Quality Measures for a Nursing Home Care Facility
NURS 8300 Organizational & System Leadership
January 7, 2018
Quality Measures for a Nursing Home Care Facility
The United States aspires for an improvement of care in various nursing homes as evidenced by the adoption of market based improvement plans, like the public reporting as well as the pay for performance. For instance, the Centers for Medicare and Medicaid began to prepare public reports about the quality of care at each of Medicaid and Medicare authorized nursing home facility in the United States via its website-Nursing Home Compare. The website contains general information related to nursing home features, nurse staffing information, inspection results as well as clinical quality measures. Public reports about quality information can improve the quality of healthcare in two significant ways. First, consumers can use the reported information to choose high quality providers. Second, providers will focus on improving the quality of healthcare to match consumer expectations and increase market share (Park, Konetzka & Werner, 2011). It is in this regard that this paper explores three different quality measures, namely percentage of resident with moderate to severe pain, percentage of lose risk residents with bowel or bladder disorder, and percentage of resident losing a lot of weight, to help customers in choosing the right nursing home care for extended stay patients.
Outcome Quality Measures for Nursing Home
Outcome quality measures usually reflect the impact of care service on a patient’s health status. For instance, surgical mortality rates, that is, the percentage of patients that died due surgical complications and the rate of hospital acquired infections. Health outcomes consists of measures of risk adjusted mortality, infections and symptoms reliefs. These standards address a specific health problem, biomedical outcomes and comprehensive analysis of the effects of a particular intervention. Outcome measures can also include a patient’s report about his or her health as well as measures of function (Park et al., 2011). The three standards of quality for this assignment include: percentage of resident with moderate to severe pain, percentage of lose risk residents with bowel or bladder disorder, and percentage of resident losing a lot of weight loss.
An Overview of Quality Measure Calculations
The quality measures are computed from the total counts of a nursing home’ extended stay and or short stay residents who are suffering from a particular condition. The nursing home scores for long term falls are always calculated by: counting the number of residents in that facility suffering from a specific disease expressed as a percentage of residents within the facility with valid minimum data set and who suffer from that particular problem (CMS, n.d.).
Risk Adjustment in Quality Measures
Risk adjustment, at its core, refines raw quality measurement scores to accurately reflect the prevalence of a problem that a facility should address. There are two significant risk adjustment approaches applied to quality measures. One approach is the exclusion of patient whose results are not under the facilities control or an outcome that is unavoidable. All quality measures, with the exception of vaccination quality measures, are shaped by at least a single exclusion. The second approach is the use of logistic regression to directly adjust the quality measures. This method utilizes the resident level covariates that increase the outcome’s risks (CMS, n.d.).
Quality Measure 1: Percentage of Resident with Moderate to Severe Pain
This is a measurement of the percentage of long stay patients or residents who report: first, a constant moderate to severe pain within the last 5 days. Second, it includes residents experiencing very severe or horrible pain of 8 to 9 within the previous 5 days. For risk adjustment, this measurement does not include exclusions (CMS, n.d.).
Percentage of Resident with Moderate to Severe Pain = (Long stay residents with moderate to severe pain / long stay residents with the selected target assessment, with the exception of exclusions) x100%
The Measurement Specifications
The numerator comprises of long stay residents or patients with the selected target assessment. The target assessment must meet at least one of the following conditions: the resident must report nearly constant moderate to severe pain within the previous 5 days. He or she should meet two critical conditions-nearly constant or frequent severe pain and at least a single event of moderate to severe pain. Also, the resident must report very sever or horrible pain (CMS, n.d.).
The denominator consists of all long stay patients with the selected target assessment with the exception of exclusions. The exclusions comprise of: target assessments that are admission assessments, a PPS 5-day assessment and a PPS readmission or return assessment. The other category is the resident missing from the numerator because he or she did meet the specified pain symptoms for the numerator. Also, the following conditions exist: the resident did not complete the pain assessment interview and the resident did not complete the pain presence item. For residents with severe pain within the last 5 days, exclusion occurs if they did not complete the pain frequency item as well as pain intensity items and numerical pain intensity section shows no pain (CMS, n.d.).
Measurement 2: Percentage of Lose Risk Residents with Bowel or Bladder Disorder
This measurement captures the percentage of long stay patients or residents who report frequent loss of control of the bowel or bladder. Like the percentage of resident with moderate to severe pain, this type of measure does not include exclusions for risk adjustments (Park et al., 2011).
Percentage of Lose Risk Residents with Bowel or Bladder Disorder = (Long stay patients with the selected target assessment that frequently indicate bowel or bladder disorders/ All long stay patients with the target chosen assessment with the exception of exclusions) x100%.
The Measurement Specifications
The numerator comprises of all residents with the selected target assessment who frequently report inconsistence of the bowel or the bladder. The denominator, on the other hand, includes all long stay residents with the selected target assessment with the exception of exclusions. For risk adjustment these measures comprise of a total of 8 exclusions. First, the measurement does not include any target assessment that qualifies as an admission assessment or a PPS-5 day or a PPS readmission or return assessment. Also, the measurement excludes all residents that are not included in the numerator (Park et al., 2011).
Moreover, it does not include residents with any of these high-risk conditions: severe cognitive impairment, totally dependent on bed mobility based self-performance, totally dependent on transfer based self-performance and totally dependent on locomotion unit based self-performance. Fourth, the patient is a non-high-risk resident and the following condition apply for target assessment- severe cognitive impairment on target assessment. Furthermore, the measurement does not include any non-high-risk resident and the following conditions apply: totally dependent on bed mobility based self-performance, totally dependent on transfer based self-performance and totally dependent on locomotion unit based self-performance. Sixth, the patient is comatose or there is lack of comatose status in the target assessment. The other exclusion occurs if a patient has an indwelling catheter or where the indwelling catheter is missing in the target assessment. Finally, the measurement omits any resident with an ostomy or where the ostomy status is lacking in the target assessment (CMS, n.d.).
Measurement 3: The Percentage of Residents with Excessive Weight Loss
This type of measurement reports the percentage of long stay patients or residents who experienced at weight loss of at least 5 percent in the last one month or more that 10 percent in the last two quarters. For the latter category, the resident must not have been on a doctor’s prescribed weight loss note or regimen included in the minimum data set assessment for the selected quarter (Park et al., 2011).
The Percentage of Residents with Excessive Weight Loss = (long stay residents or patients with the selected target assessment with weigh loss of 5 percent or 10 percent / long stay patients with the selected target assessment with the exception of exclusions) x 100% .
The Measurement Specifications
The numerator consists of long stay nursing home patients whose selected target assessment signifies a weight loss of at least 5 percent within the last one month or at least 10 percent in the past 6 months. The latter must not have been included in the doctors’ prescribed weight loss note or regimen. The denominator, on the other hand, comprises of long stay residents with the selected target assessment with the exception of exclusions. Exclusions include: a target assessment that qualifies as an OBRA admission assessment or a PPS 5- day or a PPS readmission or return assessment. Also, the measurement does not include any weight loss item missing from the target assessment (CMS, n.d.).
Data Collection Methods: The Primary Source of Data
The minimum data set alongside site inspection data are the primary sources of data for long term care in nursing homes. The Centers for Medicare and Medicaid Services has developed various minimum data set versions used to evaluate the quality of health care and to aid with direct reimbursement. One of the known sources of data set is the Long-Term Care Resident Assessment Instrument Minimum Data Set version 2.0. This type of data set comprises of three critical components, namely the Minimum Data Set version 2.0, the resident assessment protocols and the utilization guidelines (Joshi, Ransom, Nash & Ransom, 2014).
The Minimum Data Set version 2.0 comprises of a set of indicators that capture the clinical as well as functional features of the residents staying in long term facilities. This source of data contains at least 72 fields that a nursing home care must fill for every resident four times per year. The resident assessment protocols are usually built around the minimum data set data elements. Staffs from long term care facilities can use these protocols to address a patient’s medical, psychological as well as social problems in order to develop a personalized care plan. Meanwhile, utilization guidelines provide basic directs on how as well as when to use the Long-Term Care Resident Assessment Instrument (Joshi et al., 2014).
Data Collection Methods: Selecting the Quality Measures Samples
Two resident samples are always collected to compute quality measures: the short stay and the long stay samples. The samples are selected through the following steps: first, the selection of all patients whose latest episodes are either ending during or ongoing toward the end of the target time or period. The latest episode is used to calculate quality measurements. The second step is the computation of cumulative days in the facility for each episode selected. The resident is usually included in the short stay sample if the cumulative days in the facility are not more than 100. The resident is placed under the long stay sample if the cumulative days in the facility are at least 101 days (CMS, n.d.).
External Support for Quality Measures
Primary care organizations with strong quality improvement orientation continually aspire to improve not only their performance but their patients’ outcomes. To do so, they focus on some critical areas including improving patient identification, monitoring as well as follow up. However, many providers do not engage in quality improvement practices even though it can improve an organization’s skills to achieve its improvement goals. It is for this reason that some organizations outside health care system are providing external support in form of technical assistance, tools and resources as well as learning activities to assist care providers in undertaking quality improvement initiatives. Some these organizations are the area health education centers, quality improvement organizations, insurer, primary care professional organizations, health information technology regional extension centers and practice based research centers. The provide data feedback plus benchmarking practices, practice facilitation, external consultation services and shared learning opportunities (Laureate Education Inc., 2011).
Nursing home facilities must have significant goals to increase their market share in the current competitive business environment. This paper recommends two essential goals for a nursing home facility to have a competitive advantage over its rivals. First, a nursing home must reduce harms associated with delivery of care to provide safe care. According to the Centers for Medicare and Medicaid Services (n.d.) many Americans suffer from healthcare related errors. For instance, the Centers for Diseases Control and Prevention estimates that more that 1.5 million health associated infections occur every year, resulting in approximately 100,000 deaths and at least 770,000 injuries per year. As a result, healthcare facilities including nursing home cares should strive at establishing a culture of care safety to eliminate inappropriate as well as unnecessary care that can cause harm. A nursing care facility should strive for improved communication among providers, patients as well as family members to achieve the goal.
In addition, a nursing home facility should promote effective coordination as well as communication to eliminate unnecessary treatments; avoidable admissions plus readmissions as well as other harms to patients. To do so, they must promote educational and training programs for care providers on effective communication techniques with patients, their family members plus the entire community. Also, they should promote educational and training programs for clients and their family members on person based care as well as communication techniques to express their care needs plus preferences.
Importance of Quality Measures to a Nursing Home Facility
Quality measures are only useful if they are linked to results or outcomes that are more important to patients: patient safety; reduce cost of healthcare and high quality. Also, quality measures are only useful if the findings are related to actions that can be changed by a health care facility. In fact, the accountability of practitioners plus healthcare facilities for the patient health outcomes is an issue that can be addressed by health care providers as they can be well versed with societal problems (Wachter & Pronovost, 2009).
With regards to the already discussed quality measures- percentage of resident with moderate to severe pain, percentage of lose risk residents with bowel or bladder disorder, and the percentage of residents with excessive weight loss they are good quality measures as they can enable an organization to work toward improving patient safety as well as quality of care within the facility to reduce the length of stay. By doing so, a nursing home care can tremendously reduce the cost of care provision as many patients will not be overstaying in the facility.
Quality of care measures have been put in place to address pressing health care issues facing the United States. Nonetheless, there are sufficient reasons for nursing home facilities to confront quality issues with the same effort as those directed at matters of cost. This paper has clearly indicated that nursing home facilities can compute critical quality measures for quality improvement. Also, nursing home facilities can benefit from quality measures as it can result in improved quality of care, improved patient safety as well as reduced cost of care. However, to enjoy the fruits of quality measures a nursing home facility must put in place appropriate goals. References
Centers for Medicare & Medicaid Services. (n.d.). Quality initiatives: Overview. Retrieved from http://www.cms.gov/QualityInitiativesGenInfo/
Joshi, M.S., Ransom, E.R., Nash, D.B., & Ransom, S.B., (Eds.). (2014). The healthcare quality book. (3rd ed). Chicago, IL: Health Administration Press.
Laureate Education, Inc. (Executive Producer). (2011). Organizational and systems leadership for quality improvement: External quality improvement. Baltimore, MD: Author.
Park, J., Konetzka, R. T., & Werner, R. M. (2011). Performing well on nursing home report cards: Does it pay off? Health Services Research, 46(2), 531–554. doi: 10.1111/j.1475-6773.2010.01197.x
Wachter, R. M., & Pronovost, P. J. (2009). Balancing “no blame” with accountability in patient safety. New England Journal of Medicine, 361(14), 1401–1406. doi: 10.1056/NEJMsb0903885
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