What began five years ago as an effort to apply industrial and
business theory to resident care in the nursing home could soon
change the way you are paid for consultant services. Here's what
you need to know-and why.
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L. Michael Posey |
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"An educated consumer is our best customer," says the advertising slogan of one national clothing chain. For the nation's nursing homes, that might as well be the new motto, because the customers-as in payers, some residents, and family members-are in better positions than ever to assess the quality of care delivered by long-term care facilities. The next step will be to pay in the form of that quality, and consultant pharmacists will need to demonstrate a positive impact on quality of care to compete on this basis.
Two separate streams are coming together to form the new river of quality improvement, one based on resident and family satisfaction and the other in the form of quality indicators reflecting clinically appropriate care. The development of consumer-driven "report cards" is discussed in a sidebar on page 105, while the main text of this article will consider approaches to the quality of clinical care.
Developing an Index of Quality-and Tying It to Payment
A landmark paper in this field appeared in the April 1990 issue of Health Services Research.1 In it, David Zimmerman and colleagues from the University of Wisconsin-Madison introduced a methodology for developing measures of nursing home quality, proposed a specific nursing home quality measure (the Quality Assessment Index), and reported the results of several tests of the index's validity and reliability.
The model built on the Donabedian ideas from the early 1980s that divided evaluation of care into structure, process, and outcomes constructs. The index incorporated criteria from all three domains using seven components:
The work gained the attention of the Health Care Financing Administration (HCFA), which was seeking to implement a part of OBRA '87. HCFA required a comprehensive assessment of all nursing home residents using two tools: the Minimum Data Set (MDS), consisting of a resident's physical functioning and cognitive, medical, emotional, and social status, and the Resident Assessment Protocols (RAPs), corresponding care-planning tools. Members of the university's Center for Health Systems Research and Analysis (CHSRA) were soon at work developing and testing quality indicators, using the MDS as a basis.2 Quarterly use of the MDS version 2.0 was recently mandated, which has several important implications for pharmacists (see sidebar).
HCFA also funded a second project through the CHSRA: the Multistate Nursing Home Case Mix and Quality Demonstration. Six states participated in the demonstration, which has two objectives:2
1. To develop and implement a case-mix classification system (using the resident assessment information) to serve as the basis for Medicaid and Medicare payment, and a quality-monitoring system to assess the impact of case-mix payment on quality.
2. To provide better information to the nursing home survey process.
Thus, HCFA is exploring fundamental changes in the way it surveys
and reimburses nursing homes.
Table 1. Quality Indicators and Risk Adjustment Used in Demonstration Facility and Resident Reportsa
| Domain | Quality Indicator | Type of Indicator | Risk Adjustment | % Accurate b |
| Accidents | Prevalence of any injury | Outcome | No | 100 |
| Prevalence of falls | Outcome | No | 96 | |
| Behavioral and emotional patterns | Prevalence of problem behavior toward others | Outcome | Yes | 98 |
| Prevalence of symptoms of depression | Outcome | No | 100 | |
| Prevalence of symptoms of depression with no treatment | Process | No | … | |
| Clinical management | Use of nine or more scheduled medications | Process | No | 100 |
| Cognitive patterns | Incidence of cognitive impairment | Outcome | No | 98 |
| Elimination and continence | Prevalence of bladder or bowel incontinence | Outcome | Yes | 89 |
| Prevalence of occasional bladder or bowel incontinence without a toileting plan | Both | No | 85 | |
| Prevalence of indwelling catheters | Process | Yes | 100 | |
| Prevalence of fecal impaction | Outcome | No | 100 | |
| Infection control | Prevalence of urinary tract infections | Outcome | No | 97 |
| Prevalence of antibiotic or anti-infective use | Process | No | 97 | |
| Nutrition and eating | Prevalence of weight loss | Outcome | No | 93 |
| Prevalence of tube feeding | Process | No | 88 | |
| Prevalence of dehydration | Outcome | No | … | |
| Physical functioning | Prevalence of bedfast residents | Outcome | No | 88 |
| Incidence of decline of late-loss activities of daily livingc | Outcome | Yes | 97 | |
| Incidence of contractures | Outcome | Yes | 97 | |
| Lack of training or skill practice or range of motion for mobility-dependent residents | Both | No | … | |
| Psychotropic drug use | Prevalence of antipsychotic use in the absence of psychotic and related conditions | Process | Yes | 74 |
| Prevalence of antipsychotic daily dose in excess of surveyor guidelines | Process | No | 100 | |
| Prevalence of antianxiety or hypnotic drug use | Process | No | 96 | |
| Prevalence of hypnotic drug use on a scheduled or as-needed basis greater than twice in last week | Process | No | 100 | |
| Prevalence of use of any long-acting benzodiazepine | Process | No | 100 | |
| Quality of life | Prevalence of daily physical restraints | Process | No | 98 |
| Prevalence of little or no activity | Outcome | No | 94 | |
| Sensory function and communication | Lack of corrective action for sensory or communication problems | Both | No | … |
| Skin care | Prevalence of stage 1-4 pressure ulcers | Outcome | Yes | 100 |
| Insulin-dependent diabetes with no foot care | Both | No | 100 |
a Adapted from reference 2.
b Percentage of cases in which an investigator found the quality
indicator to be accurate.
c Late-loss activities of daily living are bed motility, eating,
toileting, and transfer.
Content of the Quality Indicators
CHSRA developed a set of 30 quality indicators covering 12 domains of the MDS Plus, an enhanced version of the original MDS mandated by OBRA '87. Table 1 lists these domains along with each quality indicator, its type, whether risk adjustment is required, and an indication of its validity.
Zimmerman et al.2 describe the quality indicators as "markers that indicate either the presence or absence of potentially poor care practices or outcomes." The researchers describe them according to each indicator's characteristics from three perspectives: resident versus facility level, prevalence versus incidence, and process versus outcome.
The power of the MDS lies in its ability to generate national
longitudinal data, meaning that trends can be followed over time
under different conditions operative in various parts of the country
or types of nursing homes. As translated to quality indicators,
these data can be compiled to generate benchmarks for nursing
home clinicians, administrators, and residents.
Table 2. Excerpts from a Facility-Level Report on Nursing Home Quality Indicatorsa
| Domain/Quality Indicator (QI) | No. Residents with QI | No. Residents in Denominatorb | Facility Proportion | State Proportion | Percentile Rank |
|---|---|---|---|---|---|
| Behavioral or emotions (domain 2) | |||||
| Problem behavior: | |||||
High risk | 5 | 39 | 12.8 | 35.9 | 6 |
Low risk | 4 | 34 | 11.8 | 10.5 | 55 |
| Symptoms of depression | 7 | 66 | 10.6 | 8.9 | 66 |
| Elimination and continence (domain 5) | |||||
| Incidence of bowel or bladder incontinence: | |||||
High risk | 1 | 26 | 3.8 | 14.0 | 11 |
Low risk | 1 | 27 | 3.7 | 5.3 | 43 |
| Bowel or bladder incontinence without toileting plan | 17 | 22 | 77.3 | 36.5 | 96 |
| Incidence of indwelling catheters | 0 | 65 | 0 | 0 | 0 |
| Prevalence of fecal impaction | 0 | 73 | 0 | 0.4 | 0 |
a Reprinted from reference 2.
b The denominator indicates the number of residents in the facility
who could have the quality indicators. Note that this number may
be less than the number of residents in the facility, depending
on the definition of the quality indicators.
Table 2 shows an example of a facility-level report summarizing the home's quality indicator performance and compares it with those of other homes. The number of patients with a given quality indicator is divided by the number of residents to yield a facility proportion. This proportion can be compared against the state average or placed in an ordered list of all facilities in the state to generate a percentile ranking. The higher the rank, the greater the potential for a quality of care problem in the quality indicators.2
Quality indicators that require risk adjustment are noted in Table 1. Risk factors are used to adjust for interfacility variation for those items. Surveyors will see the risk factor adjustment as shown in Table 2. Data for those indicators requiring risk factor adjustment will be provided for the facility as a whole, for those residents with the risk factor (high risk), and for those residents without the risk factor (low risk). The surveyor can thus assess the degree to which the facility's performance might be attributable to residents' clinical conditions.2
Prevalence is the number of residents with a given quality indicator at a specific point in time, whereas incidence compares the development of a condition over time. However, since assessments occur during each quarter at the facility level, prevalence data for quality indicators actually reflect pre-valence over a three-month period.2
Donabedian's process vs. outcome paradigm has been applied to
quality indicators (Table 1). Some indicators are process in nature,
while others reflect outcomes. Four indicators are both process
and outcome in nature, since they reflect staff response to clinical
situations.
Translating Data into a Management System
CHRSA staff has developed the quality indicator structure further into a quality management system to be used as a framework by nursing home surveyors. The data will be used in several ways2:
Other Quality-Driven Approaches
In addition to the HCFA effort being spearheaded by the Wisconsin group, several other private initiatives are underway to develop quality report cards for long-term care facilities. Additionally, reports of research based on MDS plus have begun to appear in the literature.3
A noteworthy private initiative is that of LTCQ, Inc., a company founded by several well-known figures in the gerontology field: Barry Fogel, MD, Lewis Lipsitz, MD, Vince Mor, PhD, and John Morris, PhD. Based in Providence, Rhode Island, LTCQ's principal product is Q-Metrics, an information and advisory system that will permit participating facilities to identify their strengths and weaknesses, compare their facilities with other homes, and facilitate implementation of new strategies to improve quality of care and economic performance.
The core of Q-Metrics is HCFA's MDS, which was originally designed by some of the LTCQ founders. The unique strength of Q-Metrics lies in tying the clinical information of MDS into economic and market information largely ignored by HCFA.
Expected in the future are announcements of proprietary quality-management
systems by large nursing home owners and providers.
What about Pharmacy?
Does pharmacy need to develop its own set of quality indicators? That is a question tossed around daily by ASCP leaders and staff. Some advocate that pharmacy is necessarily part of a bigger picture, and the data available to the pharmacy are primarily drug and dispensing cost, a negligible part of the overall cost of care, adverse drug consequences, and expenses of a long-term care facility.
However, pharmacists must surely be able to document the impact
of their activities within some system, and the crudeness of the
30 quality indicators argues in favor of a more specific pharmacy
system that might mesh with the overall nursing home report card.
Expect increased debate over this issue and prompt action by ASCP
when a need is identified.
Just the Beginning
In a separate feature in this issue, the quality indicators in the psychotropic drug domain are analyzed. During the course of 1996, articles are slated for the clinical management, infection control, and skin care domains.
Barring a further congressional attempt to eliminate nursing home
regulations, long-term care administrators can expect quality
indicators to become the mechanism by which HCFA issues many of
its future dictums. Consultant pharmacists must learn the new
game in nursing homes and how it will affect reimbursement-both
for the home and for pharmacists.
References
1. Gustafson DH, Sainfort FC, Van Konigsveld R, Zimmerman DR. The quality assessment index (QAI) for measuring nursing home quality. Health Serv Res 1990; 25: 97;127.
2. Zimmerman DR, Karon SL, Arling G et al. Development and testing of nursing home quality indicators. Health Care Finan Rev 1995 (summer); 16(4): 107-27.
3. Williams B, Betley C. Inappropriate use of nonpsychotropic
medications in nursing homes. J Am Geriatr Soc 1995; 43: 513-9.
MDS 2.0 Means Changes for Consultant Rx
The release of version 2.0 of the Minimum Data Set means important opportunities and changes for consultant pharmacists. Nancy Losben, RPh, FASCP, told ASCP conference attendees in San Francisco of five important advantages of the availability of computerized pharmacy care plans made feasible through MDS 2.0:
MDS 2.0 will produce a national database of clinical and outcomes data for nursing home residents. HCFA's mandates for this version included development of a more comprehensive assessment tool, computerization, quality indicators, and case-mix reimbursement. Losben emphasized, "Consultant pharmacists must become participants in the interdisciplinary care plan team," and the new MDS gives them the tool to do so effectively.
Audiotapes of Losben's talk, which included the effects of case-mix
reimbursement on long-term care facilities, are available by requesting
ASCP Annual Meeting educational session #2 ($11) from Convention
Cassettes Unlimited, 74-923 Hovley Lane East, Suite 250, Palm
Desert, CA 92260; 619/773-4498, 800/776-5454.
AHCA Explores a "Vision for CareGiving"
The American Health Care Association has been especially active in searching for ways that its member facilities can lead the way in quality assessments. The Washington-based trade group has devoted substantial monetary and staff resources to the development of a consumer-derived "report card" for long-term care facilities. The survey instrument is used with cognitively intact residents, families of those residents, and families of residents with mild dementia.
Timothy Case, senior quality advisor at AHCA, tells TCP that a scientifically developed, statistically validated customer satisfaction measurement instrument in now in use at about 700 facilities. The survey was developed in three steps. First, Dave Gustafson of the University of Wisconsin (who is on the team developing the quality indicators discussed in the main text of this article) conducted focus groups of nursing home residents or family members. He obtained lists of items for the three groups studied (listed in the first paragraph) and submitted those to the Gallup Organization for validation. Randomly selected nursing home residents and family-members were interviewed as to (a) whether each item was important to them and (b) how satisfied they were with their facility's performance in that area.
The result is a process by which long-term care facilities can assess their performance in areas considered important by their two key customers: residents and families. The homes can then further compare themselves with benchmark data derived nationally or by region and compare their quality scores with other homes with similar characteristics.
Case says that AHCA is developing survey instruments for three additional groups during the first quarter of 1996: medically complex subacute care residents, rehabilitative subacute care residents, and assisted living residents.
AHCA also plans to establish a home page on the World Wide Web to complete development of a "Vision for CareGiving Network" in which member facilities can upload data, download management reports, and access benchmark numbers. The home page should be up by the end of 1996.
(For more information on AHCA's system, look at these articles published in Provider during 1995:
L. Michael Posey is Academics Editor.
Copyright © 1996, American Society of Consultant Pharmacists,
Inc. All rights reserved.