Teresa Lewis

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.

Resident- and Facility-Level Predictors of Quality of Life in Long-Term Care

PURPOSE OF THE STUDY Although there is substantial research on quality of care in nursing homes (NH), less is known about what contributes to quality of life (QOL) for NH residents. This study assesses multiple domains of QOL and examines facility- and resident-level correlates for different domains. DESIGN AND METHODS Data come from (a) self-reported resident interviews using a multidimensional measure of QOL; (b) resident clinical data from the Minimum Data Set; and (c) facility-level characteristics from Minnesota Department of Human Services. We used factor analysis to confirm domains of QOL, and then employed cross-sectional hierarchical linear modeling to identify significant resident- and facility-level predictors of each domain. RESULTS We examined six unique domains of QOL: environment, personal attention, food, engagement, negative mood, and positive mood. In multilevel models, resident-level characteristics were more reliable correlates of QOL than facility characteristics. Among resident characteristics, gender, age, marital status, activities of daily living, mood disorders, cognitive limitations, and length of stay consistently predicted QOL domains. Among facility characteristics, size, staff hours, quality of care, and percent of residents on Medicaid predicted multiple QOL domains. IMPLICATIONS Examining separate domains rather than a single summary score makes associations with predictors more accurate. Resident characteristics account for the majority of variability in resident QOL. Helping residents maintain functional abilities, and providing an engaging social environment may be particularly important in improving QOL.

Minnesota's Nursing Facility Performance-Based Incentive Payment Program: An Innovative Model for Promoting Care Quality

PURPOSE Minnesotas Nursing Facility Performance-Based Incentive Payment Program (PIPP) supports provider-initiated projects aimed at improving care quality and efficiency. PIPP moves beyond conventional pay for performance. It seeks to promote implementation of evidence-based practices, encourage innovation and risk taking, foster collaboration and shared learning, and establish a solid case for investing in better quality from the perspective of the state, providers, and consumers. We explain PIPP rationale and design, describe projects and participating facilities, and present findings from interviews with project leaders. DESIGN AND METHODS Provider-initiated projects lasting from 1 to 3 years are selected through a competitive process and are funded for up to 5% of the daily operating per diem rate. Providers are at risk of losing up to 20% of their project funding if they fail to achieve targets on state nursing facility performance measures. RESULTS Minnesota has made a major investment in the PIPP by supporting 45 individual or collaborative projects, representing approximately 160 facilities and annual funding of approximately

Minnesota’s Provider-Initiated Approach Yields Care Quality Gains At Participating Nursing Homes

18 million. Projects involve a wide range of interventions, such as fall reduction, wound prevention, exercise, improved continence, pain management, resident-centered care and culture change, and transitions to the community. IMPLICATIONS The PIPP can serve as a model for other states seeking to promote nursing facility quality either in combination or in place of conventional pay-for-performance efforts.

The Influence of Cognitive Impairment, Special Care Unit Placement, and Nursing Facility Characteristics on Resident Quality of Life

Minnesotas Performance-Based Incentive Payment Program uses a collaborative, provider-initiated approach to nursing home quality improvement: up-front funding of evidence-based projects selected and designed by participating facilities, with accountable performance targets. During the first 4 rounds of funding (2007-10), 66 projects were launched at 174 facilities. Using a composite quality measure representing multiple dimensions of clinical care, we found that facilities participating during this period exhibited significantly greater gains than did nonparticipating facilities, in both targeted areas and overall quality, and maintained their quality advantage after project completion. Participating and nonparticipating facilities were similar at baseline with respect to quality scores and improvement trends, as well as acuity-adjusted payment, operating costs, and nurse staffing. Although self-selection precludes firm conclusions regarding the programs impacts, early findings indicate that the program shows promise for incentivizing nursing home quality improvement, both in facility-identified areas of concern and overall.

Facility and market factors affecting transitions from nursing home to community

Objectives: We examined the (a) influence of nursing facility characteristics on resident quality of life and (b) the impact of cognitive impairment and residence on a dementia special care unit(SCU) on QOL after controlling for resident and facility characteristics. Method: Multilevel models (resident and facility) were estimated for residents with and without cognitive impairment on conventional units and dementia SCU. Data came from the 2007 Minnesota Nursing Home Resident Quality of Life and Consumer Satisfaction Survey (N = 13,983). Results: Level of resident CI was negatively related to QOL, although residing on a dementia SCU was positively related to QOL. Certified Nursing Assistant and activity personnel hours per resident day had a positive relationship with resident QOL. Discussion: Our results highlight the need to ensure adequate levels of paraprofessional direct care staff and the availability of dementia-focused (SCU)s despite current constraints on long-term care funding.

Identifying Consistent and Coherent Dimensions of Nursing Home Quality: Exploratory Factor Analysis of Quality Indicators

BackgroundResearch into nursing home transitions has given limited attention to the facility or community contexts. ObjectiveTo identify facility and market factors affecting transitions of nursing home residents back to the community. Research DesignMultilevel models were used to estimate effects of facility and market factors on facility-level community discharge rates after controlling for resident demographic, health, and functional conditions. Facility discharge rates were adjusted using Empirical Bayes estimation. SubjectsAnnual cohort of first-time admissions (N=24,648) to 378 Minnesota nursing facilities in 75 nursing home markets from July 2005 to June 2006. MeasuresCommunity discharge within 90 days of admission; facility occupancy, payer mix, ownership, case-mix acuity, size, admissions from hospitals, nurse staffing level, and proportion of admissions preferring or having support to return to the community; and nursing market population size, average occupancy, market concentration, and availability of home and community-based services. ResultsRates of community discharge (Empirical Bayes residual) were highest in facilities with more residents preferring community discharge, more Medicare days, higher nurse staffing levels, and higher occupancy. In addition, facilities had higher community discharge rates if they were located in markets with a greater ratio of home and community-based services recipients to nursing home residents and with larger populations. ConclusionsState Medicaid programs should undertake system-level interventions that encourage nursing facilities to reduce unused bed capacity, balance the mix of payers, invest in nurse staffing, and take other steps to promote community discharges. In addition, states should increase home and community-based services, particularly in markets with low community discharge rates.

Future Development of Nursing Home Quality Indicators

There is a general belief that the markers of nursing home quality do not aggregate easily. Identifying consistent and coherent dimensions of quality that usefully summarize the multiplicity of nursing home quality measures is an important goal. It would simplify interpretation and help consumers, their families and advocates to choose nursing facilities.