Washington, DC – A report released today the Government Accountability Office (GAO) recommends that the Centers for Medicare & Medicaid Services (CMS) expand the Quality Improvement Organization (QIO) program work to include a larger number of “low-performing” nursing homes. GAO also suggests that CMS develop a plan to continuously update the quality measures used to evaluate nursing home improvement.

The report, “Nursing Homes: Federal Actions Needed to Improve Targeting and Evaluation of Assistance by Quality Improvement Organizations,” calls for CMS to strengthen the QIO nursing home improvement initiative by securing agency access to nursing home level data, increasing evaluation of QIO effectiveness in greater detail so the most effective QIO interventions can be broadly adopted, and focusing more QIO assistance on low-performing nursing homes.

“GAO is calling for expanding QIO work to help more struggling nursing homes, and we think that is a great idea. In fact, every QIO began working with low-performing nursing homes on a small scale in 2005. The problem is not a lack of willingness or skill, we have that. The key to scaling up is funding,” said David Schulke, Executive Vice President of the American Health Quality Association (AHQA), which represents QIOs. “This GAO report is the second federal study this week to recommend new nursing home work by QIOs. On Monday, the HHS OIG recommended that QIOs begin examining care transitions as patients move from hospitals into nursing homes [http://oig.hhs.gov/oei/reports/oei-07-06-00340.pdf]. It will be up to Congress to decide whether QIOs can offer more service, particularly much more costly service in low-performing nursing homes, because funding for QIO quality improvement work is now below the 2002 level,” Schulke added.

History of Success
In 2004 CMS started a pilot project to focus exclusively on low-performing nursing homes. The project included 18 QIOs, one of which was MetaStar, the Wisconsin QIO. “Our QIO was one of the first to begin working intensively with low-performing nursing homes,” said Greg Simmons, AHQA president-elect and CEO of MetaStar. “CMS expanded that pilot to the entire QIO community in 2005 with great success. National data now indicate that this ongoing collaboration with nursing homes is improving the quality of care even in facilities that have been in trouble with regulators.”

Since August 2005 QIOs have worked with 145 nursing homes identified by state regulators as low performers due to quality deficiencies. Data from the last quarter of 2006 indicate that these homes achieved a 15 percent relative improvement on pressure ulcer care and a 37 percent relative improvement in the use of physical restraints – better than the national average rate of improvement for all nursing homes, which was 9 and 21 percent, respectively (see attached chart).

GAO interviewed staff from thirty-two nursing homes selected for a variety of geographic and other characteristics. Two-thirds reported that QIO assistance helped them to improve; thirteen percent said it made no difference. “The fact that busy nursing home staff worked voluntarily with QIOs for over two years strongly suggests that the relationship has value. The staff at most facilities confirm the QIOs have helped them improve,” Schulke said.

Strengthened Quality Measurement Process Needed

Good quality measures are a key component of evaluating quality improvement efforts. GAO recommended that CMS strengthen measures to evaluate nursing home quality and QIO efforts so policymakers can tell what techniques worked and which did not. “The GAO report has a number of lessons for CMS and the QIOs. All quality measures in every setting of care must be constantly updated and improved. Through the QIO program, CMS has constantly refined quality measures used in hospitals and physician offices, and we believe this report will give a boost to their efforts to improve the resident assessment tool and nursing home quality measures,” Schulke said, adding “Meanwhile, QIOs are enthusiastic about expanding their efforts to help improve care at homes that are struggling to meet regulatory standards.”

The GAO report was requested by Senator Charles Grassley (R-IA). The report is available at: http://www.gao.gov/new.items/d07373.pdf. The Health and Human Services Office of Inspector General (OIG) report, “Consecutive Medicare Stays Involving Inpatient and Skilled Nursing Facilities,” was released on June 25; it is available at: http://oig.hhs.gov/oei/reports/oei-07-06-00340.pdf