Nursing Home Quality Initiative Research Articles

Nursing Home Responses to Performance-based Accountability: Results of a National Survey.

The Centers for Medicare & Medicaid Services (CMS) Nursing Home Quality Initiative aims to improve quality through performance measurement. We describe quality improvement (QI) changes that skilled nursing facilities (SNFs) reported making in response to CMS performance measurements and whether reported QI changes were associated with better performance on CMS performance measures. Nationally representative survey. A total of 15,475 SNFs that reported quality performance on Nursing Home Compare in 2016. A total of 1,182 SNFs (58% of random sample of 2,045 SNFs). Adoption of 22 possible QI changes, grouped into seven categories (organizational culture, health information technology, care process redesign, provider incentives, changes to staffing responsibilities, performance monitoring, and measure-specific QI initiatives and technical assistance); performance on the CMS Nursing Home Compare Five-Star Quality Rating System's quality measure rating. SNFs reported making an average of 13 QI changes (interquartile range = 11-16 changes). SNFs mostly commonly reported becoming a learning organization (87%) and providing training to staff on QI strategies (87%). After controlling for patient and facility characteristics, larger SNFs were more likely to obtain assistance on measure reporting from QI organizations and use provider champions than smaller SNFs by 14 and 11 percentage points, respectively. Rural SNFs and SNFs with higher proportions of disabled, black, or Hispanic residents adopted QI changes at similar rates as other SNFs. Of the 22 QI changes, 20 were considered at least somewhat helpful by more than 80% of adopting SNFs. Implementation of all 22 QI changes (vs no changes) was associated with a .48-star higher quality measure rating (95% confidence interval = .003-.98 stars; P = .05). In response to CMS measurement programs, SNFs reported making substantial QI investments that were associated with better performance on CMS quality measures. To guide future SNF investments in QI, work is needed to identify the QI changes that yield the greatest performance improvements.

The Role of Donations in Quality Disclosure: Evidence from Nonprofit Nursing Homes

This paper uses a quality disclosure policy—the Nursing Home Quality Initiative, which mandates the public reporting of quality information on selected dimensions—to investigate how nonprofit nursi...

Impact of Medication Aide Use on Skilled Nursing Facility Quality

A number of states have begun to allow skilled nursing facilities to employ medication aides, who have less formal education than registered nurses (RNs) or licensed practical nurses (LPNs), to administer medications. If this results in fewer RNs or LPNs, quality degradation may occur. We evaluated the effect of regulations allowing for medication aides on subsequent medication aide use and the effect of changes in medication aide use on other nurse staffing, deficiencies, and Nursing Home Quality Initiative (NHQI) health outcome measures. Staffing levels and inspection deficiencies from the Online Survey and Certification and Reporting System and NHQI data from 2004 to 2010 for facilities from eight southeastern U.S. states are used in instrumental variables models with facility fixed effects. Facilities in states allowing for medication aide use increased medication aide use with no statistically significant reduction in RN or LPN use. Medication aide use decreased the probability that a facility received a deficiency citation for unnecessary drug use or having a medication error rate greater than or equal to 5% and had no effect on deficiencies for significant or harmful medication errors. Increased medication aide use was associated with fewer pharmacy and total deficiency citations and decreased use of physical restraints; in contrast, more use of medication aides was associated with an increase in the percentage of residents needing help with activities of daily living and losing continence. This study provides support for state policies that allow skilled nursing facilities to use medication aides.

Multitasking, Information Disclosure, and Product Quality: Evidence from Nursing Homes

This paper uses a mandatory quality disclosure policy, the Nursing Home Quality Initiative (NHQI), to investigate how quality ‘report cards’ affect firms’ choices of multidimensional product quality. I show that after the introduction of NHQI: (1) scores of quality measures improve for the reported dimensions but deteriorate for the unreported ones; (2) there is no evidence that nursing homes decrease quality‐related inputs; (3) consumer demand becomes sensitive to changes in the NHQI quality measures. These findings are consistent with the multitasking hypothesis that firms may respond to information disclosure by reallocating effort across dimensions of quality without necessarily increasing overall quality.

How Do Nonprofit Organizations Respond to Quality Disclosure?

This paper uses a quality disclosure policy, the Nursing Home Quality Initiative, which mandates the public reporting of quality information on selected dimensions, to investigate how nonprofit nursing homes react to economic incentives. I find that nonprofits are as responsive as for-profits to quality disclosure: quality improves along the reported dimensions and diminishes along the unreported ones. Further tests show that nonprofits may respond to donations and fail to mimic for-profits when competing with them. These findings suggest that donor response may be the motive for nonprofits to respond to quality disclosure in the same way as for-profit alternatives.

Does Information Matter? Competition, Quality, and the Impact of Nursing Home Report Cards

We evaluate the effects of the Nursing Home Quality Initiative (NHQI), which introduced quality measures to the Centers for Medicare and Medicaid Services' Nursing Home Compare website, on facility performance and consumer demand for services. The nursing home Minimum Data Set facility reports from 1999 to 2005 merged with facility-level data from the On-Line Survey, Certification, and Reporting System. We rely on the staggered rollout of the report cards across pilot and nonpilot states to examine the effect of report cards on market share and quality of care. We also exploit differences in nursing home market competition at baseline to identify the impacts of the new information on nursing home quality. The introduction of the NHQI was generally unrelated to facility quality and consumer demand. However, nursing homes facing greater competition improved their quality more than facilities in less competitive markets. The lack of competition in many nursing home markets may help to explain why the NHQI report card effort had a minimal effect on nursing home quality. With the introduction of market-based reforms such as report cards, this result suggests policy makers must also consider market structure in efforts to improve nursing home performance.

Multitasking, Information Disclosure and Product Quality: Evidence from Nursing Homes

This paper uses a quality mandatory disclosure policy, the Nursing Home Quality Initiative (NHQI), to investigate how quality report cards affect firms' choices of multidimensional product quality. I show that after the introduction of NHQI: (1) the proportion of effort allocated to unreported dimensions decreases; (2) quality improves insignificantly along the reported dimensions, but deteriorates along the unreported ones; (3) there is no evidence that nursing homes increase quality-related inputs. These findings are consistent with the multitasking hypothesis that, rather than increasing effort for quality improvement, firms may respond to information disclosure by reallocating effort across dimensions of quality.

Physicians' Workload Has Increased at Facilities

Physicians' Workload Has Increased at Facilities

Is a Public Reporting Approach Appropriate for Nursing Home Care?

Publicizing quality information has been used as a quality improvement strategy in the acute care sector for more than a decade. Despite research showing mixed results of these efforts, publicly reporting quality measures is currently being pursued as a quality improvement strategy for nursing homes. Designed to empower consumers to make informed choices and to stimulate provider competition on quality, nursing home public reporting began in 1998 with the Nursing Home Compare Web site and has received greater emphasis in the 2002 Nursing Home Quality Initiative, both directed by the federal government. Focusing on the response of three key stakeholder groups across settings of care-consumers, providers, and purchasers-I identify several challenges that nursing home reporting must overcome to be successful. I conclude that publicly reporting quality measures for nursing homes will have a harder time promoting quality improvement than for acute care settings, where results have been disappointing thus far. In addition to the conceptual analysis, I evaluate whether the quality information reported on Nursing Home Compare had any impact on nursing home occupancy rates following its release. Using a pre/post-release design, I find that the effect of public reporting on nursing home occupancy rates has been minimal thus far. Although some estimates of effect are statistically significant and in the hypothesized direction, they all suggest very small effect sizes. It is unclear whether the absence of a larger reporting effect to date is specific to Nursing Home Compare or whether it inheres to the broader task of using quality information to promote change in the nursing home care sector.

AMDA Guidelines Clarify Treatment Goals

AMDA Guidelines Clarify Treatment Goals

The Nursing Home Quality Initiative

With great fanfare, the Centers for Medicare & Medicaid Services (CMS) in November 2002, launched the Nursing Home Quality Initiative (NHQI)—a program that promises to bring together nursing home r...

USA - Health officials praise Bush administration for national nursing home quality initiative that is yielding postive results in quality care

USA - Health officials praise Bush administration for national nursing home quality initiative that is yielding postive results in quality care

The Extent of Quality Improvement Activities in Nursing Homes

The quality of nursing home care has long been a cause for concern. The federal government has recently launched the Nursing Home Quality Initiative, in which Quality Improvement Organizations assist nursing homes in quality improvement (QI) activities. In addressing how well nursing homes are prepared for QI, this article examines the sort of QI activities that nursing homes are currently undertaking and the preparation of Administrators and Directors of Nursing to lead QI efforts. Drawing on data from surveys of 2 random samples of Kansas nursing homes, the article concludes that questions about QI activities in nursing homes tend to elicit socially acceptable answers unless the questions are carefully structured; that few nursing homes appear to have functioning QI programs; and that high leadership turnover and limited leadership training make it difficult for nursing homes to sustain effective QI programs.

Research in Long-Term Care

Expenditures for long-term care for older Americans are sizable and likely to increase as the population ages. As the largest purchaser of health care for this group of citizens, the Centers for Medicare & Medicaid Services (CMS) is working to improve the quality of the long-term care services it purchases through quality monitoring and enforcement, providing information to beneficiaries about quality of care and enhancing resources to improve quality. Although CMS has used the best scientific information available to inform the planning of quality initiative projects, there are a number of issues, dilemmas, and challenges for which the research base is insufficient to fully answer programmatic needs. In many instances, research needs in the long-term care setting differ substantially from those in acute care. Using the Nursing Home Quality Initiative as an example, this article presents a descriptive, conceptual discussion of strategic issues and a summary of research that would be valuable in informing critical areas of decision-making in quality and outcomes research over the next decade. The issues, dilemmas, and challenges discussed are grouped into 5 categories: measurement methods and tools, uses of quality data, organizational and cultural factors, information and informatics, and impact evaluation and research.

Using large data sets in long-term care to measure and improve quality

The authors explore the evolution, potential uses, and limitations of four existing large data sets in long-term care: Minimum Data Set (MDS), Outcome Assessment and Information Set (OASIS), Online Survey and Certification Reporting System (OSCAR), and Consumer Surveys. They also describe the emerging Federal Nursing Home Quality Initiative and its potential for future research. All four existing large data sets have potential to be used to improve quality of care. Their utility is presently diminished because providers are not using the data for formal continuous quality improvement. However, the Center for Medicare and Medicaid Services (CMS) is currently engaged in a series of special studies designed to build and sustain a culture of continuous quality improvement in nursing homes and to make continuous, measurable improvement a growing part of the care of Medicare beneficiaries in those settings. These CMS studies, all of which will draw on the four existing large data sets in long-term care, offer the potential to develop, explicate and test theory about the assumed causal relationships between structure and process variables and related health care outcomes in long-term care.

Medicare Quality Initiative

Department of Health and Human Services Secretary Tommy Thompson announced the Medicare Quality Initiative (MQI) in November 2001. With this announcement, a new era of public reporting of health care outcomes began. This policy update discusses the purposes of the MQI, its implementation, and the reports on the Nursing Home Quality Initiative and the Home Health Quality Initiative. Hospitals and physician practices are future targets of the MQI.

Nursing home compare: web site offers critical information to consumers, professionals.

The U.S. Department of Health and Human Services has launched a Nursing Home Quality Initiative that provides nursing home consumers and healthcare professionals with publicly reported quality information about every Medicare- or Medicaid-certified nursing facility in the United States. The initiative also offers assistance to nursing homes in their continuing efforts to improve the quality of the care they offer. This article provides an overview of that initiative, and discusses information available on the Nursing Home Compare Web site that case managers will find useful for helping clients in their nursing home decision-making process.

Approaches to quality improvement in nursing homes: lessons learned from the six-state pilot of CMS's Nursing Home Quality Initiative.

BackgroundIn November 2002, the Centers for Medicare & Medicaid Services (CMS) launched a Nursing Home Quality Initiative that included publicly reporting a set of Quality Measures for all nursing homes in the country, and providing quality improvement assistance to nursing homes nationwide. A pilot of this initiative occurred in six states for six months prior to the launch.MethodsReview and analysis of the lessons learned from the six Quality Improvement Organizations (QIOs) that led quality improvement efforts in nursing homes from the six pilot states.ResultsQIOs in the six pilot states found several key outcomes of the Nursing Home Quality Initiative that help to maximize the potential of public reporting to leverage effective improvement in nursing home quality of care. First, public reporting focuses the attention of all stakeholders in the nursing home industry on achieving good quality outcomes on a defined set of measures, and creates an incentive for partnership formation. Second, publicly reported quality measures motivate nursing home providers to improve in certain key clinical areas, and in particular to seek out new ways of changing processes of care, such as engaging physicians and the medical director more directly. Third, the lessons learned by QIOs in the pilot of this Initiative indicate that certain approaches to providing quality improvement assistance are key to guiding nursing home providers' desire and enthusiasm to improve towards a using a systematic approach to quality improvement.ConclusionThe Nursing Home Quality Initiative has already demonstrated the potential of public reporting to foster collaboration and coordination among nursing home stakeholders and to heighten interest of nursing homes in quality improvement techniques. The lessons learned from this pilot project have implications for any organizations or individuals planning quality improvement projects in the nursing home setting.

Extended Care Career Ladder Initiative (ECCLI) Round 2: Evaluation Report

The Commonwealth of Massachusetts initiated the Extended Care Career Ladders Initiative (ECCLI) as part of a broader Nursing Home Quality Initiative, adopted by the Massachusetts Legislature in 2000. Both acts were a response to high turnover and vacancies among paraprofessionals in long-term care, creating instability that threatens quality and access to health care. Basic to these initiatives is the equation of good care for consumers with good jobs and opportunities for frontline caregivers. This working paper is an 18-month evaluation of ECCLI Round 2, designed to use workforce development strategies to improve both worker and resident outcomes. This report covers Round 2, building on a prior baseline report (and KSG Working Paper RWP01-035) dated September 2001. This paper evaluates activity, lessons, barriers, and achievements of seven consortia that included 27 nursing homes, two home health agencies, and about 20 workforce partners during the period July 2001 through May 2002. It uses a case study and interview approach as its main evaluation method, as well as reporting project-wide data where available. In total, we conducted more than 80 interviews with the seven project coordinators, 25 nursing home and home health managers, 10 community or workforce expert representatives and 41 workers. Survey data were collected from 161 training participants as well. Training is one of ECCLI Round 2's most visible accomplishments to date. More than 600 workers in 27 facilities or home care agencies were trained in a wide array of skills, ranging from clinical knowledge and care giving to generally applicable skills, such as English for Speakers of Other Languages (ESOL), teamwork, communications, and problem-solving. Most ECCLI consortia have also taken small steps in improving the earning power of nursing aides and service workers. Most case study sites reported wage increases, whether for completion of career ladder courses, or for moving to certified nursing assistant from dietary or housekeeping roles. The wage increments are modest, generally in the range of 3-4%, or from 30 to 50 cents per hour. More than seven in ten workers surveyed had received a pay increase because of the training; the majority found their raises moderately helpful but not significantly so. ECCLI employers are also finding it easier to find and keep workers since implementing the program, particularly in nurse aides and ancillary staff. Participating employers are seeing fewer vacancies, lower staff replacement costs, and a reduction in employee exits, agency costs, and turnover. Some progress in changing the practices of caregiving has also occurred, though not across the participating consortia. One of the most significant changes is the individualized bathing initiative adopted by several facilities in one consortium. Career ladders of some kind now exist for workers in all the consortia, though the level of institutionalization varies. Quality improvement outcomes cannot be demonstrated definitively pending further data acquisition, but qualitative evidence suggests improvements in several key areas. Perhaps the greatest internal barrier to success has been balancing the implementation of a complex project with daily operational demands of running a 24-hour nursing facility. The compressed project schedule (of one year for implementation) contributed to these problems. State budget delays stalled the projects for six months in several consortia, further complicating implementation. Many positive lessons for how to implement career ladders and care giving improvements were identified in the evaluation report as well.

Extended Care Career Ladder Initiative (ECCLI): Baseline Evaluation Report of a Massachusetts Nursing Home Initiative

The Commonwealth of Massachusetts initiated the Extended Care Career Ladder Initiative (ECCLI) as part of a broader Nursing Home Quality Initiative, adopted by the Legislature in 2000. This legislation is a response to high turnover and vacancies among paraprofessionals in long-term care, creating instability that threatens quality and access to health care. Basic to these initiatives is the equation of good care for consumers with good jobs and opportunities for frontline caregivers. Thus it asks long-term care providers to partner with other organizations (including community based groups, unions, work force development agencies, community colleges, and other long-term care providers) to mount demonstration projects that offer insight into new care-giving and workplace practices that improve the quality of care and the quality of jobs. These projects should also demonstrate how the accomplishment of care giving and workforce quality goals can be mutually reinforcing. Sponsors hope that such projects will offer clear and replicable models for both the long term care industry, and the workforce development community that supports the industry and its potential and existing labor force. ECCLI'S overall program goal is to promote systemic change and build capacity within the long-term care and work force development communities in support of the following goals and objectives: (1) Improve quality of care; (2) Promote skill development; (3) Create and institutionalize career ladders and other workplace practices that support and develop workers; and (4) Improve employee retention. The attached baseline evaluation report is presented as a working paper for the information of researchers and practitioners in the field of nursing home quality and workforce development. It covers the period from March 2001 to June 2001 when the ECCLI program was getting underway, and was submitted to the Commonwealth Corporation of Massachusetts, the quasi-public agency that is administering the funds from the Nursing Home Quality Initiative. Future reports will analyze data collected by the researchers after this baseline and planning period. Major findings include insight into the process of forming consortia across unfamiliar realms of human services (health care and workforce development and education), and challenges for the participants as they consider and implement organizational change as well as training programs for frontline workers as well as supervisors.