Nursing Home Quality Initiatives

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

Working with the National Quality Forum, leading quality and long term care experts, and several nursing home industry stakeholders, the Centers for Medicare and Medicaid Services adopted a set of nursing home quality measures in 2002 and launched the national Nursing Home Quality Initiative to "provide consumers with an additional source of information about the quality of nursing home care by providing a set of MDS-based quality measures on Medicare?s Nursing Home Compare web site."

Purpose of health policy or idea

In the 1987 Omnibus Budget Reconciliation Act (OBRA-87), the U.S. Congress enacted the most far-reaching set of reforms to nursing home regulations since the passage of Medicare and Medicaid in 1965.  Prior to the passage in 1965 of the Medicare and Medicaid programs, there were essentially no federal standards governing nursing home care.  These reforms were passed in response to over a decade of scandals involving provider fraud and poor care, consumer complaints, pressure from advocacy organizations for the elderly, and a host of state and federal reports criticizing both nursing home quality, and industry and government regulatory efforts.  They also responded to a Congressionally mandated study by the Institute of Medicine (IOM) on how to improve nursing home quality, and they embodied most of the IOM's recommendations (C. Hawes, Assuring Nursing Home Quality: The History and Impact of Federal Standards in OBRA-87, The Commonwealth Fund, December 1996). 

In 2001, about three million elderly and disabled received care in the 17,000 Medicare and Medicaid-certified nursing homes.  A little more than half of these were long-term nursing home residents and the others had shorter stays for rehabilitation care after an acute hospitalization.  About seventy-five percent were seventy-five years or older (http://www.cms.hhs.gov/quality/nhqi/Overview.pdf).

As an outgrowth of OBRA-87, the Health Care Financing Administration (now called Centers for Medicare and Medicaid Services) began enforcing new nursing home regulations.  Furthermore, in November 2001 US Department of Health and Human Services Secretary Tommy G. Thompson announced the Nursing Home Quality Initiative to continue to improve quality of care in nursing homes.  Working with leading long term care experts, the National Quality Forum, and a diverse group of nursing home industry stakeholders, CMS adopted a set of nursing home quality measures.  In April 2002, CMS piloted a six-state Nursing Home Quality Initiative demonstration project in Colorado, Florida, Maryland, Ohio, Rhode Island, and Washington.  On November 12, 2002, the Centers for Medicare and Medicaid Services (CMS) rolled out the Nursing Home Quality Initiative (NHQI) nationwide to:

• "provide consumers with an additional source of information about the quality of nursing home care by providing a set of MDS-based quality measures on Medicare's Nursing Home Compare web site", and
• "help providers improve the quality of care for their residents by providing them with complementary clinical resources, quality improvement materials, and assistance from the Quality Improvement Organizations in every state" (http://www.cms.hhs.gov/quality/nhqi/Overview.pdf). 

A core component of the NHQI is to provide the public, specifically consumers and providers, with information on quality measures for all Medicare and Medicaid-certified nursing homes (http://www.medicare.gov/ Nursing/ Overview.asp). 

As part of the NHQI strategy, two innovative and consumer-oriented tools have been developed and implemented to empower consumers and families and improve the quality of care in nursing homes:

• Nursing Home Compare is an interactive tool available on the CMS website that allows the elderly and their families to access comparison information about nursing homes, including detailed quality information about individual nursing homes, such as: nursing home characteristics, resident characteristics, nursing homes' ratings and deficiencies from their last state inspection, staffing levels, and performance on fourteen nursing homes quality measures endorsed by the National Quality Forum.  Among the quality measures reported are the percentage of patients with: pain, delirium, walking improvement, physical restraints, infections, pressure sores, and ADL decline (see section 5.5 for the list of quality measures).  The quality measures provide additional information to help consumers make informed decisions.  The format includes easy to use tabs to provide users with simple navigation support within the tool.  Users are able to search for data on specific nursing homes by state, county, city, zip code or name.  They also are able to get maps and directions for the nursing homes.  Nursing Home Compare makes it easy for consumers to compare quality, deficiency, and staffing information about the 17,000 Medicare and Medicaid-certified nursing homes.  This breath of information on nursing homes was not easily available to consumers before Nursing Home Compare. 
• Nursing Home Checklist provides a detailed checklist for consumers to help in the selection of a nursing home. The checklist guides Medicare beneficiaries and their families through a set of questions enabling them to rate nursing homes based upon important aspects of the quality of life, quality of care, nutrition, and safety they provide.  The checklist contains questions about basic information on the nursing home (e.g., Medicare or Medicaid -certified, the level of care, special services, visiting); resident appearance (e.g.cleaniness, dressed appropriately for the season or time of day, and well groomed.); nursing home living spaces (e.g., cleanliness, odor-free, noise levels, attractiveness of furnishings, good lighting.); staff (e.g., staff/resident ratios, staff relationship with residents appears to be warm, polite, and respectful, training and continuing education program for all staff, background checks done on all staff, certified nurse assistants involved in care planning, full-time social worker and licensed doctor available); residents' rooms (e.g., personal belongings are allowed, policies and procedures to protect resident's possessions, choice of roommates, window in each bedroom, access to telephone and television.); hallways, stairs, lounges, and bathrooms (e.g., exits are clearly marked, quiet areas designated, handrails in the hallways and grab bars in the bathrooms.); menus and food (e.g., choice of menu, nutritious snacks available, staff help residents eat and drink, if needed.); activities (e.g., a variety of activities available, outdoor areas available, active volunteer program); and safety and care (e.g., emergency evacuation plan, regular fire drills, preventive care provided, including yearly flu shots, arrangement with earby hospital for emergencies.).  The checklist gives consumers a useful list of what to look for when visiting and evaluating a nursing home (The Nursing Home Checklist is available at http://www.medicare.gov/Nursing/Checklist.pdf). 

Other information provided on the CMS website are details about the nursing home inspection process; Medicare covered programs that are alternatives to nursing home care; basic information about coverage and paying for care; the rights by law that are given to all nursing home patients; information on nursing home awareness campaigns; nursing home-related publications; and nursing home-related informational sites.

Working with CMS and the nursing homes are the states' Quality Improvement Organizations (QIOs), CMS contractors that provide quality improvement assistance to hospitals, physicians offices, home health agencies, and nursing homes.  CMS' goal is for consumers to use the data available in Nursing Home Compare and the Nursing Home Checklist in selecting a nursing home and for nursing home providers to use the information to identify areas in their facilities requiring improvement and to seek assistance from the QIOs to achieve that improvement. 

Nursing Home Compare represents the first tool ever where the public can find basic (state certification results, staffing, locations) and quality information on all 17,000 Medicare and Medicaid-certified nursing homes in one location.  Dennis G. Smith, Acting CMS Administrator explained, "We launched this national Initiative in November 2002 and are already beginning to see improvements in the quality of care available in many nursing homes because of the collaboration among CMS, the states, Quality Improvement Organizations, advocates and the nursing homes.  Not only are consumers asking more questions, but nursing homes are able to identify their own strengths and weaknesses" (CMS News release, January 22, 2004, available at http://www.cms.hhs.gov/media/press/release.asp?Counter=947). 

In addition to the CMS nationwide Nursing Home Quality Initiative, there are a number of private-sector innovations to improve the quality of care provided in nursing homes worth highlighting as examples of other initiatives underway: Wellspring Innovation Solutions, Beverly Enterprises, and the Green House Project.

1.  Wellspring Innovation Solutions, Inc., an initiative developed by an alliance of 11 independent, nonprofit nursing homes in Wisconsin in 1994, offers a promising approach to improving the well-being of nursing home residents by improving care and reducing staff turnover.  Since 1996, the Wellspring Program has developed and promoted a model of "resident-centered" care in its eleven member nursing homes.

Improvements in resident health and reductions in staff turnover reported by the Wellspring facilities indicate that the program is having an impact. Under the Wellspring Program, the basic philosophy is that top management sets policies to ensure quality of care, and frontline workers-who know the residents best-decide how best to implement them. The program has five key elements:

• an alliance of nursing homes committed to making quality of resident care a top priority;
• shared services of a geriatric nurse practitioner (GNP), who develops training materials and teaches staff at each nursing home how to apply nationally recognized clinical guidelines;
•  "care resource teams" that receive training in a specific area of care and are responsible for implementing what they have learned at their respective facilities;
• empowerment of all nursing home staff to make decisions that affect the quality of resident care and the work environment; and
• regular reviews by CEOs and nursing staff of performance data on resident outcomes relative to other nursing homes in the Wellspring alliance.

A nursing home's commitment to the Wellspring Program starts at the top. The CEOs of participating facilities agree to work together to reorient organizational culture toward an emphasis on high-quality resident care. Each nursing home that takes part in the program contributes toward overall costs. Facilities in the original Wellspring alliance are all independent, nonprofit institutions, though they vary in their size. The program's developers believe that an alliance of more than three but not greater than 12 nursing homes-10 is considered ideal-is critical to its success.

A key strength of the Wellspring approach is allowing frontline staff, especially the certified nursing assistant (CNA), to make decisions that affect the quality of both resident care and the work environment. In addition, providing staff with permanent assignments allows them to develop closer relationships with specific residents and thus greater understanding of patients' individual needs.

A board comprising the CEOs of each facility meets monthly to share and review data on clinical outcomes and other performance measures. Resident health outcome data is also used by staff to evaluate quality of care within each home and to compare results across Wellspring facilities and with national benchmarks. The information encourages staff to think about how to improve resident care further and, at the same time, fosters a healthy competition and pride in the care being provided.

Preliminary data analysis suggests that the care provided in Wisconsin nursing homes that currently participate in the program may be better than the care offered in facilities that do not.  In 1998, state officials cited Wellspring nursing homes for an average of 2.1 health deficiencies per facility, while all other Wisconsin nursing homes were cited for 3.7 deficiencies. All 11 Wellspring facilities had zero deficiencies in 1999-a remarkable record. Wellspring patients were also more likely to be ambulatory; more likely to receive preventive skin care, bladder and bowel training, and assistance with eating; and less likely to be restrained or to be given psychoactive medications. One member facility reports that annual turnover among CNAs was reduced from 105 percent prior to the Wellspring Program to 25 percent in 1999.

In October 2003, MetaStar, the Wisconsin QIO, has received a $1 million grant to study Wellspring and determine which of its key features have the strongest impact on quality improvement. In addition, the Commonwealth Fund has provided finanical and staff assistance to Wellspring Innovation Solutions to develop, evaluate, and disseminate its model.

Wellspring Innovations Solutions represent nonprofit facilities, which account for less than one-third of nursing homes in the United States. Clearly, if "resident-centered" care is to become the standard within the industry, commercial, for-profit nursing homes must be enlisted in the cause as well.

2.  Beverly Enterprises, the U.S.' largest for-profit nursing home chain, is the first for-profit nursing home chain to attempt to implement culture change initiatives to improve quality.  Headquartered in Fort Smith, Arkansas, Beverly is the largest nursing home chain in the country, with operations in thirty-two states and the District of Columbia. Over the last two decades, many of Beverly's facilities have been singled out by state nursing home inspectors as providing poor care, and the company has been the target of litigation brought by dissatisfied residents or their families.

Since taking over as Beverly's president and CEO in 2001, William R. Floyd has worked to improve corporate performance by raising quality of care, enhancing risk management, and fostering business innovation. As part of the initiative, twenty Beverly nursing facilities have already implemented a culture change program.  In April 2002, the Commonwealth Fund supported a six-month preliminary planning effort in anticipation of a full-scale evaluation of the program beginning in 2003.

To evaluate the impact of culture change on performance outcomes, the project team will perform a two-year comparative analysis of Beverly nursing homes that are undergoing culture change and those that are not. The first part of the study would examine secondary data for the following performance measures: staff satisfaction and staff turnover; resident falls, weight loss, and pressure sores; use of restraints and antipsychotic drugs; state survey results; family caregiver satisfaction; and facility pretax income, occupancy, reduction in accounts receivable, and bad debt.  For the second part of the evaluation, project staff will collect primary data on performance outcomes at a sample of Beverly facilities. A total of nine nursing homes undergoing culture change would be matched with nine comparison homes not undergoing change in three states (Minnesota, Pennsylvania, and Wisconsin).

3. The Green House Project goal is to establish small group homes for the elderly that are designed to foster more resident-centered care and has so far established four small group homes for the elderly in Tupelo, Mississippi, each of which is staffed by trained elder assistants and provides resident-centered care to ten adults. These homes are the first of their kind in the country.

In August 2003, The Commonwealth Fund provided support for an evaluation of the Green House Project, which includes interviews of residents and families, nursing home staff, corporate personnel, and regulators about the creation and operation of the model homes. The evaluation will gauge the effects of the small group design on residents, family, staff, and organizational outcomes, considering levels of satisfaction, quality of care, mortality rates, quality of life, staff turnover, capital and operating costs, offsetting savings and revenue enhancements, and performance on regulatory inspections. The lessons learned from this evaluation will be used to enhance and refine the prototype and develop templates for its replication. The analysis will also examine the business case for this model of nursing home care.

Main points

Main objectives

The overall goal is to improve the quality of care in nursing homes.  The objective of the informational tools on CMS' website is to share quality information with consumers, health care providers, intermediaries and other key stakeholders to help them make informed decisions about nursing home care.

Key innovations implemented as part of the initiative are:

1. Nursing Home Compare, a Web-based interactive tool that allows consumers to access comparison information about nursing homes including: nursing home characteristics, resident characteristics, state inspection results, staffing levels, and performance on a set of 14 nursing home quality measures endorsed by the National Quality Forum. Users are able to search for data on nursing homes by state, county, city, zip code or name.
2. Nursing Home Checklist, a detailed checklist available to consumers on the U.S. Department of Health and Human Services website, for rating nursing homes based upon quality of life, quality of care, nutrition, and safety.

Type of incentives

Improved reporting of quality information for public and provider use.  No direct financial or non-financial incentives are given to providers as part of the Nursing Home Quality Initiative.

Groups affected

Medicare and Medicaid certified nursing homes, Nursing home residents and their families, State Quality Improvement Organizations and Regulatory Agencies

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Nursing Home Compare represents the first tool ever where the public can find basic (state certification results, staffing, locations) and quality information on all 17,000 Medicare and Medicaid-certified nursing homes in one location.  The NHQI and Nursing Home Compare tool have been used by nursing homes and providers to improve quality of care.  A challenge, however, will be to ensure that the Nursing Home Compare tool and Nursing Home Checklist are accessed and used to their maximum potential by consumers, nursing home residents and their families.

Political and economic background

The IOM report, Improving the Quality of Care in Nursing Homes came out in 1986, in response to a Congressional mandate for the IOM to study how to better regulate the quality of care in the nation's Medicaid and Medicare certified nursing homes.  In order to assure implementation of the IOM recommendations, the National Citizens' Coalition for Nursing Home Reform (http://www.nccnhr.org/) organized the "Campaign for Quality Care" to support the federal reforms.  National organizations representing consumers, nursing homes, and health care professionals worked together to create consensus positions on major nursing home issues.  Their consensus positions on the IOM report laid the foundation for the Omnibus Budget Reconciliation Act passed by Congress in 1987 (OBRA-87).

The OBRA-87 reforms addressed the major deficits found in a series of more than 30 state and federal reports between 1970 and 1986 that presented evidence about seriously substandard care and analyzed the weaknesses in federal and state regulatory systems.  The OBRA-87 reforms were a comprehensive and innovative approach to nursing home regulation: (1) They altered three fundamental elements of the federal regulatory system (the standards, the process for inspecting homes to determine whether they are in compliance with the standards, and the enforcement system for dealing with homes that are not in compliance); (2) The reforms in all three of the components of the new regulatory system were resident-focused and outcome-oriented; (3) The reforms incorporated the best of the enforcement strategies used by states to encourage homes to comply with standards.

The reforms in OBRA-87 were endorsed by a substantial bipartisan majority in Congress and had widespread support from nursing home residents, families, organizations representing the elderly, and a host of long-term care providers, including nursing home owners, administrators, nurses, social workers, therapists and physicians.

The effect of the OBRA-87 reforms on quality of care and life for nursing home residents has been "impressive."  Several studies have found significant improvements in quality of care and resident outcomes since implementation of the OBRA-87 reforms.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

Please see above (Content of idea, Background of policy) on the Nursing Home Quality Initiative and OBRA '87.



The Nursing Home Quality Initiative is part of a broader CMS Quality Initiative to provide quality data on nursing homes, home health, and hospitals (http://www.cms.hhs.gov/quality/).

Stakeholder positions

Efforts at nursing home reforms have enjoyed widespread support.

Stakeholders and supporters of the CMS NHQI include:

• Medicare and Medicaid certified nursing homes - long-term care providers, including nursing home owners, administrators, nurses, social workers, therapists and physicians
• Federal and State agencies funding, regulating and monitoring long term care
• Quality Improvement Organizations (QIOs - CMS contractors that provide quality improvement assistance to hospitals, physician offices, home health agencies and nursing homes).  The QIOs are responsible for promoting awareness and use of information available as part of the NHQI and to assist nursing homes in their state which seek to improve performance.
• State Survey Agencies ensure that facilities in their state meet regulatory standards.  Under some state laws and directives, many State Survey Agencies have also undertaken activities to promote improvement.
• The National Quality Forum (NQF), which set up a steering committee that recommend domains of care for the public reporting pilot of the NHQI. NQF's nursing home steering committee included providers, state government representatives, consumer advocates, and others.
• The Agency for Health Care Research and Quality, which assisted in producing clinical guidelines reported by Nursing Home Compare.

Organizations representing the elderly (i.e., National Citizens' Coalition for Nursing Home Reform,  Nursing Home Abuse Support) and consumer advocacy organizations.

Influences in policy making and legislation

The nursing home quality measures continue to be evaluated and enhanced.

Adoption and implementation

The Nursing Home Quality Initiative (NHQI) is part of a broader CMS Quality Initiative to provide data on quality to consumers and providers.  The NHQI has had support from all stakeholders.

Monitoring and evaluation

The government's Nursing Home Quality Initiative will continue to develop and the quality measures used in Nursing Home Compare will continue to be refined.  For example, in 2004, CMS began reporting an enhanced set of 14 quality measures that have been endorsed by the National Quality Forum.  The set of enhanced quality measure went through an extensive review process, including review by the NQF Nursing Home Steering Committee meeting and then being posted on the NQF website for public comment, following which the NQF Board sent forward to CMS the recommended final set of endorsed quality measures.  Quality measure scores for all facilities are updated quarterly.

Results of evaluation

A January 22, 2004 CMS News press release reports (http://www.cms.hhs.gov/media/press/release.asp?Counter=947):

According to the Centers for Medicare and Medicaid Services, since the Nursing Home Quality Initiative began in 2002:

• "Approximately 2500 nursing homes are actively pursuing quality improvement efforts with the help of their state QIO.
• More than 99.5 percent of the nation's 17,000 nursing homes have been contacted by quality improvement organizations in their state about the Nursing Home Quality Initiative, the quality measures, and how to become involved in quality improvement efforts.
• More than 60 percent of nursing homes nationwide have attended at least one QIO-sponsored workshop on the quality measures and/or quality improvement techniques as applied in the nursing home environment.
• The Nursing Home Compare tool received 9.3 million page views in 2003 and was the most popular tool on www.medicare.gov. The 1-800-MEDICARE call centers received 5.9 million calls in 2003, a nine percent increase over 2002.

In addition, there have been improvements in outcomes in the following measures:

• The percent of residents with chronic pain dropped by more than 30 percent (from 10.7 percent to 7.3 percent) and has been seen in every state. Nationally, the chronic pain measure improved each quarter since the initial rollout in November 2002.
• The percent of residents who were physically restrained declined by 15 percent (from 9.7 percent to 8.2 percent) nationally and has been seen in 92 percent of states. Nationally, the daily physical restraint measure has improved each quarter since the initial rollout in November 2002.
• The percent of short stay residents who experienced pain decreased nationally by 11 percent in one year (from 25.4 percent to 22.6 percent).

The Pressure Ulcer measure has not changed significantly over the past 12 months, (from 8.5 percent to 8.8 percent). However, the trend is toward worse performance on this measure in 82 percent of states, so it is a widespread finding. This change may or may not mean that clinical care has deteriorated. CMS and the QIOs are working closely with nursing homes to monitor this, and assure that care does indeed improve. As clinicians focus on a given kind of care (such as skin care) they also become more accurate in measurement."

Expected outcome

Continued evaluations need to be conducted to determine effects on quality.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

Initial findings are promising, although further research needs to be done to evaluate the effectiveness of the NHQI on quality.

References

Sources of Information

Centers for Medicare and Medicaid Services Nursing Homes Initiative webpage (http://www.medicare.gov/Nursing/Overview.asp and http://www.cms.hhs.gov/quality/nhqi/)

The Commonwealth Fund website (http://www,cmwf.org).

C. Hawes, Assuring Nursing Home Quality: The History and Impact of Federal Standards in OBRA-87, The Commonwealth Fund, December 1996.  (available at http://www.cmwf.org/programs/elders/hawes.asp).

National Quality Forum website (http://www.qualityforum.org).

J.A. Rhoades and N. Krauss, MEPS Chartbook #3: Nursing Home Trends, 1987 and 1996 (available at http://www.meps.ahrq.gov/papers/cb3_99-0032/cb3.htm).

Author/s and/or contributors to this survey

Phuong Huynh, Robin Osborn

Empfohlene Zitierweise für diesen Online-Artikel:

Phuong Huynh, Robin Osborn. "Nursing Home Quality Initiatives". Health Policy Monitor, February 2004. Available at http://www.hpm.org/survey/us/c2/2