Advancing Excellence in America’s Nursing Homes Mary Jane Koren, M.D., MPH Chair, Advancing Excellence Vice President, The Commonwealth Fund

Advancing Excellence: The NH Quality Campaign Overview of the presentation Background Description of Advancing Excellence: – Purpose and structure – Process: how it works Accomplishments – Evidence of impact – Other achievements Building on what works – Using AE to test new ideas – Working with CMS: QA/PI and the QIO’s 10 th SOW – Factors associated with why AE has been successful 2

Background 3

4 Industry CharacteristicsFacility Characteristics 15,800 facilities ( approx million beds) million residents on any given day; million discharges/yr >95% of beds are Medicare or Medicaid certified 66% for-profit, 28% not-for- profit, 6% gov’t. 52% are part of a multi- facility group 110 beds average size Median occupancy 86% and dropping gradually Generally, high staff turnover - CNAs 71% annually - Nurses 48.9% - Administrative staff 35.5% Old buildings: average NH is over 30 years old Context for the NH Quality Campaign

Antecedents to Advancing Excellence The Sioux Falls Group formed in 2000 – Share information about each others’ initiatives and strategies; – Create effective coordination among themselves; and – Proactively, through their respective organizations, lead important national improvement initiatives IHI’s 100,000 Lives Campaign 12/04-6/06 – “Some is not a number, soon is not a time” – Modeled on a political campaign – Based on 6 evidence-based practices – Established and promoted a set of achievable goals for US hospitals – Generated unprecedented amounts of social pressure for hospitals to participate 5

Description of AE: Purpose and Structure 6

Advancing Excellence is… Largest national coalition of NH stakeholders (30 organizations) working together to help NHs improve care An opportunity for NHs to demonstrate their commitment to self-improvement (>47% participate) outside regulation An independent organization incorporated in 2010, recognized as 501(c)(3)in 2011 Funded by – CMS for the web-site and analytic support – The Commonwealth Fund for program support – Members for communications and other special needs

8 Nationally: Board of Directors Sets Goals Develops resources Provides support Statewide: LANES Recruit NHs Coordinate statewide activities Provide support Facility Registers for AE Selects 3 goals and sets targets Uses AE’s web- based tools and resources AE functions on 3 levels

Board of Directors Voting Members Alliance for Quality Nursing Home Care Alzheimer’s Association American Academy of Nursing -- Expert Panel on Aging American Association for Long Term Care Nursing (AALTC) American Association of Nurse Assessment Coordinators (AANAC) American College of Health Care Administrators (ACHCA) American Health Care Association (AHCA) American Health Quality Association (AHQA) AMDA – Long Term Care LeadingAge (formerly AAHSA) National Association of Health Care Assistants (NAHCA) National Consumer Voice for Long Term Care The Commonwealth Fund The Evangelical Lutheran Good Samaritan Society

Association of Health Facility Survey Agencies (AHFSA) Foundation of the National Association of Boards of Examiners of LTC Administrators (NAB) Gerontological Advance Practice Nurses Association (GAPNA) Hartford Institute for Geriatric Nursing National Association of Directors of Nursing Administration in Long Term Care (NADONA/LTC) National Association of State Long- Term Care Ombudsman Programs (NASOP) National Gerontological Nursing Association (NGNA) PHI Pioneer Network Service Employees International Union (SEIU) Non-voting/Government Members Administration on Aging Agency for Healthcare Research and Quality (AHRQ) Assistant Secretary for Policy and Evaluation (ASPE) Centers for Disease Control and Prevention (CDC) Centers for Medicare & Medicaid Services (CMS) and its contractors, the Quality Improvement Organizations (QIOs) and State Survey Agencies Department of Veteran’s Affairs

11 3. Restraints 6. Advance Care Planning 5. Pain 8. Staff Satisfaction 7. Resident Satisfaction 4. Pressure Ulcers 2.Consistent Assignment 1. Staff Turnover Advancing Excellence Goals

AE is committed to three audiences: NHs: – AE selects meaningful issues aligned with national initiatives – Provides free, practical, evidence-based resources to support organizational stability and performance improvement Direct care staff: – AE’s tools designed so workers can join in on QI efforts – Solicits feedback about how they feel about their job Residents and their families: – AE promotes open communication and participation of families and residents in care planning. – Encourages measurement of “customer” satisfaction as a part of the home’s QI process

13 AE goals compared to other initiatives

Local Area Networks of Excellence (LANES) Neutral space where stakeholders can come together to build working relationships Divisive issues (e.g. 5 Star, reimbursement, the survey) are deliberately set aside or avoided Must learn to work together toward a shared goal – better care for the resident The aim is create ongoing learning networks or “learning communities” of stakeholders and of NHs

Key Members of the LANE QIO Ombudsman State Survey Agency Nursing Home Association Reps Culture Change Coalition Rep Others can include consumer advocacy groups, state Medicaid agency, health care professionals (e.g. state AMDA chapters), unions, etc.

Process: how it works 16

Becoming part of the AE Campaign Nursing homes register on website Choose 3 goals minimum – 1 clinical, 1 organizational plus 1 more (however, may pick all 8) Identify benchmarks and set targets Use the web-site to access AE’s resources and tools Collect and monitor data using PDSA/PI methods Enter data on AE website regularly

Campaign Benefits Focuses on things consumers, surveyors and payers are concerned about Increased staff stability: less turnover, better retention Saves money Improves performance Builds better relationships among staff and residents/families Improves satisfaction (staff/resident/family) Lets them be part of a learning network, lets them compare their performance with others Complements other initiatives QA/PI (ACA section 6102) QIO program initiatives (10 th SOW just starting) Preparation for payment reforms

Free Campaign Tools Evidence-based or field tested Downloadable, ready to use Standardized formatting, user-friendly Excel worksheets for data collection Clear, easy to understand instructions Calculations, trend graphs and charting functions built-in Compatible materials provided for consumers

Advancing Excellence Tools Staff Turnover Calculator Consistent Assignment Calculator Pressure Ulcer Monitoring Tool Restraint Monitoring Tool Pain Monitoring Tool Advance Care Plan Monitoring Tool Suggest tools to measure Staff Satisfaction and Resident/Family Satisfaction

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Accomplishments 27

Recruitment Participating nursing homes in Phase 2: ( 47%) 4726 Charter members 1965 New participants Participating consumers: 3053 Participating nursing home staff: September 1,

29 Recruitment % by State

30 Recruitment % by State

The Relative and Absolute Number of Residents at High Risk for Developing Pressure Ulcers is Increasing

Physical Restraints

High Risk Pressure Ulcers

Campaign Progress Campaign participants* have improved faster than non-participants in all things measured. Campaign participants* improved faster in the goals they selected to work on in every case. Campaign participants that set targets improved the most *In the aggregate…

Accelerated Improvement Since Campaign Start 2005 Q Q3 (year before) vs Q Q3 (last year) Percent Improvement Comparing Participants Selecting Goal and Non-Participants for the year before the Campaign and for the last year of the Campaign. Those selecting the clinical goal realized greater relative improvement than non-participants for Pressure Ulcers and Restraint use after joining the Campaign

Progress toward Campaign Goal

37 Change and Relative Improvement in National QMs Q to Q3 2010

Advancing LANE Performance 21 Statewide Performance Improvement Projects in 14 States Increased use of Consistent Assignment Decreased Staff Turnover Decreased Pressure Ulcers Decreased Physical Restraints Increased Advance Care Planning Increased website data entry

More than 50% nursing home participation Accelerating LANE Performance States Critical Access Nursing Home State Changing LANEs Project LANE Participation in Advancing Excellence Fall 2010

Arkansas Restraint Rate 2005 Q3 through 2009 Q Residents who Were Physically Restrained (%) Q3

Finding new ways to measure quality: a new measure for Consistent Assignment Consistent Assignment: Uses a person-centered frame for the measure by asking, “How many CNAs touched the resident in the course of the month” Same CNA takes care of the same resident every time, all of the time Optimally? Could be as low as 6 – 8 over the course of a month

Promoting research on the impact of this staffing practice: Using Consistent Assignment 85% of the time associated with fewer survey deficiencies, 41 % fewer empty beds, and 31% less turnover – recent study by Dr. Nick Castle Small study by Dr. Barbara Bowers on consistent assignment – currently in progress

Building on what works 43

The Critical Access NH Pilot: Can AE LANEs help to reduce disparities in NHs? 18 NHs from 4 States (GA, IL, IN, OH) NH selection based on quality measures, number of deficiencies, % Medicaid, % minority population, geographical area, media attention, etc. Only one nursing home has dropped out. One nursing home was added at the request of the State Health Department.

CANH LANE Successes LANE members, and the NHs, stayed at the table NHs were enabled to share experiences with peers LANEs learned to take responsibility for overcoming impediments e.g. getting NH corporate offices to pay attention CMS Region IV very engaged Possible use of model following the project in at least 2 states

CANH: Facility Successes – “We used to have 5 or 6 call-outs a night. Now we only have one a week…” – “We’ve gone back to Nursing 101. Instead of having the nurses call the doctor when a resident has a fever, we have empowered the nurse and allow him or her to try Tylenol, compresses and other nursing care… our hospital admissions have decreased” – “The dietary staff that used to fight with each other all the time are now working together to help the residents…” – DON and Administrators are doing MDS resident interviews and realize they have been “missing the boat.” CANH: Facility Successes

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

Aims for the 10 th SOW: C.6 Beneficiary and Family Centered Care – Patient and Family Engagement Campaign C.7 Improving Individual Patient Care – Reduction of Health-Care Acquired Conditions C.8 Integrating Care for Populations and Communities – Improving Care Transitions Leading to the Reduction of Readmissions – Using Data to Drive Dramatic Improvement in Communities Drivers for creating change: Tasks under the 10 th SOW C.10.1 Supporting and Convening Learning and Action Networks; C.10.2 Providing Technical Assistance; and C.10.3 Care Reinvention through Innovation Spread 48 QIO 10 th SOW

Lessons from IHI Why Learning Networks are Important Engages leaders Shared aims or goals Welcomes everyone and harnesses energy Self-conscious – participants are a part of the whole Non-linear Devolves control/bottom-up learning Manages knowledge nimbly Seeks critical mass – not total coverage Values asking, not merely sharing 13

AE is an example of a collective impact initiative Collective impact initiatives represent ongoing commitments by key stakeholders from different sectors to a common agenda for solving a specific social problem – Use the LANE, often with major help from the QIOs, as the supporting infrastructure – Forge new partnerships across interest groups – Build strong working relationships among important players through continuous, ongoing communication – Concentrate on identifying and then addressing the common problem – Jointly agree on what success will look like and having a shared measurement system – Use mutually reinforcing activities to maximize existing resources

Mary Jane Koren Or Carol Benner