Predicting Quality in Nursing Homes: What do the Stars

Tell Us?ARIF NAZIR MD, CMD

President, Indiana Medical Directors AssociationAssistant Professor, Clinical Medicine

Division of General Internal Medicine & GeriatricsDepartment of Medicine

August 20, 2010

My colleagues and Mentors advice:

• Don’t be too detailed• Don’t use Geriatric lingo• Bottom line: “Think of the time when you were

a resident and think of what would you have want to know about nursing homes”

Objectives:

By the end of this presentation, participants will be familiar with:

1.Nursing home compare and 5 Star rating system for nursing home quality

2.Other factors impacting nursing home quality

3.The role of an interdisciplinary team in nursing home discharges

You are attending this presentation because:

April 19, 2023

1. You see (or used to see) pts in nursing homes

2. You manage nursing home patients in hospital

3. Neither of above but interested in the topic

4. Someone said that there was free lunch

Why is this presentation important?

• A significant proportion of older inpatients are discharged to nursing homes (NHs).

• Not all NHs are similar and offer a wide spectrum of quality

• Re-hospitalizations: Increasing consequences for hospitals and nursing homes

• Reimbursement models are evolving with focus on “bundled payments”

• A third of us will spend some time in a nursing home!

April 19, 2023

April 19, 2023Customize footer: View menu/Header and Footer

Do you have a loved one in a nursing facility?

April 19, 2023Customize footer: View menu/Header and Footer

1. Yes

2. No

Regarding Nursing Home Quality of Care:

April 19, 2023Customize footer: View menu/Header and Footer

1. I have NO concerns

2. I am concerned

3. I am seriously concerned

4. Not sure

A Case• Mrs. Smith an 79 yo AAF with mild

dementia admitted with pneumonia and intubated in the ICU

• Survives and transferred to monitored floor but still very weak

• Team assess for discharge options• Mrs. Smith lived alone with the help from

a daughter and a son who live few miles away

Case…..cont’d• Physical therapy recommends a NH discharge

for rehab• Mrs. Smith agrees BUT wants to:

- ask Aunt Gina who “knows it all”- stay close to daughters house

• Her son states, “Doc, since I read the newspaper articles, I am very concerned about care provided in nursing homes. Can you make sure that mom goes to the best facility in the town”

April 19, 2023

Case…..cont’d

• Social worker provides a list of 6 “decent” NHs within 5 miles of daughter’s home

• Next day son calls, “Doc, aunt Gina recommends these two homes, but I need your help to make the decision”

Happy Meadows4-STAR Rated Facility

Sloppy Shadows2 -STAR Rated Facility

How should the team respond?

April 19, 2023

1. Avoid saying much due to “patient choice act”

2. Help arrange visits to a couple nursing homes

3. Provide nursing home websites

4. Provide information on “Nursing Home Compare” and other resources

5. Consult with Aunt Gina

I discharge patients to nursing homes:

April 19, 2023

1. Frequently

2. Sometimes

3. Rarely

4. Never

Measuring Quality in NHs

• Quality of long-term care is multidimensional. Ideally it should include:

– Clinical care issues– Functional independence– Current Minimum Data Set records – Quality of life, and – Patients’ and families’ satisfaction

Mor V, Berg K, Angelelli J, Gifford D, Morris J, Moore T. The quality of

quality measurement in US nursing homes. Gerontologist 2003;43(Spec No 2):37– 46

• A CMS website to help consumers choose a NH• Allows search for a NH by geography (state or

county), by proximity (city or zip code), or by name.

• Also provides a “Nursing Home Checklist,”• Provides the 5 Star rating for all facilities in the

nation compared to other state facilities

April 19, 2023

Nursing Home Compare

Audience and Nursing Home Compare

April 19, 2023

1. I utilized the website for a loved one

2. I have visited the website

3. I have only heard of it

4. I just learned about it

• Available thru Nursing Home Compare. • Bell shaped distribution:

- Ten percent 5- star and 20% 1- star• Ratings aggregate of three sources:

- State survey results.- Staffing data.- Quality Measures.

• Limitations

Customize footer: View menu/Header and Footerhttps://www.cms.gov/CertificationandComplianc/Downloads/usersguide.pdf

5 Star rating for Nursing Homes

April 19, 2023

5 Star Rating System

State Survey

Staffing Quality Measures

Happy Meadows

3 STARS +1 0 4 STARS

Sloppy Shadows

4 STARS -1 -1 2 STARS

State surveys

April 19, 2023

State survey process

• Carry the heaviest weight in the 5-Star ratings

• Unannounced every 9-15 months• Compares facility to standards in

the Code of Federal Regulations(CFR)

• A 3-5 surveyor team reviews records and interviews all parties as needed.

• Deficiencies or tags cited• “Plan of correction”• Repeat state survey• Publicly reported survey score

for comparison

April 19, 2023Customize footer: View menu/Header and Footer

State survey process

Indiana Report Card

http://www.in.gov/isdh/reports/QAMIS/ltc/repcard/search.htm

Issues with State Survey process

Government Accountability Office (GAO; 2004)

1. Depends upon staff competency

2. Complex regulations

3. Inadequate state oversight of the survey process and predictable timing of surveys.

4. Variation in deficiency citation exists between and within states (Detection bias)

So the State Survey Process is….

- Well structured and quite broad in scope

- Creates sense of accountability- Helps in quality improvement

process- Provides the consumers a

voice- Scores are publicly available for

comparison- Not a perfect science

April 19, 2023

1. Carry the heaviest weight in 5 Star ratings

2. Scores are only available to the facility

3. Detection bias is a concern

4. Surveyors can interview anyone they chose

April 19, 2023

1. Carry the heaviest weight in 5 Star ratings

2. Scores are only available to the facility

3. Detection bias is a concern

4. Surveyors can interview anyone they chose

Nursing Home TriviaWhich of the following is FALSE about the State Surveys:

April 19, 2023Customize footer: View menu/Header and Footer

NH Environment and Staffing

• NHs are nursing homes and NOT “mini hospitals”• Administration (owner, administrator, Director of

Nursing)• Nursing Staff:

- Registered Nurses (RNs)

- Licensed Practical Nurses

- Certified Nurses Assistants• Other departments

April 19, 2023

Staffing and Quality• Better nurse staffing ratios lead to better NH

quality of care

• Also higher quality related to:– Low staff turnover rates– Director of Nursing retention– Higher number of Licensed staff (RNs and LPNs)

related to low probability of death and higher discharge to home

(Fish 2001; Unruh 2004; Schnelle 2004; Bostick 2007)

Appropriate Staffing ratios

Customize footer: View menu/Header and FooterAbt Associates Inc. Appropriateness of Minimum Staffing Ratios in Nursing Home: Report to Congress Phase II Final. Executive Summary: Phase II Report . 2001;I(Contract # 500-0062/TO#3)

• Measured in nursing hours per resident per day or per week:

National average 17

Indiana Average 15

For 5 STAR facilities >18

For MAX credit towards 5 STAR rating 28

For BEST results 31.5

April 19, 2023

Quality Measures/Quality Indicators

Quality Measures/Quality Indicators

Type 1963 1987 1999 2009

Structure 55 98 81 104

Process 22 38 48 62

Outcome - 3 24 24

Slow progression over time and belong to structure, process and outcomes categories

• Omnibus Budget Reconciliation Act (OBRA, 87)• Mandated comprehensive functional

assessments for all residents called Minimum Data Set (MDS)

• MDS information assists with:

• Reimbursements• Survey processes• Generating quality data including indicators

and measures

Current Assessments and Quality Data

• MDS data summarized into a monthly Quality Indicator/measures report.

• Quality measures (QMs):• percentages of residents in the facility with

certain problems• Help in monitoring/tracking of care• Reported on Nursing Home Compare website• Carry least weight towards the 5 Star ratings

April 19, 2023

MDS and Quality Measures

Sample Quality Measures

(O) Percent of long-stay residents who had a urinary tract infection/wt loss/ pressure ulcers

(O) Percent of long-Stay residents whose need for help with daily activities has increased

(O) Percent of long-stay residents who are more depressed or anxious

(P) Percent of long-stay residents who have/had a catheter inserted and left in their bladder

(P) Percent of short-stay residents who were assessed and given pneumococcal vaccination

http://www.medicare.gov/NHCompare/Static/tabHelp.asp?language=English&activeTab=4&subTab=1

• Present a cross-section of time• Staff dependent• Less beds may limit statistical power• Higher acuity facilities may have poor scores• Conservative Risk Adjustments:

- Comorbidities- Cognition- Type of facility (Mor, Berg et al. 2003)

Limitations of Quality Measures

So the Quality Measures .….

- Are well balanced between processes and outcomes

- Provide a cross section of quality - Are used for quality improvement and tracking

care- Are publicly available and “point” to possible

care issues- Have several limitations

April 19, 2023

Nursing Home Trivia

1

April 19, 2023Customize footer: View menu/Header and Footer

Nursing Home TriviaWhich of the following is FALSE:

April 19, 2023

1. High staffing ratio improve quality in NHs

2. Quality measures originate from the state survey scores

3. Indiana NHs lag behind in their staffing ratios

4. Current quality measures represent a good balance of outcome and process measures

Nursing Home Compare Overview

• Offers multiple resources including 5 Star ratings and NH checklist

• Provides a snapshot of care in a facility• Facilities that utilize the scores for quality

improvements tend to improve• A crucial but only an initial tool in the process

of selecting a NH (Mr. Edward Mortimer)

April 19, 2023

Other Evidence Based predictors of Quality of Care and Life in NHs

• Medical staffing patterns

• Consistent nursing assignments

• Profit/ non-for-profit status of the facility

• Patient factors and co-morbidities

• Patient and/or family Satisfaction

April 19, 2023Customize footer: View menu/Header and Footer

Patient Satisfaction

April 19, 2023

Quality Improvements in NH care

• Use of MDS led to significant decrease in multiple measures (restraints, ulcers, pain etc)

• CMS supported Advancing Excellence in Nursing Home Care Campaign

- Multiple successes in Indiana and nationwide- Achieving targets in multiple quality measures

• Indiana Pressure Ulcer Reduction Initiative• Culture Change Movement (www.pioneernetwork.com)

Back to Mrs. Smith

1. What steps can the team take to help transition to a high quality facility

2. How much the team can say?

3. What responsibilities do they have?

April 19, 2023

For Physicians Who Discharge Patients to NHs

1. I only write the discharge orders

2. I also discuss NH options with the social worker

3. I use some tool to assess NH quality

Patient Choice in Discharge process

• The Social Security Act guidance:- Appropriateness of the discharge setting- The availability of the discharge venue- Conflict of interest and not steer patients to

a partner facility• The team is responsibility to assure that

discharge venue is appropriate

Team’s Role in Discharging Mrs. Smith

• Case Management Society of America (CMSA): Five Ethical Principles of Case Management- Non-Maleficence: Do no harm- Beneficence: Look out for patient benefit- Autonomy: Right to information and self

determination with free and informed consent- Veracity: Truth telling and obligation to full

honest disclosure

- Justice: Actions are consistent and transparent

April 19, 2023

Team’s Role in Discharging Mrs. Smith

• Inquire preferences • NH Compare information to help assess

quality (“weather” analogy)• Discuss other factors that may impact quality• Advise to visit facility using the NH checklist

http://www.medicare.gov/nursing/checklist.pdf

• Review any patient/ family satisfaction tools• Hospital relationships• Provide accurate discharge orders and

summariesApril 19, 2023

So to Summarize…..

1. Nursing Home Compare and 5- star ratings can help patients in selecting the appropriate NH.

2. 5 Star rating and its components do have limitations and be used as an initial step in selecting a nursing home.

3. Several other factors impact quality of NH care

4. Inpatient teams should help patients to select high quality nursing homes.