Improving the Quality of Long-Term Care (2001) / Chapter Skim
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Information Systems for Monitoring Quality
Information Systems for Monitoring Quality
Pages 110-134
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From page 110... ...
Over the last decade, the long-term care field has moved to develop and implement uniform, universally required individual level data collection systems that can form the basis for measures of quality performance. The 1986 Institute of Medicine report recommended a uniform minimum data set for nursing home resident assessment.
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From page 111... ...
This chapter discusses the current state of the major information systems in long-term care, their implementation status, their reliability and validity, and their application for clinical assessment, quality monitoring, and reimbursement. The discussion primarily focuses on the federal systems that provide basic information on monitoring compliance with regulations and on the quality of long-term care offered by nursing homes and home health agencies.
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From page 112... ...
At the time of state surveys, nursing facilities complete information on their facility characteristics, resident characteristics, and staffing on HCFA forms. Staffing data include the number of full-time equivalent positions in the facility employees or contract workers over the previous 14 days.
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From page 113... ...
. In addition, several commercial firms have Internet-based systems that use OSCAR data in ranking nursing homes on the basis of their designated deficien1The site includes selected facility characteristics, resident characteristics, and deficiencies.
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From page 114... ...
Moreover, the data collected on resident characteristics are not audited by state surveyors. OSCAR data on staffing also are not audited by state surveyors, and analyses of staff-to-resident ratios show some facilities reporting data that are likely to be inaccurate (Harrington et al., 1998a)
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From page 115... ...
HCFA is working to improve the complaint investigation and reporting system. THE RESIDENT ASSESSMENT INSTRUMENT AND THE MINIMUM DATA SET FOR NURSING HOMES An important requirement of the nursing home reforms in the Omnibus Budget Reconciliation Act of 1987 (OBRA 87)
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From page 116... ...
The final version has 15 domains: cognitive patterns, communication and hearing patterns, vision patterns, physical functioning and structural problems, continence, psychosocial well-being, mood and behavior patterns, activity pursuit patterns, disease diagnoses, health conditions, nutritional status, oral and dental status, skin condition, medication use, and special treatments and procedures (Morris et al., 1990~. Extensive testing and analysis of the MDS has been undertaken to examine the reliability, validity, and sensitivity of individual MDS data elements, as well as composite scales constructed from these data elements.
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From page 117... ...
Concerns About Use of the MDS The rationale for using the MDS to obtain data related to the quality of care is that the information collected is integral to the care process, forming the basis for the individualized care plan. Furthermore, state regulators are supposed to check the internal consistency of the MDS data in a resident's chart and their conformance to the picture of the resident as described in the medical chart and in nursing notes.
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From page 118... ...
One can speculate that as with the effect of the hospital prospective payment system on coding practices for hospital discharge diagnoses, higher payment rates for care of more seriously ill nursing home residents potentially could create incentives for nursing homes to "upcode" that might distort the MDS data. HCFA is conscious of this possibility and is currently pursuing the development of automated programs to monitor the accuracy and consistency of MDS data.
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From page 119... ...
In addition, HCFA has commissioned the development of a new set of facility performance measures that will supplement MDS data with data from residents and their families that capture their values, preferences, and satisfaction with the care received. These facility-level quality indicators can be valuable for targeting internal quality improvement activities by nursing facilities.
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From page 120... ...
HCFA's vision of this process is that the MDS data constitute the basis for directing survey and certification activities, setting payment levels, and developing information about the quality of long-term care providers to consumers and purchasers. OUTCOME AND ASSESSMENT INFORMATION SET FOR HOME HEALTH CARE The perceived utility of the nursing home resident assessment system, particularly its use in developing a Medicare casemix reimbursement method based on resident data, has prompted HCFA to mandate the introduction of a similar data system for Medicare-certified home health care agencies.
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From page 121... ...
. During the development of OASIS, several different reports were designed, tested, and refined by having home health agencies collect, computerize, and transmit OASIS data, and then use the resulting reports for clinical and administrative decision making, and, most importantly, quality improvement (Shaughnessy et al., 1998a)
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From page 122... ...
Some of the applications of OASIS data that serve these various groups include the following: evaluating outcomes of home health care at the agency level; assessing quality of care across multiple provider settings; adjusting prospective payment rates for casemix differences; determining the impacts of payment and regulatory policies on home health care casemix and outcomes; detecting discrimination and access barriers to home health care; increasing efficiencies and effectiveness of Medicare and Medicaid survey and certification; facilitating voluntary accreditation; informing consumers; and marketing successful home health care programs. OASIS is being studied for use in Medicare prospective payment systems.
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From page 123... ...
Residents of nursing homes are generally more disabled than people using home health care services, and nursing home residents may, therefore, be at greater risk for certain adverse health outcomes regardless of the quality of care they receive. Even within a single care setting, the populations served by some providers may have more serious health problems than those served by other providers.
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From page 124... ...
Regulated entirely by states under an often confusing array of labels, these facilities vary widely in terms of their staffing levels and staff training, and the impairment levels and medical and nursing care needs of the population they serve (Mor et al., 1986; Spore et al., 1996~. Several states have developed assessment systems for use in such residential care settings drawing on the RAI and MDS for nursing homes for assessing key functional status items.
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From page 125... ...
Assessment instruments vary from state to state but typically include functional status, a summary of health status, cognitive status, affective status (especially depression) , and social well-being including social and economic resources.
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From page 126... ...
Integrated Assessment Instruments for Long-Term Care Several states have begun to restructure their long-term care assessment instruments to be more compatible with HCFA'S MDS because of the increasing proportion of the population that moves into and out of nursing homes, returning home in need of other long-term care services. Compatibility of the assessment instruments might ease the care planning process once patients are discharged into the community.
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From page 127... ...
Recommendation 4.1: The committee recommends that the Department of Health and Human Services and other appropriate organizations fund scientifically sound research toward further development of quality assessment instruments that can be used appropriately across the different long-term care settings and with different population groups. The committee notes that the Agency for Healthcare Research and Quality has initiated some efforts in this area.
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From page 128... ...
Although much of the work on measuring quality of life and consumer satisfaction with care has focused on primary and acute care, some efforts are being made to develop measures of consumer and family perspectives on quality of care appropriate for long-term care. For example, the major provider associations have developed data sets that they recommend to their members interested in assessing residents' and family members' satisfaction with care.
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From page 129... ...
Some of the initial work on instruments for obtaining consumercentered reports on medical care in acute care situations was done by Cleary and colleagues (1991~. As shown in Figure 4.1, consumer-centered reports either ask a patient a factual question (e.g., Did someone speak to you about treatment for your concern?
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From page 130... ...
Another important concern is the reluctance of consumers to discuss quality of medical care, even to an anonymous interviewer over the phone (Vouri, 1987~. Persons receiving long-term care services may feel especially vulnerable because they are dependent on providers for basic needs.
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From page 131... ...
Social desirability and acquiescent response biases are prevalent among dependent groups, such as the institutionalized elderly, in part due to fear of repercussions from caregivers (La Monica et al., 1986~. Nursing home residents reported high levels of satisfaction with care at the same time that interviewer observations and resident's open-ended comments suggest dissatisfaction and a reluctance to criticize nursing home staff (Pearson et al., 1993)
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From page 132... ...
Bias in Assessments. The cognitive impairments prevalent in long-term care populations, as well as some physical impairments, make the collection and interpretation of consumer information more problematic than in some other health care areas.
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From page 133... ...
One of the health care industry standards for quality assessment, the Health Plan Employer Data and Information Set (also known as HEDIS) , has only limited numbers of measures addressing quality of care for children and almost none addressing children with chronic conditions (Kuhlthau et al., 1998~.
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From page 134... ...
Despite the potential weaknesses inherent in using staff-reported data, such data are currently more readily available than consumerreported data for both the institutional and the home health arena. A substantial amount of research is devoted to the application of these individual-level data to aggregated performance measures.
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