Dementia-Dementia-Specific NH Specific NH

Quality Quality IndicatorsIndicators

IDND MeetingIDND Meeting

May 2008May 2008

Greg Arling, Ph.D.Greg Arling, Ph.D.

Dementia-Specific QI (D-QI) Dementia-Specific QI (D-QI) ProjectProject

Funded by the Alzheimer’s Association Funded by the Alzheimer’s Association (Investigator-Initiated Research Grant)(Investigator-Initiated Research Grant)

October 2007 – September 2010October 2007 – September 2010 Greg Arling (PI) and Malaz Boustani Greg Arling (PI) and Malaz Boustani

(Co-PI) -- IU Center for Aging Research(Co-PI) -- IU Center for Aging Research Christine Mueller (Co-PI) – U of Christine Mueller (Co-PI) – U of

Minnesota School of NursingMinnesota School of Nursing Focus on nursing home care in Focus on nursing home care in

MinnesotaMinnesota

D-QI Project ObjectivesD-QI Project Objectives Form an Form an advisory groupadvisory group to provide guidance for to provide guidance for

the project;the project; Identify current and new Identify current and new quality indicatorsquality indicators (D- (D-

QIs) most relevant to dementia residents;QIs) most relevant to dementia residents; Assemble Assemble available dataavailable data on clinical care and on clinical care and

quality of life of nursing home residents;quality of life of nursing home residents; Analyze available data to arrive at a final set of Analyze available data to arrive at a final set of

D-QIs for D-QIs for profiling nursing facilities and their profiling nursing facilities and their residentsresidents;;

Describe Describe best practicesbest practices in care of dementia in care of dementia residents through interviews with nursing home residents through interviews with nursing home staff in high quality facilities (high D-QI scores).staff in high quality facilities (high D-QI scores).

Incorporate D-QIs into the Minnesota Incorporate D-QIs into the Minnesota NH NH Report CardReport Card, , P4PP4P, and facility , and facility quality quality improvement effortsimprovement efforts..

Minnesota NH Quality andMinnesota NH Quality andPayment SystemPayment System

Multidimensional Multidimensional measures of nursing home measures of nursing home qualityquality

NH Report CardNH Report Card to inform consumer to inform consumer decisionsdecisions

Facility reporting systemFacility reporting system and and training training sessionssessions to promote quality improvement. to promote quality improvement.

Provider Payment Incentive ProgramProvider Payment Incentive Program which which funds quality improvement projects to foster funds quality improvement projects to foster innovation and organizational learninginnovation and organizational learning

Minnesota NH Quality Minnesota NH Quality MeasuresMeasures

StructStructureure

ProcesProcesss

OutcoOutcomeme

Nurse staffing level & Nurse staffing level & retention rateretention rate

Clinical Quality Clinical Quality Indicators (QI)Indicators (QI)

Quality of Life and Quality of Life and Resident Satisfaction Resident Satisfaction Survey (QoL/RS)Survey (QoL/RS)

State NH inspection State NH inspection results (quality of care results (quality of care violations)violations)

NH Quality Indicators NH Quality Indicators (QIs)(QIs)

Based on Minimum Data Set (MDS) Based on Minimum Data Set (MDS) assessmentsassessments Standardized assessment of health and Standardized assessment of health and

functional conditionsfunctional conditions Administered to all residents by NH staff at Administered to all residents by NH staff at

admission and every 90 days thereafteradmission and every 90 days thereafter Transmitted monthly to the state in a Transmitted monthly to the state in a

standardized electronic formatstandardized electronic format 24 QIs representing care processes and 24 QIs representing care processes and

outcomesoutcomes Binary variable (yes/no) at resident levelBinary variable (yes/no) at resident level Prevalence or incidence rate at the facility levelPrevalence or incidence rate at the facility level

NH QualityIndicators

Skin Care Continence Functioning

Burns or Cuts

NewPressure Sores

Improved BladderContinence

Worse BladderContinence

Improved Bowel Continence

Worse Bowel Continence

No ToiletingPlan

IndwellingCatheter

ADL Decline

ADLImprovement

MobilityDecline

Mobility Improvement

ROM Decline

Psychosocial

WorseningBehavior

WorseningDepression

Under-use ofAntidepressants

Overuse ofAntipsychotics

PhysicalRestraints

Other

Moderate toSevere Pain

Infections

Urinary TractInfection

Weight Loss

Falls

CuredPressure Sores

Quality of Life & Resident Quality of Life & Resident SatisfactionSatisfaction

Annual survey carried out by Annual survey carried out by professional survey organization professional survey organization involving face-to-face interviews involving face-to-face interviews with 14,000+ NH residentswith 14,000+ NH residents

Probability sample designed to yield Probability sample designed to yield facility-specific QoL rates for all 400 facility-specific QoL rates for all 400 nursing homes.nursing homes.

53 QoL and other items adapted 53 QoL and other items adapted from established instrumentsfrom established instruments

Surveys conducted in 2005 – 2008Surveys conducted in 2005 – 2008

MoodMood(9)(9)

SatisfactionSatisfactionwith Carewith Care

(7)(7)

Relation-Relation-ShipsShips

(3)(3)

SafetySafety(3)(3)

IndividualityIndividuality(3)(3) PersonalPersonal

AutonomyAutonomy(5)(5)

EnjoyEnjoyFoodFood(3)(3)

MeaningfulMeaningfulActivityActivity

(4)(4)

DignityDignity(4)(4)

PrivacyPrivacy(3)(3)

PhysicalPhysicalEnvironmentEnvironment

(4)(4)

ComfortComfort(4)(4)

Quality of Life &Quality of Life &SatisfactionSatisfaction

QoL/RS DimensionsQoL/RS Dimensions(# of survey items)(# of survey items)

Facility Quality ReportsFacility Quality Reports

Detailed QI and QoL/RS reports sent Detailed QI and QoL/RS reports sent periodically to each facilityperiodically to each facility Most current QI and QoL/RS resultsMost current QI and QoL/RS results Tracking of QI or QoL/RS rates over timeTracking of QI or QoL/RS rates over time

Special training programs on priority Special training programs on priority areas identified through quality reportsareas identified through quality reports Meaningful activitiesMeaningful activities Skin careSkin care Psychotropic medicationsPsychotropic medications Pain managementPain management

Provider Incentive Payment Provider Incentive Payment Program Program

FundingFunding $5 Million available in Year 1 (10/07-9/08)$5 Million available in Year 1 (10/07-9/08) $20 Million available in Year 2 (10/08-9/09)$20 Million available in Year 2 (10/08-9/09)

Response to Request for ProposalsResponse to Request for Proposals Over 200 applications receivedOver 200 applications received 35 projects (75 facilities) funded35 projects (75 facilities) funded

Variety of projects:Variety of projects:Culture changeCulture change Wound careWound care

Quality of lifeQuality of life Employee retentionEmployee retention

Pressure ulcersPressure ulcers Pain managementPain management

ExerciseExercise CHFCHF

D-QI ProjectD-QI Project Advisory Committee Meeting in March Advisory Committee Meeting in March

20082008 Front-line caregivers (e.g., medical directors, Front-line caregivers (e.g., medical directors,

nurses, and nursing assistants)nurses, and nursing assistants) Family membersFamily members State agency staffState agency staff Other local expertsOther local experts

Advances in Nursing Home Dementia Advances in Nursing Home Dementia Care (June 2008 Workshop, Minneapolis)Care (June 2008 Workshop, Minneapolis) Wide audience of local experts – particularly Wide audience of local experts – particularly

front-line caregiversfront-line caregivers Identify high priority D-QIs and recommend Identify high priority D-QIs and recommend

areas for applicationareas for application Advances in Nursing Home Dementia Advances in Nursing Home Dementia

Care (Fall 2008 Workshop, Indianapolis)Care (Fall 2008 Workshop, Indianapolis)

D-QI Initial List of D-QI Initial List of IndicatorsIndicators

From Advisory Group MeetingFrom Advisory Group Meeting BrainstormBrainstorm Consider QIsConsider QIs

Currently measured or present in Currently measured or present in available data (MDS or QoL survey)available data (MDS or QoL survey)

Need to be developed and possible new Need to be developed and possible new data collectiondata collection

Refine D-QIs in subsequent meetings Refine D-QIs in subsequent meetings and data analysisand data analysis

Resident-Centered CareResident-Centered Care

Consistent staffingConsistent staffing FlexibilityFlexibility Individualized care plan and careIndividualized care plan and care Knowledgeable and respectful staffKnowledgeable and respectful staff Good communication with residentsGood communication with residents Staff have accessible/easy-to-use information Staff have accessible/easy-to-use information

about residents (e.g. needs, care)about residents (e.g. needs, care) Residents can engage in meaningful activityResidents can engage in meaningful activity Behavioral problems are handled effectively Behavioral problems are handled effectively Appropriated decisions about care – e.g., Appropriated decisions about care – e.g.,

advanced directives and surrogate decision-advanced directives and surrogate decision-makingmaking

Family Engagement and Family Engagement and SupportSupport

Promotion of family involvementPromotion of family involvement Family-staff partnership/collaborationFamily-staff partnership/collaboration Environment whereEnvironment where

families can freely be advocates for their loved onefamilies can freely be advocates for their loved one family’s perspective is welcomed/families are family’s perspective is welcomed/families are

engaged with staff in addressing resident’s needs engaged with staff in addressing resident’s needs Family participationFamily participation

Family involved in assessmentFamily involved in assessment Family input into caregiving plans and activitiesFamily input into caregiving plans and activities Two-way communication between staff and familyTwo-way communication between staff and family Family participates/shares in caregiving according Family participates/shares in caregiving according

to their preferences and capabilitiesto their preferences and capabilities

Staff Capabilities and Staff Capabilities and EmpowermentEmpowerment

Staff learning/knowledge about dementiaStaff learning/knowledge about dementia Staff is empowered and empoweringStaff is empowered and empowering

respond to resident’s needsrespond to resident’s needs can individualizecan individualize

Staff given support to manage their own stress & Staff given support to manage their own stress & avoid burnoutavoid burnout

TeamworkTeamwork among front-line staffamong front-line staff across disciplines and staff typesacross disciplines and staff types

Staff stability and Avoidance of turnoverStaff stability and Avoidance of turnover Sufficient number of staff & Right skill mix and Sufficient number of staff & Right skill mix and

expertiseexpertise Staff adequately paid/compensatedStaff adequately paid/compensated

Physical EnvironmentPhysical Environment Make it home-like (familiar objects)Make it home-like (familiar objects) Intuitive layoutIntuitive layout Safety and SecuritySafety and Security

unobtrusive ways of keeping people safeunobtrusive ways of keeping people safe appropriate securityappropriate security

Sensory aids – cues & labelingSensory aids – cues & labeling Good physical design – flooring, lighting, & Good physical design – flooring, lighting, &

exercise/wandering areasexercise/wandering areas Stimulation sensitiveStimulation sensitive

Effective use of colorEffective use of color Noise levels (not over stimulation)Noise levels (not over stimulation) Music-appropriate to individual/groupsMusic-appropriate to individual/groups Effective use of technology to ↓ noise stimulationEffective use of technology to ↓ noise stimulation Sensory deprivation attended toSensory deprivation attended to

Organization and Organization and ManagementManagement

Organizational cultureOrganizational culture Learning communityLearning community Innovation seekingInnovation seeking Empowering & flexibleEmpowering & flexible

Organization of careOrganization of care Unique programmingUnique programming Activities-appropriate for dementia care Activities-appropriate for dementia care (RC)(RC)

Unit types and resident mixUnit types and resident mix IntergenerationalIntergenerational Specialized dementia units or dementia residents mixed Specialized dementia units or dementia residents mixed

with otherswith others Do residents get “placed” or “moved” based on clinical Do residents get “placed” or “moved” based on clinical

and cognitive needs? Debatableand cognitive needs? Debatable Information TechnologyInformation Technology

IT (Integration) & other Technology UseIT (Integration) & other Technology Use Electronic Medical/Health RecordElectronic Medical/Health Record Computer Decision SupportComputer Decision Support

Clinical CareClinical Care Dementia expertiseDementia expertise

Specialist in dementia involved in care (assessment and Specialist in dementia involved in care (assessment and prescription) ongoingprescription) ongoing

Proficiency of Geriatric Clinical ProviderProficiency of Geriatric Clinical Provider Diagnosis and assessmentDiagnosis and assessment

Diagnosis for dementia and typeDiagnosis for dementia and type Fully assess needsFully assess needs Identify triggers/causes of behavioral symptomsIdentify triggers/causes of behavioral symptoms

StagingStaging Assessment should determine dementia stageAssessment should determine dementia stage Care tailored to Care tailored to stagestage of dementia (need work on of dementia (need work on

criteria for criteria for stagingstaging)) Delirium diagnosis and treatmentDelirium diagnosis and treatment

Assessment/diagnoses of deliriumAssessment/diagnoses of delirium Prevention and treatment strategies/interventionsPrevention and treatment strategies/interventions Delirium treatment strategies/interventionsDelirium treatment strategies/interventions DeliriumDelirium -- -- close observation, assessment & close observation, assessment &

managementmanagement

Clinical Care (Cont.)Clinical Care (Cont.) Short stay dementia residents receiving Short stay dementia residents receiving

appropriate/equal care (medical, clinical)appropriate/equal care (medical, clinical) Discharge decisionsDischarge decisions Rehabilitation decisions, rehabilitation attemptedRehabilitation decisions, rehabilitation attempted

Rehabilitation and functional outcomesRehabilitation and functional outcomes Physical Therapy/Occupational TherapyPhysical Therapy/Occupational Therapy** Successful rehabilitation outcomesSuccessful rehabilitation outcomes Maintaining/promoting functionMaintaining/promoting function

Choice of Therapies Validation, vs. Choice of Therapies Validation, vs. OrientationOrientation** Tx (Traction?) Tx (Traction?)

Non-traditional TherapiesNon-traditional Therapies Pet therapyPet therapy Music therapyMusic therapy TouchTouch

Clinical Care (Cont.)Clinical Care (Cont.) Clinical IssuesClinical Issues

DeliriumDelirium PainPain DepressionDepression Communication/speechCommunication/speech Feeding/ NutritionFeeding/ Nutrition Tube FeedingTube Feeding WeightWeight ContinenceContinence Skin careSkin care Functional DeclineFunctional Decline Vision and hearingVision and hearing

MedicationsMedications End of Life CareEnd of Life Care**

Hospice CareHospice Care Palliative CarePalliative Care