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Brant E. Fries Please do not cite without permission1 Development of Home Care Quality Indicators Based on the MDS-HC Brant E. Fries, Ph.D. University.

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Presentation on theme: "Brant E. Fries Please do not cite without permission1 Development of Home Care Quality Indicators Based on the MDS-HC Brant E. Fries, Ph.D. University."— Presentation transcript:

1 Brant E. Fries Please do not cite without permission1 Development of Home Care Quality Indicators Based on the MDS-HC Brant E. Fries, Ph.D. University of Michigan May 7, 2002

2 Brant E. Fries Please do not cite without permission 2 Agenda l RAI-HC as the basis for Quality Indicators l Home Care Quality Indicators (HCQIs) Development Summarizing HCQIs l Use of HCQIs in evaluating the MI Choice Programs

3 Brant E. Fries Please do not cite without permission 3 Agenda l RAI-HC as the basis for Quality Indicators l Home Care Quality Indicators (HCQIs) Development Summarizing HCQIs l Use of HCQIs in evaluating the MI Choice Programs

4 Brant E. Fries Please do not cite without permission 4 RAI-Home Care Assessment System l Developed by interRAI, a multi-nation group of clinicians, researchers and policymakers l Community analogue to the RAI, mandated in U.S. nursing homes

5 Brant E. Fries Please do not cite without permission 5 Improvements in the RAI l Primary purpose: Improve care plans through improved assessment

6 Brant E. Fries Please do not cite without permission 6 Improvements in the RAI Three parts of the RAI-HC l Minimum Data Set (MDS-HC) l Triggers l Client Assessment Protocols (CAPs) (Care planning guidelines)

7 Brant E. Fries Please do not cite without permission 7 Improving Assessment Process l Items clearly defined, including: full definitions examples and exclusions time delimiters l Cover all relevant domains individuals strengths and weaknesses tradeoff of breadth/depth and length

8 Brant E. Fries Please do not cite without permission 8 Improving Assessment Process l Use all possible sources of information individual, formal/informal caregivers, MD, medical record, etc. self-reporting may be inaccurate assessor decides when sources are inconsistent

9 Brant E. Fries Please do not cite without permission 9 Improving Assessment Process l Careful testing of psychometric properties l Training manual l Ongoing refinement - RAI-HC Version 2

10 Brant E. Fries Please do not cite without permission 10 Applications of MDS-HC Data ASSESSMENT Care Plan (CAP) Eligibility Systems (MI Choice) Quality Measures (HCQI) Case-Mix Algorithm (RUG-III/HC)

11 Brant E. Fries Please do not cite without permission 11 RAI Family of Instruments l Chronic care/nursing homesRAI 2.0 l Home CareRAI-HC 2.0 l Mental HealthRAI-MH l Acute CareRAI-AC l Post-Acute Care-RehabilitationRAI-PAC l Assisted LivingRAI-AL l Palliative CareRAI-PC

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13 Brant E. Fries Please do not cite without permission 13 Common Basis l All interRAI instruments have common basis of care planning l Major items in common l Possible to link across time and setting l Start of a language to describe long- term care users

14 Brant E. Fries Please do not cite without permission 14 Implementation of RAI-HC l InterRAI grants royalty-free license to governments l Adopted by 10 states, Department of Veterans Affairs l International adoptions l Used in fee-for-service and managed care programs

15 Brant E. Fries Please do not cite without permission 15 Agenda l RAI-HC as the basis for Quality Indicators l Home Care Quality Indicators (HCQIs) Development Summarizing HCQIs l Use of HCQIs in evaluating the MI Choice Programs

16 Brant E. Fries Please do not cite without permission 16 Uses of MDS-HC Data for Quality Measurement l User Profiles Whom are we serving? l Performance Benchmarks Are we serving the right people? l Outcome Measures What happens to the people we serve? l Quality Indicators How do care strategies affect the people we serve?

17 Brant E. Fries Please do not cite without permission 17 Why HCQIs Are Important l HCQI= Home Care Quality Indicators l Citizens, legislators, administrators want proof that programs work

18 Brant E. Fries Please do not cite without permission 18 Uses of HCQIs l Regulation Who is doing a substandard job? l Management How well am I doing? Compared with last year? l Consumers Where should I get care? l Best practices Who is doing an outstanding job? l Benchmarking How do I compare with others?

19 Brant E. Fries Please do not cite without permission 19 HCQI Authors John P. Hirdes Ph.D. Brant E. Fries Ph.D. John N. Morris Ph.D. David Zimmerman Ph.D. Naoki Ikegami M.D., Ph.D. Dawn Dalby M.Sc. Suzanne Hammer M.Sc. Pablo Aliaga M.Sc. Rich Jones, Ph.D.

20 Brant E. Fries Please do not cite without permission 20 Considerations in Developing HCQIs l Reliability and validity of data items l Points of comparison Prevalence, incidence l Validity of indicators l Application – when agency is responsible Prevalence: follow-up data only Incidence: intake to follow-up

21 Brant E. Fries Please do not cite without permission 21 HCQI Research in a Nutshell l Two year effort in Canada, USA, Japan l Involved many stakeholders l Started with QIs from other sectors l Workgroups in Canada and Michigan l Identification of exclusions l Analysis with data from Canada, US, Italy l HCQIs with reasonable prevalence l Adjustments

22 Brant E. Fries Please do not cite without permission 22 Prevalence HC Quality Indicators l Nutrition Inadequate Meals Weight Loss Dehydration l Pain Disruptive/Intense Pain Unmanaged Pain l Physical function No Assistive Device for Clients with Difficulty in Locomotion ADL/Rehabilitation Potential and No Therapies l Psychosocial function Social Isolation with Distress Delirium Negative mood l Medication No medication review l Safety/Environment Falls Any injuries Neglect/Abuse l Other No Influenza Vaccination Hospitalization

23 Brant E. Fries Please do not cite without permission 23 Incidence HC Quality Indicators l Psychosocial function Failure to improve/ incidence of cognitive decline Failure to improve/ incidence of difficulty in communication l Other Increased health instability l Incontinence Failure to improve/ incidence of bladder continence l Ulcers Failure to improve/ incidence of skin ulcers l Physical function Failure to improve/ incidence of decline in ADL Failure to improve/ incidence of impaired locomotion in the home

24 Brant E. Fries Please do not cite without permission 24 Adjusting HCQIs l Risk adjustment Should we adjust? Team identified candidate risk adjusters Analyze Ontario, Michigan and Italian data: –Adjustment in same direction/ magnitude in 2 out of 3 countries

25 Brant E. Fries Please do not cite without permission 25 Example: Two Nutrition HCQIs

26 Brant E. Fries Please do not cite without permission 26 Adjusting HCQIs l Selection/Ascertainment adjustment Should we adjust? Use intake rates to derive agency-level measure of bias Analysis of Ontario and Michigan data

27 Brant E. Fries Please do not cite without permission 27 Risk/Ascertainment Adjustments for Mood, 8 Michigan Agencies

28 Brant E. Fries Please do not cite without permission 28 Two HCQIs, by Agency Disruptive/intense daily pain Delirium

29 Brant E. Fries Please do not cite without permission 29 All HCQI – Agency A

30 Brant E. Fries Please do not cite without permission 30 All HCQI – Agency B

31 Brant E. Fries Please do not cite without permission 31 People want simple quality measures l Good Housekeeping Seal l Consumer Report Circles l Olympic Medals l Michelin Stars

32 Brant E. Fries Please do not cite without permission 32 Average Relative QIHC, by Michigan Agency

33 Brant E. Fries Please do not cite without permission 33 Single Measure of Home Care Quality l People want simple, but… We lose critical information May not be feasible l When we present multiple measures… Difficult to interpret Still seeking good views

34 Brant E. Fries Please do not cite without permission 34 Agenda l RAI-HC as the basis for Quality Indicators l Home Care Quality Indicators (HCQIs) Development Summarizing HCQIs l Use of HCQIs in evaluating the MI Choice Programs

35 Are you just pissing and moaning, or can you verify what youre saying with data?

36 Brant E. Fries Please do not cite without permission 36 Methods l Used adjusted HCQIs l 23 agencies l Over 8 quarters, from Jan 99 to Dec 01 Training and computerization in 2 nd quarter

37 Change in Agency Average HCQI Score, by Period Worse

38 Brant E. Fries Please do not cite without permission 38 Results l Over 8 periods (2 years) – (p<.005) l 16 HCQIs improved (e.g., mood, falls, hospitalizations, weight loss, social isolation, decubiti) l 4 HCQIs remained the same (e.g., pain, disruptive pain, injuries, no assistive dev.) l 2 HCQIs worsened (intense pain, rehab potential without therapies)

39 Brant E. Fries Please do not cite without permission 39 GOODPOOR Defining Good /Poor Quality

40 Average Good/ Bad HCQIs, by Quarter Bad Good RAI Training

41 Brant E. Fries Please do not cite without permission 41 GOODBAD Distribution of a HCQI

42 Brant E. Fries Please do not cite without permission 42 Next Steps l Further validation of HCQIs l Develop archives for benchmarking l Applicability to subpopulations l Quality of Life?

43 Brant E. Fries Please do not cite without permission 43 Conclusions l RAI-HC has potential to improve care directly, through improved care planning l MDS-HC has multiple uses, including measuring quality of care l HCQIs can be used to monitor care Directly computed from MDS-HC Useful for comparisons, benchmarking


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