Heightening Person-Centered Care Processes in the Delivery of Nursing Restorative Care.

The objective of the current study was to investigate the perspectives of nursing home (NH) providers regarding the requirements to achieve reimbursement for nursing restorative care (NRC) services and propose recommendations to state agencies to assist NH providers to conduct NRC programs that are person-centered and able to achieve full reimbursement. Methods included a survey of NH providers in one state and a stakeholder focus group to discuss survey findings and develop recommendations. Key findings are that NH providers perceive value to residents from the provision of NRC; providers do not associate these benefits with the stringent reimbursement requirements; and NHs often provide NRC that is individualized, based on resident goals and activity tolerance, as well as realistic given competing demands on staff, even when doing so means giving up reimbursement for NRC services. Recommendations include basing reimbursement for NRC on outcomes rather than the process; reconsideration of the frequency and intensity requirements for NRC components; and increased availability of NRC training/education and resources for providers and case-mix reviewers. [Journal of Gerontological Nursing, 45(5), 5-10.].

A Statewide Model for Assisting Nursing Home Residents to Transition Successfully to the Community.

Minnesota's Return to Community Initiative (RTCI) is a novel, statewide initiative to assist private paying nursing home residents to return to the community and to remain in that setting without converting to Medicaid. The objective of this manuscript is to describe in detail RTCI's development and design, its key operational components, and characteristics of its clients and their care outcomes. Data on client characteristics and outcomes come from the Minimum Data Set, staff assessments of clients and caregivers, and Medicaid eligibility files. Most clients transitioned by the RTCI had entered the nursing facility from a hospital. Clients overwhelmingly wanted to return to the community and fit a health and functional profile making them good candidates for community discharge. Most clients went to a private residence, living alone or with a spouse; yet, adult children were the most frequent caregivers. At one year of follow-up 76% of individuals were alive and living in the community and only a small percentage (8.2%) had converted to Medicaid. The RTCI holds promise as a successful model for states to adopt in assisting individuals who are at risk to become long stay nursing home residents instead to return to the community.

Does the Volume of Post-Acute Care Affect Quality of Life in Nursing Homes?

Although short-stay, post-acute nursing home stays are increasing, little is known about the impact of volume of post-acute care on quality of life (QOL) within nursing homes. We analyzed data from the 2010 Minnesota QOL and Consumer Satisfaction survey ( N = 13,433 residents within 377 facilities) and federal Minimum Data Set to determine the influence of living in a facility with an above-average proportion of post-acute care residents on six domains of resident QOL. In bivariate analyses, an above-average proportion of Medicare-funded post-acute care had a significant negative influence on four domains (mood, environment, food, engagement) and overall facility QOL. However, when resident and facility covariates were added to the model, only the food domain remained significant. Although the challenges of caring for residents with a diverse set of treatment and caregiving goals may negatively affect overall facility QOL, negative impacts are moderated by individual resident and nursing home characteristics.

Pay-for-performance policy and data-driven decision making within nursing homes: a qualitative study.

INTRODUCTION: Health systems globally and within the USA have introduced nursing home pay-for-performance (P4P) programmes in response to the need for improved nursing home quality. Central to the challenge of administering effective P4P is the availability of accurate, timely and clinically appropriate data for decision making. We aimed to explore ways in which data were collected, thought about and used as a result of participation in a P4P programme. METHODS: Semistructured interviews were conducted with 232 nursing home employees from within 70 nursing homes that participated in P4P-sponsored quality improvement (QI) projects. Interview data were analysed to identify themes surrounding collecting, thinking about and using data for QI decision making. RESULTS: The term 'data' appeared 247 times in the interviews, and over 92% of these instances (228/247) were spontaneous references by nursing home staff. Overall, 34% of respondents (79/232) referred directly to 'data' in their interviews. Nursing home leadership more frequently discussed data use than direct care staff. Emergent themes included using data to identify a QI problem, gathering data in new ways at the local level, and measuring outcomes in response to P4P participation. Alterations in data use as a result of policy change were theoretically consistent with the revised version of the Promoting Action on Research Implementation in Health Services framework, which posits that successful implementation is a function of evidence, context and facilitation. CONCLUSIONS: Providing a reimbursement context that facilitates the collection and use of reliable local evidence may be an important consideration to others contemplating the adaptation of P4P policies.

Minnesota's provider-initiated approach yields care quality gains at participating nursing homes.

Minnesota's Performance-Based Incentive Payment Program uses a collaborative, provider-initiated approach to nursing home quality improvement: up-front funding of evidence-based projects selected and designed by participating facilities, with accountable performance targets. During the first 4 rounds of funding (2007-10), 66 projects were launched at 174 facilities. Using a composite quality measure representing multiple dimensions of clinical care, we found that facilities participating during this period exhibited significantly greater gains than did nonparticipating facilities, in both targeted areas and overall quality, and maintained their quality advantage after project completion. Participating and nonparticipating facilities were similar at baseline with respect to quality scores and improvement trends, as well as acuity-adjusted payment, operating costs, and nurse staffing. Although self-selection precludes firm conclusions regarding the program's impacts, early findings indicate that the program shows promise for incentivizing nursing home quality improvement, both in facility-identified areas of concern and overall.

Facility and market factors affecting transitions from nursing home to community.

BACKGROUND: Research into nursing home transitions has given limited attention to the facility or community contexts. OBJECTIVE: To identify facility and market factors affecting transitions of nursing home residents back to the community. RESEARCH DESIGN: Multilevel models were used to estimate effects of facility and market factors on facility-level community discharge rates after controlling for resident demographic, health, and functional conditions. Facility discharge rates were adjusted using Empirical Bayes estimation. SUBJECTS: Annual cohort of first-time admissions (N=24,648) to 378 Minnesota nursing facilities in 75 nursing home markets from July 2005 to June 2006. MEASURES: Community discharge within 90 days of admission; facility occupancy, payer mix, ownership, case-mix acuity, size, admissions from hospitals, nurse staffing level, and proportion of admissions preferring or having support to return to the community; and nursing market population size, average occupancy, market concentration, and availability of home and community-based services. RESULTS: Rates of community discharge (Empirical Bayes residual) were highest in facilities with more residents preferring community discharge, more Medicare days, higher nurse staffing levels, and higher occupancy. In addition, facilities had higher community discharge rates if they were located in markets with a greater ratio of home and community-based services recipients to nursing home residents and with larger populations. CONCLUSIONS: State Medicaid programs should undertake system-level interventions that encourage nursing facilities to reduce unused bed capacity, balance the mix of payers, invest in nurse staffing, and take other steps to promote community discharges. In addition, states should increase home and community-based services, particularly in markets with low community discharge rates.

Targeting residents for transitions from nursing home to community.

OBJECTIVE: To analyze nursing home utilization patterns in order to identify potential targeting criteria for transitioning residents back to the community. DATA SOURCES: Secondary data from minimum data set (MDS) assessments for an annual cohort of first-time admissions (N=24,648) to all Minnesota nursing homes (N=394) from July 2005 to June 2006. STUDY DESIGN: We conducted a longitudinal analysis from admission to 365 days. Major MDS variables were discharge status; resident's preference and support for community discharge; gender, age, and marital status; pay source; major diagnoses; cognitive impairment or dementia; activities of daily living; and continence. PRINCIPAL FINDINGS: At 90 days the majority of residents showed a preference or support for community discharge (64 percent). Many had health and functional conditions predictive of community discharge (40 percent) or low-care requirements (20 percent). A supportive facility context, for example, emphasis on postacute care and consumer choice, increased transition rates. CONCLUSIONS: A community discharge intervention could be targeted to residents at 90 days after nursing home admission when short-stay residents are at risk of becoming long-stay residents.

Minnesota's Nursing Facility Performance-Based Incentive Payment Program: an innovative model for promoting care quality.

PURPOSE: Minnesota's Nursing Facility Performance-Based Incentive Payment Program (PIPP) supports provider-initiated projects aimed at improving care quality and efficiency. PIPP moves beyond conventional pay for performance. It seeks to promote implementation of evidence-based practices, encourage innovation and risk taking, foster collaboration and shared learning, and establish a solid case for investing in better quality from the perspective of the state, providers, and consumers. We explain PIPP rationale and design, describe projects and participating facilities, and present findings from interviews with project leaders. DESIGN AND METHODS: Provider-initiated projects lasting from 1 to 3 years are selected through a competitive process and are funded for up to 5% of the daily operating per diem rate. Providers are at risk of losing up to 20% of their project funding if they fail to achieve targets on state nursing facility performance measures. RESULTS: Minnesota has made a major investment in the PIPP by supporting 45 individual or collaborative projects, representing approximately 160 facilities and annual funding of approximately $18 million. Projects involve a wide range of interventions, such as fall reduction, wound prevention, exercise, improved continence, pain management, resident-centered care and culture change, and transitions to the community. IMPLICATIONS: The PIPP can serve as a model for other states seeking to promote nursing facility quality either in combination or in place of conventional pay-for-performance efforts.

Medicaid nursing home pay for performance: where do we stand?

PURPOSE: Nursing home pay-for-performance (P4P) programs are intended to maximize the value obtained from public and private expenditures by measuring and rewarding better nursing home performance. We surveyed the 6 states with operational P4P systems in 2007. We describe key features of six Medicaid nursing home P4P systems and make recommendations for further development of nursing home P4P. DESIGN AND METHODS: We surveyed the six states with operational P4P systems in 2007. RESULTS: The range of performance measures employed by the states is quite broad: staffing level and satisfaction, findings from the regulatory system, clinical quality indicators, resident quality of life or satisfaction with care, family satisfaction, access to care for special populations, and efficiency. The main data sources for the measures are the Minimum Data Set (MDS), nursing home inspections, special surveys of nursing home residents, consumers or employees, and facility cost reports or other administrative systems. The most common financial incentive for better performance is a percentage bonus or an add-on to a facility's per diem rate. The bonus is generally proportional to a facility performance score, which consists of simple or weighted sums of scores on individual measures. IMPLICATIONS: States undertaking nursing home P4P programs should involve key stakeholders at all stages of P4P system design and implementation. Performance measures should be comprehensive, valid and reliable, risk adjusted where appropriate, and communicated clearly to providers and consumers. The P4P system should encourage provider investment in better care yet recognize state fiscal restraints. Consumer report cards, quality improvement initiatives, and the regulatory process should complement and reinforce P4P. Finally, the P4P system should be transparent and continuously evaluated.

A quality-based payment strategy for nursing home care in Minnesota.

This article describes a pay-for-performance system developed for Minnesota nursing homes. In effect, nursing homes can retain a greater proportion of the difference between their costs and the average costs on the basis of their quality scores. The quality score is a derived and weighted composite measure currently composed of five elements: staff retention (25 points), staff turnover (15 points), use of pool staff (10 points), nursing home quality indicators (40 points), and survey deficiencies (10 points). Information on residents' quality of life and satisfaction, derived from interviews with a random sample of residents in each Minnesota nursing home, is now available for inclusion in the quality measure. The new payment system was designed to create a business case for quality when used in addition to a nursing home report card that uses the same quality elements to inform potential consumers about the quality of nursing homes. Although the nursing home industry has announced general support for the new approach, it has lobbied the legislature to delay its implementation, claiming concerns about operational details.