Predicting Quality in
Nursing Homes: What
do the Stars Tell Us?
ARIF NAZIR MD, CMD
President, Indiana Medical Directors Association
Assistant Professor, Clinical Medicine
Division of General Internal Medicine & Geriatrics
Department of Medicine
August 20, 2010
My colleagues and Mentors
advice:
• Don’t be too detailed
• Don’t use Geriatric lingo
• Bottom line: “Think of the time when you were
a resident and think of what would you have
want to know about nursing homes”
Objectives:
By the end of this presentation, participants will
be familiar with:
1. Nursing home compare and 5 Star rating
system for nursing home quality
2. Other factors impacting nursing home quality
3. The role of an interdisciplinary team in nursing
home discharges
You are attending this presentation
because:
1. You see (or used to see)
pts in nursing homes
2. You manage nursing
home patients in hospital
3. Neither of above but
interested in the topic
4. Someone said that there
was free lunch
April 8, 2015
Why is this presentation important?
• A significant proportion of older inpatients are
discharged to nursing homes (NHs).
• Not all NHs are similar and offer a wide spectrum of
quality
• Re-hospitalizations: Increasing consequences for
hospitals and nursing homes
• Reimbursement models are evolving with focus on
“bundled payments”
• A third of us will spend some time in a nursing
home!
April 8, 2015
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April 8, 2015
Do you have a loved one in a nursing
facility?
1. Yes
2. No
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April 8, 2015
Regarding Nursing Home Quality
of Care:
1. I have NO
concerns
2. I am concerned
3. I am seriously
concerned
4. Not sure
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April 8, 2015
A Case
• Mrs. Smith an 79 yo AAF with mild
dementia admitted with pneumonia and
intubated in the ICU
• Survives and transferred to monitored
floor but still very weak
• Team assess for discharge options
• Mrs. Smith lived alone with the help from
a daughter and a son who live few miles
away
Case…..cont’d
• Physical therapy recommends a NH
discharge for rehab
• Mrs. Smith agrees BUT wants to:
- ask Aunt Gina who “knows it all”
- stay close to daughters house
• Her son states, “Doc, since I read the
newspaper articles, I am very concerned
about care provided in nursing homes. Can
you make sure that mom goes to the best
facility in the town”
Case…..cont’d
• Social worker provides a list of 6 “decent” NHs
within 5 miles of daughter’s home
• Next day son calls, “Doc, aunt Gina recommends
these two homes, but I need your help to make
the decision”
Happy Meadows
4-STAR Rated Facility
Sloppy Shadows
2 -STAR Rated Facility
April 8, 2015
How should the team respond?
1. Avoid saying much due
to “patient choice act”
2. Help arrange visits to a
couple nursing homes
3. Provide nursing home
websites
4. Provide information on
“Nursing Home
Compare” and other
resources
5. Consult with Aunt Gina
April 8, 2015
I discharge patients to nursing
homes:
1.
2.
3.
4.
Frequently
Sometimes
Rarely
Never
April 8, 2015
Measuring Quality in NHs
• Quality of long-term care is
multidimensional. Ideally it should
include:
– Clinical care issues
– Functional independence
– Current Minimum Data Set records
– Quality of life, and
– Patients’ and families’ satisfaction
Mor V, Berg K, Angelelli J, Gifford D, Morris J, Moore T. The quality of
quality measurement in US nursing homes. Gerontologist
2003;43(Spec No 2):37– 46
Nursing Home Compare
• A CMS website to help consumers choose a NH
• Allows search for a NH by geography (state or
county), by proximity (city or zip code), or by
name.
• Also provides a “Nursing Home Checklist,”
• Provides the 5 Star rating for all facilities in the
nation compared to other state facilities
April 8, 2015
Audience and Nursing Home
Compare
1. I utilized the website
for a loved one
2. I have visited the
website
3. I have only heard of it
4. I just learned about it
April 8, 2015
5 Star rating for Nursing Homes
• Available thru Nursing Home Compare.
• Bell shaped distribution:
- Ten percent 5- star and 20% 1- star
• Ratings aggregate of three sources:
- State survey results.
- Staffing data.
- Quality Measures.
• Limitations
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https://www.cms.gov/CertificationandComplianc/Downloads/usersguide.pdf
5 Star Rating System
State
Survey
Staffing
Quality
Measures
Happy
3 STARS
Meadows
+1
0
4 STARS
Sloppy
4 STARS
Shadows
-1
-1
2 STARS
April 8, 2015
State surveys
April 8, 2015
State survey process
• Carry the heaviest weight in the 5Star ratings
• Unannounced every 9-15 months
• Compares facility to standards in
the Code of Federal
Regulations(CFR)
• A 3-5 surveyor team reviews
records and interviews all parties
as needed.
State survey process
•
•
•
•
Deficiencies or tags cited
“Plan of correction”
Repeat state survey
Publicly reported survey score
for comparison
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April 8, 2015
Indiana Report Card
http://www.in.gov/isdh/reports/QAMIS/ltc/repcard/search.htm
Issues with State Survey process
Government Accountability Office
(GAO; 2004)
1. Depends upon staff competency
2. Complex regulations
3. Inadequate state oversight of the
survey process and predictable
timing of surveys.
4. Variation in deficiency citation
exists between and within states
(Detection bias)
So the State Survey Process is….
- Well structured and quite broad
-
-
in scope
Creates sense of accountability
Helps in quality improvement
process
Provides the consumers a
voice
Scores are publicly available for
comparison
Not a perfect science
April 8, 2015
1. Carry the heaviest
weight in 5 Star ratings
2. Scores are only
available to the facility
3. Detection bias is a
concern
4. Surveyors can interview
anyone they chose
Nursing Home Trivia
Which of the following is FALSE about
the State Surveys:
1. Carry the heaviest
weight in 5 Star ratings
2. Scores are only
available to the facility
3. Detection bias is a
concern
4. Surveyors can interview
anyone they chose
April 8, 2015
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April 8, 2015
NH Environment and Staffing
• NHs are nursing homes and NOT “mini hospitals”
• Administration (owner, administrator, Director of
Nursing)
• Nursing Staff:
- Registered Nurses (RNs)
- Licensed Practical Nurses
- Certified Nurses Assistants
• Other departments
April 8, 2015
Staffing and Quality
• Better nurse staffing ratios lead to better NH
quality of care
• Also higher quality related to:
– Low staff turnover rates
– Director of Nursing retention
– Higher number of Licensed staff (RNs and
LPNs) related to low probability of death and
higher discharge to home
(Fish 2001; Unruh 2004; Schnelle 2004; Bostick 2007)
Appropriate Staffing ratios
• Measured in nursing hours per resident per day
or per week:
National average
17
Indiana Average
15
For 5 STAR facilities
>18
For MAX credit towards 5 STAR rating
28
For BEST results
31.5
Abt Associates Inc. Appropriateness of Minimum Staffing Ratios in Nursing Home: Report to Congress Phase
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II Final. Executive
Phase
II Report . 2001;I(Contract # 500-0062/TO#3)
Quality Measures/Quality
Indicators
April 8, 2015
Quality Measures/Quality Indicators
Type
1963
1987
1999
2009
Structure
55
98
81
104
Process
22
38
48
62
Outcome
-
3
24
24
Slow progression over time and belong to
structure, process and outcomes categories
Current Assessments and Quality Data
• Omnibus Budget Reconciliation Act (OBRA, 87)
• Mandated comprehensive functional
assessments for all residents called Minimum
Data Set (MDS)
• MDS information assists with:
• Reimbursements
• Survey processes
• Generating quality data including indicators
and measures
MDS and Quality Measures
• MDS data summarized into a monthly Quality
Indicator/measures report.
• Quality measures (QMs):
• percentages of residents in the facility with
certain problems
• Help in monitoring/tracking of care
• Reported on Nursing Home Compare website
• Carry least weight towards the 5 Star ratings
April 8, 2015
Sample Quality Measures
(O) Percent of long-stay residents who had a
urinary tract infection/wt loss/ pressure ulcers
(O) Percent of long-Stay residents whose need for
help with daily activities has increased
(O) Percent of long-stay residents who are more
depressed or anxious
(P) Percent of long-stay residents who have/had a
catheter inserted and left in their bladder
(P) Percent of short-stay residents who were
assessed and given pneumococcal vaccination
http://www.medicare.gov/NHCompare/Static/tabHelp.asp?language=English&activ
eTab=4&subTab=1
Limitations of Quality Measures
•
•
•
•
•
Present a cross-section of time
Staff dependent
Less beds may limit statistical power
Higher acuity facilities may have poor scores
Conservative Risk Adjustments:
- Comorbidities
- Cognition
- Type of facility (Mor, Berg et al. 2003)
So the Quality Measures .….
- Are well balanced between processes and
-
outcomes
Provide a cross section of quality
Are used for quality improvement and tracking
care
Are publicly available and “point” to possible
care issues
Have several limitations
April 8, 2015
Nursing Home Trivia
1
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April 8, 2015
Nursing Home Trivia
Which of the following is FALSE:
1. High staffing ratio improve
quality in NHs
2. Quality measures originate
from the state survey scores
3. Indiana NHs lag behind in
their staffing ratios
4. Current quality measures
represent a good balance of
outcome and process
measures
April 8, 2015
Nursing Home Compare Overview
• Offers multiple resources including 5 Star
ratings and NH checklist
• Provides a snapshot of care in a facility
• Facilities that utilize the scores for quality
improvements tend to improve
• A crucial but only an initial tool in the process
of selecting a NH
(Mr. Edward Mortimer)
April 8, 2015
Other Evidence Based predictors of
Quality of Care and Life in NHs
•
•
•
•
•
Medical staffing patterns
Consistent nursing assignments
Profit/ non-for-profit status of the facility
Patient factors and co-morbidities
Patient and/or family Satisfaction
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April 8, 2015
Patient Satisfaction
April 8, 2015
Quality Improvements in NH care
• Use of MDS led to significant decrease in
multiple measures (restraints, ulcers, pain etc)
• CMS supported Advancing Excellence in
Nursing Home Care Campaign
- Multiple successes in Indiana and nationwide
- Achieving targets in multiple quality measures
• Indiana Pressure Ulcer Reduction Initiative
• Culture Change Movement (www.pioneernetwork.com)
Back to Mrs. Smith
1. What steps can the team take to help
transition to a high quality facility
2. How much the team can say?
3. What responsibilities do they have?
For Physicians Who Discharge
Patients to NHs
1. I only write the
discharge orders
2. I also discuss NH
options with the
social worker
3. I use some tool to
assess NH quality
April 8, 2015
Patient Choice in Discharge process
• The Social Security Act guidance:
- Appropriateness of the discharge setting
- The availability of the discharge venue
- Conflict of interest and not steer patients to
a partner facility
• The team is responsibility to assure that
discharge venue is appropriate
Team’s Role in Discharging Mrs. Smith
• Case Management Society of America (CMSA):
Five Ethical Principles of Case Management
- Non-Maleficence: Do no harm
- Beneficence: Look out for patient benefit
- Autonomy: Right to information and self
determination with free and informed consent
- Veracity: Truth telling and obligation to full
honest disclosure
- Justice: Actions are consistent and transparent
April 8, 2015
Team’s Role in Discharging Mrs. Smith
• Inquire preferences
• NH Compare information to help assess
quality (“weather” analogy)
• Discuss other factors that may impact quality
• Advise to visit facility using the NH checklist
http://www.medicare.gov/nursing/checklist.pdf
• Review any patient/ family satisfaction tools
• Hospital relationships
• Provide accurate discharge orders and
summaries
April 8, 2015
So to Summarize…..
1. Nursing Home Compare and 5- star ratings can
help patients in selecting the appropriate NH.
2. 5 Star rating and its components do have
limitations and be used as an initial step in
selecting a nursing home.
3. Several other factors impact quality of NH care
4. Inpatient teams should help patients to select
high quality nursing homes.