Improving End-of-Life Care for Nursing Home Residents: Approaching the Issue Side-ways

Mary Jane Koren, M.D., MPHVice-President, LTC Quality Improvement

The Commonwealth Fundmjk@cmwf.org

www.commonwealthfund.orgGIH Annual Conference

3/14/13

Why This is an Issue for Nursing Home Residents

• 88% are over age 65 and 45% over 851

• Average length of stay is 835 days2

• Many are in their last years of life - 35% mortality rate for NH residents3

1 Table 12, CDC National Nursing Home Survey 2004, Current Resident Tables, http://www.cdc.gov/nchs/nnhs/resident_tables_estimates.htm2 Table 12, CDC National Nursing Home Survey 2004, Current Resident Tables, http://www.cdc.gov/nchs/nnhs/resident_tables_estimates.htm3 Individuals age 65 or older; from ‘Who Stays and Who Goes Home: Using National Data on Nursing Home Discharges and Long-Stay Residents to Draw Implications for Nursing Home Transition Programs’’ Judy Kaspar, Kaiser Commission on Medicaid and the Uninsured, August 2005, using CDC National Nursing Home Survey 1999.

Putting a face on the problem• A 75 year-old man with heart failure and increasing dyspnea who

is inadvertently transferred to a hospital because his preferences for “comfort care” are not adequately documented.

• An 89 year-old woman with dementia whose family is unaware of her care plan and uncertain whether the nursing home staff or the hospice is primarily responsible.

• A 72 year-old man with colon cancer and uncontrolled pain whose family insists on a hospital transfer in order to obtain pain management

• An 84 year-old woman with metastatic lung cancer who receives no personal care on several days because hospice staff believe that nursing home staff are responsible and vice versa.*

* These vignettes are courtesy of Dr. David Caserett, U. Penn.

Three Fund projects that aim to address these problems

• The Intervention to Reduce Acute Care Transfers or INTERACT program (PI: Joseph Ouslander/Florida Atlantic University)

• Advancing Excellence: The Nursing Home Quality Campaign (PI: Cheryl Phillips/Leading Age)

• Identifying Best Practices in the Care of Seriously Ill Nursing Home Residents (PI: David Casarett/ University of Pennsylvania)

Communication Tools

Decision Support Tools

Advance Care Planning Tools

Quality Improvement Tools

A quality improvement program designed to improve the care of nursing home residents with acute changes in

condition

The INTERACT II tools are meant to be used together in your daily work in the nursing home

www.nhqualitycampaign.org

What is Advancing Excellence?

• An ongoing quality improvement campaign to help nursing homes (NHs) become high performance organizations

• Voluntary (>58% of all U.S. NHs, or 9,070 facilities registered)

• Based on measureable improvement of meaningful goals

• Recognizes staff and consumers as important and valued partners

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MobilityFebruary 2013

Person-CenteredCare and

Decision-MakingMarch 2013

ConsistentAssignmentNovember 2012

InfectionsMarch 2013

Pressure UlcersNovember 2012

Staff Stability November 2012

Medications(Antipsychotic use) March 2013

Hospitalizations

November 2012

AE Goals with roll-out dates

Pain ManagementDecember 2012

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Person-Centered Care Planning and Decision Making

“In person-centered care, staff places a premium on active listening and observing, so staff can adapt to each resident’s changing needs regardless of cognitive abilities.”• Keeps the person at the center of the care planning and

decision-making process. • Promotes choice, purpose and meaning in daily life. • Achieves highest practicable level of physical, mental and

psychosocial well-being. • Care plans are revised on ongoing basis to reflect a person’s

changing preferences. • Staff adapts to each resident’s changing preferences

regardless of cognitive abilities. 10

Person-Centered Care Planning and Decision Making - Measures

• Consistency of Resident Experience with Expressed Resident Preferences: Congruence of resident-reported "importance" vs "frequency" of activities identified in MDS Section F

• Participation in Care Planning: Composite score based on resident, family & direct care staff participation in care planning process

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Safely Reducing Hospitalizations

“Allows residents with acute changes in medical condition to remain in nursing home with staff who know them and can safely care for them without compromising residents’ well-being or wishes.”

• Avoids trauma and other risks associated with hospitalization.

• Prepares facilities to be able to provide needed care

• Increases communication between hospital and nursing home to ensure continuity of care and improve care transitions.

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Hospitalizations: Measures

Outcome measures:

• 30-day Readmission Rate as percent of those admitted from a hospital during the month

• Hospital Admission Rate per 1000 resident days this month

• Rate of Transfers to ER Only per 1000 resident days this month

• Rate of Transfers Resulting in Observation Stay per 1000 resident days this month

Includes “process measures” to help with root cause analysis, e.g. asks “Was an advanced care plan in place? Was it reviewed prior to the transfer?”

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Example Reports Produced

One year pilot project led by Dr David Casarett, Associate Professor, University of Pennsylvania

• The ultimate aim is to develop a quality improvement program and toolkit (analogous to INTERACT for hospital transfers) that will help hospices and nursing homes work together to ensure that residents can get the care that they need in the setting of their choice.

• The goal for this project is to identify best hospice practices that can help NHs provide high-quality care for residents with advanced illness and/or at the end of life, without resorting to transfers either to a hospice unit or to a hospital.

Identifying Best Practices in the Care of Seriously Ill Nursing Home Residents:

A Positive Deviance Approach

The team has used the CHOICE1’s research network along with a national dataset of FEHC2 scores to identify 3 hospices whose partnerships with nursing homes have achieved:

• Rates of transfers from nursing home to hospital in the last week of life that are less than 5%; AND

• FEHC results for hospice nursing home residents that are in the top 10% nationally (compared to approximately 1300 hospices that contribute FEHC data to the national NHPCO dataset).

Using these 3 high-performing hospices, the team will identify potential best practices in 3 sequential steps:- Preliminary telephone interviews, - An in-depth “failure analysis” of those residents who were transferred either

to a hospital or inpatient hospice unit, and - Site visits to look at structures and processes of care, organizational culture

with regard to transfers and communication/coordination processes.

Methods

1 CHOICE is the Coalition of Hospices Organized to Investigate Comparative Effectiveness that comprises 14 hospices caring for approximately 12,000 patients.2 Family Evaluation of Hospice Care

Products from this pilot project will include:• 3-5 best practices that are associated with the dual outcomes

of excellent family perceptions of care together with low rates of transfers. These best practices will be the basis for a quality improvement collaborative leveraging CHOICE’s electronic health record data to promote rapid improved performance;

• A set of 5-10 key lessons for the families of nursing home residents receiving hospice care, which will be made available in a brochure for families for CHOICE hospices, Institute clients, and other hospices and nursing homes by request; and

• Online educational training in collaboration with the Suncoast Institute, a nonprofit hospice education foundation affiliated with Suncoast Hospice, one of the CHOICE member hospices.

Products

Discussion• Does your foundation currently have a focus on this topic or is it

integrated in some way into your existing work? If so, tell us about what are you supporting?

• When prospecting for new work, is planning for or improving the end of peoples’ lives being considered as a focus area by your foundation?

• If not, have you thought about how to integrate into existing areas of focus? Any success or challenges?

• Foundations have played an important part in the past in this area but much still needs to be done.

• Are there lessons we should consider to enhance effectiveness? • Has the environment changed in such a way that work in this

area will be seen as particularly useful or timely?• Other?