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LTC Quality: The Sound and the Fury

August 1, 2004
by root
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Are quality initiatives a breath of fresh air or a tempest in a teapot? by Richard L. Peck, Editor-in-Chief
LTC QUALITY

THE SOUND
AND THE FURY


Far from "signifying nothing," as per Shakespeare, today's quality initiatives seem to be signaling big change

BY RICHARD L. PECK, EDITOR-IN-CHIEF With the word "quality" sounding as a steady drumbeat throughout, the past two years have seen a flurry of announcements, pronouncements, programs, projects, and publications trumpeting a movement toward improved long-term care. Skeptics have had to yield to emerging evidence showing that long-term care facilities have indeed grasped the opportunity to learn new best practices and put them into effect. Solid proof of an industry-wide upgrade is a long way off, to be sure. But there is no shortage of initiatives on several fronts.

The forerunner in all this has been the federal Centers for Medicare and Medicaid Services (CMS), which has moved beyond its state survey-oriented Quality Indicators to develop Quality Measures (QMs), in concert with a consultative organization called the National Quality Forum (NQF), and assigned its quality improvement organizations (QIOs) to collaborate hand-in-hand with individual nursing homes throughout the United States on specific care improvement projects. NQF is overseeing the brand-new National Commission on Quality Long-Term Care, which has been charged with monitoring, reporting on, and proposing policy recommendations for improving care. Taken altogether, this is, in essence, a quality-oriented network that didn't even exist four years ago.

LTC provider organizations have responded in kind with programs under the common title "Quality First"; the American Health Care Association (AHCA), the Alliance for Quality Nursing Home Care (a coalition of 14 major national chains), and the American Association of Homes and Services for the Aging (AAHSA) have each come up with their own interpretation of quality improvement through development of extensive guidelines and helpful "tool kits" for their members, whose commitment is sealed by their signing of "covenants" to that end.

How has the quality movement fared thus far? Let's take the initiatives-and the players-one-by-one.

The CMS/NQF/QIO Network
In 2002, CMS launched its Nursing Home Quality Initiative as an adjunct to the established state survey process. It was, in effect, a response to LTC provider organizations' longtime call for a collaborative relationship with government on quality improvement, rather than exclusive reliance on a state-enforced policing system. CMS joined forces with NQF, a broad-based organization founded in 2000 and consisting of representatives of healthcare system stakeholders (including providers, consumers, purchasers, and researchers), to develop 10, and eventually 14, long-term care QMs. These were intended to help nursing homes identify operational problems and gauge their progress in solving them. (For all levels of the healthcare system, NQF invites stakeholders to propose standards, which NQF then reviews, develops, publishes for comment, and revises, in a process modeled on the federal government's rule-making approach. Government agencies are, in turn, legally required to adopt NQF's voluntarily developed standards [unless they can come up with a solid reason not to].) The 14 QMs are the culmination of the process for long-term care; today, NQF is moving onto other areas, such as home healthcare.

CMS has used the QMs as a blueprint for guiding specific quality-improvement projects developed by its 50-plus QIOs in conjunction with selected nursing homes in their areas. QIOs were founded originally to monitor and work with physicians and hospitals billing Medicare on fixing their quality problems. Today, each QIO works directly with approximately 10 to 15% of the LTC facilities in their respective areas but strives to dispense information to all facilities. So far, it is the QIOs that have produced the most specific data on nursing homes' quality-improvement progress.

According to a January report by CMS based on QIO data, for example, the percentage of residents with chronic pain has dropped by one-third since 2002, and the percentage of residents who were physically restrained declined 15%. Although pressure ulcer incidence actually increased somewhat (for reasons that are unclear but could reflect better diagnosis, more problematic hospital discharges or, simply, poorer performing nursing homes), individual facilities did have success stories. The American Health Quality Association (the QIOs' professional organization) published these dramatic results on its Web site this spring: a 66% reduction of pressure ulcers in 90 days at Westwood Hills Nursing Home (Poplar Bluff, Missouri); a 69% reduction in facility-acquired pressure sores at St. Mary's Nursing Center (Leonardtown, Maryland); and an almost 50% reduction of pressure ulcers at Chestnut Hill Convalescent Center (Passaic, New Jersey)-all as a result of the intensely focused programs by the facilities involved.

Approximately 20 QIOs are initiating a project this year with state survey agencies to identify nursing homes that have had repeated problems with higher-than-average deficiencies in their surveys and to work directly with them. Other new projects include train-the-trainer sessions for coaching nursing homes on resident-centered care and continuing education teleconferencing. "QIOs are loving working with nursing homes," says Gail Patry, project manager for Rhode Island Quality Partners, the lead QIO overseeing the CMS Quality Initiative. "This has become a great interest for them, and they've warmed very much to this environment."

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