This paper looks at nursing home quality initiatives, built around public reporting of quality data, that have been inaugurated by the Centers for Medicare and Medicaid Services and the California HealthCare Foundation. How the projects were developed is explored, along with preliminary indicators of their impact on consumers and providers and likely next steps in their evolution

Sprague, Lisa

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George Washington University: Health Sciences Research Commons (HSRC)

NHPF Issue BriefNo.787 / January 9, 2003Converging onNursing Home QualityLisa Sprague, Senior Research AssociateOVERVIEW — This paper looks at nursing home quality initiatives, builtaround public reporting of quality data, that have been inaugurated by theCenters for Medicare and Medicaid Services and the California HealthCareFoundation. How the projects were developed is explored, along with pre-liminary indicators of their impact on consumers and providers and likelynext steps in their evolution.2NHPF Issue Brief No.787 / January 9, 2003National Health Policy Forum2131 K Street NW, Suite 500Washington DC 20037202/872-1390202/862-9837    [fax]nhpf@gwu.edu [e-mail]www.nhpf.org  [web]Judith Miller JonesDirectorJudith D. MooreCo-DirectorMichele BlackPublications DirectorNHPF is a nonpartisan education andinformation exchange for federalhealth policymakers.Converging onNursing Home QualityQuality of care in nursing homes—where more than half of Americansover 65 will spend time at some point in their lives—has long been amatter of concern for residents, families, consumer groups, andpolicymakers. While various quality-related efforts have been under-taken at the federal and state levels, none has proved wholly satisfac-tory, as attested by the titles of General Accounting Office (GAO) re-ports from 1998 (California Nursing Homes: Care Problems Persist DespiteFederal and State Oversight) through 2002 (Nursing Homes: More Can BeDone to Protect Residents from Abuse).1Quality initiatives inaugurated in recent months have seized on publicreporting of quality data as key to steering people away from inad-equate or negligent care. Sponsors suggest that making information avail-able to consumers—for example, via the Centers for Medicare and Med-icaid Services’ (CMS’) “Nursing Home Compare” or the CaliforniaHealthCare Foundation’s (CHCF’s) “California Nursing Home Search”Web sites—could serve several purposes:■ Stimulate market forces by driving consumers toward the top-performing facilities, thereby forcing underachieving facilities toimprove in order to remain competitive.■ Provide benchmarks and motivation to help facilities initiate qualityimprovement efforts.■ Develop an information base on which to build public policy.2As might be said of almost any policy issue, there is a need in theseinitiatives to balance burden against benefit, the boon of readily avail-able information against the danger that it could be inaccurate or mis-used, the desire for thoroughly valid quality measures against the perilof inertia and delay.THE CMS NURSING HOME QUALITY INITIATIVEIn 1998, CMS launched its “Nursing Home Compare” Web site, whichnow provides information about nursing homes (such as number of cer-tified beds, type of ownership, and deficiencies found during the laststate inspection) and their residents (such as percentage of residentswith pressure sores or delirium). In 2001, Secretary of Health and Hu-man Services Tommy G. Thompson announced an initiative to identify,collect, and publish nursing home quality information that would helpconsumers compare nursing homes in their local area. A six-month pilot3NHPF Issue Brief No.787 / January 9, 2003project in Colorado, Florida, Maryland, Ohio, Rhode Island, and Wash-ington was expanded to all 50 states in November 2002.The pilot, designed to test new communication mechanisms for reach-ing Medicare beneficiaries, kicked off in April 2002 with newspaper adsin 30 newspapers in the six pilot states, each containing comparativequality information on nursing homes in that market. As Thompsondescribed it, “We are both helping consumers to make decisions thatbest meet their needs and creating market incentives for nursing homesto further improve quality.”3 In support of the latter effort, CMS di-rected its contracting quality improvement organizations to offer train-ing to nursing homes on using the nursing homes’ own data to identifyopportunities for improvement, to share best practices among nursingfacilities, and to partner with nursing homes in quality-improvementprograms.4Settling on quality indicators to be publicly reported was a complicatedprocess—one that is still not fully resolved. CMS originally contractedwith two organizations, Abt Associates and the National Quality Forum(NQF), to study potential quality indicators and recommend those suit-able for public reporting. Abt identified and analyzed existing qualityindicators from the literature, including those developed earlier for CMSby the Center for Health Systems Research and Analysis (CHSRA) atthe University of Wisconsin. Abt eventually recommended a set of theseto CMS, along with a number of additional indicators that Abt itselfdeveloped to address perceived gaps in measuring care in the chronicand post-acute (short-stay) populations. The recommended indicatorswere based on the quarterly Minimum Data Set (MDS) reporting re-quired of nursing homes by CMS.NQF was charged with reviewing Abt’s results and (a) recommending aset of indicators suitable for use in CMS’ six-state pilot project and (b)developing a set of core quality measures to be used nationwide. Fol-lowing its consensus-based model, NQF con-vened a steering committee, which eventu-ally recommended 11 indicators to CMS. Ninewere chosen. The agency’s criteria were thata set of measures represent a cross-sectionof domains of care and that they relate toeach other to form a picture of overall qual-ity of care. Nursing home industry represen-tatives pointed out that all but one of the in-dicators were cast as negatives, such that ahigh score is worse than a low score.Results of an Abt-conducted validation studyof the measures it had recommended to CMS(including those used in the pilot) were re-ported in August 2002. The study’s purpose“Indicator” vs. “Measure”Quality indicators, as GAO explains it, are essentially nu-meric warning signs of problems, such as a higher-than-expectedincidence of pressure sores. They are used to identify concernsthat need further investigation, but are not enough on their ownto make judgments about quality of care.Quality measures have undergone validation tests to deter-mine whether indicators actually reflect the quality of care pro-vided, after taking resident- and facility-level conditions intoaccount. Measures are reliable predictors of quality. The distinc-tion probably is lost on the typical consumer.“We are both helpingconsumers to makedecisions that bestmeet their needs andcreating market in-centives for nursinghomes to further im-prove quality.”4NHPF Issue Brief No.787 / January 9, 2003was to confirm that the indicators were accurate reflec-tions of the quality of care provided by nursing homes.All but one of the pilot indicators (weight loss) passedmuster and were accepted for use in the national rollout.CMS also made explicit the issue of risk adjustment, whichhas always been crucial in indicator analysis.Many quality indicators have an associated risk factor atthe level of the individual patient; that is, a patient’s un-derlying health or functional status may make him or hermore or less likely to develop one of the conditions thatwould trigger a quality indicator. Resident-level adjust-ment is built into the indicators for delirium in short-staypatients and pain in long-term residents. Moreover, facil-ity risk profiles differ as well; a nursing home that admitsa large number of frail or cognitively-impaired residentsmay expect to score differently than one whose popula-tion is less impaired. To address this, the Abt team pro-posed an approach that adjusts quality measures basedon a nursing home’s admission profile. CMS elected toinclude facility admission profile information for threeindicators: pressure sores for long-term residents and de-lirium and walking for short-stay patients.CALIFORNIA NURSING HOME SEARCHBoth CMS and CHCF recognized that it has been difficult for consum-ers to find and understand information on nursing home quality. InFebruary 2000, CHCF funded a two-year program to evaluate the qual-ity of California’s nursing homes and to distribute the findings to thepublic via an interactive Web site. The CHCF project also included avalidation of MDS-based clinical quality performance indicators beforepublicly reporting these measures. The research phase of the projectrevealed that there were significant problems with quality of care inmost nursing homes in the state and in most of the clinical areas beingreviewed.The “California Nursing Home Search” Web site presents facility-specificinformation in a number of categories: facility characteristics, residentcharacteristics (including demographics, care needs, length of residence,and need for assistance), nurse staffing, quality performance indicators,complaints that have been substantiated by the state licensing and certifi-cation agency, deficiencies and citations, and financial indicators.While some of the information found on “California Nursing Home Search”is similar to that found on CMS’ “Nursing Home Compare” Web site, theCalifornia project made use of state-specific data in order to broaden andimprove the categories of information available to the consumer. For ex-ample, California nurse staffing information is augmented to includeQuality Indicators Used NationwidePercentage of chronic care patients who:■ Have lost ability in basic daily tasks.■ Have a pressure ulcer (bed sore).■ Have a pressure ulcer, with adjustment forfacility risk.■ Are in severe pain at any time or moderatepain every day for seven days.■ Are in physical restraints.■ Have certain types of infections.Percentage of post-acute patients who:■ Have symptoms of delirium.■ Have symptoms of delirium, withadjustment for facility risk.■ Are in severe pain at any time or moderatepain every day for seven days.■ Walk as well as or better than when lastmeasured.5NHPF Issue Brief No.787 / January 9, 2003turnover rates and recommended as well as average staffing ratios. Fi-nancial information (not available from CMS) also is included. Financialindicators are compiled from cost report data that nursing homes arerequired to submit to California’s Office of Statewide Health Planningand Development.CHCF’s original seven quality performance indicators are all CHSRA-developed measures for chronic care: weight loss, being in bed all ormost of the time, use of physical restraints, presence of pressure ulcers,problems controlling bowel or bladder functions, and loss of functioningor ability to carry out activities of daily living. The validation study foundthat the relationship between the quality performance indicator and thelevel of care provided at a facility was strong enough to allow a facility tobe rated as better than average, average, or worse than average for threequality performance indicators: weight loss, being in bed all or most ofthe time, and use of physical restraints.5 Ratings for these three are nowincluded on the Web site. The four others are included on the site but notrated, because “no significant differences in care processes were observedbetween homes that scored high and low on these indicators.”6“California Nursing Home Search” went live on October 15, 2002. Onthat same day—not coincidentally—Gov. Gray Davis announced his Long-Term Care Consumers initiative, designed to expand consumer protec-tion for seniors and impose stiffer penalties for nursing home violations.Three states, Maryland, Rhode Island, and Florida, also report facility-specific CHSRA-based quality indicators, and other states are in theprocess of developing their own reporting systems.NEXT STEPSWhile CMS was preparing for its pilot and CHCF for its launch, theNQF steering committee continued to work on the second part of itscharge from CMS, a core set of nursing home quality measures for usenationwide. In making recommendations for the pilot, the committeehad agreed to limit itself to considering those indicators already recom-mended by Abt. For the core set, NQF made clear, no such limitationwould apply. The steering committee felt strongly that domains of carebeyond the clinical should be considered, such as quality of life andpatient satisfaction.In April 2002, NQF released a draft consensus report for NQF member-ship and public comment. The thought was then to proceed to a boardvote in the summer. However, various interested parties (notably CMS,but also stakeholders such as the American Association of Homes andServices for the Aging) requested that NQF delay a vote, on the groundsthat additional information, including the Abt validation study and an-other carried out by CHCF, was soon to become available. The NQFboard agreed to a delay, and has undertaken a de novo consideration ofa core set of measures under a new CMS contract.Financial informationnot available on theCMS site is includedon the CHCF site.6NHPF Issue Brief No.787 / January 9, 2003CMS elected to go forward with the initiative in all 50 states before NQFcompleted its work, drawing criticism from the General Accounting Of-fice (GAO) for its precipitancy. GAO’s reservations were based in con-cern about the accuracy of underlying MDS data, the representativenessof Abt’s validation sample, and CMS’ capacity to respond to questionsraised by the public about how to interpret and use the newly availableinformation, as well as the fact that the pilot had not been fully evaluated.In the same report, however, GAO described CMS’ public-reportinginitiative as “a commendable and worthwhile goal.”7 This assessmentappears to be shared by all concerned, including nursing home industrytrade associations.8 Differences of opinion about implementation haveyet to be resolved, though both CMS and CHCF have pledged to adoptthe consensus measures once these have been promulgated by NQF.How meaningful quality measures are to consumers at the time of seek-ing a nursing home placement will have to be studied over time. Ob-servers agree that the most important test will be to establish links be-tween quality initiatives and demonstrable quality improvement in nurs-ing home care.ENDNOTES1. U.S. General Accounting Office, California Nursing Homes: Care Problems Persist De-spite Federal and State Oversight (GAO/HEHS-98-202), Washington, D.C., July 27, 1998;U.S. General Accounting Office, Nursing Homes: More Can Be Done to Protect Residentsfrom Abuse (GAO-02-312), Washington, D.C., March 1, 2002.2. California Nursing Home Search, “Web Site Overview and Research Findings,” accessedDecember 10, 2002, at http://www.calnhs.org/research/view.cfm?itemID=19963.3. U.S. Department of Health and Human Services,”HHS Releases Quality Data aboutIndividual Nursing Homes,” press release, Washington, D.C., April 24, 20024. Yael Harris and Steven B. Clauser, “Achieving Improvement through Nursing HomeQuality Measurement,” Health Care Financing Review, 23, no. 4 (Summer 2002): 12.5. California Nursing Home Search, “Web Site Overview.”6. California Nursing Home Search, “Web Site Overview.”7. U.S. General Accounting Office, Nursing Homes: Public Reporting of Quality IndicatorsHas Merit, but National Implementation Is Premature (GAO-03-187) Washington, D.C.,October 31, 2002.8. For example, the American Health Care Association’s press releases in connection withthe pilot launch and the national rollout were headlined, respectively, “Administration’sNursing Home Quality Initiative ‘Bold, Timely, and Historic’” and “National Nursing HomeQuality Initiative to Improve Patient Care, Consumer Power to Choose.”

Converging on Nursing Home Quality

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Converging on Nursing Home Quality

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