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 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 Overview of Minnesota NH Quality

Assessment System Applications

Public Reporting – NH Report Card Quality-Based Payment Incentives Quality Improvement

Responses by consumers and providers Future Development

Quality Assessment System

Goals Develop effective measures of nursing home

quality Apply the measures

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 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 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 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 Based on MDS assessments 24 QIs representing care processes and outcomes Dimensions (# of QIs)

Psychosocial (4) Accidents (2)

Restraints (1) Nutrition (1)

Continence (6) Pain (1)

Infections (2) Skin Care (2)

Functioning (5) Drugs (1)

Quality of Life & Resident Satisfaction 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) Autonomy (5)Environmental (4) Individuality (3)Privacy (3) Security (3)Dignity (4) Relationships (3)Meaningful Activity (3) Satisfaction with Care (7)Food Enjoyment (3) Mood (9)

Statistical Adjustment QIs risk adjusters

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)

QoL/RS score risk adjusters 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 ScoreMeasure Max PointsStaffing level (HPRD) 10Staff retention 20Use of pool staff 5QIs 35QoL/RS 20Survey deficiencies 10Total 100

Quality Enhancement Initiatives

Nursing Home Report Card

Transparency to consumers 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 ScoreQuality Score Bonus (% of PD Rate)

0-40 0.0%41-99 0.1% to 2.3%100 2.4%

Quality score also used to adjust Medicaid cost limits Reduces rates for high cost & low quality facilities Increases rates for low cost and high quality facilities

Facility Quality Reports Detailed QI and QoL/RS reports sent periodically to

each facility 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 Meaningful activities Skin care Psychotropic medications Pain management

Performance-Based Incentives Facilities propose a new program to:

Improve quality outcomes Increase efficiency Re-balance long-term care (e.g., community discharges)

Facilities receive a 5% rate increase IF they: 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 Use of Report Card

26,000 “hits” the first week 1,800/month since then

Consumer feedback on Report Card 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 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

Trends in QI RatesTotal Improvement in Risk-Adjusted QIs (July 2004 - Dec 2006)

-0.01

0.00

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08Decline Improvement

Performance-Based Incentive Projects 155 applications received, 19 projects and 32

facilities approved in first year Focus of projects:

Culture change Wireless call systems

QoL for dementia residents Employee retention

Pressure ulcers Pain management

Exercise CHF

Future Development

Expand Quality Measures 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 Track quality measures over time

Trends in QI rates (quarterly) Changes in annual QoL/RS scores

Drill down capability Dimension scores Individual survey items or QIs

Decision support tools

Build a Business Case for Quality 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 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 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