ATX22-Assisted Living Day "The National Perspective on Assisted Living and Quality”

The National Perspective on Assisted Living & Quality

Dave Kyllo

Texas Health Care Association Austin, Texas

November 5, 2013

[email protected]

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National Survey of Residential Care Facilities (NSRCF)

Includes•Assisted living•Board and care homes•Congregate care•Enriched housing programs•Homes for the aged•Personal care homes•Shared housing

Source: U.S. Dept. of HHS 2010 National Survey of Residential Care Facilities

http://www.cdc.gov/nchs/data/databriefs/db78.htm

National Survey of Residential Care Facilities: Key Findings

•31,100 facilities

•971,900 licensed beds

•733,200 residents

•19% of residents covered by Medicaid

•43% of facilities with at least one resident receiving Medicaid LTC services



National Survey of Residential Care Facilities: Facility Size

While about half of facilities are small, most residents

live in larger communities.

Facility Size Percentage of Residents

Extra Large (100+ beds) 29%

Large (26-100 beds) 52%

Medium (11-25 beds) 9%

Small (4-10 beds) 10%



National Survey of Residential Care Facilities: Regional

Variation

Residential care facility beds per 1,000 persons aged 85 and over, by region



Region Beds/1,000 persons 85+

West 245

South 164

Midwest 177

Northeast 131

Total: United States 177

Percent of facilities offering selected services, and residents using them


Assisted Living Residents

Data from ALFA, ASHA, AAHSA, NCAL & NIC 2009 Overview of Assisted Living

•Average Age = 86.9

•Average Age at Move-in = 84.6

•73.6% Female; 26.4% Male

•Average Income = $27,260

•Average Assets (including home) = $431,020

•Median Income = $18,972

•Median Assets (including home) = $205,000

Caffrey, C. Sengupta M., Park-Lee E, et al. Residents living in residential care facilities: United States, 2010. NCHS data brief, no 91. Hyattsville, MD: National Center for Health Statistics. 2012.

Common Chronic Conditions

Activities of Daily Living

Caffrey, C. Sengupta M., Park-Lee E, et al. Residents living in residential care facilities: United States, 2010. NCHS data brief, no 91. Hyattsville, MD: National Center for Health Statistics. 2012.

∗19.9 % bowel incontinent in last 7 days

∗36.6% urinary incontinent in last 7 days

∗77.1% need help with medications

∗38% receive help with 3+ADLs

∗24% admitted to a hospital in last 12 months

∗35% treated in hospital ED in last 12 months

∗14% fell in last 12 months resulting in injuries other than hip fractures

National Survey of Residential Care Facilities: Other Health-Related

Characteristics

∗48.7% experience confusion∗46% experienced difficulty with short term memory

in the last 7 days∗28% experienced difficulty with long term memory

in the last 7 days∗18% could not find apartment∗21% could not recognize staff names & faces∗15% don’t know they are in a facility∗22% don’t know what season it is

National Survey of Residential Care Facilities: Residents’Cognitive Abilities


• Keep Regulation at the state level• Keep Assisted Living Included in CMS’

definition of Medicaid HCB settings • Protect, Improve Medicaid Coverage • Ensure that AL thrives in an episodic

payment/ACO Environment• Help Members navigate health care reform• Make the move to EHRs• Demonstrate that we can manage quality• Get residents’ diabetic testing strips

delivered

NCAL’s Policy Priorities

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Over the past years, the U.S. Senate Aging Committee has focused several hearings on AL quality of oversight.

In 2012, Sen. Bill Nelson (D-FL) considered introducing disclosure legislation after Florida legislature failed to act following a breakdown in the state’s AL regulatory system detailed by Miami Herald series.

Sen. Nelson now chair of Aging Committee and AL likely to be a focal point of committee attention.

“Frontline” investigative report on AL aired July 30 and may increase scrutiny by the media.

Federal Regulation of AL

• ACO• MCO• OIG• ACA• HIT• EHR• EMR• HIE• HIE (but now you call me “HIX” if you mean insurance)• LTSS

• Response: (LOL, OMG,)

Navigating the New Alphabet Soup

Advice from Hospital Sector Analysts…

• Engage Early• Bring Data

• Hospital Discharges• Discharges to their Hospital• DRGs (Resident conditions)

• Make an Investment (time & money)

ACOs will narrow who they work with and increase volume with their partners

Accountable Care Organizations

Major Challenges include:Rates often inadequate.

Payment for AL Incomplete (housing, food, utilities not covered; SSI check insufficient to fill gap).

States shifting to managed care.

Many recent federal initiatives tend to exclude AL, including CMS proposed rules defining HCBS settings.

Medicaid & Assisted Living

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Source: CMS Percentage of LTSS Spending for HCBS Usinig FFY 2009 Data)“State Medicaid Reimbursement Policies and Practices in Assisted Living,” Robert Mollica, National Center for Assisted Living/AHCA, September 2009. Available at www.ncal.org.

Home & Community-based Services (HCBS) as a % of Medicaid LTC Spending

State Percent HCBS

New Mex.

83.2%

Iowa 39.8%

Texas 46.9%

Minn. 67.9%

Miss. 14.4%

CMS has published a series of proposed rules intending to enforce Olmstead decision in Medicaid community-based settings.Concepts being promoted include: community integration, resident-centered care, home-like settings, and individual autonomy. Raises issue of whether assisted living is too institutional in nature.Possible consequence: exclusion of AL from Medicaid.

CMS Proposed Rules Defining HCBS Settings

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In April and May, 2012, CMS published a revised definition of Medicaid HCBS settings in final rule implementing Community First Choice program and proposed rules implementing revisions to 1915i program.

While improved, the proposed definition still could exclude some AL communities.

CMS Issues Revised Proposed Rules Defining HCBS Settings

in 2012

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In the latest proposed rules, CMS states:

“…home and community-based settings shall have all of the following qualities, and such other qualities as the Secretary determines to be appropriate, based on the needs of the individual as indicated in their person-centered service plan:

The setting is integrated in, and facilitates the individual’s full access to, the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, in the same manner as individuals without disabilities;

Revised Proposed Definition of HCBS Settings

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• The setting is selected by the individual from among all available alternatives and is identified in the person-centered service plan;

• An individual’s essential personal rights of privacy, dignity and respect, and freedom from coercion and restraint are protected;

• Individual initiative, autonomy, and independence in making life choices, including but not limited to, daily activities, physical environment, and with whom to interact are optimized and not regimented;

• Individual choice regarding services and supports, and who provides them, is facilitated.;

Revised Proposed Definition of HCBS Settings (2)

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• In a provider-owned or controlled residential setting, the following additional conditions must be met. Any modification of the conditions, for example, to address the safety needs of an individual with dementia, must be supported by a specific assessed need and documented in the person-centered service plan: The unit or room is a specific physical place that

can be owned, rented or occupied under another legally enforceable agreement by the individual receiving services, and the individual has, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord tenant law of the State, county, city or other designated entity;


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Each individual has privacy in their sleeping or living unit:-- Units have lockable entrance doors, with appropriate staff having keys to doors;--Individuals share units only at the individual’s choice; and--Individuals have the freedom to furnish and decorate their sleeping or living units;

Individuals have the freedom and support to control their own schedules and activities, and have access to food at any time;

Individuals are able to have visitors of their choosing at any time; and

The setting is physically accessible to the individual.


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We also plan to propose that home and community-based settings do not include the following:

1) A nursing facility;2) An institution for mental diseases; 3) An intermediate care facility for the mentally retarded;4) A hospital providing long-term care services; or5) Any other locations that have qualities of an institutional setting, as determined by the Secretary.


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The Secretary will apply a rebuttable presumption that a setting is not a home and community-based setting, and engage in heightened scrutiny, for any setting that is located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment in a building on the grounds of, or immediately adjacent to, a public institution or disability-specific housing complex...”


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NCAL & AHCA asks CMS to:

Strike the “rebuttable presumption” that certain provider-controlled settings are institutional (those on or near institutional settings or disability-specific housing complexes); Use care planning process to ensure resident-centered care, not arbitrary definitions related to facility location;Make sure eviction procedures accommodate state standards for residential care/assisted living facilities;Make sure that standards for sharing units are workable and realistic about economic constraints facing states; and, Permit secure perimeters (locked units) for residents with dementia.

AHCA/NCAL Issues with Latest CMS Proposed Rule Defining HCBS Settings

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In December 2012, HHS’ OIG released a report today documenting deficiencies in meeting state and federal requirements for assisted living facilities (ALFs) providing Medicaid services. Examined data, inspection reports, and provider care plans for

2009 in the seven states with the most assisted living Medicaid beneficiaries: Georgia, Illinois, Minnesota, New Jersey, Oregon, Texas, and Washington.

The study encompassed many types of facilities including private residences where beneficiaries were taken care of by relatives; single-family homes that served six or fewer individuals; and multi-unit residences, some serving more than 200 individuals.

The report, Home and Community-Based Services in Assisted Living Facilities, can be found at: https://oig.hhs.gov/oei/reports/oei-09-08-00360.pdf .

OIG Finds Deficiencies in State Regulation of AL Communities Providing Medicaid Services

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Report Findings: Greatest area of concern is meeting care plan standards. 77 percent of beneficiaries receiving HCBS resided in ALFs cited for at least one deficiency or noncompliance with state licensure or certification standards.Nine percent of beneficiaries’ records did not include care plans required by the states and federal government.Forty two percent of the care plans did not include the frequency of HCBS furnished, as required. In five of the seven states that also required (as a state option) care plans to specify the beneficiaries’ goals and the interventions to meet them, 69 of 105 care plans did not meet that requirement.In two of the seven states that required care plans to be signed by beneficiaries or their representatives, 12 of 25 care plans did not meet that requirement.

OIG Report on State Enforcement

of Medicaid Standards

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RTI study presented in November 2012 found that AL facilities accepting Medicaid payment were similar in many ways to those that do not: In general, found that Medicaid facilities are “not that different” from non-Medicaid facilities.” Levels of services provided and staffing generally similar.

Source: “Do Residential Care Facilities That Serve Medicaid Beneficiaries Differ From Those That Do Not?” Angela Greene, Galina Khatutsky, Joshua Wiener & Ruby Johnson, slides, Gerontological Society annual meeting, Nov. 17, 2012

Differences between Facilities Serving Medicaid Beneficiaries and Those That Do

Not

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RTI study found some differences between Medicaid and non-Medicaid facilities:More Medicaid residential care facilities (RCFs) are smaller (4-25 beds).

More non-Medicaid RCFs have dementia or Alzheimer's units.

Higher proportion of Medicaid RCFs provide skilled nursing care.

A slightly higher mean number of LPN hours for direct care per resident are provided in the non-Medicaid facilities and the mean number of hours of direct care per person provided by administrators in Medicaid facilities is higher.

Non-Medicaid RCFs have higher monthly base rate.

RTI Medicaid study (2)

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Resident profiles in Medicaid facilities differ from those in non-Medicaid facilities: Medicaid residents tend to be younger (under 65) and a

higher proportion are minorities. Higher proportion of Medicaid residents have diabetes. Higher proportion of non-Medicaid residents are female

and a higher proportion have Alzheimer’s disease or other dementias.

Higher proportion of Medicaid residents are intellectually disabled or have a serious mental illness.

Higher proportion of Medicaid residents exhibit problem behaviors such as wandering, and being verbally and physically abusive.

RTI Medicaid study (3)

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Another recent RTI study attempting to explore whether AL/residential care is more “community-based” or institutional in nature found differences between Medicaid and non-Medicaid residents living arrangements.

However, the study found that, with exception of living arrangements and visitors, Medicaid facilities are roughly comparable to non-Medicaid facilities.

Source: “Are Residential Care Facilities ‘Community Services’?,” Joshua Wiener, Galina Khatutsky, Ruby Johnson, Angela Greene, slides, Gerontological Society annual meeting, Nov. 17, 2012

Resident Living Arrangements

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Non-Medicaid residents more likely to have single room or apartment.

Source: “Are Residential Care Facilities ‘Community Services’?,” Joshua Wiener, Galina Khatutsky, Ruby Johnson, Angela Greene, slides, Gerontological Society annual meeting, Nov. 17, 2012

Resident Living Arrangements

Type of Living

Arrangement

Total Residents

(%)

Non-Medicaid Residents

(%)

Medicaid Residents

(%)

Room designed for 2 or more persons

26.9 22.5 45.5

Room designed for 1 person

31.6 32.8 26.6

Apartment 41.5 44.7 27.9

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Most states currently allow sharing of rooms/units for AL Medicaid services providers.

Medicaid does not pay for room and board. If CMS is going to require single rooms, then a

funding mechanism needs to be found to pay for them (HUD vouchers?). This might save government dollars if structured properly by substituting AL for more expensive institutional settings.

If CMS requires single rooms w/o funding, then ironically many AL Medicaid residents will end up in institutional settings sharing rooms at a greater public cost.

Issue: Single Rooms for AL Medicaid Beneficiaries?

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In 2012, at least 18 states made AL legislative/regulatory changes (January 2012-January 2013).

Many states made major changes.

In recent years focal points of change include: Staff education/training, more focused surveys, disclosure, fire safety, infection control/TB testing, medication management.

Source: NCAL 2013 State Regulatory Review

State Regulatory Trends

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Colorado: On Jan. 1, 2013, the Assisted Living Residence (ALR ) program began conducting risk-based re-licensure inspections, initially on a pilot basis. Under the new system, ALRs meeting the following

criteria will be eligible for an extended survey cycle: licensed for at least three years, and, within that prior three years, having had no enforcement activity, no pattern of deficient practice, and no significant deficiency cited in response to a complaint that negatively affected the life, health, or safety of residents.

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Innovative Survey Models

New Jersey: In 2012, the state Department of Health (DOH) collaborated with The Health Care Association of New Jersey Foundation to create a voluntary program titled Advanced Standing. To receive the department’s distinction of Advanced Standing, a facility must comply with all applicable local, state, and federal regulations as well as submit quality data that reaches benchmarks established by a peer review panel. A facility participating in the program does not receive a routine

survey by DOH. However, any time a facility falls below DOH standards, such as poor performance on a complaint investigation, that facility can be removed for cause from the program by DOH. In addition, DOH provides follow-up surveys based on a random sample of facilities that participate in the program. The program is open to all licensed assisted living residences and comprehensive personal care homes.

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Innovative Survey Models (2)

Other Innovative Assisted Living State Oversight Models:

North Carolina recently extended survey cycle to two years for “Four-Star” assisted living facilities. Those with highest rating can be inspected every two years instead of annually.

Wisconsin has abbreviated survey for consistently good performers (based on outcomes reported to the state)Many state agencies continue dealing with limited resources, personnel changes.

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Innovative Survey Models (3)

Four-year effort led by NCAL’s life safety engineer succeeded in updating and harmonizing two major life safety standards for assisted living: The National Fire Protection Association adopted

the changes in 2012 edition of Life Safety Code for existing buildings.

Key committees of the International Code Committee recently adopted similar standards for new construction in 2012.

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Life Safety – a Major Breakthrough

The new standards address major issues: As residents become less able to evacuate without

assistance, the standards allow AL facilities to remain in residential classification while ensuring high level of safety. Results in major cost savings for many providers and

improved quality of life for residents who won’t have to move to institutional settings.

Over time most states adopt these two bodies’ standards. NCAL generally recommends adoption of 2012 edition of Life Safety Code.

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Life Safety Standards

Major Components take effect Jan. 1, 2014.Individual responsibility to maintain coverage.Employer coverage requirements but the Administration has delayed penalties for not offering coverage until Jan. 1, 2015.Health plan reforms.Insurance exchanges offering subsidized coverage (enrollment begins in October 2013).Major expansion of the Medicaid program in about ½ the states that opted to expand.

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Health Coverage Expansion under the Affordable Care Act

(ACA)

The new requirements for employers to offer specified levels of coverage or pay penalties may increase costs for many long term care providers in 2015.

Working with employee benefit specialists and insurance brokers and carriers, providers have begun the process of analyzing their options for providing affordable coverage or potentially paying penalties.

However, until more key policy decisions are made, it is impossible for employers to precisely gauge the extent of the financial impact of the new requirements.

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Implications for LTC Providers

LTC providers most at risk for financial impact include:Those with high percentage of low-wage workers.

Small firms not able to self-insure.

Those offering limited health benefits or not offering coverage to some full-time workers.

Those with low margins.

Those reliant on government reimbursement (they cannot unilaterally raise prices if their labor costs suddenly go up).

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Employer Pay-or-Play Mandates:

LTC Providers Most at Risk

www.ncalbenefits.com&

Learn more about the ACA at:

www.ncal.orgwww.ahca.org

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Evaluate Your Optionsfor Compliance with ACA

• CDC-- Infection Control + Hepatitis B Outbreaks

• National Labor Relations Board (NLRB)

• AHRQ– LTSS Public Reporting

• DOL Wage and Hour Enforcement

• DEA –Disposal of Controlled Substances• EPA Disposal of Medications• FDA Disposal of Narcotics and Fentanyl patches

• CPSC Ban on Portable Bedrails in Assisted Living

• CMS Definition of HCB Setting

• EPA Energy Star Program

• CFPB Efforts on Senior Fraud and Scams

Federal Agencies with Initiatives Impacting Assisted Living

Working before and after shifts Working during an employee’s scheduled

meal break including interruptions of short duration

Employees not being paid for staff meetings and compensable training session

Why the violations? Lack of understanding of the FLSA “We did it that way the last place I worked” Caring employees LTC culture and environment

Fair Labor Standards Act EnforcementContinues in LTC Settings including AL

#31 Nursing Care Under the FLSA (Guidance applicable to all provider types)

#52 Youth Employment

#53 Hours Worked

#54 Calculating Overtime

LTC Specific Fact Sheets are Available at: www.dol.gov/whd

ENERGY STAR

Medical Office Building

Office Building

Hospital

Warehouse

Dormitory Supermarket Court House

School

Bank/FinancialHotel

Waste Water Treatment Plant

Retail

Eligible for ENERGY STAR score

Senior Care Communities

Benefits of Energy Conservation

• Senior Care Providers– Margin maximization strategy– Performance management

• Residents– Enhanced affordability– Quality enhancement program

• Environmental Leadership– Lead on addressing climate change

• EHR: electronic health record – across health care organizations

• EMR: electronic medical record – within a health organization

• eMAR: technology that automatically documents the administration of medication into certified EHR technology using radio frequency ID or bar coding

• HIE: health information exchange across providers, purchasers, regulators

• HIE –HIX: health insurance exchange• m-Health: health care through mobile devices

Health Information Technology will Transform

Assisted Living and All Health Care

Basic interoperability: ability to electronically communicate health data

Semantic interoperability: enable the receiving computer to display the text or data received AND accurately interpret the meaning of the data

Levels of Interoperability:• Non-electronic data (paper)• Machine transportable data (fax/e-mail)• Machine-organizable data (structured messages,

unstructured content –documents and images)• Machine-interpretable data (structured

messages, and standardized content) – Ultimate Goal!

What Does Interoperability Mean?

Allegations at AL Facilities Highest Frequency Closed Claims:Resident fall 46.2% Abuse 9.5%Pressure ulcer 7.7%Elopement 7.1%Improper care 7.1%

Death occurred in 37.2% of the closed claims associated with falls.

Source: “Aging Services 2012: Data Analysis Supporting the Need for Industry Change,” CNA.

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Liability: CNA Analysis of Allegations at Assisted Living

Facilities

Allegations at AL Facilities Highest Average Total Paid for Closed Claims:Gross improper care $541,908Elopement $378,312Failure to follow physician’s order $360,939Delay in seeking medical treatment $256,309Pressure ulcer $251,370


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Liability: CNA Analysis of Allegations at Assisted Living

Facilities (2)

Injuries at AL Facilities Highest Frequency Closed Claims:Death 37.3%Fracture(s) 32.5%Pain and suffering 6.5%Emotional distress 4.1%Contusion/bruise 4.1%


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Liability: CNA Analysis of Injuries at Assisted Living

Facilities

Injuries at AL Facilities Highest Average Total Paid for Closed Claims:Death $291,060Emotional distress $230, 926Contusion/bruise $215,590Loss of limb/amputation $188,080Fracture(s) $174,469


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Liability: CNA Analysis of Injuries at Assisted Living

Facilities (2)

Fractures/Head Injuries 47%

Minor/No Injury 31%

Sudden/Unexpected Death 6%

Pain/Suffering 3%

Burns 2%

Sexual Assault 2%

Pressure Ulcer 1%

HealthCap Resolved Claims 2001 – 2011

Choking $214,168

Burns $203,580

Unexpected Death $145,470

Pressure Ulcer $133,503

Pain & Suffering $ 92,050

Sexual Assault $ 63,769

Fractures/Head Inj. $ 49,416*HealthCap (2001 to 2011 Data)

Average Paid for Closed Claims

Source: “HealthCap Data based on resolved claims from 2001-2011 for residential

care/assisted living/independent living

Common causes: Fractures and head injuries primarily due

to falls

Sudden/unexpected deaths due to unnoticed change of conditions, elopements, bedrails and medication errors.

Burns due to cigarette smoking and inappropriate use of hot packs

What Led to the Litigation?

AHCA Quality Initiative Goals

Safely reduce 30-day hospital readmissions by 15% by 2015

Maintain nursing staff turnover below 30% until 2015

Maintain customer satisfaction above 90% by 2015

Safely reduce the off-label use of antipsychotics by 15% by March 2015

Hospital Readmissions

Target: By March 2015, individual communities will safely reduce hospital readmissions by 15 percent (this includes any admitting diagnosis).

Individual communities that have less than 5 percent of residents with hospital readmissions will maintain hospital readmissions below 5 percent.

Safely Reduce Hospital Readmissions

Calculation:

# of AL residents admitted to a hospital (excluding ER-only visits and observation stays) from the AL within 30 days of hospital discharge

DIVIDED BY

All AL admissions to this community within 30 days of hospital discharge

Hospital Readmissions: Measurement

Resident Transfer from Hospital to AL

Hospital Readmission

Date Resident 1 January 1 Resident 2 January 3 Resident 3 January 4 January 31Resident 4 January 8 Resident 5 January 10 Resident 6 January 15 February 5Resident 7 January 19Resident 8 January 25 Resident 9 January 31 Resident 10 January 31 February 28

Let’s Practice

# of AL Residents admitted to a hospital from the AL within 30 days of hospital discharge = 3

Divided by

All AL admissions to this community within 30 days of hospital discharge: 10

3/10 = .30 or (.30 x 100) = 30% hospital readmission rate

Let’s Practice

• Percent of all admissions sent to any hospital within 30, 60, and 90 days of admission to your community

• Percent of all admissions sent to any hospital within 30, 60, and 90 days of admission to your community, excluding planned readmissions

• Track the number of days since your last readmission

Other Ways to Track Your Progress

• Simple counts • # of hospitalizations last week

• Time between events (e.g. OHSA employee injuries)• # of days since last hospitalization

• Use for any clinical measure• As you increase the time between events you will

improve on any quality measure risk adjusted or not• Simple• Easy to display where all staff can see • Rapid feedback

Using Counts: “Time Between Events”

Tracking Counts & Time Between Events

Factors Associated with low rehospitalizations

1Young Y et al. Clinical and Nonclinical Factors Associated with potentially preventable hospitalizations among nursing home residents in NYS. JAMDA 2011;12:364-371.

INTERACT Is a comprehensive program that uses these strategies•Track your rehospitalizations•Improve Communication

• Externally (e.g. with hospital/ER)• Internally (e.g. between nursing & physicians)

•Identify small changes in a resident’s status early on•Change Staffing

• Consistent Assignment• Reduce staff turnover• Utilize nurse practitioners

•Advance Care Planning

Strategies to Reduce Hospitalizations

• Decreases hospital acquired infections, resulting in less opportunity for skin breakdown, injury or harm from transfers.

• Decreases the exacerbation of symptoms for people with dementia.

• Means less stress for nurses who must take time for the readmission and transfer requirements.

• Better outcomes make your facility more attractive as a preferred provider in integrated care models (such as ACOs)

Hospital Readmissions: The Business Case

• CMS has implemented a payment penalty to hospitals with high 30 day readmission rates for discharges diagnoses• CHF• Pneumonia• Myocardial infarction

• Hospitals participating in ACO or Bundle payment demos can only achieve savings by reducing rehospitalizations

• Hospitals are partnering with LTC providers• Referring to low readmission providers

Why Hospitals Care About You

• Adopt the INTERACT program • Ensure seamless information exchanges between

providers through the use of electronic health records (EHRs)

• Engage providers at all points throughout the spectrum of care. Expand the use of nurse practitioners

• Use consistent assignment of staff to ensure that staff are familiar with residents’ normal patterns and characteristics so that they detect early changes in resident’s conditions before they lead to a hospitalization

• Utilize the tools on the Quality Initiative for Assisted Living website

Hospital Readmissions: Achieving the Goal

• Business Case• Measurement Summary• INTERACT SBAR for Assisted Living Nurses• INTERACT SBAR for Assisted Living Caregivers• INTERACT Stop & Watch• INTERACT Measurement of Hospital Transfer Rates• INTERACT Change in Condition Cards

*All the above resources are available at qualityinitiative.ncal.org

Hospital Readmissions: Resources

• NCAL Quality Committee nurses and AALNA Board worked together to revise INTERACT tools for AL – approved by developers of INTERACT

• These are posted on NCAL’s website (www.NCAL.org) and recommended for use until the developers of INTERACT release INTERACT for AL

INTERACT for Assisted Living

Stop & Watch for AL

• Purpose:• Guide front-line

staff through brief review of early, often subtle, indicators of change in condition

• Improve communication between frontline staff and the nurse in charge

• Stop & Watch• Send staff to learn from another facility using tool• Pilot test 1 team on 1 unit• Let team decide how to use stop & watch• Meet with pilot team daily for feedback• Make changes based on feedback

• Start with CNA – Nurse using• Gradually expand to other staff, then to families

Tips on Implementing Stop & Watch

6 months to successfully roll out Stop & Watch

• Need to work with staff to remind them to complete stop & watch

• Need to work with RN’s to follow-up on submitted stop & watch

• Look at stop & watch forms (or lack thereof) • Engage Physicians

• Support notification of MDs/NPs on early signs

Tips on Implementing Stop & Watch

6 months to successfully roll out Stop & Watch

SBAR for Assisted Living Nurses

• Structured format to assemble key information physicians need to make a decision

• Complete prior to calling MD

4-6 months to successfully roll out

SBAR

• Situation• Background• Assessment (RN) or Appearance (LPN/LVN)

• Request

SBAR for AL Nurses

• Start with 1 nurse/staff • Announce to all staff that your using SBAR but piloting

with <insert nurse’s name>• Review each day nurse’s experience with SBAR• Modify SBAR protocol based on each day’s feedback

• Engage Physicians• Seek feedback from attending and covering MDs

• Try pilot testing for 1 condition on 1 unit• INR calls to physicians• Elevated blood glucose• Falls

4-6 months to successfully roll out SBAR

Tips on SBAR implementation

SBAR for AL Caregivers

• Structured format to assemble key information physicians need to make a decision

• Complete prior to calling MD

4-6 months to successfully roll out

SBAR

• Situation• Background• Appearance• Ready to call

SBAR for AL Caregivers

Staff Stability

Target: Each year, until March 2015, maintain nursing staff turnover rates below 30 percent.

Increase Staff Stability

Calculation:

# of terminations for nursing staff in the calendar year

DIVIDED BY:

Total # of current nursing staff employees at the end of the year

*total includes full-time, part-time, permanent, short-term, seasonal salaried and hourly RN, LPN/LVN, CNA, CMA, personal caregivers and other similar front-line staff directly responsible for the daily care of residents. Employees of temporary agencies and outside contractors are not included. For Minnesota, include home health aides.

Staff Stability: Measurement

• The better staff members know a resident, the easier it is to deliver person-centered care.

• Staff who are satisfied are more likely to recommend the community as a place to work. Good caregivers recruit good caregivers.

• Communities have a positive reputation that spreads in the community leading to greater opportunity for business development.

• Training new staff and turnover costs are high.

Staff Stability: The Business Case

• Focus on staff satisfaction, turnover, and empowerment, as well as consistent assignment.

• Regularly measure staff satisfaction, including drill-down to specific factors to inform quality improvement efforts

• Measure and track staff turnover to identify patterns, trends and potential root causes of high turnover in order to act on them

• Empower staff at all levels to participate in problem-solving and quality improvement


Staff Stability: Achieving the Goal

• Staff Turnover Calculator (Excel Spreadsheet)• Introducing Peer Mentoring in Long-Term Care Settings• Staff Stability toolkit (available in the AHCA/NCAL Bookstore!)


Staff Stability: Resources

Recognize deserving staff!

Noble Caregiver in Assisted Living AwardNCAL Assisted Living Nurse of the Year

NCAL Administrator of the YearNational Assisted Living Week Programming Award

Application submission for 2013 is now closed. Visit www.ncal.org for more information.

Customer Satisfaction

Target: By March 2015, maintain the number of customers who would recommend the community to others at or above 90 percent.

Communities with customer satisfaction below 90 percent should improve to 90 percent by March 2015

Increase Customer Satisfaction

Calculation: Current residents/families who would recommend the community

# of current residents/families who answer a survey question about “willingness to recommend” a community positively

DIVIDED BY:

# of current residents/families responding to a survey question on “willingness to recommend”

Customer Satisfaction: Measurement

Calculation: Residents who have moved out of AL who would recommend community

# of residents who moved out and answer a survey question about “willingness to recommend” a community

positively

DIVIDED BY:

# of residents who moved out and respond to a surveyquestion on “willingness to recommend”

Customer Satisfaction: Measurement

• Increasing customer satisfaction can have a direct impact on increasing census and generating additional revenue from positive customer referrals.

• Achieving customer satisfaction is the root of person-centered care.

• High customer satisfaction data can be used to support participation in preferred provider plans, including Accountable Care Organizations medical homes and other organizations that provide health care services in the care continuum.

• High customer satisfaction data can help the community differentiate themselves from other providers.

Customer Satisfaction: The Business Case

• Regularly measuring customer satisfaction, including identifying key factors that are contributing to overall ratings

• Utilizing satisfaction data to prioritize quality improvement needs and act on them.

• Using consistent assignment of staff to allow positive and continuing relationships to develop that allow staff to successfully provide individualized, person-centered care.


Customer Satisfaction: Achieving the Goal

• Better Serving the Lesbian, Gay, Bisexual, and Transgender Populations in AL

• Preparing Residents to Move Out• Assisted Living Staff Checklist for Responding to

Complaints• Making Resident and Family Councils Successful in

AL• Turning Complaints into Compliments• The Power of Ethical Marketing

Customer Satisfaction: Resources


Antipsychotic Medications

Target: By March 2015, safely reduce off-label use of antipsychotics by 15 percent.

Communities that have less than 5 percent of off-label use maintain rates at or below 5 percent.

All communities will implement use of at least one tool aimed at reducing off-label use of antipsychotics by March 2015.

Safely Reduce Off-Label Use of Antipsychotics

Antipsychotic Medications

Atypical (Generic)• Abilify (Aripiprazole)• Saphris (Asenapine)• Clozaril Fazaclo

(Clozapine)• Fanapt (Iloperidon)• Zyprexa (Olanzapine)• Invega (Paliperidone)• Seroquel

(Quetiapine)• Risperdal

(Risperidone)• Geodon

(Ziprasidone)

• Conventional (Generic)• Haldol (Haloperidol)• Loxitane (Loxapine)• Navane (Thiothixene)• Orap (Pimozide)• Compazine

(Prochlorperazine)• Mellaril (Thioridazine)• Moban (Molindone)• Prolixin (Fluphenazine)• Stelazine (Trifluoperazine)• Thorazine (Chlorpromazine)

• Schizophrenia• Bi-polar Disorder• Irritability associated with Autistic Disorder

(Aripiprazole & Risperidone)• Treatment Resistant Depression (Olanzapine)• Major Depressive Disorder (Quetiapine)• Tourettes (Orap)When prescribed to a patient without an FDA

approved diagnosis; considered off-label use, which is allowed by FDA and Medical Boards

FDA Approved Diagnoses

• Dementia with behavior difficulties• Agitation• Aggression• Wandering

• Acute Delirium• Depression• Obsessive-compulsive disorder• Psychotic symptoms (e.g. hallucinations,

delusions) with neurological diseases• Parkinson’s disease• Stroke

Common Off-label uses

• Antipsychotic effect takes 3-7 days • Acute response most likely due to sedating

properties, not antipsychotic effect

• In RCTs, recipients do a little bit better than placebo but the effect beyond 3 months is unclear and: • Not everyone who receives the meds improves • A large number of people getting the placebo

improve • The net effect is that 10 to 20 people out of 100

who receive the medication improve due to the medication

Effectiveness in Dementia

• Off-label use of antipsychotics in nursing facility residents is associated with increase in: • Death (heart failure or pneumonia) 1.6 x greater than

placebo• Hospitalization (40% increase)• Falls & fractures• Venothrombotic events

• Conventional antipsychotics are worse than atypical antipsychotics

Associated with Adverse Outcomes

• Low dose Risperidone (<1 mg/d): small positive effect but also increased risk of adverse events

• Low dose Olanzapine (5 mg/d): no positive effect but does have increase risk of adverse events

• Low dose Aripiprazole and Quetiapine: effectiveness unknown, but Quetiapine at normal dose has no evidence of effectiveness

Source: Cochrane Review 2012; Meta-analysis 16 RCTs in dementia

Effectiveness with Low Doses

• RCTs for withdrawal of medication show • No difference in outcomes between placebo and

continued medication • About 75% remain off the drug after the trial • Less than 25% need to be restarted on the

medication • Placebo group (drug withdrawal) have fewer

adverse events

Evidence for Discontinuing Low Doses

Calculation: Incidence: % of residents who have an antipsychotic

drug initiated for an off-label use within the first 90 days at assisted living community

# of residents with antipsychotic drug use indicated on medical records over the first 90

days at the assisted living

DIVIDED BY: # of residents who have been at the assisted

living for 90 or less days

Antipsychotic Measurement: Incidence

# of residents with antipsychotic drug use indicated on medical records over the first 90 days at the assisted living = 2

DIVIDED BY:

# of residents who have been at the assisted living for 90 or less days = 10

Incidence: 2/10 = 0.20 or (0.20 x 100) = 20%

Let’s Practice!

Calculation Prevalence:% of resident with off-label use of an antipsychotic drug

# of residents (who have been at the AL over 90 days) with antipsychotic drug use indicated on medical records at the end of the target period

DIVIDED BY:# of residents (who have been at the AL over 90 days) at the end of the target period

Antipsychotic Measurement: Prevalence

# of residents (who have been at the AL over 90 days) with antipsychotic drug use indicated on medical records at the end of the target period = 10

DIVIDED BY:

# of residents (who have been at the AL over 90 days) at the end of the target period = 100

Prevalence: 10/100 = 0.10 or (0.10 x 100) = 10%

Let’s Practice

By December 2013 your community now has 8 residents on antipsychotics

% reduction = ((Initial value – final value) / (Initial value) ) x 100

% reduction = ((10-8) / 10) x 100

% reduction = (2/ 10) x 100

% reduction = .20 x 100

% reduction = 20%

Percent Reduction – Let’s Practice!

• Percent of new admissions without approved psychiatric diagnoses admitted to your community on antipsychotic drugs that have those drugs discontinued at 30, 60, 90 days of their stay

• Percent of new admissions without FDA approved diagnoses that are admitted without antipsychotic prescriptions and started on these.

• Percent of residents in the community for more than 90 days that are taking antipsychotic drugs without psychiatric diagnoses that are on antipsychotic drugs

• On an ongoing basis, track the number of days since the last person was started on an antipsychotic medication in the community.

Tracking On a Real-time Basis

• Decreases the side effects and adverse drug reactions associated with these medications.

• Non-pharmacologic interventions help to enhance an individual’s ability to direct their care, which improves their independence, dignity, and quality of life.

• Adverse Drug Events (ADEs) may require hospitalization and the community may experience lost revenue for days the resident is not in the community.

• A reputation for using innovative, person-centered care approaches will provide a competitive advantage.

Antipsychotics: The Business Case

• Focus on non-pharmacologic approaches for preventing the frustrations that can lead to challenging behavior and for addressing resident’s behavioral expressions when they do occur

• Using a positive physical approach, engaging residents in meaningful activity, and using therapeutic strategies for catastrophic events can make a real difference for residents with dementia.

• Environmental changes : reducing noise, improving lighting, and allowing flexible scheduling.

Antipsychotics: Achieving the Goal

SBAR for Antipsychotics

• Qualityinitiative.ncal.org• CEAL Clearinghouse www.theceal.org• Alzheimer’s Association• IA-ADAPT

https://www.healthcare.uiowa.edu/igec/iaadapt/• The National Dementia Initiative White Paperhttp://www.ccal.org/national-dementia-initiative/

white-paper.shtml

Antipsychotics: Resources

The assisted living portion of the AHCA/NCAL Quality Initiative Recognition Program is designed to recognize NCAL members that demonstrate the attainment and a commitment to one or more of the four NCAL Quality Initiative goals: •Safely reduce hospital readmissions by 15% •Increase staff stability by maintaining nursing staff turnover below 30% •Increase customer satisfaction to 90% •Safely reduce the off-label use of antipsychotics by 15%.

All submissions must be received by NCAL no later than 11:59 PM (EDT) September 30, 2013. Those receiving recognition will be notified in November.

Assisted living communities must submit their staff turnover data to NCAL through the

Assisted living communities must submit their 2012 customer satisfaction survey results to NCAL through the online Customer Satisfaction survey.

Assisted living communities may pledge their intent to join the PSO by submitting their information through NCAL’s online survey. Communities will need to sign-up for the PSO by a specified date once official registration is open

Get Recognized!

Recognition Levels

Data Collection in Assisted Living

“In God we trust, all others bring data” – Elements of

Statistical Learning

Why Representative Data Matters

• Identified 10 performance measures related to:

Operational performance Resident quality of life

• Completed 3 years of surveys (2010-2012)

• Links to survey reports on NCAL Website

Quality of LifePerformance Measures

• Family councils• Mission and vision

statements• Safety programs• Nurse availability• State criminal

background checks

Quality of Life Performance Measures

• Resident & family satisfaction

• Employee satisfaction

• Staff retention• Census/Occupancy

rate• Resident Councils

• NCAL launched the first national survey for assisted living in January 2010

• Fourth annual survey launched January 2013

• Supported by Leading Age, ALFA, and ASHA

• Links to results on NCAL’s Website

Vacancy, Retention, and Turnover

• Medication management

• Hospitalizations• Depression• Elopements• Advanced care

planning

Next Step: Clinical Performance Measures

• Falls• Pain management• Pressure ulcers• Infection control• End-of-life care• Demographics

January 2013 – NCAL Board of Directors voted to collaborate with the New Jersey Hospital Association’s (NJHA) Institute for Quality and Patient Safety Organization (PSO) to collect Tier II Clinical Performance Measure

Patient Safety Organizations

• PSOs serve as a group of independent, external experts who can collect, analyze, and aggregate Patient Safety Work Products locally, regionally, and nationally to develop insights into the underlying causes of patient safety events.

• Communications with PSOs are protected from disclosure to allay fears of increased risk of liability because of collection and analysis of patient safety events

• PSOs are certified by the Agency for Healthcare Research & Quality (AHRQ)

What is a PSO?

• Improve safety and quality leading to better resident outcomes• Participate in a non-punitive reporting system that is designed to reduce or

minimize harm to members• Contribute to national safety initiatives • Move toward a culture of safety and awareness and away from a culture of blame

and shame• Reduce liability costs and exposures • Use of de-identified quality data to assist members in quality efforts• Detect and address emerging quality issues as they arise through alerts and other

communication methods

Benefits of Partnering with a PSO

PSO: Timeline & Cost

Timeline

• August 2013- Contract between NCAL & NJHA signed and measures finalized

• September start signing up pilot communities

• October-December Pilot study• Nov-Dec – sign-up NCAL

members• January 1, 2014 data collection

for all NCAL members

Cost

• 25 or less beds: $35 per unit with a $250 minimum

• 26 or more units: $35 per unit with a maximum annual compensation of $3,500

• Multi-community Entities (with 100+ units): $3,500 for the first 2 communities plus $800 for each additional community

*Note that multi-community entities with less than 100 units will pay $35 per unit with a maximum annual compensation of $3,500.

NCAL 2014 Spring Conference

March 10 -12, 2014Casers Palace, Las Vegas, NV

Registration opens in November!

Visit www.NCAL.org for more information

The Future is Now

Questions?

www.ncal.org

Dave Kyllo – [email protected]

ATX22-Assisted Living Day "The National Perspective on Assisted Living and Quality”

Health & Medicine

Transcript of ATX22-Assisted Living Day "The National Perspective on Assisted Living and Quality”