Long Term Quality Measurement for Older Adults

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Long Term Quality Measurement for Older Adults

• Tamara L. Burket, MS, GCNS-BC, ACNS-BC, CCRN
• Fellow Geriatric Nursing Leadership Academy

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Resources

• http//www.cms.gov/Medicare/Quality-Initiatives-Pa
  tient-Assessment-Instruments/NursingHomeQualityIni
  ts/index.html?redirect/NursingHomeQualityInits/

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http//www.newschool.edu/ltcc/pdf/txBackground03-1
0-05FINAL.pdf
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Objective

• Discuss valid quality measures and their
  application in diverse gerontological settings
  throughout the community.

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Points of Emphasis

• Enhanced QOL as prime directive
• History Alphabet soup!!
• ACOVE /IOM/ CMS/
• QI/ OBQI/ RAI
• 3. Nursing Home Compare
• 4. Where do I start?

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Target Population

• The Administration on Aging defines the older
  population as persons 65 and older (2004).
• The U.S. Census Bureau defines the older adult as
  elderly and includes persons 65 years of age
  and older (2001).

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• Young old 65-75
• Old 75-85
• Old old 85
• Centurions are now the fastest growing age group

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Target Population Statistics

• According to the U.S. Census Bureau
  1 in 8 Americans were elderly in
  1994 1in 5 or 20 will be elderly by the year
  2030.
• The U.S. Census Bureau predicts the fastest
  growing portion of the elderly population is the
  oldest old (individuals 85 years of age and
  older).

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Population Age Projections 2005 - 2050

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Persons 65 and Over - by age group - 1900-2000
- projected 2010-2050
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Target Population Complex Issues

• The elderly are living longer and they place
  increasing demands on the healthcare system and
  on medical and social services (CDC, 2005).
• Though we see the health of older Americans
  improving, many of these individuals are disabled
  or coping with chronic diseases/conditions (U.S.
  Census Bureau, 2006).
• Older adults are dealing with chronic diseases,
  diminished quality of life, and increased costs
  of healthcare (CDC, 2005).

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Socioeconomic Issues

• 30of the Medicare budget is spent on 6 of the
  Medicare population in the last year of life
• Federal spending in the elderly has double since
  1960
• Hospitals receive the majority of Medicare
  expenditures and nursing facilities receive the
  majority of Medicaid expenditures.
• Following retirement, income drops 50 on the
  average

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Minority Elderly

• 15- 65
• 8 Black
• 2 Asian or Pacific Islanders
• 1 Native American
• 4 Hispanic

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• 12 of Black population are elderly
• 13 of those are over 85
• They are the fastest growing segment of the black
  population

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Health Care Disparities

• http//www.census.gov/Press-Release
  /www/releases/ archives/aging_population/
  006544.html

http//www.agingstats.gov/chartbook2004/population
.html
http//www.census.gov/population/www/pop-profile/
elderlypop.html
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Vulnerable Elders

• ACOVE
• community dwelling elders aged 65 and older who
  are at greater risk of death or functional
  decline over a 2-year period.
• JAGS 55S247-S252, 2007

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Characteristics of Vulnerable Elders

• Patient Safety Concerns
• Deficits In Quality of Care
• Particular Care Needs of Older Persons
• JAGS 55S247-S252, 2007
• Iatrogenic Cascade

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Complicated by

• Multiple Medical Conditions
• Chronicity
• Ageism
• Functional Status
• Substantial Variation in Preferences
• Diversity

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Top 4 Major Chronic Illnesses in Older Adults

• Asthma
• Hypertension
• Hearing Impairment
• Heart Conditions

Robinson, D., Kish, C. (2001) Advanced Practice
Nursing. St. Louis, MO Mosby, Inc., 570
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Geriatric Care Priorities

• Medical
• Cognitive
• Affective
• Functional
• Social support/care giver

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Elements Of Geriatric Assessment

• Economic
• Environmental
• Quality of life/well-being
• Advance Directives

• SPICES
• Sleep
• PO
• Incontinence
• Confusion
• Evidence of falls
• Skin breakdown

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Legislation

• 1935-Social Security Act Intended as old-age
  insurance
• 1965-Older Americans Act established the
  foundation for the development of todays senior
  centers.
• 1981- Omnibus Budget Reconciliation Act (OBRA)
  reduced Medicaid eligibility for older Americans,
  care, set limits for health care services,
  established criteria for nursing home care
• 1983-Prospective Payment System reduced
  reimbursement for home health services
• 1990-OBRA provided direct reimbursement for NPs
  and specialists in rural areas

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(No Transcript)
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...NEVER EVENTS

• 2008- A list of 28 medical errors from the
  National Quality Forum
• Should never happen
• Never getting paid
• Among them Death or disability related to
• falls
• use of restraints or bedrails
• stage 3 or 4 pressure ulcers
• suicide or attempted suicide
• medication error
• sexual or physical assault
• while being cared for in a healthcare facility

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Healthy People 2010

• Physical activity
• Overweight and obesity
• Responsible sexual behavior
• Injury and violence
• Immunizations
• Tobacco use
• Substance abuse
• Mental health
• Environmental quality
• Access to quality care

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10 KEYS TO HEALTHY AGING(From Healthy People
2020)

• Lower Systolic Blood Pressure
• Stop Smoking
• Participate in Cancer Screening
• Get Immunized Regularly
• Regulate Blood Glucose
• Lower LDL Cholesterol
• Be Physically Active
• Prevent Bone Loss and Muscle Weakness
• Maintain Social Contact
• Combat Depression

The Center for Healthy Aging University of
Pittsburgh Graduate School of Public
Health http//www.healthyaging.pitt.edu/home.html
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Process Measures
Timely initiation of care How often the home health team began their patients care in a timely manner.
Influenza immunization received for current flu season How often the home health team determined whether patients received a flu shot for the current flu season.
Pneumococcal polysaccharide vaccine ever received How often the home health team determined whether their patients received a pneumococcal vaccine (pneumonia shot).
Heart failure symptoms during short-term episodes How often the home health team treated heart failure (weakening of the heart) patients symptoms.
Diabetic foot care and patient education implemented during short-term episodes of care For patients with diabetes, how often the home health team got doctors orders, gave foot care, and taught patients about foot care.
Pain assessment conducted How often the home health team checked patients for pain.
Pain interventions implemented during short-term episodes How often the home health team treated their patients pain.
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More Process Measures


Depression assessment conducted How often the home health team checked patients for depression.
Drug education on all medications provided to patient/caregiver during short-term episodes How often the home health team taught patients (or their family caregivers) about their drugs.
Multifactor fall risk assessment conducted for patients 65 and over How often the home health team checked patients risk of falling.
Pressure ulcer risk conducted How often the home health team checked patients for the risk of developing pressure sores (bed sores).
Pressure ulcer prevention included in the plan of care How often the home health team included treatments to prevent pressure sores (bed sores) in the plan of care.
Pressure ulcer prevention implemented during short term episodes of care How often the home health team took doctor-ordered action to prevent pressure sores (bed sores).
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Improvement Measures
 
Improvement in ambulation How often patients got better at walking or moving around.
Improvement in bed transfer How often patients got better at getting in and out of bed.
Improvement in pain interfering with activity How often patients had less pain when moving around.
Improvement in bathing How often patients got better at bathing.
Improvement in management of oral medications How often patients got better at taking their drugs correctly by mouth.
Improvement in dyspnea How often patients breathing improved.
Improvement in status of surgical wounds How often patients wounds improved or healed after an operation.

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Healthcare utilization measures

Acute care hospitalizations How often home health patients had to be admitted to the hospital.
Emergency department use without hospitalization How often patients receiving home health care needed any urgent, unplanned care in the hospital emergency room without being admitted to the hospital.

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Impacting Quality Measures
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Safety Evidence Hospitals face mounting costs
and decreased reimbursement based on indicators
like injuries related to falls, pressure ulcers,
and nosocomial infections. Nurses and other
providers are challenged to define their
contribution to patient safety in meeting
regulatory requirements and standards. Teamwork Ev
idence The Institute of Medicine (2008) supports
interdisciplinary teamwork as evidenced in the
review of 128 successful, innovative models for
geriatric care.
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TransdisciplinaryTeamwork

• Population
• Intervention
• Comparison
• Intervention

• Plan
• Do
• Change
• Assess

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Advocacy Evidence Nurses have multiple
opportunities within their organizations and
communities to advocate for timely and just
dispersal of increasingly sparse resources in
the care of older adults. Rounds Evidence The
Studer Group recommends Rounding for Outcomes
and the use of rounding logs and care plans to
support nursing intervention, care coordination,
and reward and recognition as patient and staff
goals are achieved.
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SPICES Sleep PO Incontinence Confusion Evidence
of falls Skin breakdown
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PICO

• P Elder Trauma Victims over 65 years of age
• I Targeted Geriatric Rounding
• C Absence of targeted geriatric rounding
• 0 Effects of intervention

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Will targeted geriatric rounds provide measurable
outcome improvements in nursing care for victims
of injury patients over 65 years old?
Sample PICO Question
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Potential Qualitative Outcome Measures

• Nurse Satisfaction
• Patient Satisfaction
• Quality of life
• Patient Safety/Compliance Data
• Nurse Sensitive Quality Indicators

• Geriatric Syndromes
• Vulnerabilities

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Qualitative

• Each time, those who espouse only
  evidencewithout narratives about real
  peoplestruggle to control the debate. Typically,
  they lose.
• Jason Karlawish
• http//scienceprogress.org/2011/11/the-importance-
  of-narrative-in-communicating-evidence-based-scien
  ce/

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10 Most Common Geriatric Consult Team
Interventions

• 1. Confusion Assessment
• 2. Falls Assessment Precautions
• 3. Polypharmacy Issues
• 4. Dehydration
• 5. Pain Management

• 6. Discharge Recommendations
• 7. Bowel Regimen
• 8. Blood Pressure Management
• 9. Urinary Sepsis Screening
• 10. Dysphagia Screening

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Population of Nursing Care Plans Before After
Targeted Rounding
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ExamplesNurse Satisfaction Data Before and
After Rounding for Outcomes
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Nurse Satisfaction Data Before and After Rounding
for Outcomes
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Patient Satisfaction Data
KEY Baseline 3Q11 4Q11 1Q12
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Quality Indicators per 1000 Patient/Device Days
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FY11 BOOST Results

• 30-Day Related Cause Readmission Rates

Comparison Groups FY10 FY11 11 Jul-Dec 11 Jan-June
Organization 5.2 5.18 5.26 5.09
Internal Medicine 3.48 4.53 4.86 4.25
Family Comm Med. 4.2 4.91 5.68 4.08
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Additional Resources

• Penn State Milton S. Hershey Medical Center and
  Penn State College of Medicine.(2011). FY11
  Project BOOST results inform the FY12 Care
  Transitions Project. Crescent. Hershey, PA.
  Sept. 14, 2011.
• Institute of Medicine. (2008). Retooling for an
  aging America building the health care
  workforce. Washington, DC. The National
  Academies Press.
• Resnick, B. (2010). Function of older adults in
  acute care optimizing an opportunity. In M.D.
  Foreman, K Milison T.T. Fulmer (Eds.), Critical
  Care Nursing of Older Adults Best Practices (3rd
  ed., pp. 209-238). New York Springer.

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• http//www.studergroup.com/dotCMS/knowledgeAssetDe
  tail?inode111088
• http//www.iom.edu/Global/News20Announcements/Cro
  ssing-the-Quality-Chasm-The-IOM-Health-Care-Qualit
  y-Initiat
• http//consultgerirn.org/searched?qSPICESive.aspx