1. Using Public Information to Improve Nursing Home Quality in Minnesota Academy Health Annual Research Meeting, June 2007 Greg Arling, Ph.D. Indiana University Center for Health Policy and Center for Aging Research

2. Purpose  Address issues of nursing home quality measurement and application  Describe how these issues have been dealt with in the Minnesota NH Quality Assessment System  Suggest ways for more effective use of information about nursing home quality

3. Topics  Overview of Minnesota NH Quality Assessment System  Applications Public Reporting – NH Report Card Quality-Based Payment Incentives Quality Improvement  Responses by consumers and providers  Future Development

4. Quality Assessment System

5. Goals  Develop effective measures of nursing home quality  Apply the measures Informing consumer decisions Guiding nursing home quality improvement Offering financial incentives for better care  Engage consumers and providers in efforts to achieve better quality

6. Guiding Principles  Comprehensive – contains process and outcome indicators, quality of care and quality of life  Relevant – taps dimensions of care that are important to consumers and providers  Credible – has strong research base  Understandable – effectively presented to different audiences  Actionable – informs consumer decision-making and provider quality improvement  Transparent – methods are well described, in the public domain, and open to scrutiny by stakeholders and the research community

7. Measurement and Application  Quality measurement and application should proceed iteratively and be mutually reinforcing  Application of quality information gives providers a greater stake in data collection (can also introduce bias)  Reporting systems encourage provider and other stakeholder feedback which can serve as an accuracy check and raise important analytical issues

8. Guiding Principles Example: Consumer Reports

9. Science and Uncertainty in Everyday Life

10. Comprehensive Quality Measures  Direct care staffing level (salary and CM adjusted HPRD)  Direct care staff retention rate  Use of pool staff  Quality Indicators (QI)  Quality of Life and Resident Satisfaction (QoL/RS) Survey  State Inspection (NH Survey) Results

11. MN Nursing Home QIs  Based on MDS assessments  24 QIs representing care processes and outcomes  Dimensions (# of QIs) Psychosocial (4)Accidents (2) Restraints (1)Nutrition (1) Continence (6)Pain (1) Infections (2)Skin Care (2) Functioning (5)Drugs (1)

12. Quality of Life & Resident Satisfaction  Annual survey carried out by professional survey organization involving face-to-face interviews with 14,000+ NH residents  53 QoL and other items adapted from established instruments  Dimensions (# of survey items) Comfort (4)Autonomy (5) Environmental (4)Individuality (3) Privacy (3)Security (3) Dignity (4)Relationships (3) Meaningful Activity (3)Satisfaction with Care (7) Food Enjoyment (3)Mood (9)

13. Statistical Adjustment  QIs risk adjusters Age and gender Diagnoses (e.g, stroke, hip fracture, end-stage) functional status (e.g., ADL, cognitive status) health conditions (e.g., hemiplegia, sensory loss)  QoL/RS score risk adjusters Resident gender, ADL, age, cognitive status & LOS Facility location and average LOS  Empirical Bayes estimates of facility QI or QoL/RS rates

14. Quality Scores - Facility Distributions

20. Summary Quality Score Measure Max Points Staffing level (HPRD)10 Staff retention20 Use of pool staff 5 QIs35 QoL/RS20 Survey deficiencies10 Total 100

22. Quality Enhancement Initiatives

23. Nursing Home Report Card  Transparency to consumers Make better LTC choices Advocate for care improvement  Provider benchmarking and quality improvement  Nursing homes selected by geographical areas  Facility assigned 1-5 stars on each of seven dimensions

25. Quality Adjustment to Payment Rate  Bonus added annually to Medicaid per diem payment rate -- proportional to Quality Score Quality ScoreBonus (% of PD Rate) 0-400.0% 41-990.1% to 2.3% 1002.4%  Quality score also used to adjust Medicaid cost limits Reduces rates for high cost & low quality facilities Increases rates for low cost and high quality facilities

26. Facility Quality Reports  Detailed QI and QoL/RS reports sent periodically to each facility Most current QI and QoL/RS results Tracking of QI or QoL/RS rates over time  Special training programs on priority areas identified through quality reports Meaningful activities Skin care Psychotropic medications Pain management

27. Performance-Based Incentives  Facilities propose a new program to: Improve quality outcomes Increase efficiency Re-balance long-term care (e.g., community discharges)  Facilities receive a 5% rate increase IF they: Implement the program effectively Achieve outcome objectives  Most projects linked to improvement in QIs, QoL/RS, and other quality measures

28. Response to the System

29. Consumer Response  Use of Report Card 26,000 “hits” the first week 1,800/month since then  Consumer feedback on Report Card 87% rate “easy” or “pretty easy” to use 55% “definitely” would use in selecting a nursing home 36% “probably” would use in selecting a nursing home

30. Feedback from Report Card Users (N=108,000) Quality Dimension% Giving it Top Priority Quality of Life/RS84% State NH Survey Results61% NH Quality Indicators59% Staffing Level (HPRD)38% Staff Retention16% Use of Pool Staff6%

31. Provider Response  Even modest financial incentives have stirred considerable provider interest  Providers have asked for more frequent and detailed QI and QoL/RS reports  Providers have been supportive of QI and QoL/RS risk adjustment with some calling for expanded adjusters  State-sponsored quality improvement training programs have been attended by 100’s of nursing home staff

32. Trends in QI Rates DeclineImprovement

33. Performance-Based Incentive Projects  155 applications received, 19 projects and 32 facilities approved in first year  Focus of projects: Culture changeWireless call systems QoL for dementia residentsEmployee retention Pressure ulcersPain management ExerciseCHF

34. Future Development

35. Expand Quality Measures  QI or QoL/RS measures designed specifically for dementia residents  Post-acute QIs  Family satisfaction survey  Environmental assessments  Measures of community discharge or NH transition  Refined scoring of NH inspection results

36. Improve Reporting  Track quality measures over time Trends in QI rates (quarterly) Changes in annual QoL/RS scores  Drill down capability Dimension scores Individual survey items or QIs  Decision support tools

37. Build a Business Case for Quality  Increase quality adjustment of payment rate Reward high quality Discourage poor quality  Expand funding for Performance-Based Incentive projects Emphasize organizational change and technology Encourage provider collaboration and diffusion of best practices

38. Stress Value and Cost-Effectiveness  Wide variation in nursing home per diem prices & quality  Information about NH prices and their relationship to quality is not publicly available  Many consumers are receiving very poor value for their long-term care dollars  Need to focus on connection between price and quality – greater value and cost-effectiveness

40. Continue Research  Improving validity and reliability of quality measures  Identifying trends in quality over time  Facilitating consumer decision-making  Understanding organizational and management practices associated with better quality  Evaluating quality improvement strategies  Building a business case for better quality

41. Where we are … 1914 Stutz Bearcat

42. Where we want to be … 2007 Indy 500 Winner

43. MN DHS Contact Valerie Cooke, Project Director Department of Human Services Nursing Facility Rates & Policy PO Box 64973 St. Paul, MN 55164-0973 651-431-2263 valerie.cooke@state.mn.us