Improving End-of-Life Care for
Nursing Home Residents:
Approaching the Issue Side-ways
Mary Jane Koren, M.D., MPH
Vice-President, LTC Quality Improvement
The Commonwealth Fund
mjk@cmwf.org
www.commonwealthfund.org
GIH Annual Conference
3/14/13
Why This is an Issue for
Nursing Home Residents
• 88% are over age 65 and 45% over 85
1
• Average length of stay is 835 days
2
• Many are in their last years of life - 35%
mortality rate for NH residents
3
1 Table
12, CDC National Nursing Home Survey 2004, Current Resident Tables, http://www.cdc.gov/nchs/nnhs/resident_tables_estimates.htm
12, CDC National Nursing Home Survey 2004, Current Resident Tables, http://www.cdc.gov/nchs/nnhs/resident_tables_estimates.htm
3 Individuals age 65 or older; from ‘Who Stays and Who Goes Home: Using National Data on Nursing Home Discharges and Long-Stay Residents
to Draw Implications for Nursing Home Transition Programs’’ Judy Kaspar, Kaiser Commission on Medicaid and the Uninsured, August 2005,
using CDC National Nursing Home Survey 1999.
2 Table
Putting a face on the problem
• A 75 year-old man with heart failure and increasing dyspnea
who is inadvertently transferred to a hospital because his
preferences for “comfort care” are not adequately documented.
• An 89 year-old woman with dementia whose family is unaware
of her care plan and uncertain whether the nursing home staff
or the hospice is primarily responsible.
• A 72 year-old man with colon cancer and uncontrolled pain
whose family insists on a hospital transfer in order to obtain pain
management
• An 84 year-old woman with metastatic lung cancer who receives
no personal care on several days because hospice staff believe
that nursing home staff are responsible and vice versa.*
* These vignettes are courtesy of Dr. David Caserett, U. Penn.
Three Fund projects that aim to
address these problems
• The Intervention to Reduce Acute Care Transfers or
INTERACT program (PI: Joseph Ouslander/Florida
Atlantic University)
• Advancing Excellence: The Nursing Home Quality
Campaign (PI: Cheryl Phillips/Leading Age)
• Identifying Best Practices in the Care of Seriously Ill
Nursing Home Residents (PI: David Casarett/ University
of Pennsylvania)
A quality improvement program
designed to improve the care of nursing
home residents with acute changes in
condition
Communication Tools
Decision Support Tools
Advance Care Planning Tools
Quality Improvement Tools
The INTERACT II
tools are meant to
be used together in
your daily work in
the nursing home
What is Advancing Excellence?
• An ongoing quality improvement campaign to
help nursing homes (NHs) become high
performance organizations
• Voluntary (>58% of all U.S. NHs, or 9,070
facilities registered)
• Based on measureable improvement of
meaningful goals
• Recognizes staff and consumers as important
and valued partners
www.nhqualitycampaign.org
7
AE Goals with roll-out dates
Hospitalizations
Staff Stability
Pressure Ulcers
November 2012
November 2012
November 2012
Medications
Consistent
Assignment
Infections
(Antipsychotic
use) March 2013
Mobility
February 2013
November 2012
Person-Centered
Care and
Decision-Making
March 2013
8
March 2013
Pain
Management
December 2012
Person-Centered Care Planning and
Decision Making
“In person-centered care, staff places a premium on active
listening and observing, so staff can adapt to each
resident’s changing needs regardless of cognitive abilities.”
• Keeps the person at the center of the care planning and
decision-making process.
• Promotes choice, purpose and meaning in daily life.
• Achieves highest practicable level of physical, mental and
psychosocial well-being.
• Care plans are revised on ongoing basis to reflect a person’s
changing preferences.
• Staff adapts to each resident’s changing preferences
regardless of cognitive abilities.
10
Person-Centered Care Planning and
Decision Making - Measures
• Consistency of Resident Experience with Expressed
Resident Preferences: Congruence of resident-reported
"importance" vs "frequency" of activities identified in
MDS Section F
• Participation in Care Planning: Composite score based
on resident, family & direct care staff participation in
care planning process
11
Safely Reducing Hospitalizations
“Allows residents with acute changes in medical condition
to remain in nursing home with staff who know them and
can safely care for them without compromising residents’
well-being or wishes.”
• Avoids trauma and other risks associated with
hospitalization.
• Prepares facilities to be able to provide needed care
• Increases communication between hospital and
nursing home to ensure continuity of care and improve
care transitions.
12
Hospitalizations: Measures
Outcome measures:
• 30-day Readmission Rate as percent of those admitted
from a hospital during the month
• Hospital Admission Rate per 1000 resident days this month
• Rate of Transfers to ER Only per 1000 resident days this
month
• Rate of Transfers Resulting in Observation Stay per 1000
resident days this month
Includes “process measures” to help with root cause analysis,
e.g. asks “Was an advanced care plan in place? Was it
reviewed prior to the transfer?”
13
Example Reports Produced
Identifying Best Practices in the Care of
Seriously Ill Nursing Home Residents:
A Positive Deviance Approach
One year pilot project led by Dr David Casarett, Associate
Professor, University of Pennsylvania
• The ultimate aim is to develop a quality improvement
program and toolkit (analogous to INTERACT for hospital
transfers) that will help hospices and nursing homes work
together to ensure that residents can get the care that they
need in the setting of their choice.
• The goal for this project is to identify best hospice practices
that can help NHs provide high-quality care for residents with
advanced illness and/or at the end of life, without resorting to
transfers either to a hospice unit or to a hospital.
Methods
The team has used the CHOICE1’s research network along with a national
dataset of FEHC2 scores to identify 3 hospices whose partnerships with nursing
homes have achieved:
• Rates of transfers from nursing home to hospital in the last week of life
that are less than 5%; AND
• FEHC results for hospice nursing home residents that are in the top 10%
nationally (compared to approximately 1300 hospices that contribute
FEHC data to the national NHPCO dataset).
Using these 3 high-performing hospices, the team will identify potential best
practices in 3 sequential steps:
- Preliminary telephone interviews,
- An in-depth “failure analysis” of those residents who were transferred either
to a hospital or inpatient hospice unit, and
- Site visits to look at structures and processes of care, organizational culture
with regard to transfers and communication/coordination processes.
1
CHOICE is the Coalition of Hospices Organized to Investigate Comparative Effectiveness that comprises 14
hospices caring for approximately 12,000 patients.
2 Family Evaluation of Hospice Care
Products
Products from this pilot project will include:
• 3-5 best practices that are associated with the dual outcomes
of excellent family perceptions of care together with low rates
of transfers. These best practices will be the basis for a quality
improvement collaborative leveraging CHOICE’s electronic
health record data to promote rapid improved performance;
• A set of 5-10 key lessons for the families of nursing home
residents receiving hospice care, which will be made available
in a brochure for families for CHOICE hospices, Institute clients,
and other hospices and nursing homes by request; and
• Online educational training in collaboration with the Suncoast
Institute, a nonprofit hospice education foundation affiliated
with Suncoast Hospice, one of the CHOICE member hospices.
Discussion
• Does your foundation currently have a focus on this topic or is it
integrated in some way into your existing work? If so, tell us about
what are you supporting?
• When prospecting for new work, is planning for or improving the
end of peoples’ lives being considered as a focus area by your
foundation?
• If not, have you thought about how to integrate into existing areas
of focus? Any success or challenges?
• Foundations have played an important part in the past in this area
but much still needs to be done.
• Are there lessons we should consider to enhance effectiveness?
• Has the environment changed in such a way that work in this
area will be seen as particularly useful or timely?
• Other?