS results Tracking of QI or QoL/RS rates over time Tracking of QI or QoL/RS rates over time Special training programs on priority areas identified through quality reports Special training programs on priority areas identified through quality reports Meaningful activities Meaningful activities Skin care Skin care Psychotropic medications Psychotropic medications Pain management Pain management

Trends in QI Rates DeclineImprovement

Quality Adjustment to Payment Rate Bonus added annually to Medicaid per diem payment rate -- proportional to Quality Score Bonus added annually to Medicaid per diem payment rate -- proportional to Quality Score Quality ScoreBonus (% of PD Rate) % % to 2.3% % Quality score also used to adjust Medicaid cost limits Quality score also used to adjust Medicaid cost limits Reduces rates for high cost & low quality facilities Reduces rates for high cost & low quality facilities Increases rates for low cost and high quality facilities Increases rates for low cost and high quality facilities

Performance-Based Incentives Facilities propose a new program to: Facilities propose a new program to: Improve quality outcomes Improve quality outcomes Increase efficiency Increase efficiency Re-balance long-term care (e.g., community discharges) Re-balance long-term care (e.g., community discharges) Facilities receive a 5% rate increase IF they: Facilities receive a 5% rate increase IF they: Implement the program effectively Implement the program effectively Achieve outcome objectives Achieve outcome objectives Most projects linked to improvement in QIs, QoL/RS, and other quality measures Most projects linked to improvement in QIs, QoL/RS, and other quality measures

Response to Performance-Based Incentives 155 applications received, 19 projects and 32 facilities approved in first year 155 applications received, 19 projects and 32 facilities approved in first year Focus of projects: Focus of projects: Culture changeWireless call systems QoL for dementia residentsEmployee retention Pressure ulcersPain management ExerciseCHF

Overall Provider Response Even modest financial incentives have stirred considerable provider interest Even modest financial incentives have stirred considerable provider interest Providers have asked for more frequent and detailed QI and QoL/RS reports Providers have asked for more frequent and detailed QI and QoL/RS reports Providers have been supportive of QI and QoL/RS risk adjustment with some calling for expanded adjusters Providers have been supportive of QI and QoL/RS risk adjustment with some calling for expanded adjusters State-sponsored quality improvement training programs have been attended by 100’s of nursing home staff State-sponsored quality improvement training programs have been attended by 100’s of nursing home staff

Continued Research Improve validity and reliability of quality measures Improve validity and reliability of quality measures Track trends in quality over time Track trends in quality over time Facilitate consumer decision-making Facilitate consumer decision-making Develop better provider reports Develop better provider reports Identify effective management practices Identify effective management practices Evaluate quality improvement strategies Evaluate quality improvement strategies Build a business case for better quality Build a business case for better quality

Expand Quality Measures QI or QoL/RS measures designed specifically for dementia residents QI or QoL/RS measures designed specifically for dementia residents Post-acute QIs Post-acute QIs Family satisfaction survey Family satisfaction survey Community discharge/NH transitions Community discharge/NH transitions Re-hospitalization rates Re-hospitalization rates Refined scoring of NH inspection results Refined scoring of NH inspection results

Stress Value and Cost-Effectiveness Wide variation in nursing home per diem prices & quality Wide variation in nursing home per diem prices & quality Information about NH prices and their relationship to quality is not publicly available Information about NH prices and their relationship to quality is not publicly available Many consumers are receiving very poor value for their long-term care dollars Many consumers are receiving very poor value for their long-term care dollars Need to focus on connection between price and quality – greater value and cost-effectiveness Need to focus on connection between price and quality – greater value and cost-effectiveness

Improve Reporting Track quality measures over time Track quality measures over time Trends in QI rates (quarterly) Trends in QI rates (quarterly) Changes in annual QoL/RS scores Changes in annual QoL/RS scores Drill down capability Drill down capability Dimension scores Dimension scores Individual survey items or QIs Individual survey items or QIs Decision support tools Decision support tools

Build a Business Case for Quality Increase quality adjustment of payment rate Increase quality adjustment of payment rate Reward high quality Reward high quality Discourage poor quality Discourage poor quality Expand funding for Performance-Based Incentive projects Expand funding for Performance-Based Incentive projects Emphasize organizational change and technology Emphasize organizational change and technology Encourage provider collaboration and diffusion of best practices Encourage provider collaboration and diffusion of best practices