Post on 25-Dec-2015
Dementia-Dementia-Specific NH Specific NH
Quality Quality IndicatorsIndicators
IDND MeetingIDND Meeting
May 2008May 2008
Greg Arling, Ph.D.Greg Arling, Ph.D.
Dementia-Specific QI (D-QI) Dementia-Specific QI (D-QI) ProjectProject
Funded by the Alzheimer’s Association Funded by the Alzheimer’s Association (Investigator-Initiated Research Grant)(Investigator-Initiated Research Grant)
October 2007 – September 2010October 2007 – September 2010 Greg Arling (PI) and Malaz Boustani Greg Arling (PI) and Malaz Boustani
(Co-PI) -- IU Center for Aging Research(Co-PI) -- IU Center for Aging Research Christine Mueller (Co-PI) – U of Christine Mueller (Co-PI) – U of
Minnesota School of NursingMinnesota School of Nursing Focus on nursing home care in Focus on nursing home care in
MinnesotaMinnesota
D-QI Project ObjectivesD-QI Project Objectives Form an Form an advisory groupadvisory group to provide guidance for to provide guidance for
the project;the project; Identify current and new Identify current and new quality indicatorsquality indicators (D- (D-
QIs) most relevant to dementia residents;QIs) most relevant to dementia residents; Assemble Assemble available dataavailable data on clinical care and on clinical care and
quality of life of nursing home residents;quality of life of nursing home residents; Analyze available data to arrive at a final set of Analyze available data to arrive at a final set of
D-QIs for D-QIs for profiling nursing facilities and their profiling nursing facilities and their residentsresidents;;
Describe Describe best practicesbest practices in care of dementia in care of dementia residents through interviews with nursing home residents through interviews with nursing home staff in high quality facilities (high D-QI scores).staff in high quality facilities (high D-QI scores).
Incorporate D-QIs into the Minnesota Incorporate D-QIs into the Minnesota NH NH Report CardReport Card, , P4PP4P, and facility , and facility quality quality improvement effortsimprovement efforts..
Minnesota NH Quality andMinnesota NH Quality andPayment SystemPayment System
Multidimensional Multidimensional measures of nursing home measures of nursing home qualityquality
NH Report CardNH Report Card to inform consumer to inform consumer decisionsdecisions
Facility reporting systemFacility reporting system and and training training sessionssessions to promote quality improvement. to promote quality improvement.
Provider Payment Incentive ProgramProvider Payment Incentive Program which which funds quality improvement projects to foster funds quality improvement projects to foster innovation and organizational learninginnovation and organizational learning
Minnesota NH Quality Minnesota NH Quality MeasuresMeasures
StructStructureure
ProcesProcesss
OutcoOutcomeme
Nurse staffing level & Nurse staffing level & retention rateretention rate
Clinical Quality Clinical Quality Indicators (QI)Indicators (QI)
Quality of Life and Quality of Life and Resident Satisfaction Resident Satisfaction Survey (QoL/RS)Survey (QoL/RS)
State NH inspection State NH inspection results (quality of care results (quality of care violations)violations)
NH Quality Indicators NH Quality Indicators (QIs)(QIs)
Based on Minimum Data Set (MDS) Based on Minimum Data Set (MDS) assessmentsassessments Standardized assessment of health and Standardized assessment of health and
functional conditionsfunctional conditions Administered to all residents by NH staff at Administered to all residents by NH staff at
admission and every 90 days thereafteradmission and every 90 days thereafter Transmitted monthly to the state in a Transmitted monthly to the state in a
standardized electronic formatstandardized electronic format 24 QIs representing care processes and 24 QIs representing care processes and
outcomesoutcomes Binary variable (yes/no) at resident levelBinary variable (yes/no) at resident level Prevalence or incidence rate at the facility levelPrevalence or incidence rate at the facility level
NH QualityIndicators
Skin Care Continence Functioning
Burns or Cuts
NewPressure Sores
Improved BladderContinence
Worse BladderContinence
Improved Bowel Continence
Worse Bowel Continence
No ToiletingPlan
IndwellingCatheter
ADL Decline
ADLImprovement
MobilityDecline
Mobility Improvement
ROM Decline
Psychosocial
WorseningBehavior
WorseningDepression
Under-use ofAntidepressants
Overuse ofAntipsychotics
PhysicalRestraints
Other
Moderate toSevere Pain
Infections
Urinary TractInfection
Weight Loss
Falls
CuredPressure Sores
Quality of Life & Resident Quality of Life & Resident SatisfactionSatisfaction
Annual survey carried out by Annual survey carried out by professional survey organization professional survey organization involving face-to-face interviews involving face-to-face interviews with 14,000+ NH residentswith 14,000+ NH residents
Probability sample designed to yield Probability sample designed to yield facility-specific QoL rates for all 400 facility-specific QoL rates for all 400 nursing homes.nursing homes.
53 QoL and other items adapted 53 QoL and other items adapted from established instrumentsfrom established instruments
Surveys conducted in 2005 – 2008Surveys conducted in 2005 – 2008
MoodMood(9)(9)
SatisfactionSatisfactionwith Carewith Care
(7)(7)
Relation-Relation-ShipsShips
(3)(3)
SafetySafety(3)(3)
IndividualityIndividuality(3)(3) PersonalPersonal
AutonomyAutonomy(5)(5)
EnjoyEnjoyFoodFood(3)(3)
MeaningfulMeaningfulActivityActivity
(4)(4)
DignityDignity(4)(4)
PrivacyPrivacy(3)(3)
PhysicalPhysicalEnvironmentEnvironment
(4)(4)
ComfortComfort(4)(4)
Quality of Life &Quality of Life &SatisfactionSatisfaction
QoL/RS DimensionsQoL/RS Dimensions(# of survey items)(# of survey items)
Facility Quality ReportsFacility Quality Reports
Detailed QI and QoL/RS reports sent Detailed QI and QoL/RS reports sent periodically to each facilityperiodically to each facility Most current QI and QoL/RS resultsMost current QI and QoL/RS results Tracking of QI or QoL/RS rates over timeTracking of QI or QoL/RS rates over time
Special training programs on priority Special training programs on priority areas identified through quality reportsareas identified through quality reports Meaningful activitiesMeaningful activities Skin careSkin care Psychotropic medicationsPsychotropic medications Pain managementPain management
Provider Incentive Payment Provider Incentive Payment Program Program
FundingFunding $5 Million available in Year 1 (10/07-9/08)$5 Million available in Year 1 (10/07-9/08) $20 Million available in Year 2 (10/08-9/09)$20 Million available in Year 2 (10/08-9/09)
Response to Request for ProposalsResponse to Request for Proposals Over 200 applications receivedOver 200 applications received 35 projects (75 facilities) funded35 projects (75 facilities) funded
Variety of projects:Variety of projects:Culture changeCulture change Wound careWound care
Quality of lifeQuality of life Employee retentionEmployee retention
Pressure ulcersPressure ulcers Pain managementPain management
ExerciseExercise CHFCHF
D-QI ProjectD-QI Project Advisory Committee Meeting in March Advisory Committee Meeting in March
20082008 Front-line caregivers (e.g., medical directors, Front-line caregivers (e.g., medical directors,
nurses, and nursing assistants)nurses, and nursing assistants) Family membersFamily members State agency staffState agency staff Other local expertsOther local experts
Advances in Nursing Home Dementia Advances in Nursing Home Dementia Care (June 2008 Workshop, Minneapolis)Care (June 2008 Workshop, Minneapolis) Wide audience of local experts – particularly Wide audience of local experts – particularly
front-line caregiversfront-line caregivers Identify high priority D-QIs and recommend Identify high priority D-QIs and recommend
areas for applicationareas for application Advances in Nursing Home Dementia Advances in Nursing Home Dementia
Care (Fall 2008 Workshop, Indianapolis)Care (Fall 2008 Workshop, Indianapolis)
D-QI Initial List of D-QI Initial List of IndicatorsIndicators
From Advisory Group MeetingFrom Advisory Group Meeting BrainstormBrainstorm Consider QIsConsider QIs
Currently measured or present in Currently measured or present in available data (MDS or QoL survey)available data (MDS or QoL survey)
Need to be developed and possible new Need to be developed and possible new data collectiondata collection
Refine D-QIs in subsequent meetings Refine D-QIs in subsequent meetings and data analysisand data analysis
Resident-Centered CareResident-Centered Care
Consistent staffingConsistent staffing FlexibilityFlexibility Individualized care plan and careIndividualized care plan and care Knowledgeable and respectful staffKnowledgeable and respectful staff Good communication with residentsGood communication with residents Staff have accessible/easy-to-use information Staff have accessible/easy-to-use information
about residents (e.g. needs, care)about residents (e.g. needs, care) Residents can engage in meaningful activityResidents can engage in meaningful activity Behavioral problems are handled effectively Behavioral problems are handled effectively Appropriated decisions about care – e.g., Appropriated decisions about care – e.g.,
advanced directives and surrogate decision-advanced directives and surrogate decision-makingmaking
Family Engagement and Family Engagement and SupportSupport
Promotion of family involvementPromotion of family involvement Family-staff partnership/collaborationFamily-staff partnership/collaboration Environment whereEnvironment where
families can freely be advocates for their loved onefamilies can freely be advocates for their loved one family’s perspective is welcomed/families are family’s perspective is welcomed/families are
engaged with staff in addressing resident’s needs engaged with staff in addressing resident’s needs Family participationFamily participation
Family involved in assessmentFamily involved in assessment Family input into caregiving plans and activitiesFamily input into caregiving plans and activities Two-way communication between staff and familyTwo-way communication between staff and family Family participates/shares in caregiving according Family participates/shares in caregiving according
to their preferences and capabilitiesto their preferences and capabilities
Staff Capabilities and Staff Capabilities and EmpowermentEmpowerment
Staff learning/knowledge about dementiaStaff learning/knowledge about dementia Staff is empowered and empoweringStaff is empowered and empowering
respond to resident’s needsrespond to resident’s needs can individualizecan individualize
Staff given support to manage their own stress & Staff given support to manage their own stress & avoid burnoutavoid burnout
TeamworkTeamwork among front-line staffamong front-line staff across disciplines and staff typesacross disciplines and staff types
Staff stability and Avoidance of turnoverStaff stability and Avoidance of turnover Sufficient number of staff & Right skill mix and Sufficient number of staff & Right skill mix and
expertiseexpertise Staff adequately paid/compensatedStaff adequately paid/compensated
Physical EnvironmentPhysical Environment Make it home-like (familiar objects)Make it home-like (familiar objects) Intuitive layoutIntuitive layout Safety and SecuritySafety and Security
unobtrusive ways of keeping people safeunobtrusive ways of keeping people safe appropriate securityappropriate security
Sensory aids – cues & labelingSensory aids – cues & labeling Good physical design – flooring, lighting, & Good physical design – flooring, lighting, &
exercise/wandering areasexercise/wandering areas Stimulation sensitiveStimulation sensitive
Effective use of colorEffective use of color Noise levels (not over stimulation)Noise levels (not over stimulation) Music-appropriate to individual/groupsMusic-appropriate to individual/groups Effective use of technology to ↓ noise stimulationEffective use of technology to ↓ noise stimulation Sensory deprivation attended toSensory deprivation attended to
Organization and Organization and ManagementManagement
Organizational cultureOrganizational culture Learning communityLearning community Innovation seekingInnovation seeking Empowering & flexibleEmpowering & flexible
Organization of careOrganization of care Unique programmingUnique programming Activities-appropriate for dementia care Activities-appropriate for dementia care (RC)(RC)
Unit types and resident mixUnit types and resident mix IntergenerationalIntergenerational Specialized dementia units or dementia residents mixed Specialized dementia units or dementia residents mixed
with otherswith others Do residents get “placed” or “moved” based on clinical Do residents get “placed” or “moved” based on clinical
and cognitive needs? Debatableand cognitive needs? Debatable Information TechnologyInformation Technology
IT (Integration) & other Technology UseIT (Integration) & other Technology Use Electronic Medical/Health RecordElectronic Medical/Health Record Computer Decision SupportComputer Decision Support
Clinical CareClinical Care Dementia expertiseDementia expertise
Specialist in dementia involved in care (assessment and Specialist in dementia involved in care (assessment and prescription) ongoingprescription) ongoing
Proficiency of Geriatric Clinical ProviderProficiency of Geriatric Clinical Provider Diagnosis and assessmentDiagnosis and assessment
Diagnosis for dementia and typeDiagnosis for dementia and type Fully assess needsFully assess needs Identify triggers/causes of behavioral symptomsIdentify triggers/causes of behavioral symptoms
StagingStaging Assessment should determine dementia stageAssessment should determine dementia stage Care tailored to Care tailored to stagestage of dementia (need work on of dementia (need work on
criteria for criteria for stagingstaging)) Delirium diagnosis and treatmentDelirium diagnosis and treatment
Assessment/diagnoses of deliriumAssessment/diagnoses of delirium Prevention and treatment strategies/interventionsPrevention and treatment strategies/interventions Delirium treatment strategies/interventionsDelirium treatment strategies/interventions DeliriumDelirium -- -- close observation, assessment & close observation, assessment &
managementmanagement
Clinical Care (Cont.)Clinical Care (Cont.) Short stay dementia residents receiving Short stay dementia residents receiving
appropriate/equal care (medical, clinical)appropriate/equal care (medical, clinical) Discharge decisionsDischarge decisions Rehabilitation decisions, rehabilitation attemptedRehabilitation decisions, rehabilitation attempted
Rehabilitation and functional outcomesRehabilitation and functional outcomes Physical Therapy/Occupational TherapyPhysical Therapy/Occupational Therapy** Successful rehabilitation outcomesSuccessful rehabilitation outcomes Maintaining/promoting functionMaintaining/promoting function
Choice of Therapies Validation, vs. Choice of Therapies Validation, vs. OrientationOrientation** Tx (Traction?) Tx (Traction?)
Non-traditional TherapiesNon-traditional Therapies Pet therapyPet therapy Music therapyMusic therapy TouchTouch
Clinical Care (Cont.)Clinical Care (Cont.) Clinical IssuesClinical Issues
DeliriumDelirium PainPain DepressionDepression Communication/speechCommunication/speech Feeding/ NutritionFeeding/ Nutrition Tube FeedingTube Feeding WeightWeight ContinenceContinence Skin careSkin care Functional DeclineFunctional Decline Vision and hearingVision and hearing
MedicationsMedications End of Life CareEnd of Life Care**
Hospice CareHospice Care Palliative CarePalliative Care