Using Public Information to
Improve Nursing Home Quality
in Minnesota
Academy Health Annual Research Meeting, June 2007
Greg Arling, Ph.D.
Indiana University Center for Health Policy and Center
for Aging Research
Purpose
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Address issues of nursing home quality
measurement and application
Describe how these issues have been dealt
with in the Minnesota NH Quality Assessment
System
Suggest ways for more effective use of
information about nursing home quality
Topics
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Overview of Minnesota NH Quality
Assessment System
Applications
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Public Reporting – NH Report Card
Quality-Based Payment Incentives
Quality Improvement
Responses by consumers and providers
Future Development
Quality Assessment
System
Goals
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Develop effective measures of nursing home
quality
Apply the measures
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Informing consumer decisions
Guiding nursing home quality improvement
Offering financial incentives for better care
Engage consumers and providers in efforts to
achieve better quality
Guiding Principles
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Comprehensive – contains process and outcome
indicators, quality of care and quality of life
Relevant – taps dimensions of care that are important
to consumers and providers
Credible – has strong research base
Understandable – effectively presented to different
audiences
Actionable – informs consumer decision-making and
provider quality improvement
Transparent – methods are well described, in the
public domain, and open to scrutiny by stakeholders
and the research community
Measurement and Application
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Quality measurement and application should
proceed iteratively and be mutually
reinforcing
Application of quality information gives
providers a greater stake in data collection
(can also introduce bias)
Reporting systems encourage provider and
other stakeholder feedback which can serve as
an accuracy check and raise important
analytical issues
Guiding Principles Example: Consumer Reports
Science and Uncertainty in Everyday Life
Comprehensive Quality Measures
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Direct care staffing level (salary and CM
adjusted HPRD)
Direct care staff retention rate
Use of pool staff
Quality Indicators (QI)
Quality of Life and Resident Satisfaction
(QoL/RS) Survey
State Inspection (NH Survey) Results
MN Nursing Home QIs
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Based on MDS assessments
24 QIs representing care processes and outcomes
Dimensions (# of QIs)
Psychosocial (4)
Restraints (1)
Continence (6)
Infections (2)
Functioning (5)
Accidents (2)
Nutrition (1)
Pain (1)
Skin Care (2)
Drugs (1)
Quality of Life & Resident Satisfaction
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Annual survey carried out by professional survey
organization involving face-to-face interviews with
14,000+ NH residents
53 QoL and other items adapted from established
instruments
Dimensions (# of survey items)
Comfort (4)
Environmental (4)
Privacy (3)
Dignity (4)
Meaningful Activity (3)
Food Enjoyment (3)
Autonomy (5)
Individuality (3)
Security (3)
Relationships (3)
Satisfaction with Care (7)
Mood (9)
Statistical Adjustment
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QIs risk adjusters
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QoL/RS score risk adjusters
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Age and gender
Diagnoses (e.g, stroke, hip fracture, end-stage)
functional status (e.g., ADL, cognitive status)
health conditions (e.g., hemiplegia, sensory loss)
Resident gender, ADL, age, cognitive status & LOS
Facility location and average LOS
Empirical Bayes estimates of facility QI or QoL/RS
rates
Quality Scores - Facility
Distributions
Summary Quality Score
Measure
Staffing level (HPRD)
Staff retention
Use of pool staff
QIs
QoL/RS
Survey deficiencies
Total
Max Points
10
20
5
35
20
10
100
Quality Enhancement
Initiatives
Nursing Home Report Card
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Transparency to consumers
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Make better LTC choices
Advocate for care improvement
Provider benchmarking and quality
improvement
Nursing homes selected by geographical areas
Facility assigned 1-5 stars on each of seven
dimensions
Quality Adjustment to Payment Rate

Bonus added annually to Medicaid per diem
payment rate -- proportional to Quality Score
Quality Score
0-40
41-99
100

Bonus (% of PD Rate)
0.0%
0.1% to 2.3%
2.4%
Quality score also used to adjust Medicaid cost
limits
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Reduces rates for high cost & low quality facilities
Increases rates for low cost and high quality facilities
Facility Quality Reports
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Detailed QI and QoL/RS reports sent periodically to
each facility
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Most current QI and QoL/RS results
Tracking of QI or QoL/RS rates over time
Special training programs on priority areas identified
through quality reports
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Meaningful activities
Skin care
Psychotropic medications
Pain management
Performance-Based Incentives
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Facilities propose a new program to:
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Facilities receive a 5% rate increase IF they:
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Improve quality outcomes
Increase efficiency
Re-balance long-term care (e.g., community discharges)
Implement the program effectively
Achieve outcome objectives
Most projects linked to improvement in QIs,
QoL/RS, and other quality measures
Response to the System
Consumer Response
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Use of Report Card
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26,000 “hits” the first week
1,800/month since then
Consumer feedback on Report Card
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87% rate “easy” or “pretty easy” to use
55% “definitely” would use in selecting a nursing
home
36% “probably” would use in selecting a nursing
home
Feedback from Report Card Users
(N=108,000)
Quality Dimension
% Giving it Top Priority
Quality of Life/RS
84%
State NH Survey Results
61%
NH Quality Indicators
59%
Staffing Level (HPRD)
38%
Staff Retention
16%
Use of Pool Staff
6%
Provider Response
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Even modest financial incentives have stirred
considerable provider interest
Providers have asked for more frequent and detailed
QI and QoL/RS reports
Providers have been supportive of QI and QoL/RS
risk adjustment with some calling for expanded
adjusters
State-sponsored quality improvement training
programs have been attended by 100’s of nursing
home staff
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Trends in QI Rates
Total Improvement in Risk-Adjusted QIs (July 2004 - Dec 2006)
0.08
0.07
Decline
Improvement
0.06
0.05
0.04
0.03
0.02
0.01
0.00
-0.01
Performance-Based Incentive Projects
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155 applications received, 19 projects and 32
facilities approved in first year
Focus of projects:
Culture change
QoL for dementia residents
Pressure ulcers
Exercise
Wireless call systems
Employee retention
Pain management
CHF
Future Development
Expand Quality Measures
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QI or QoL/RS measures designed specifically
for dementia residents
Post-acute QIs
Family satisfaction survey
Environmental assessments
Measures of community discharge or NH
transition
Refined scoring of NH inspection results
Improve Reporting
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Track quality measures over time
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Drill down capability
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Trends in QI rates (quarterly)
Changes in annual QoL/RS scores
Dimension scores
Individual survey items or QIs
Decision support tools
Build a Business Case for Quality
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Increase quality adjustment of payment rate
 Reward high quality
 Discourage poor quality
Expand funding for Performance-Based
Incentive projects
 Emphasize organizational change and
technology
 Encourage provider collaboration and
diffusion of best practices
Stress Value and Cost-Effectiveness
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Wide variation in nursing home per diem prices &
quality
Information about NH prices and their relationship
to quality is not publicly available
Many consumers are receiving very poor value for
their long-term care dollars
Need to focus on connection between price and
quality – greater value and cost-effectiveness
Continue Research
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Improving validity and reliability of quality
measures
Identifying trends in quality over time
Facilitating consumer decision-making
Understanding organizational and
management practices associated with better
quality
Evaluating quality improvement strategies
Building a business case for better quality
Where we are …
1914 Stutz Bearcat
Where we want to be …
2007 Indy 500 Winner
MN DHS Contact
Valerie Cooke, Project Director
Department of Human Services
Nursing Facility Rates & Policy
PO Box 64973
St. Paul, MN 55164-0973
651-431-2263
valerie.cooke@state.mn.us