Greg Arling

Targeting residents for transitions from nursing home to community.

OBJECTIVE To analyze nursing home utilization patterns in order to identify potential targeting criteria for transitioning residents back to the community. DATA SOURCES Secondary data from minimum data set (MDS) assessments for an annual cohort of first-time admissions (N=24,648) to all Minnesota nursing homes (N=394) from July 2005 to June 2006. STUDY DESIGN We conducted a longitudinal analysis from admission to 365 days. Major MDS variables were discharge status; residents preference and support for community discharge; gender, age, and marital status; pay source; major diagnoses; cognitive impairment or dementia; activities of daily living; and continence. PRINCIPAL FINDINGS At 90 days the majority of residents showed a preference or support for community discharge (64 percent). Many had health and functional conditions predictive of community discharge (40 percent) or low-care requirements (20 percent). A supportive facility context, for example, emphasis on postacute care and consumer choice, increased transition rates. CONCLUSIONS A community discharge intervention could be targeted to residents at 90 days after nursing home admission when short-stay residents are at risk of becoming long-stay residents.

Does Cognitive Impairment Influence Quality of Life among Nursing Home Residents

PURPOSE We investigated the relationship between cognitive status and quality of life (QOL) of Minnesota nursing home (NH) residents and the relationship between conventional or Alzheimers special care unit (SCU) placement and QOL. The study may inform development of dementia-specific quality measures. DESIGN AND METHODS Data for analyses came from face-to-face interviews with a representative sample of 13,130 Minnesota NH residents collected through the 2007 Minnesota NH Resident Quality of Life and Consumer Satisfaction survey. We examined 7 QOL domains: comfort, meaningful activities, privacy, environment, individuality, autonomy, relationships, and a positive mood scale. We applied multilevel models (resident and facility) to examine the relationship between the residents score on each QOL domain and the residents cognitive impairment (CI) level and SCU placement after controlling for covariates, such as activities of daily living dependency, pain, depression or psychiatric diagnosis, and length of stay. RESULTS Residents with more severe CI reported higher QOL in the domains of comfort and environment and lower QOL in activities, individuality, privacy and meaningful relationships, and the mood scale. Residents on SCU reported higher QOL in the meaningful activities, comfort, environment, and autonomy domains but had lower mood scores. IMPLICATIONS Our findings point to QOL domains that show significant variation by CI and thus may be of greatest interest to consumers, providers, advocacy groups, and other stakeholders committed to improving dementia care. Findings are particularly applicable to the development of NH quality indicators that more accurately represent the QOL of NH residents with CI.

The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care Approach: Preliminary Data from the Implementation of a Centers for Medicare and Medicaid Services Nursing Facility Demonstration Project

The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project aims to reduce avoidable hospitalizations of long‐stay residents enrolled in 19 central Indiana nursing facilities. This clinical demonstration project, funded by the Centers for Medicare and Medicaid Services Innovations Center, places a registered nurse in each nursing facility to implement an evidence‐based quality improvement program with clinical support from nurse practitioners. A description of the model is presented, and early implementation experiences during the first year of the project are reported. Important elements include better medical care through implementation of Interventions to Reduce Acute Care Transfers tools and chronic care management, enhanced transitional care, and better palliative care with a focus on systematic advance care planning. There were 4,035 long‐stay residents in 19 facilities enrolled in OPTIMISTIC between February 2013 and January 2014. Root‐cause analyses were performed for all 910 acute transfers of these long stay residents. Of these transfers, the project RN evaluated 29% as avoidable (57% were not avoidable and 15% were missing), and opportunities for quality improvement were identified in 54% of transfers. Lessons learned in early implementation included defining new clinical roles, integrating into nursing facility culture, managing competing facility priorities, communicating with multiple stakeholders, and developing a system for collecting and managing data. The success of the overall initiative will be measured primarily according to reduction in avoidable hospitalizations of long‐stay nursing facility residents.

Medicaid Nursing Home Pay for Performance: Where Do We Stand?.

PURPOSE Nursing home pay-for-performance (P4P) programs are intended to maximize the value obtained from public and private expenditures by measuring and rewarding better nursing home performance. We surveyed the 6 states with operational P4P systems in 2007. We describe key features of six Medicaid nursing home P4P systems and make recommendations for further development of nursing home P4P. DESIGN AND METHODS We surveyed the six states with operational P4P systems in 2007. RESULTS The range of performance measures employed by the states is quite broad: staffing level and satisfaction, findings from the regulatory system, clinical quality indicators, resident quality of life or satisfaction with care, family satisfaction, access to care for special populations, and efficiency. The main data sources for the measures are the Minimum Data Set (MDS), nursing home inspections, special surveys of nursing home residents, consumers or employees, and facility cost reports or other administrative systems. The most common financial incentive for better performance is a percentage bonus or an add-on to a facilitys per diem rate. The bonus is generally proportional to a facility performance score, which consists of simple or weighted sums of scores on individual measures. IMPLICATIONS States undertaking nursing home P4P programs should involve key stakeholders at all stages of P4P system design and implementation. Performance measures should be comprehensive, valid and reliable, risk adjusted where appropriate, and communicated clearly to providers and consumers. The P4P system should encourage provider investment in better care yet recognize state fiscal restraints. Consumer report cards, quality improvement initiatives, and the regulatory process should complement and reinforce P4P. Finally, the P4P system should be transparent and continuously evaluated.

Nursing home case-mix reimbursement in Mississippi and South Dakota

OBJECTIVE To evaluate the effects of nursing home case-mix reimbursement on facility case mix and costs in Mississippi and South Dakota. DATA SOURCES Secondary data from resident assessments and Medicaid cost reports from 154 Mississippi and 107 South Dakota nursing facilities in 1992 and 1994, before and after implementation of new case-mix reimbursement systems. STUDY DESIGN The study relied on a two-wave panel design to examine case mix (resident acuity) and direct care costs in 1-year periods before and after implementation of a nursing home case-mix reimbursement system. Cross-lagged regression models were used to assess change in case mix and costs between periods while taking into account facility characteristics. DATA COLLECTION Facility-level measures were constructed from Medicaid cost reports and Minimum Data Set-Plus assessment records supplied by each state. Resident case mix was based on the RUG-III classification system. PRINCIPAL FINDINGS Facility case-mix scores and direct care costs increased significantly between periods in both states. Changes in facility costs and case mix were significantly related in a positive direction. Medicare utilization and the rate of hospitalizations from the nursing facility also increased significantly between periods, particularly in Mississippi. CONCLUSIONS The case-mix reimbursement systems appeared to achieve their intended goals: improved access for heavy-care residents and increased direct care expenditures in facilities with higher acuity residents. However, increases in Medicare utilization may have influenced facility case mix or costs, and some facilities may have been unprepared to care for higher acuity residents, as indicated by increased rates of hospitalization.

Communication and effectiveness in a US nursing home quality-improvement collaborative.

In this study, we explored the relationship between changes in resident health outcomes, practitioner communication patterns, and practitioner perceptions of group effectiveness within a quality-improvement collaborative of nursing home clinicians. Survey and interview data were collected from nursing home clinicians participating in a quality-improvement collaborative. Quality-improvement outcomes were evaluated using US Federal and State minimum dataset measures. Models were specified evaluating the relationships between resident outcomes, staff perceptions of communication patterns, and staff perceptions of collaborative effectiveness. Interview data provided deeper understanding of the quantitative findings. Reductions in fall rates were highest in facilities where respondents experienced the highest levels of communication with collaborative members outside of scheduled meetings, and where respondents perceived that the collaborative kept them informed and provided new ideas. Clinicians observed that participation in a quality-improvement collaborative positively influenced the ability to share innovative ideas and expand the quality-improvement program within their nursing home. For practitioners, a high level of communication, both inside and outside of meetings, was key to making measurable gains in resident health outcomes.

Nurse Staffing and Quality: The Unanswered Question

Researchers have spent decades trying to answer the question: Does more nurse staff lead to better quality of nursing home care? Many nurses, consumers, nursing home providers, and other stakeholders believe intuitively that the answer is “yes.” Yet, the research literature fails to give us a clear answer. Bostick and colleagues 1 reached a relatively positive conclusion about the nurse staffing and quality relationship from their review of 87 articles and reports published from 1975 to 2003. Spilsbury and colleagues, 2 in their systematic review of 50 carefully screened studies from 1987 to 2008, were much more critical of methods and findings from these studies. In this issue of the Journal, Backhaus and colleagues 3 offer a systematic review of more recent research, with most of the reviewed studies conducted between 2000 and 2012. They limited their review to studies using a longitudinal design, which is better able to detect causal effects and less susceptible to spurious interpretation than a cross-sectional design. Backhaus and colleagues 3 assessed the strength of the study design, generalizability, control variables, and other issues, and they examined studies from different angles: staffing level and skill mix; different care processes and outcomes; and resident, facility, and multiple levels of measurement and analysis. Echoing the conclusions reached by Spilsbury and colleagues, 2

Incentivizing Nursing Home Quality and Physician Performance

1 states are creating innovative financial models to reward the delivery of higher quality care, and the American Medical Directors Association (AMDA) is developing strategies to better gauge the performance of NH physicians and medical directors. The interplay of these factors not only has provided new opportunities to impact approaches to quality measurement in the NH but also has rejuvenated interest in measuring the impact of physician performance on NH quality. In this article, we highlight the efforts of one state that is in process of implementing an incentivized model for highquality care that includes physician certification in the model. We end by offering potential solutions to enhancing physician