Advancing Excellence in America’s Nursing Homes Cheryl Phillips, M.D. AGSF Co-Chair Advancing Excellence Campaign SVP Public Policy and Advocacy, LeadingAge

Mission “ The Collaborative assists all stakeholders of long term care supports and services to achieve the highest practicable level of physical, mental, and psychosocial well- being for all individuals receiving long term care services.”

AE Organizations Voting Members American Academy of Nursing -- Expert Panel on Aging American Association for Long Term Care Nursing American Association of Nurse Assessment Coordinators American College of Health Care Administrators American Health Care Association American Health Quality Association AMDA – Long Term Care LeadingAge (formerly AAHSA) National Association of Health Care Assistants National Consumer Voice for Long Term Care The Commonwealth Fund The Evangelical Lutheran Good Samaritan Society Association of Health Facility Survey Agencies Foundation of the National Association of Long Term Care Administrator Boards Gerontological Advance Practice Nurses Association Hartford Institute for Geriatric Nursing National Association of Directors of Nursing Administration in Long Term Care National Association of State Long-Term Care Ombudsman Programs National Gerontological Nursing Association PHI Pioneer Network Service Employees International Union Non-voting/Government Members Administration on Aging Agency for Healthcare Research and Quality Assistant Secretary for Policy and Evaluation Centers for Disease Control and Prevention Centers for Medicare & Medicaid Services Department of Veterans Affairs

Campaign Overview Largest national coalition (30 organizations) of nursing home stakeholders working together to help nursing homes improve care Voluntary for nursing homes (54% registered!) Based on measurement of meaningful goals Initially a two-year campaign; incorporated in 2010 and recognized as 501(c)(3)in 2011 The data show that the Campaign works!

5 Board of Directors Sets Goals Develops Resources Provides Support Statewide LANES Recruit nursing homes Coordinates statewide activities Provides support Nursing Home Registers for AE Selects 3 goals, sets targets Uses Campaign’s web-based resources for QA/PI How the Campaign Works

What does the Campaign do? Provides free, practical and evidence-based Quality Assurance/Process Improvement (QAPI) resources to support quality improvement efforts in America’s nursing homes. Commits support to those on the frontlines of nursing home care and encourages engagement of frontline staff. Promotes open communication and transparency among families, residents, and nursing home staff.

Key Elements of Advancing Excellence Based on meaningful issues Aligned with national initiatives Measurement is key

Culture Change and Advancing Excellence Leadership Person-Centered Organizational Goals cross-over Complement one another – AE focuses on the science of change (QA/PI) – Culture change focuses on the psychology Must have both!!!

Our Working Hypothesis… If you have good organizational workplace practices and good care planning practices, the good clinical outcomes will follow and the staff/residents/families will be happy.

Benefits of Participating in Advancing Excellence Focus on meaningful issues Increased staff retention and focus Better relationships in the nursing home Improved satisfaction (staff/resident/family) Saved money (improved quality and staff retention) Preparation for Pay-for-Performance Brings many stakeholders to the table Complementary of other initiatives Preparation for QAPI!

A Model for Change Outcomes Care Planning Person-centered Care Organizational Workplace Practices

Quality Assurance/Performance Improvement (QA/PI) The Affordable Care Act, Section 6102 requires CMS to strengthen QA requirements in nursing homes CMS must provide technical assistance to nursing homes in order to meet new requirements. Law requires implementation by December 31, 2011 QA/PI Plans must be submitted to HHS Secretary one year later

QAPI Techniques Identify meaningful area for improvement – things people care about! Define the problem Determine the starting point – the baseline Figure out the “root” of the problem Decide what the target or improvement will be Figure out what processes will impact change Choose a solution that makes sense Implement the solution Use “Plan-Do-Study-Act Cycle” for improvement Monitor

How does AE Help? AE identifies meaningful topics for nursing homes to use and provides a data collection tool, examples of root cause analyses, possible interventions and other QAPI tools for improvement.

Using Advancing Excellence for PI Nursing homes register on website Choose 3 goals – 1 clinical, 1 organizational and 1 more (may pick all 8 goals) Identify benchmarks Set targets Use Campaign resources and tools Collect and monitor data using PDSA methods Enter data on AE website regularly

16 Restraints Advance Care Planning Pain Staff Satisfaction Resident Satisfaction Pressure Ulcers Consistent Assignment Staff Turnover Current Advancing Excellence Goals

17 Mobility Person-Centered Care and Decision-Making Consistent Assignment Infections Pressure Ulcers Staff Stability Medications (Antipsychotic use) Hospitalizations “New” Advancing Excellence Goals Pain Management

Pain, Pressure Ulcers, Antipsychotics, Hospitalizations, Mobility, Infections Person Centered Care Staff Stability Consistent Assignmen t New AE Goals 2012

Staff Stability Staff work in the nursing home long enough to learn each resident’s needs and preferences. Residents are more comfortable with caregivers who know their personal preferences and caregiving needs. A stable staff allows the nursing home to benefit from experience and knowledge that staff gains over time, increasing the overall competence and confidence of staff, while building strong bonds between residents and caregivers.

QI Process for Staff Turnover Measure Turnover – Narrow the problem Determine if turnover is where you want it to be. What’s the impact of high turnover? On quality? Morale? Financial? Investigate Reasons for Turnover – Root Cause Analysis If turnover is high, look for reasons why. Ask the right questions: Is it low morale, no public transportation, low pay, not enough staff, poor hiring practices, etc.? Identify and Implement Solutions to Improve Turnover Use interventions that address the specific problem. Use appropriate resources for solutions that are known to work. Monitor and try different interventions if necessary. Enter turnover data on AE website & monitor trend graphs Provide feedback to staff and others

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Consistent Assignment Builds positive relationships Increases resident and family satisfaction Creates quicker awareness of clinical problems Improves staff accountability Improves communication between shifts and with other disciplines Improves staff satisfaction Improves Clinical and Quality Outcomes!!!

Using the Consistent Assignment Tool Use the AE Tool for Calculating Consistent to collect and analyze monthly data Not as “intuitive” as the others…so be sure to view the instructional Webex video before attempting to use it The tool is resident centered not staff centered The tool counts the number of caregivers taking care of residents NOT the number of residents being cared for by the caregiver The ONLY National Standardized way to collect this data

26 Consistent Assignment Calculator

27 Instructions TAB

28 Common Qs & As TAB

29 Summary TAB

Website: Consistent Assignment Resources 30

Person-Centered Care Planning and Decision Making Keeps the person at the center of the care planning and decision-making process. Promotes choice, purpose and meaning in daily life. Achieves highest practicable level of physical, mental and psychosocial well-being Care plans are revised on ongoing basis to reflect a person’s changing needs. Staff adapts to each resident’s changing needs regardless of cognitive abilities.

Person-Centered Care Planning Consistency of Resident Experience with Expressed Resident Preferences Participation in Care Planning Based on the MDS Measures

Hospitalizations Allows residents with acute changes in medical condition to remain in nursing home with staff who know them and can safely care for them without compromising residents’ well-being or wishes. Avoids trauma and risks associated with hospitalization. Increases communication between hospital and nursing home to ensure continuity of care.

Medications Ensures that residents receive medications that are needed and appropriate for their medical condition. Promotes use of alternative non-pharmacological interventions may be better suited for residents who otherwise would likely be treated with antipsychotic medications.

Resident Mobility Enhances and maintains mobility (range of motion, bed mobility, transferring, walking, elimination of physical restraints, wheelchair mobility, and reduction of fall risk) as a part of daily care to helps maintain a person’s function as well as physical and psychological well-being. Improves health and quality of life by increasing freedom of movement and activity.

Infections Prevents incidence and spread of infections to residents and staff that can cause respiratory or gastrointestinal symptoms. Although initial focus is on C.difficile, proposed evidence-based strategies to will help carry over to other

Pain Management Residents have individualized, person-centered care plans to ensure appropriate care that prevents and minimizes episodes of moderate to severe pain. Improves a resident’s ability to carry out daily activities and improves quality of life. Prevents depression, sleeplessness, restlessness, decline in appetite and unintentional weight loss due to pain.

Pressure Ulcers Prevents pressure ulcers or bed sores caused by staying too long in one position or by tubing or devices that press on the skin. Prevents pain, infection and other complications that are caused by pressure.

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Advancing Excellence Tools Evidence-based, tried and tested…they work! Developed by experts Similar to one another and user-friendly Excel worksheets Simple how-to instructions Calculations, trend graphs and charts built-in Downloadable and ready to use Complimentary materials for consumers, CNAs Free

Monthly Quality Tracking Develop a HABIT of tracking key quality information MONTHLY!!!

Questions For additional information please contact Cheryl Phillips, M.D.