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3 Quality Measurement and Quality Improvement
Pages 89-144

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From page 89...
... . This chapter provides an overview of quality measurement in the nursing home setting and describes how such measures can, in turn, be used to improve the quality of care for residents of nursing homes.
From page 90...
... However, people often say that they want "high-quality care" or the "best care" instead of care that meets a minimal, fundamentally safe level. This desire to know when nursing homes actually provide high-quality care underlies the need for good measures of quality in nursing homes.
From page 91...
... . The tragedy of the pandemic provides an opportunity for re-envisioning nursing home care using quality measurements to guide those changes.
From page 92...
... More importantly, quality data will show if those changes have produced measurable improvements for the residents of nursing homes and their families or significant others in areas that are important to them. Any system of quality measurement needs to support quality improvement through comparative reports, often designed as feedback reports.
From page 93...
... The 1986 IOM report Improving the Quality of Care in Nursing Homes laid the foundation for the evolution of quality measurement based on resident assessment information, noting that a "system to obtain standardized data on residents is essential" (IOM, 1986, p.
From page 94...
... . CARE COMPARE3 AND THE CMS FIVE-STAR RATING SYSTEM In the late 1990s, federally mandated public reporting began for nursing homes on Nursing Home Compare, a web-based report card for certified nursing homes.
From page 95...
... Calculation of the Star Rating Calculating the overall star rating begins with assigning ratings in the inspections domain, based on the in-state distribution of inspection scores, divided into percentiles. Nursing homes can then gain one or two extra stars by performing well in the staffing or quality measures domains, or they can lose up to two stars by performing poorly in them.
From page 96...
... receive fewer points than those with more potential for improvement. There have also been multiple changes in how the total quality measure scores are assigned to star ratings, as keeping constant thresholds would result in an increasing number of nursing homes receiving four or five stars in this domain.
From page 97...
... . As shown in Table 3-3, many nursing homes' subsequent ratings fell (Bose and Wilson, 2019; Reape, 2019)
From page 98...
... Risk Adjustment One concern regarding the measures included in Care Compare is inadequate risk adjustment -- that is, a failure to account for the fact that some nursing homes serve a sicker population than others, which makes it difficult to perform as well on measures of quality. Many providers believe their facilities' ratings misrepresent the quality of the care they provide due inadequate risk adjustment (Kim et al., 2014; Perraillon et al., 2019a)
From page 99...
... . Second, nursing homes with higher star ratings have lower rates of hospital admissions or readmissions and mortality (Cornell et al., 2019; Unroe et al., 2012)
From page 100...
... However, more work is needed in regards to the individual measures including better approaches to risk adjustment, improved correlation among measures that should be correlated, and refinement of the composite measure to better distinguish modest increments in quality. Relationship between the Five-Star Rating and COVID-19 Limited, but mixed, evidence exists on the relationship between COVID-19 cases among residents in nursing homes and the home's quality ratings.
From page 101...
... questioned whether the improved performance shown by providers on Care Compare measures truly reflects improvements in residents' outcomes. Part of the challenge of the current rating system is that both staffing and quality measures are based on selfreported data from nursing homes, which could allow for "gaming" where nursing homes could falsify their data or use questionable strategies to improve scores.
From page 102...
... . Similarly, a study of the early years of the five-star rating system showed that 71 percent of nursing homes had four or five stars in the quality measures domain while only 34.1 percent of nursing homes had four or five stars in the inspections domain (Abt Associates Inc., 2014)
From page 103...
... , staff satisfaction, staff employment arrangements, health information technology adoption and interoperability, and the nursing home's financial performance. Palliative and End-of-Life Care Measures Nursing homes often serve as the final home for many residents prior to death; currently, about 25 percent of Medicare beneficiaries die in a nursing home (Teno et al., 2018)
From page 104...
... . To date, the quality of end-of-life care in nursing homes is consistently measured and reported by the Veterans Health Administration's community living centers.
From page 105...
... ; • Measuring outcomes (Edelen and Saliba, 2010; NQF, 2013; Saliba et al., 2012) ; and • Assigning relative values to quality measures (Weimer et al., 2019)
From page 106...
... . Design Considerations Several important design principles need to be considered in efforts to systematically assess and report on the experience of residents in nursing homes.
From page 107...
... Under a contract from CMS, researchers developed and tested a survey to measure nursing home resident-reported QOL in order to determine the psychosocial domains that were absent or not sufficiently emphasized in the MDS (Kane et al., 2003, 2004)
From page 108...
... . Nursing Home CAHPS CAHPS, with support from CMS, developed three "experience of care" surveys, available in English and Spanish, for nursing homes: the Long-Stay Resident Survey, the Discharged Resident Survey (for short-stay patients)
From page 109...
... . However, not implementing CAHPS in nursing homes when the surveys are carried out in other health care settings disadvantages nursing home residents and families in preventing their ability to provide feedback about their care experiences, and to use such information to make informed decisions when choosing a nursing home.
From page 110...
... In Michigan, nursing homes can receive incentive payments for submitting resident satisfaction surveys, though the exact design and content of those surveys is determined by the facility or chain (Michigan DHHS, 2021a)
From page 111...
... . These surveys are administered annually and are also part of the Minnesota Performance-Based Incentive Program for nursing home quality improvement (Kane et al., 2007)
From page 112...
... to oversee the quality of care delivered by health care organizations to Medicare beneficiaries, including those in nursing homes. In 2002, these programs were renamed as Quality Improvement Organizations (QIOs)
From page 113...
... FEDERAL INITIATIVES FOR QUALITY IMPROVEMENT The federal government has played a key role in improving the quality of care in nursing homes. Notable efforts include implementation of quality assurance and performance improvement (QAPI)
From page 114...
... . CMS oversees several quality improvement initiatives for nursing homes, but QAPI is meant to be ongoing and more comprehensive, so enrolling in another initiative does not necessarily mean a nursing home is meeting QAPI regulations.
From page 115...
... . The National Nursing Home Quality Improvement Campaign The National Nursing Home Quality Improvement Campaign, which began in 2006 as the Advancing Excellence in America's Nursing Homes Campaign, provides long-term care providers, consumers, advocates, and quality improvement professionals with freely accessible, evidence-based resources to support quality improvement activities (National Consumer Voice, 2021)
From page 116...
... . Additionally, the nurses focused on improving care processes and communication among providers using INTERACT and assisted in training staff on how to use quality improvement methods to improve all key aspects of care delivery (e.g., nutrition, hydration, mobility, communication, end-of-life care planning)
From page 117...
... Academic–Provider Partnerships Many targeted quality improvement efforts in nursing homes focus on such topics as pressure ulcers, falls, antibiotic use, pain, palliative care, and hospital transfers (Rantz et al., 2009, 2012a, 2012b; Sloane et al., 2020)
From page 118...
... . The Arkansas Coalition for Nursing Home Excellence The Arkansas program was a broad coalition of nursing home organizations, state survey representatives, academics specializing in geriatrics, the Arkansas ombudsman, and advocates, all focusing on efforts to improve quality and support culture change in the state's nursing homes.
From page 119...
... Teaching Nursing Homes In the 1980s the National Institute on Aging and the Robert Wood Johnson Foundation funded teaching nursing home models that linked nursing homes, nursing programs, and academic medicine (Mezey et al., 2008)
From page 120...
... . The summit participants saw value in teaching nursing homes for interdisciplinary team training, faculty development, and enhancing the educating and credentialing of nursing home staff.
From page 121...
... and provided culture change training and curriculum from The Eden Alternative12 to nursing home staff as part of a quality improvement initiative. The participating nursing homes admitted 12 For more information, see https://www.edenalt.org (accessed November 16, 2021)
From page 122...
... While these projects have not been fully evaluated, they may provide insight as to how focusing on person-centered care can lead to demonstrable changes in quality. OTHER APPROACHES TO QUALITY IMPROVEMENT In addition to specific efforts at the federal, state, and local levels, other approaches have been used to improve the quality of care in nursing homes.
From page 123...
... . For example, one study of instituting quality improvement methods in nursing homes identified "readiness indicators" among those that were most likely to improve, including • A leadership team (e.g., nursing home administrator, director of nursing)
From page 124...
... 451) The Value of Technical Assistance in Nursing Homes The examples of national, state, and local approaches to quality improvement in nursing homes discussed earlier in this chapter all have their foundation in assisting workers to increase their knowledge, skills, and capacity to deliver up-to-date, necessary care.
From page 125...
... . When some nursing homes are not ready to operationalize quality improvement initiatives but others are, technical assistance programs need to consider readiness in prioritizing their efforts.
From page 126...
... . COORDINATED EFFORTS DURING THE COVID-19 PANDEMIC While not framed as quality improvement efforts, several initiatives during the COVID-19 pandemic were intended to assist nursing homes with infection control and prevention issues.
From page 127...
... . AHRQ and the Institute for Healthcare Improvement partnered with Project ECHO to create the AHRQ– ECHO National Nursing Home COVID-19 Action Network, which offers quality improvement training programs for CMS-certified nursing homes aimed at stopping the spread of COVID-19 (AHRQ, 2021)
From page 128...
... • Obtaining residents' assessment of their care experience becomes even more important in the nursing home setting, where residents have high levels of support needs and rely on the nursing home staff and environment to meet their needs on a continuing basis for weeks, months, or even years. • Not implementing surveys of resident and family satisfaction and experience in nursing homes disadvantages nursing home residents and families from providing feedback about their care experiences, and making informed decisions when choosing a nursing home.
From page 129...
... • Quality improvement cannot be accomplished by making one or two staff members accountable for the process; effective quality improvement initiatives need team effort and a persistent, long-term commitment to examining all aspects of the nursing home operation. Quality and Disparities • Nursing homes in low-income neighborhoods, with high numbers of African American and other minority residents, and nursing homes primarily serve Medicaid residents have lower quality of care ratings and lower direct-care staffing.
From page 130...
... nursing home quality improvement collaborative. Nursing & Health Sciences 16(3)
From page 131...
... 2019. Nursing homes' star ratings significantly impacted by new CMS updates.
From page 132...
... 2017b. Data show National Partnership to Improve Dementia care achieves goals to reduce unnecessary antipsychotic medications in nursing homes.
From page 133...
... 2016. Pioneer ing a nursing home quality improvement learning collaborative: A case study of method and lessons learned.
From page 134...
... 2019. National Nursing Home Quality Improvement Campaign changes.
From page 135...
... 2020. Quality concerns in nursing homes that serve large proportions of residents with serious mental illness.
From page 136...
... 2015. What the 5-star rating system changes mean for nursing homes.
From page 137...
... nursing homes. Journal of the American Geriatrics Society 68(11)
From page 138...
... 2008. Does risk adjustment of the CMS quality measures for nursing homes matter?
From page 139...
... 2011. Interventions to reduce hospitalizations from nursing homes: Evaluation of the INTERACT II collaborative quality improvement project.
From page 140...
... 2012b. Challenges of using quality improvement methods in nursing homes that "need improvement." Journal of the American Medical Directors Association 13(8)
From page 141...
... 1995. Quality of care in teach ing nursing homes: Findings and implications.
From page 142...
... 2014. Medicare star ratings allow nursing homes to game the system.
From page 143...
... 2010. Advancing nursing home quality through quality improvement itself.
From page 144...
... 2013. Quality improvement under Nursing Home Compare: The association between changes in process and outcome measures.


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