Commentary on long Term Care Quality A Provider Perspective

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Commentary on long Term Care QualityA Provider
Perspective

• Bradley Shiverick
• Second National Medicaid Congress
• June 14, 2007

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A Brief Overview of Initiatives and Progress on
Long Term Care Quality

• Nursing Home Reform Act 1987
• Prospective Payment Implications 1999
• Quality First 2002
• Nursing Home Quality Initiative 2002
• Advancing Excellence 2006
• Programs and Progress

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IOM Study 1986

• 1986 Institute of Medicine Report Improving the
  Quality of Care in Nursing Homes
• Recommendations
• Stronger Federal Role in LTC Quality
• Strengthening of Performance Standards
• Training Standards for Staff
• Improved Resident Assessment
• Strengthened Regulatory Process

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First There was OBRA

• Minimum Regulatory Standards for LTC
• Process Standards for
• Quality of Life
• Quality of Care
• Support for Activities of Daily Living
• Resident Rights
• Resident Assessment
• Physical and Chemical Restraints
• Regulatory Process and Remedies

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Regulation and Enforcement

• 150 Individual Requirements
• Annual, Complaint and Incident Surveys
• Cycle of Compliance
• Scope and Severity 1995
• Outcomes Focus (Double G) 1999
• Revised Outcomes Focus 2006
• Minimal Standards and Penalties

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Prospective Payment

• 1998 1999 Prospective Payment System(Medicare)
• RUGS III System 44 Utilization Groups
• 10 of all US Nursing Homes Under Bankruptcy
  Protection
• Five of Top 7 LTC Firms Under Bankruptcy
• Significant Pressure on Resources
• Quality Indicators Introduced Nationally

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1999 Nursing Home Quality Indicators24 QIs in 11
Domains

• Accidents
• Clinical Management
• Cognitive Patterns
• Elimination/Incontinence
• Infection Control
• Nutrition/Eating

• Behavior/Emotional Patterns
• Physical Functioning
• Psychotropic Drug Use
• Quality of Life
• Skin Care

www.medicare.gov/nhcompare
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Quality First Pledge - 2002

• Strategic Alliance Between Major Provider Groups
  to Improve Quality
• American Health Care Association (AHCA)
• American Association of Homes and Services for
  the Aging (AAHSA)
• Alliance for Quality Nursing Home Care (AQNHC)

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Quality First - 2002

• Seven Core Principles
• Continuous Quality Assurance and Quality
  Improvement
• Public Disclosure and Accountability
• Patient/Resident and Family Rights
• Workforce Excellence
• Public Input and Community Involvement
• Ethical Practices
• Financial Stewardship

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Alliance for Quality Nursing Home CareQF Code of
Conduct and Ethical Practices

• Commitment to Patient Well-Being Through Quality
  Care
• Leadership Commitment to Quality
• Continuous Quality Improvement
• Quality Improvement Goals
• Uniform Measures of Quality
• Public Disclosure and Accountability
• Patient and Family Rights
• Workforce Excellence
• Employee Recruitment, Assessment.
• Employee Training.
• Commitment to Employees
• Public Input on Quality
• Ethical Practices
• Financial Stewardship

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Quality First Pledge - 2002

• Expected Outcomes
• Compliance with Federal Regulations
• Financial Integrity and Reduction in Fraud
• Improvements in Abuse and Neglect
• Improvements in Clinical Outcomes
• Customer Satisfaction
• Employee Retention

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Nursing Home Quality Improvement Initiative -
2002

• CMS Led Initiative to Improve Quality
• Regulation and Enforcement
• Consumer Information on Quality of Care
• Improved Quality Measures
• Community Based Quality Improvement
• QIO Role
• Assistance with Clinical Processes
• Clinical Collaboratives
• Culture Change Initiatives
• Collaboration and Partnership
• Federal and State Agencies
• QIOs / Providers / Advocates

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Results

• Nearly 50 drop from 1999 to 2005 in the number
  of nursing homes with serious quality problems"
  (GAO, January 2006)
• Decrease in facilities receiving G or above
  deficiencies from 2002 2004 (AHCA OSCAR data)
• Marked improvement in compliance with abuse and
  neglect standards since Quality First began in
  2002. (AHCA)
• Since the inception of Quality First, the U.S.
  Department of Labor has pledged to work with the
  profession. They declared that 2006 is the Year
  of Long Term Care.

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Select Results
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Select Results
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NHQI / Quality First

• Secretary Tommy Thompson (12/04)
• it has worked better than we could have hoped
  for we are pleased that nursing home residents
  are now receiving better care compared to just
  two years ago we stabilized the funding in the
  last two years and improved care quality.

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Quality First in Action Advancing Excellence -
2006
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National Coalition
Unprecedented

• Centers for Medicare and Medicaid Services
  Survey Group
• Centers for Medicare and Medicaid Services
  --Quality Improvement Group
• National Citizens Coalition for Nursing Home
  Reform
• Service Employees International Union
• The Commonwealth Fund
• National Commission for Quality Long-term Care
• Agency for Healthcare Research and Quality
• Association of Health Facility Survey Agencies
• American Association of Nurse Assessment
  Coordinators
• American College of Health Care Administrators
• American Medical Directors Association
• National Association of Health Care Assistants
• American Association of Homes and Services for
  the Aging (AAHSA)
• American Health Care Association (AHCA)
• The Alliance for Quality Nursing Home Care
• The Evangelical Lutheran Good Samaritan Society

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Campaign Components

• Meaningful Goals
• Measures and Data Sources
• Technical Assistance - Evidenced-based Protocols
• National and State-based Infrastructure

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Advancing Excellence - 2006

• Clinical Outcome Goals
• High Risk Pressure Ulcers
• Physical Restraints
• Chronic Care Pain
• Post Acute Care Pain
• Process (Organizational Improvement Goals)
• Setting Clinical Targets
• Customer Satisfaction
• Staff Retention
• Consistent Staffing

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Advancing Excellence 5360 Enrolled LTC Providers

• Clinical Goals
• Pressure Ulcers 68
• Restraints 42
• LTC Pain 53
• PAC Pain 40

• Process Goals
• Targets 29
• Satisfaction 65
• Retention 39
• Assignment 31

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What Does it All Mean?

• Are We Making Progress?
• Do Negative Outcomes Matter?
• Do Residents and Families Care?
• Consumer Experience of Care

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Any Progress?
Source 1987-1984 Schoeneman AHSR 2003-2006
NHQI-STAR
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Any Progress?
Source 2003-2006 NHQI-STAR
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Any Progress?
Source 2003-2006 NHQI-STAR
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Any Progress?
Source 2003-2006 NHQI-STAR
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Customer Satisfaction

• Satisfaction Largely Linked to Positive Outcomes
  and Experiences of Care

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Continued Progress?

• The Road Ahead
• Population Change / Role of PAC
• Nursing Shortage / Aging Workforce
• Medicare Stability / Medicaid Shortfalls
• Electronic Medical Records
• Person Centered Care

A culture of aging that is life-affirming,
satisfying, humane and meaningful. Pioneer
Network Vision
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Changing Population
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Medicare Stability
Historic and Projected SNF Medicare Per
Diems 1998 - 2006
(p)
Source Alliance for Quality Nursing Home Care
Database and the Muse Associates Reality
Baseline
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Medicaid Underfunding
BDO Seidman - 2006
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Medicaid Shortfalls
BDO Seidman - 2006
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Medicaid Shortfalls

• Its Only 13
• Times 100 Residents 1300 / day
• Times 365 Days 474,500
• Is That a Lot?
• At 12/hour 25,000/year
• Equivalent Shortfall 19 FTEs.

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• Thank You