CHRONIC LONGTERM CARE QIs: FILLING IN THE GAPS

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NATIONAL ACADEMY FOR STATE HEALTH POLICY ANNUAL
CONFERENCE
Richard H. Lee Deputy Secretary for Quality
Assurance August 2, 2004
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Focus of Quality Assurance System
Sanctions
Consumers
Provider Education
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BEST PRACTICESProject Concepts

• Provide positive assistance for improving quality
  of care in nursing homes
• Use existing data sets, measurement tools and
  quality standards for better outcomes
• Develop outcomes-based best practices that are
  effective in improving quality of care
• Scientific validity ensures replicability

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BEST PRACTICESProject Operations

• Each Best Practice has
• Protocols for targeting specific residents
• Familiar mandated processes as vehicle for
  introducing change (MDS assessments)
• Processes comparable to usual care costs
  (substitute one process for another)
• Effective training techniques
• Quality monitoring

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BEST PRACTICESPhase 1 Activity

• December 2001 Public Kick Off
• February 2002 Workshop for Non Participating
  Facilities
• June 2003 Workshop for Participating Facilities
  with Phase 1 Outcomes
• November 2003 Media Event Montgomery County
  Geriatric and Rehabilitation Center
• March 2004 Legislative Updates
• Positive Trade Publication Articles

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Best PracticesDeveloped 2001-2003

• 3 Best Practice protocols
• ADL Functional Rehabilitation
• Pain Reduction
• Depression Reduction
• Continue to implement and test in
• Original control homes
• As 2nd intervention in original testhomes
• Released Pain Protocol

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BEST PRACTICESPhase 1 Outcomes

• ADL Test sites improved 30 to 40 controls
  experienced lower rate of improvement
• PAIN Test sites improved 19 controls
  improved only 7
• DEPRESSION Test sites improved 22 controls
  declined 15

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ADL Percent Improvement change in QI
rates (Based on the mean change of improvement of
QI rates at baseline, January through March 2002,
and after protocol implementation.)

ADL Late Loss Worsening
8.3
32.1
0 5 10 15 20 25 30
35
CONTROL FACILITIES
TEST FACILITIES
0 Baseline
9
PAIN Percent Improvement in QI rates
(Based on the mean change of improvement of QI
rates at baseline, January through March 2002,
and after protocol implementation.)
Pain Mean QI
7.1
18.8
0 5 10 15 20
CONTROL FACILITIES
TEST FACILITIES
0 Baseline
10
DEPRESSION Percent Improvement in QI
rates (Based on the mean change of improvement of
QI rates at baseline, January through March 2002,
and after protocol implementation.)
Depression Mean QI
- 15.4
22.2
-20 -10 0 10 20

CONTROL FACILITIES
TEST FACILITIES
0 Baseline
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PHASE 1 CONCLUSIONS

• Improved protocols improve outcomes
• Outcomes can be measured
• Nurse educator support is critical
• Outcomes can be improved without cost
• Staff Satisfaction is improved

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BEST PRACTICESPhase 1 Summary

• Systematic, consistent implementation of
  protocols
• Commitment by all staff at all levels
• Nurse educator support and education
• Best practices are interrelated
• Empower facility staff and increase staff
  satisfaction
• Pain Protocol now available to PA facilities
  through Department website

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BEST PRACTICESTRANSITION
Phase 1 20 Sites Apr01 to May03
Phase 2 60 Sites Jun03 to May05
28 Control
5
10 Control
Phase 1 Control (5) Phase 2 New Control (23)
2
9
10 Test
32 Test
ADL (2) 2 as second Best Practice Pain (4) 3
as second Best Practice Depression (3) 2 as
second Best Practice
ADL (2) Pain (4) Depression (4)
New ADL (4) New Pain (3) New Depression (4) New
Pressure Ulcers (6) New Urinary Incontinence (6)
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BEST PRACTICESPhase 2 Activities

• Added 2 new protocols
• Urinary Continence
• Pressure Ulcers
• Continued Nurse Educator support for original
  protocols
• Continued empirical evaluation

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BEST PRACTICES Phase 2 Selection

• QI Analysis to identify care areas with
  differential performance
• Survey of Stakeholders priorities for quality
  improvement activities
• Survey of DoH inspectors observations and
  priorities
• Analysis of DoH Quality of Care citations

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PHASE 2 STATUS
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PHASE 2 CARE AREAPRESSURE ULCERS

• 6 13 of nursing home residents have pressure
  ulcers another 13 have had one in the past
• Additional 60 at risk of developing pressure
  ulcer
• Pressure ulcers are expensive to treat
• Resident well-being
• Prevent pain and other associated outcomes
• Improve quality of life
• Decrease mortality risk

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PHASE 2 CARE AREAURINARY INCONTINENCE

• Traditional interventions extremely
  time-consuming for staff to implement
• Protocol aimed at
• Targeted population
• Approach
• Protocol ready for implementation in early May
• Received resident input

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BEST PRACTICESISSUES

• Staff Turnover Administrator, DON, Project
  Coordinator, other key staff
• Physician cooperation
• Staff buy in
• Family Acceptance
• Careful coordination with QIO

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CONCLUSIONS

• Phase 1 Successful
• Phase 2 Well Underway
• Much Positive Media
• Solid Empirical Evidence