Nursing Home Regulations Manual—Sept. 2002 Quality Initiative Set for October, Concerns Linger Despite continued uncertainty regarding quality measures, the Centers for Medicare and Medicaid Services (CMS) and long-term care stakeholders are preparing for the October 2002 roll out of the nationwide Nursing Home Quality Initiative. The six-state pilot project that began in April is being heralded by most observers as the one federal initiative that forced nursing homes to look at their quality and address underlying concerns. Through the Nursing Home Quality Initiative, CMS will compile data for each facility in the country and create quality measures that will be disseminated to the public. The initiative is designed to use the incentive of competition to encourage nursing facilities to voluntarily improve quality. The comparative quality measures will be made available to the public through newspaper ads in each state as well as on CMS' Nursing Home Compare Web site. "The advertisements were like a starter's gun at a race," said David Schulke, executive vice president for the American Health Quality Association (AHQA), during a press briefing. "They got everyone's attention and got them moving." Schulke was referring to the full-page newspaper ads that CMS used to launch the pilot project (see the Monthly Bulletin, June 2002, page 1). The ads publicized various quality information about nursing homes in the six participating states. Targeted Assistance AHQA represents the Quality Improvement Organizations (QIOs) - formerly called Peer Review Organizations - with whom CMS has contracted to provide technical assistance to nursing homes during the quality initiative. A July meeting of AHQA in Baltimore, Md., was designed to finalize the QIOs role in the initiative and determine to what extent their efforts were successful during the pilot project. Schulke was optimistic about the QIOs role in the quality initiative, explaining that the regional organizations will assist nursing home staff by identifying best practices that can be implemented in facilities to improve quality. However, the QIOs' reach may be limited, according to Schulke, because funding levels will not allow the organizations to reach all nursing homes. CMS initially expected the QIOs to provide intensive, onsite assistance to just 10 percent of the facilities in each state. But reports from the pilot project show that as many as 20 percent of facilities are seeking intensive help, while up to 40 percent of all nursing homes are participating in statewide workshops, another component of the QIOs' assistance. "The nursing home community responded in much larger numbers that we though," Schulke stated, during a press briefing. He told reporters that CMS has provided new funding to the initiative, but the amount is a third of what AHQA estimates is needed to adequately help facilities. The remaining two-thirds, about $60 million to $70 million, must be approved by the administration before it can be distributed for QIO activities, he said. Schulke noted that CMS Administrator Thomas Scully was skeptical about the quality initiative at first, but was impressed by the response from the provider community. Regardless of whether QIOs receive additional funding from CMS, Schulke said there will have to be some type of process in place to select technical assistance recipients. Not all facilities will be able to receive intensive assistance, he said. Part of the selection process will be based on the "commitment" of facilities to "stay the course," Schulke explained. "QIOs can't help nursing homes without a commitment; if they are going to drop out," he said. In addition to facilities' commitment to quality improvement, financial issues such as location and facility size will also determine participants, Schulke told the Monthly Bulletin. Along with the intensive, onsite assistance, QIOs will also provide larger, more collaborative workshops in an effort to reach as many facilities as possible. These workshops will bring together facilities with successful policies and practices and those that are seeking help to share best practices. The final component of the QIOs' contract with CMS, which may be scaled back dramatically if sufficient funding is not available, is the outreach activities designed to help consumers and communities understand the publicly available data, what it means and how to use it. Quality Measures The data used in the newspaper ads and on the Nursing Home Compare Web site are culled from the minimum data set (MDS) that facilities use to assess Medicare residents for quality and reimbursement purposes. CMS officials, using a set of nine quality measures developed specifically for the project by the National Quality Forum and other industry stakeholders, compile the data into facility-specific documents that are made available to the public. The quality measures are an ongoing concern for providers and their representatives. The pilot project measured facility quality against nine measures, encompassing factors for both long-stay and short-stay, post-acute residents. However, advocates question the validity of the measures, their negative connotations and whether the public will understand them. Suzanne Weiss, senior vice president for advocacy with the American Association for Homes and Services for the Aging (AAHSA), told the Monthly Bulletin that measures are reported in a negative way, rather than focusing on the positive aspects of the data. For example, when addressing pressure ulcers, the quality measures note that 17 percent of residents had pressure ulcers, rather than mentioning the 83 percent that did not, Weiss explained. Weiss added that the data represented in the newspaper ads and on the Web site are of limited use to consumers. "That type of information is difficult to convey in a single-page ad ... it should direct [consumers] to other resources," Weiss suggested. While the quality measures for the project have not been finalized, CMS told the Monthly Bulletin that it would go ahead with the nationwide launch in October or November 2002, adopting the quality measures that were used in the pilot project. "We are going ahead with the full launch and will improve on the measures during the run," a CMS official said. The National Quality Forum delayed its final report on the quality measures so that it could further examine information garnered under the pilot project, as well as other research on the quality measures. The forum's final recommendations are expected in December, after the national roll-out. Sandy Fitzler, director of clinical operations for the American Health Care Association, said that the pilot project should not be the final blueprint for the initiative. Rather, the attainment of quality outcomes is an ongoing, evolutionary process that will need good communication, partnerships and patience. "The debate [on the quality initiative] will help us learn more and force us in the right direction," Fitzler said. "I anticipate pushes and pulls along the way." The success of the initiative will be determined by tracking the performance of facilities on the various quality measures, as well as the quality indicators used on the state level, Schulke said. However, AHQA does not expect measurable improvements for at least a year. Also, CMS is developing a new satisfaction survey for facilities and consumers to gauge if the QIOs are meeting their needs and helping to improve quality. AAHSA's Weiss added that facilities will recognize the signs of success: less staff turnover and lower recruitment needs. "Something special happens when [facilities] make this effort," Weiss said. Added Pressure As nursing homes prepare for the nationwide launch, some stakeholders are worried about the added pressure the quality initiative will have on facility staff. AHCA's Fitzler said she had not heard of any facilities in the pilot states experiencing a drop in the number of residents because of the ads, but noted that facilities are anxious about the publicized data. Some of the pressure will be heaped on the shoulders of facilities' MDS coordinators and interdisciplinary teams who are responsible for preparing the assessment data used to determine a facility's quality. "Making the MDS look better has been an issue since [the prospective payment system (PPS)] and quality indicators were implemented," Rena Shepard, president of the American Association of Nurse Assessment Coordinators, told the Monthly Bulletin. "We've been hearing about pressure to manipulate the data, she said. State surveyors are charged with ensuring MDS assessments are correct; however, this task is often overlooked, according to recent accounts by the General Accounting Office (see the Monthly Bulletin, June 2002, page 1). The office recommended that CMS take a leading role in verifying MDS data. In November 2001, CMS began the Date Accuracy and Verification program to assess MDS accuracy, independent of the survey process. Shepard was optimistic about ongoing CMS efforts to ensure the accuracy of MDS data, but said that it is very difficult to use one tool for all of the purposes (PPS, survey and certification, and the quality initiative). "There is no focus and they're pulling in different directions to make it work," Shepard said. Essential to the success of the Nursing Home Quality Initiative and the future of the MDS is in-depth training for MDS coordinators and the interdisciplinary team. "The only way to deal with this situation is for facilities to provide training and let the assessment coordinators do their job, letting the chips fall where they may," she asserted. Unfortunately, the nursing home staff that take advantage of available MDS training are usually those that are "really in the loop already," Shepard said. "Most of these training sessions are preaching to the choir," she added. The first step, according to Shepard, is to raise the consciousness of facility administrators and directors of nursing about the complexities of the MDS process. *This article was taken from the Sept. 2002 issue of the Nursing Home Regulations Manual from Thomspon Publishing Group, Inc. For more informtion, visit http://www.thompson.com/libraries/healthcare/home/index.html.