John F. Schnelle, PhD Vanderbilt Center for Quality Aging Professor School of Medicine

Point 1 Quality can be improved with care identified in practice and regulatory guidelines. Quality can be improved with care identified in practice and regulatory guidelines. Care is labor intensive and hard to manage. Care is labor intensive and hard to manage.

Point 2 Nursing Homes can or do not implement recommended care for three major reasons Nursing Homes can or do not implement recommended care for three major reasons Staffing :numbers and poor information for management. Staffing :numbers and poor information for management. Motivation: regulatory system does not reinforce improvement in direct care. Motivation: regulatory system does not reinforce improvement in direct care. Knowledge: Required care is not described with adequate specificity to implement. Knowledge: Required care is not described with adequate specificity to implement.

Point 3 There are immediate and realistic solutions if we think differently. There are immediate and realistic solutions if we think differently. Solutions are outlined in the last slide. Solutions are outlined in the last slide.

Point 1: Quality can be improved with simple but labor intense care Functional incidental training controlled clinical trial. Functional incidental training controlled clinical trial. Incontinent Nursing Home Residents (60% +) Incontinent Nursing Home Residents (60% +) Care every 2 hours. Care every 2 hours. Resident offered toileting assistance (choice). Resident offered toileting assistance (choice). Resident assisted with incidental exercise standing; transfer; movement. Resident assisted with incidental exercise standing; transfer; movement.

Outcomes Intervention group significantly better than control group. Intervention group significantly better than control group. Urinary Incontinence Urinary Incontinence One constipation measure One constipation measure ADL decline ADL decline Resident family report of met needs Resident family report of met needs Family report of positive communication with staff Family report of positive communication with staff

Labor costs and Management 21 minutes aide time per resident ever 2 hours. 21 minutes aide time per resident ever 2 hours. 30 minutes of supervisory time per day. 30 minutes of supervisory time per day. Staffing projection- Ratio 5 residents to 1 aide. Staffing projection- Ratio 5 residents to 1 aide. 90% Nursing homes are staffed below this level. 90% Nursing homes are staffed below this level. Staffing ratios are only part of the problem. Staffing ratios are only part of the problem. Schnelle et al. Journal of American Geriatric Society Schnelle et al. Journal of American Geriatric Society.2002.

Management Homes staffed at high levels (5-1 ratio) did better but still did not implement consistent care in some areas. Homes staffed at high levels (5-1 ratio) did better but still did not implement consistent care in some areas. Schnelle et al. Health Services Research Schnelle et al. Health Services Research.2004.

Barriers to Management Inaccurate information about care. Inaccurate information about care. Unrealistic expectations given resources. Unrealistic expectations given resources. No objective method to target care given suboptimal staffing. No objective method to target care given suboptimal staffing.

Regulatory Issues Nursing homes highly sensitive to regulatory feedback. Nursing homes highly sensitive to regulatory feedback. Regulatory feedback does not reinforce improvement. Regulatory feedback does not reinforce improvement.

External regulation works best if… provider/regulator consensus Definition of Quality Measures Definition of Quality Measures Methods of measurement. Methods of measurement. Rules to link measures to deficiency statements. Rules to link measures to deficiency statements.

Current regulatory system meets none of these criteria Unrealistic expectations about how many recommended care processes can be measured. Unrealistic expectations about how many recommended care processes can be measured. Poor definition of measures and methods of measurement Poor definition of measures and methods of measurement (e.g.) observe quality of assistance at meal times. (e.g.) observe quality of assistance at meal times. Confusing rules linking measures to deficiency statements. Confusing rules linking measures to deficiency statements.

Failure to provide realistic survey task and standardized protocols Survey culture that depends on expert judgment. Survey culture that depends on expert judgment. Inconsistency Inconsistency Confused providers who do not know how to improve care. Confused providers who do not know how to improve care.

Solutions for improving quality More active bedside research as opposed to statistical manipulation of secondary data. More active bedside research as opposed to statistical manipulation of secondary data. Labor costs and management Labor costs and management Outcomes (Quality of Life and Clinical) Outcomes (Quality of Life and Clinical)

Staffing and Management Issues: Best practice demonstration site Develop consensus about important care. Develop consensus about important care. Implement care and document labor costs and outcomes. Implement care and document labor costs and outcomes. Improve efficiency (alternative staffing models, alternative environments). Improve efficiency (alternative staffing models, alternative environments). Match staffing levels to care expectations. Match staffing levels to care expectations.

Regulatory System Develop and test standardized investigation protocols based on existing survey guidelines. Develop and test standardized investigation protocols based on existing survey guidelines. Determine resources to implement protocols. Determine resources to implement protocols. Focus on realistic set of quality measures. Focus on realistic set of quality measures. Make procedures known to Nursing Home Staff and obtain consensus. Make procedures known to Nursing Home Staff and obtain consensus.