Dementia-Specific NH Quality Indicators IDND Meeting May 2008 Greg Arling, Ph.D.

Dementia-Specific QI (D-QI) Project Funded by the Alzheimer’s Association (Investigator-Initiated Research Grant) Funded by the Alzheimer’s Association (Investigator-Initiated Research Grant) October 2007 – September 2010 October 2007 – September 2010 Greg Arling (PI) and Malaz Boustani (Co-PI) -- IU Center for Aging Research Greg Arling (PI) and Malaz Boustani (Co-PI) -- IU Center for Aging Research Christine Mueller (Co-PI) – U of Minnesota School of Nursing Christine Mueller (Co-PI) – U of Minnesota School of Nursing Focus on nursing home care in Minnesota Focus on nursing home care in Minnesota

D-QI Project Objectives Form an advisory group to provide guidance for the project; Form an advisory group to provide guidance for the project; Identify current and new quality indicators (D-QIs) most relevant to dementia residents; Identify current and new quality indicators (D-QIs) most relevant to dementia residents; Assemble available data on clinical care and quality of life of nursing home residents; Assemble available data on clinical care and quality of life of nursing home residents; Analyze available data to arrive at a final set of D-QIs for profiling nursing facilities and their residents; Analyze available data to arrive at a final set of D-QIs for profiling nursing facilities and their residents; Describe best practices in care of dementia residents through interviews with nursing home staff in high quality facilities (high D-QI scores). Describe best practices in care of dementia residents through interviews with nursing home staff in high quality facilities (high D-QI scores). Incorporate D-QIs into the Minnesota NH Report Card, P4P, and facility quality improvement efforts. Incorporate D-QIs into the Minnesota NH Report Card, P4P, and facility quality improvement efforts.

Minnesota NH Quality and Payment System Multidimensional measures of nursing home quality Multidimensional measures of nursing home quality NH Report Card to inform consumer decisions NH Report Card to inform consumer decisions Facility reporting system and training sessions to promote quality improvement. Facility reporting system and training sessions to promote quality improvement. Provider Payment Incentive Program which funds quality improvement projects to foster innovation and organizational learning Provider Payment Incentive Program which funds quality improvement projects to foster innovation and organizational learning

Minnesota NH Quality Measures StructureProcessOutcome Nurse staffing level & retention rate Clinical Quality Indicators (QI) Quality of Life and Resident Satisfaction Survey (QoL/RS) State NH inspection results (quality of care violations)

NH Quality Indicators (QIs) Based on Minimum Data Set (MDS) assessments Based on Minimum Data Set (MDS) assessments Standardized assessment of health and functional conditions Standardized assessment of health and functional conditions Administered to all residents by NH staff at admission and every 90 days thereafter Administered to all residents by NH staff at admission and every 90 days thereafter Transmitted monthly to the state in a standardized electronic format Transmitted monthly to the state in a standardized electronic format 24 QIs representing care processes and outcomes 24 QIs representing care processes and outcomes Binary variable (yes/no) at resident level Binary variable (yes/no) at resident level Prevalence or incidence rate at the facility level Prevalence or incidence rate at the facility level

NH Quality Indicators Skin Care Burns or Cuts New Pressure Sores Cured Pressure Sores Continence Improved Bladder Continence Worse Bladder Continence Improved Bowel Continence Worse Bowel Continence No Toileting Plan Indwelling Catheter Functioning ADL Decline ADL Improvement Mobility Decline Mobility Improvement ROM Decline Psychosocial Worsening Behavior Worsening Depression Under-use of Antidepressants Overuse of Antipsychotics Physical Restraints Other Moderate to Severe Pain Infections Urinary Tract Infection Weight Loss Falls

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 Probability sample designed to yield facility- specific QoL rates for all 400 nursing homes. Probability sample designed to yield facility- specific QoL rates for all 400 nursing homes. 53 QoL and other items adapted from established instruments 53 QoL and other items adapted from established instruments Surveys conducted in 2005 – 2008 Surveys conducted in 2005 – 2008

Quality of Life & Satisfaction Comfort(4) PhysicalEnvironment(4) Privacy(3) Dignity(4) MeaningfulActivity(4) EnjoyFood(3) PersonalAutonomy(5) Individuality(3) Safety(3) Relation-Ships(3) Satisfaction with Care (7) Mood(9) QoL/RS Dimensions (# of survey items)

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

Provider Incentive Payment Program Funding Funding $5 Million available in Year 1 (10/07-9/08) $5 Million available in Year 1 (10/07-9/08) $20 Million available in Year 2 (10/08-9/09) $20 Million available in Year 2 (10/08-9/09) Response to Request for Proposals Response to Request for Proposals Over 200 applications received Over 200 applications received 35 projects (75 facilities) funded 35 projects (75 facilities) funded Variety of projects: Variety of projects: Culture changeWound care Quality of lifeEmployee retention Pressure ulcersPain management ExerciseCHF

D-QI Project Advisory Committee Meeting in March 2008 Advisory Committee Meeting in March 2008 Front-line caregivers (e.g., medical directors, nurses, and nursing assistants) Front-line caregivers (e.g., medical directors, nurses, and nursing assistants) Family members Family members State agency staff State agency staff Other local experts Other local experts Advances in Nursing Home Dementia Care (June 2008 Workshop, Minneapolis) Advances in Nursing Home Dementia Care (June 2008 Workshop, Minneapolis) Wide audience of local experts – particularly front-line caregivers Wide audience of local experts – particularly front-line caregivers Identify high priority D-QIs and recommend areas for application Identify high priority D-QIs and recommend areas for application Advances in Nursing Home Dementia Care (Fall 2008 Workshop, Indianapolis) Advances in Nursing Home Dementia Care (Fall 2008 Workshop, Indianapolis)

D-QI Initial List of Indicators From Advisory Group Meeting From Advisory Group Meeting Brainstorm Brainstorm Consider QIs Consider QIs Currently measured or present in available data (MDS or QoL survey) Currently measured or present in available data (MDS or QoL survey) Need to be developed and possible new data collection Need to be developed and possible new data collection Refine D-QIs in subsequent meetings and data analysis Refine D-QIs in subsequent meetings and data analysis

Resident-Centered Care  Consistent staffing  Flexibility  Individualized care plan and care  Knowledgeable and respectful staff  Good communication with residents  Staff have accessible/easy-to-use information about residents (e.g. needs, care)  Residents can engage in meaningful activity  Behavioral problems are handled effectively  Appropriated decisions about care – e.g., advanced directives and surrogate decision-making

Family Engagement and Support Promotion of family involvement Promotion of family involvement Family-staff partnership/collaboration Family-staff partnership/collaboration Environment where Environment where families can freely be advocates for their loved one families can freely be advocates for their loved one family’s perspective is welcomed/families are engaged with staff in addressing resident’s needs family’s perspective is welcomed/families are engaged with staff in addressing resident’s needs Family participation Family participation Family involved in assessment Family involved in assessment Family input into caregiving plans and activities Family input into caregiving plans and activities Two-way communication between staff and family Two-way communication between staff and family Family participates/shares in caregiving according to their preferences and capabilities Family participates/shares in caregiving according to their preferences and capabilities

Staff Capabilities and Empowerment Staff learning/knowledge about dementia Staff learning/knowledge about dementia Staff is empowered and empowering Staff is empowered and empowering respond to resident’s needs respond to resident’s needs can individualize can individualize Staff given support to manage their own stress & avoid burnout Staff given support to manage their own stress & avoid burnout Teamwork Teamwork among front-line staff among front-line staff across disciplines and staff types across disciplines and staff types Staff stability and Avoidance of turnover Staff stability and Avoidance of turnover Sufficient number of staff & Right skill mix and expertise Sufficient number of staff & Right skill mix and expertise Staff adequately paid/compensated Staff adequately paid/compensated

Physical Environment Make it home-like (familiar objects) Make it home-like (familiar objects) Intuitive layout Intuitive layout Safety and Security Safety and Security unobtrusive ways of keeping people safe unobtrusive ways of keeping people safe appropriate security appropriate security Sensory aids – cues & labeling Sensory aids – cues & labeling Good physical design – flooring, lighting, & exercise/wandering areas Good physical design – flooring, lighting, & exercise/wandering areas Stimulation sensitive Stimulation sensitive Effective use of color Effective use of color Noise levels (not over stimulation) Noise levels (not over stimulation) Music-appropriate to individual/groups Music-appropriate to individual/groups Effective use of technology to ↓ noise stimulation Effective use of technology to ↓ noise stimulation Sensory deprivation attended to Sensory deprivation attended to

Organization and Management  Organizational culture  Learning community  Innovation seeking  Empowering & flexible  Organization of care  Unique programming  Activities-appropriate for dementia care (RC)  Unit types and resident mix  Intergenerational  Specialized dementia units or dementia residents mixed with others  Do residents get “placed” or “moved” based on clinical and cognitive needs? Debatable  Information Technology  IT (Integration) & other Technology Use  Electronic Medical/Health Record  Computer Decision Support

Clinical Care Dementia expertise Dementia expertise Specialist in dementia involved in care (assessment and prescription) ongoing Specialist in dementia involved in care (assessment and prescription) ongoing Proficiency of Geriatric Clinical Provider Proficiency of Geriatric Clinical Provider Diagnosis and assessment Diagnosis and assessment Diagnosis for dementia and type Diagnosis for dementia and type Fully assess needs Fully assess needs Identify triggers/causes of behavioral symptoms Identify triggers/causes of behavioral symptoms Staging Staging Assessment should determine dementia stage Assessment should determine dementia stage Care tailored to stage of dementia (need work on criteria for staging) Care tailored to stage of dementia (need work on criteria for staging) Delirium diagnosis and treatment Delirium diagnosis and treatment Assessment/diagnoses of delirium Assessment/diagnoses of delirium Prevention and treatment strategies/interventions Prevention and treatment strategies/interventions Delirium treatment strategies/interventions Delirium treatment strategies/interventions Delirium -- close observation, assessment & management Delirium -- close observation, assessment & management

Clinical Care (Cont.) Short stay dementia residents receiving appropriate/equal care (medical, clinical) Short stay dementia residents receiving appropriate/equal care (medical, clinical) Discharge decisions Discharge decisions Rehabilitation decisions, rehabilitation attempted Rehabilitation decisions, rehabilitation attempted Rehabilitation and functional outcomes Rehabilitation and functional outcomes Physical Therapy/Occupational Therapy* Physical Therapy/Occupational Therapy* Successful rehabilitation outcomes Successful rehabilitation outcomes Maintaining/promoting function Maintaining/promoting function Choice of Therapies Validation, vs. Orientation* Tx (Traction?) Choice of Therapies Validation, vs. Orientation* Tx (Traction?) Non-traditional Therapies Non-traditional Therapies Pet therapy Pet therapy Music therapy Music therapy Touch Touch

Clinical Care (Cont.) Clinical Issues Clinical Issues Delirium Delirium Pain Pain Depression Depression Communication/speech Communication/speech Feeding/ Nutrition Feeding/ Nutrition Tube Feeding Tube Feeding Weight Weight Continence Continence Skin care Skin care Functional Decline Functional Decline Vision and hearing Vision and hearing Medications Medications End of Life Care* End of Life Care* Hospice Care Hospice Care Palliative Care Palliative Care