Identifying Star Performers: The Relationship Between Ambitious Targets and Nursing Home Quality Improvement

Setting Targets—Achieving Results (STAR) is a Web-based tool that helps nursing home leadership select annual performance goals, or targets, for a subset of publicly reported quality measures. Previous results demonstrate that nursing homes whose staff implement STAR targets demonstrate greater improvement on the related outcomes. In this analysis, the authors hypothesized that nursing homes whose staff select the most ambitious targets (reflecting large improvement over their current performance) may be more successful in their related quality improvement efforts than homes with less-ambitious targets (reflecting lesser improvement). The authors analyzed data from 7,091 Medicare- or Medicaid-certified nursing homes that set STAR targets in 2005 or 2006 for two quality measures: the proportion of residents who were physically restrained daily and the proportion of high-risk residents with pressure ulcers. Targets were classified as ambitious or less ambitious based on the 75th and 50th rank-ordered percentiles, respectively. Improvement was calculated using four-quarter averages for baseline (the year ending when the target was set) and remeasurement (the subsequent year). The results indicate that nursing homes with ambitious targets demonstrate greater improvement than their peers selecting less-ambitious targets. With limited federal and local resources to assist providers with quality improvement, target values may be a used as a "flag" to help agencies allocate scarce resources to nursing homes committed to quality improvement efforts and with the organizational capacity to improve.     

Purchasing or providing nursing home care: can quality of care data provide guidance

OBJECTIVES: To examine whether quality of care differed for veterans in Department of Veterans Affairs (VA) nursing homes and those on contract in community nursing homes, and whether the VA was contracting with nursing homes providing better quality of care than other nursing homes. DESIGN: Observational study using administrative databases from 1997 to 1999. SETTING: Ten VA and 650 community nursing homes in New York state. PARTICIPANTS: Four thousand seven hundred sixty-three veteran and 195,438 nonveteran residents of these nursing homes. MEASUREMENTS: Risk-adjusted rates of pressure ulcer development, functional decline, behavioral decline, and mortality. RESULTS: Veterans in VA nursing homes were significantly (P< .05) less likely to develop a pressure ulcer (odds ratio (OR)=0.63) but more likely to experience functional decline (OR=1.6) than veterans in community nursing homes. Residents of community nursing homes with VA contracts were significantly (P< .05) less likely to develop a pressure ulcer (OR=0.91) but more likely to die than residents in noncontract homes. Few nursing homes were consistently among the best or worst performers on all measures; only seven of 650 nursing homes were in the top or bottom decile and 34 in the top or bottom quartile for each measure. CONCLUSION: Large purchasers and providers of nursing home care such as the VA are unlikely to find information on quality of care useful in making decisions on whether they should "make" or "buy" care. Nursing homes performing well on one quality measure may perform poorly on another, and it is difficult to identify nursing homes that are consistently among the best or worst. Other consumers may encounter similar difficulties when using data on nursing home quality.     

Osteoporosis and living of residents in a nursing home

Residents in a nursing home can become bedridden following fracture caused by osteoporosis or falls. To prevent fall and fracture is important, and conceived to reflect quality of caregiving in individual facilities. The incidence of falling is around 35% in all nursing homes related to our facility. Incidents of falling occur mostly during walking among ambulatory residents, and during performing transfers among residents using wheelchairs. Dementia is suggested to be a factor influencing the incidence of falling. In order to prevent fracture resulting from falling and osteoporosis in nursing homes, it is important that all working members in each facility examine prevention measures comprehensively, while considering characteristics of an environment of their facility and residents therein. All working members should thereby activity interven in the QOL (quality of life) of residents, and assist them to lead a healthy and joyful life n their nursing home.     

Nursing home staff networks and COVID-19

Nursing homes and other long-term care facilities account for a disproportionate share of COVID-19 cases and fatalities worldwide. Outbreaks in US nursing homes have persisted despite nationwide visitor restrictions beginning in mid-March. An early report issued by the Centers for Disease Control and Prevention identified staff members working in multiple nursing homes as a likely source of spread from the Life Care Center in Kirkland, WA, to other skilled nursing facilities. The full extent of staff connections between nursing homes—and the role these connections serve in spreading a highly contagious respiratory infection—is currently unknown given the lack of centralized data on cross-facility employment. We perform a large-scale analysis of nursing home connections via shared staff and contractors using device-level geolocation data from 50 million smartphones, and find that 5.1% of smartphone users who visited a nursing home for at least 1 h also visited another facility during our 11-wk study period—even after visitor restrictions were imposed. We construct network measures of connectedness and estimate that nursing homes, on average, share connections with 7.1 other facilities. Traditional federal regulatory metrics of nursing home quality are unimportant in predicting outbreaks, consistent with recent research. Controlling for demographic and other factors, a home’s staff network connections and its centrality within the greater network strongly predict COVID-19 cases.

Linked to more than 40% of all US fatalities as of August 31, 2020, nursing homes and other long-term care facilities have been disproportionately afflicted by the ongoing coronavirus pandemic (1–3).^*With an elderly resident population, many with underlying chronic medical conditions, congregate living quarters, and routine contact with staff members and outside visitors, nursing homes are particularly vulnerable to outbreaks of respiratory pathogens (4, 5). The US Centers for Medicare and Medicaid Services (CMS), the primary federal regulator of nursing homes, estimates that more than 30% of all nursing home residents in New Jersey, Connecticut, and Massachusetts had contracted severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as of June 28, 2020, and that more than 9% of the entire nursing home population died in these states (6).Evidence from the early outbreak at the Life Care Center in Kirkland, WA, demonstrated that nursing homes and other congregate facilities face extremely elevated risks of virus spread (7, 8). CMS guidance issued on March 13, 2020 significantly restricted visitor access to long-term care facilities—effectively locking down nursing homes to residents, staff, and contractors (9). Nevertheless, many COVID outbreaks subsequently occurred in nursing homes, suggesting the unwitting introduction of the virus into homes by staff and contractors as one potential channel. The practice of employing nursing home staff across multiple facilities may play a key role in the spread of SARS-CoV-2, as a US Centers for Disease Control and Prevention (CDC) report issued on March 18, 2020 identified staff working in multiple nursing homes as a likely source of spread from the Life Care Center to other skilled nursing facilities in Washington State (8). Of the first four nursing homes with COVID outbreaks following this initial outbreak, two facilities received patient transfers from Life Care, and two facilities employed staff working in both places (10).Despite this early recognition of cross-traffic between congregate settings as a potentially important transmission mode, the extent of connections between nursing homes remains unknown due to lack of systematic data. Furthermore, although the CDC identified staff members working in multiple long-term care facilities as a key high-risk group, CMS has not provided any specific guidance on this practice or on reducing contacts between homes more generally (9, 11, 12).Using device-level geolocation data for 501,503 smartphones observed in at least one of the 15,307 nursing homes in the continental United States, we find that 5.1% of individuals who spent at least 1 h in a nursing home also spent at least 1 h in one or more other nursing homes in the 11-wk period following the March 13 nationwide restriction on nursing home visitors. We construct several measures from network theory to characterize nursing home connectedness, and examine whether such connectivity predicts confirmed and suspected COVID-19 cases. These data are anonymized, but, given the prohibition of social visitors, this cross-traffic between homes is likely traceable to staff and contractors. While our methodology cannot establish causation, we find that the number and strength of connections between nursing homes—and a home’s centrality within the greater network—strongly predict COVID cases, even after controlling for location, demographic factors, number of beds, for-profit status, and CMS quality ratings. Consistent with recent research (13–15), we observe that traditional federal regulatory metrics of nursing home quality are unimportant in predicting outbreak size.     

Nursing home quality, cost, staffing, and staff mix

PURPOSE:The purpose of this study was to describe the processes of care, organizational attributes, cost of care, staffing level, and staff mix in a sample of Missouri homes with good, average, and poor resident outcomes. DESIGN AND METHODS:A three-group exploratory study design was used, with 92 nursing homes randomly selected from all nursing homes in Missouri and classified into resident outcome groups. Resident outcomes were measured by use of quality indicators derived from nursing home Minimum Data Set resident assessment data. Cost and staffing information were derived from Medicaid cost reports. Participant observation methods were used to describe the care delivery processes. RESULTS:In facilities with good resident outcomes, there are basics of care and processes surrounding each that staff consistently do: helping residents with ambulation, nutrition and hydration, and toileting and bowel regularity; preventing skin breakdown; and managing pain. The analysis revealed necessary organizational attributes that must be in place in order for those basics of care to be accomplished: consistent nursing and administrative leadership, the use of team and group processes, and an active quality improvement program. The only facility characteristic across the outcome groups that was significantly different was the number of licensed beds, with smaller facilities having better outcomes. No significant differences in costs, staffing, or staff mix were detected across the groups. A trend in higher total costs of 13.58 dollars per resident per day was detected in the poor-outcome group compared with the good-outcome group. IMPLICATIONS:For nursing homes to achieve good resident outcomes, they must have leadership that is willing to embrace quality improvement and group process and see that the basics of care delivery are done for residents. Good quality care may not cost more than poor quality care; there is some evidence that good quality care may cost less. Small facilities of 60 beds were more likely to have good resident outcomes. Strategies have to be considered so larger facilities can be organized into smaller clusters of units that could function as small nursing homes within the larger whole.     

Nursing home staffing and quality under the nursing home reform act

PURPOSE: We examine whether the Nursing Home Reform Act (NHRA) improved nursing home staffing and quality. DESIGN AND METHODS: Data from 5,092 nursing homes were linked across the 1987 Medicare/Medicaid Automated Certification System and the 1993 Online Survey, Certification and Reporting system. A dummy-year model was used to examine the effects of the NHRA on pressure ulcers, physical restraints, and urinary catheters, and a first-difference approach to fixed-effects regression analyses was used to estimate the effects of time-varying staffing on the quality of care. RESULTS: Overall, we found a significant increase in nursing home staffing levels from 1987 to 1993. Moreover, after controlling for other facility, resident, market, and state factors, there was a significant decrease in the proportion of residents with pressure ulcers, physical restraints, and urinary catheters following the implementation of the NHRA. Across all facilities, the increase in staffing was not directly related to the improvement in quality over the period of our study, but there was a positive relationship between registered nurse staffing and quality for facilities that were particularly deficient prior to the NHRA. IMPLICATIONS: Following the NHRA, quality improvements were found in nursing homes nationwide, and these results suggest that part of this improvement was due to the quality and staffing regulations within the NHRA.     

Increasing influenza immunization for long-term care facility staff using quality improvement

OBJECTIVES: To improve staff immunization rates for influenza in long-term care facilities (LTCFs).
DESIGN: A quality improvement project.
SETTING: LTCFs ranging in size from 50 to 2,000 beds.
PARTICIPANTS: Staff members at facilities.
MEASUREMENTS: Change in staff influenza immunization rate.
RESULTS: Of the 13 nursing homes involved, 11 improved their staff influenza immunization rates; nine improved more than 10%, and six improved to a rate greater than 55%, a level that corresponds to substantial protection against outbreaks. Staff education was essential but insufficient. Direct encouragement and dramatic informative endeavors helped, as did financial incentives, competitions, and requiring unambiguously worded consents for refusals. Paying staff members $150 each achieved improvement rapidly.
CONCLUSION: Quality improvement increased staff immunization rates at LTCFs, which reduces the risk of an influenza outbreak. Based on the insights learned about effective changes, the project developed a change package for use by other LTCFs.     

Collaborative clinical quality improvement for pressure ulcers in nursing homes

The National Nursing Home Improvement Collaborative aimed to reduce pressure ulcer (PU) incidence and prevalence. Guided by subject matter and process experts, 29 quality improvement organizations and six multistate long-term care corporations recruited 52 nursing homes in 39 states to implement recommended practices using quality improvement methods. Facilities monitored monthly PU incidence and prevalence, healing, and adoption of key care processes. In residents at 35 regularly reporting facilities, the total number of new nosocomial Stage III to IV PUs declined 69%. The facility median incidence of Stage III to IV lesions declined from 0.3 per 100 occupied beds per month to 0.0 (P<.001) and the incidence of Stage II to IV lesions declined from 3.2 to 2.3 per 100 occupied beds per month (P=.03). Prevalence of Stage III to IV lesions trended down (from 1.3 to 1.1 residents affected per 100 occupied beds (P=.12). The incidence and prevalence of Stage II lesions and the healing time of Stage II to IV lesions remained unchanged. Improvement teams reported that Stage II lesions usually healed quickly and that new PUs corresponded with hospital transfer, admission, scars, obesity, and immobility and with noncompliant, younger, or newly declining residents. The publicly reported quality measure, prevalence of Stage I to IV lesions, did not improve. Participants documented disseminating methods and tools to more than 5,359 contacts in other facilities. Results suggest that facilities can reduce incidence of Stage III to IV lesions, that the incidence of Stage II lesions may not correlate with the incidence of Stage III to IV lesions, and that the publicly reported quality measure is insensitive to substantial improvement. The project demonstrated multiple opportunities in collaborative quality improvement, including improving the measurement of quality and identifying research priorities, as well as improving care.     

Quality improvement and incontinence in long-term care

The quality improvement framework provides a practical way for nursing homes to prevent and reduce urinary incontinence (UI)for residents. It provides a means for facilities to identify organizational factors that may be hindering appropriate continence care from being provided to residents. It enables nursing homes to integrate evidence-based UI practices and monitor the consistent application of those practices by staff. The regular collection and analysis of data related to UI is essential for identifying problems,seeking accurate solutions, providing staff with feedback regarding their performance, and evaluating the overall quality of continence care provided to residents.     

Nursing homes' response to the nursing home compare report card

OBJECTIVE: The Centers for Medicare and Medicaid Services have recently begun publishing the Nursing Home Compare report card. The objective of this study was to examine the initial reactions of nursing homes to publication of the report card and to evaluate the impact of the report card on quality-improvement activities. METHODS: We conducted a survey of a random national sample of 1,502 nursing home administrators; 724 responded. We analyzed frequency of responses to questions regarding views of the quality measures and actions taken. RESULT: A model of nursing homes' behavior predicted that the report card would provide an incentive for facilities to improve quality. A majority of facilities (69%) reported reviewing their quality scores regularly, and many have taken specific actions to improve quality. Homes with poor quality scores were more likely to take actions following the publication of the report card. DISCUSSION: These findings suggest that the Nursing Home Compare report card has the potential to positively affect nursing home quality.     

Challenges to Achieving Adequate Sample Sizes for Facility Level Evaluations of Nursing Home Resident Satisfaction

Residents with cognitive limitations by necessity are excluded from nursing home satisfaction initiatives. We used national data from the Minimum Data Set (MDS) to examine the distribution of resident cognitive status across nursing homes to gain further insight into how residents with cognitive limitations could impact the sample size of respondents. We estimate the associations of cognitive status (using the MDS Cognitive Performance Scale, [CPS]) with length-of-stay, bed size, and hospital affiliation. The analyses were performed using approximately 3.5 million MDS records collected from nursing homes during 2001. The results show adequately precise information for long-stay residents will be available from 4 to 46% of hospital-based facilities and 67–90% of freestanding facilities, whereas information from short-stay residents will be available from 34 to 95% of hospital-based facilities and 14–50% of freestanding facilities. Several initiatives are underway to measure and report the satisfaction of nursing home residents. In all of these large satisfaction initiatives the sampling strategy of respondents needs to be sufficient to allow for nursing home comparisons, and second, to allow interfacility benchmarking comparisons. We highlight the difficulty in obtaining information for these initiatives.     

Nursing home care quality: insights from a Bayesian network approach

PURPOSE: The purpose of this research is twofold. The first purpose is to utilize a new methodology (Bayesian networks) for aggregating various quality indicators to measure the overall quality of care in nursing homes. The second is to provide new insight into the relationships that exist among various measures of quality and how such measures affect the overall quality of nursing home care as measured by the Observable Indicators of Nursing Home Care Quality Instrument. In contrast to many methods used for the same purpose, our method yields both qualitative and quantitative insight into nursing home care quality. DESIGN AND METHODS: We construct several Bayesian networks to study the influences among factors associated with the quality of nursing home care; we compare and measure their accuracy against other predictive models. RESULTS: We find the best Bayesian network to perform better than other commonly used methods. We also identify key factors, including number of certified nurse assistant hours, prevalence of bedfast residents, and prevalence of daily physical restraints, that significantly affect the quality of nursing home care. Furthermore, the results of our analysis identify their probabilistic relationships. IMPLICATIONS: The findings of this research indicate that nursing home care quality is most accurately represented through a mix of structural, process, and outcome measures of quality. We also observe that the factors affecting the quality of nursing home care collectively determine the overall quality. Hence, focusing on only key factors without addressing other related factors may not substantially improve the quality of nursing home care.     

Factors related to satisfaction with long-term care services among low-income Korean elderly adults: A national cross-sectional survey

BackgroundWith the growing demand for long-term care (LTC) services, it is increasingly important to explore experience with care. This study examined care satisfaction in a nursing home and at home among low-income elders in South Korea.MethodsThis cross-sectional study was conducted with 246 elderly recipients of welfare benefits using a proportional stratified sampling method. Two self-reported versions of a questionnaire developed for users of nursing home care and homecare were used.ResultsThose at home reported higher care satisfaction than those in nursing homes did. Both users of nursing home care and homecare were less satisfied with the food served. Users of nursing homes had comparatively less satisfaction regarding the daily activities available to them and less autonomy concerning their care decisions. Factors that influenced satisfaction with nursing home care and homecare were the quality of caregivers, care facilities, and physical wellbeing.ConclusionsAn approach focused on improving the quality of the care facilities and caregivers could help enhance care satisfaction among low-income Korean elders receiving LTC.     

Stroke rehabilitation in nursing homes: how do we measure quality?

Over one-third of Medicare stroke patients are admitted to nursing homes for rehabilitation. Patients with stroke who are admitted to nursing homes are extremely heterogeneous, including both those with minimal physical and cognitive impairment and those who are totally physically dependent. Quality measures that are appropriate for evaluating stroke care in nursing homes include outcome measures, particularly those that are patient-centered, such as self-reported functional recovery and return to the community; process measures involving essential services such as screening for depression and pain; and structural measures such as the availability of a psychologist or presence of an interdisciplinary team. In measuring quality, nursing home professionals must allow sufficient time for outcomes to unfold, such as 3 to 6 months, rather than measuring outcome at discharge from a setting. Nursing home professionals must also take into consideration patient heterogeneity in terms of risk factors for outcomes of interest.     

Developing a method of assessing quality of care in nursing homes, using key indicators and population norms

This article illustrates how population norms on key indicators of quality can be used to assess quality of care in nursing homes. Five key indicators of quality were chosen from a Patient Care and Services Survey carried out by the Rhode Island State Department of Health: prevalence of contractures, in-house-acquired decubiti, use of restraints, lack of participation in an activities program, and nasogastric tube feeds. The population prevalence of these indicators was adjusted according to the case mix and size of each nursing home. A measure of quality suggested was the difference between the case-mix-adjusted prevalence and the prevalence observed by state surveyors. It was concluded that although the system is still in the exploratory stages, it has the potential to supplement the clinical judgment of nursing home surveyors with a more objective method of assessing compliance with quality of care standards.     

Building community and resilience in Massachusetts nursing homes during the COVID-19 pandemic

During the COVID-19 pandemic, frontline nursing home staff faced extraordinary stressors including high infection and mortality rates and ever-changing and sometimes conflicting federal and state regulations. To support nursing homes in evidence-based infection control practices, the Massachusetts Senior Care Association and Hebrew SeniorLife partnered with the Agency for Healthcare Research and Quality AHRQ ECHO National Nursing Home COVID-19 Action Network (the network). This educational program provided 16 weeks of free weekly virtual sessions to 295 eligible nursing homes, grouped into nine cohorts of 30–33 nursing homes. Eighty-three percent of eligible nursing homes in Massachusetts participated in the Network, and Hebrew SeniorLife's Training Center served the vast majority. Each cohort was led by geriatrics clinicians and nursing home leaders, and coaches trained in quality improvement. The interactive sessions provided timely updates on COVID-19 infection control best practices to improve care and also created a peer-to-peer learning community to share ongoing challenges and potential solutions. The weekly Network meetings were a source of connection, emotional support, and validation and may be a valuable mechanism to support resilience and well-being for nursing home staff.     

Approaches to quality improvement in nursing homes: Lessons learned from the six-state pilot of CMS's Nursing Home Quality Initiative

Background  

In November 2002, the Centers for Medicare & Medicaid Services (CMS) launched a Nursing Home Quality Initiative that included publicly reporting a set of Quality Measures for all nursing homes in the country, and providing quality improvement assistance to nursing homes nationwide. A pilot of this initiative occurred in six states for six months prior to the launch.