FactSheet: Nursing Home Projects

QIO Nursing Home Projects (1999-2002) Current Quality Improvement Organization projects focus on improved prevention of pressure sores, falls prevention, pain management, better rehabilitation services, better diabetes care, improving anticoagulant use, immunization campaigns, treatment of depression, and reduced use of restraints. Prevention/Treatment of Pressure Sores : Falls Prevention Pain Management : Developing Quality Measures for Rehabilitation Services Improving Diabetes Outcomes : Immunization Projects Improving Anticoagulant Use Improving Screening and Management of Depression Reducing Inappropriate Use of Restraints Addressing Antibiotic-Resistant Bacteria Prevention/Treatment of Pressure Sores QIOs in Arkansas, New Jersey, Pennsylvania, Puerto Rico, Texas, and Virginia are implementing interventions to improve the prevention and treatment of pressure sores. Examples include: The Arkansas Foundation for Medical Care (AFMC) launched a pressure ulcer prediction and prevention project in 2001, partnering with the state surveying agency and nursing home trade association to clarify issues affecting quality improvement. AFMC collaborated with the associations that helped develop national pressure ulcer prevention guidelines—the Arkansas Medical Directors Association, the National Pressure Ulcer Advisory Panel, and the Wound, Ostomy, Continence Nursing Society—to create a project toolkit, intervention tools, and quality indicators. Contact Krissa Thompson: 501-649-8501. The Peer Review Organization of New Jersey is conducting a project to improve initial assessments, care plans, and preventive interventions for nursing home residents at high risk for pressure ulcers. Currently, eleven facilities are implementing different interventions to address problem areas. Reductions in the rate of new pressure ulcers were reported by seven of the nine facilities that submitted data from July 2001 to November 2001. Contact Cari Miller at 732-238-5570. The TMF Health Quality Institute is working with more than 30 nursing facilities to increase the use of protocols to assess risk factors associated with pressure ulcers and select treatments for patients at different levels of risk. TMF is collaborating on this project with the Texas Health Care Association, Texas Homes and Services for the Aging, Texas Department of Human Services, and the Texas Medical Directors Association. Visits to participating facilities indicate a decline in facility-acquired ulcers. Contact: Carol McCauley at 512-329-6610. KePRO, the Pennsylvania QIO, worked with 12 nursing homes to test interventions designed to reduce incidence of pressure ulcers. There was a significant increase in care plans that used cushions to reduce pressure for patients while sitting in chairs (57% vs. 90%) and lifting devices to shift patients in chairs (43 vs. 95%); and the percentage of residents who received better mattresses to reduce pressure ulcers increased from 25% to 58%. For more: Bonnie Zink at 717-564-8288. The Virginia Health Quality Center is conducting a 12-month quality improvement collaborative with eight to ten nursing homes, targeting those facilities volunteering to learn rapid cycle quality improvement techniques and convene quality improvement teams to focus on the prevention of pressure ulcers in residents. The state trade associations support this initiative and have been valuable resources for recruiting participants. Contact Annette Holmes at 804.289.5320. Falls Prevention Nearly half of all residents in nursing homes fall each year, with many sustaining fractures. QIOs in Alabama and Missouri are seeking to reduce falls without increased use of physical restraints. The Alabama Quality Assurance Foundation Falls Prevention Project began in 2001 with a focus on adoption of the Vanderbilt Fall Prevention Program. The VFPP establishes policies and procedures; creates a multidisciplinary falls team knowledgeable about continuous improvement techniques; tracks and analyze falls within the facility; and disseminates program information throughout the facility. Within six months, the aggregate facility fall rate decreased from 7 to 6 per 1000 resident days—the equivalent of a 100-bed facility decreasing its falls by 3 per month. Extrapolated to cover the state’s 25,000 LTCF residents, falls would be reduced by 9,000 per year. Contact Bill Hawkins: 205-970-1600. The Missouri Patient Care Review Foundation (MPCRF) estimates that almost 25,000 Medicare beneficiaries in Missouri fall every year, with at least 1,200 sustaining fractures. MPCRF is working with nursing homes to encourage adoption of care planning incorporating individual risk assessments and patient exercise programs. Contact Deborah Finley at 573-893-7900. Pain Management QIOs and nursing homes are working together in several states to test quality improvement plans to reduce and manage pain, especially during end of life care. Examples include: North Dakota Health Care Review, Inc. is working with nursing homes representing 30% of the state’s skilled nursing facility residents. NDHCRI staff used on-site visits to assess organizational structures, quality improvement experience, pain management activities, and special barriers. Staff developed quality indicators designed to evaluate the prevalence of pain, determine how often residents are screened for pain, check if pain management guidelines are followed, and to see if pain is reduced as a result of better management. NDHCRI is disseminating the indicators, data collection instruments and interventions to all of the state’s nursing homes. Contact Barbara Groutt at 701-852-4231. Quality Partners of Rhode Island is conducting project to improve pain assessment and management in nursing homes across the state. Participating nursing homes attended educational seminars, developed pain policies and procedures, and worked with RIQP to implement new protocols. More than half of all Rhode Island nursing homes participated in the project. Preliminary results showed that all nursing homes that completed the project had put into place procedures employing medication management and the use of non-drug interventions. Re-measurement showed that residents with a non-pharmacological treatment for pain had doubled from 40% to more than 80%. Contact: Cindi Forcier at 401-528-3200. Carolinas Center for Medical Excellence is conducting a quality improvement project for nursing homes that focuses on improving pain management practices. Nine facilities are participating in the project in which MRNC helps nursing home staff reduce the number of residents in pain. The project includes the development of quality indicators based on clinical practice guidelines focusing on pain assessment and treatment. All facilities are attending in educational teleconferences and monitoring progress through monthly audits using a data collection tool provided by MRNC. In Fall 2002, MRNC will help the facilities collect data to evaluate the project and allow facilities to share successes, challenges and lessons learned from the effort. Contact: Janice Horner, (919) 851-2955. Developing Quality Measures for Rehabilitation Services Successful rehabilitation programs in nursing homes are associated with functional improvement and earlier discharge to less restrictive settings. Four QIOs are working jointly on a pilot project to develop quality improvement measures for rehabilitation services. Colorado Foundation for Medical Care, Carolinas Center for Medical Excellence, Health Services Advisory Group of Arizona, and Delmarva Foundation for Medical Care of Maryland have partnered with fiscal intermediaries, state survey agencies and trade associations to test the validity of data to measure the quality of rehab services. The project involves refinement of data and the development of quality improvement interventions. Contact Kam Valentine (CO) at 303-695-3300; Patricia Dubick (AZ) at 602-264-6382; Nicki Shugart (MD) at 410-822-0697; Peg O’Connell (NC) at 919-851-2955. Improving Diabetes Outcomes Nearly one out of five nursing home residents suffers from diabetes. QIOs in Alaska and Indiana are collaborating with skilled nursing facilities to improve care for residents with this disease. In Indiana, Health Care Excel has implemented a project to improve the rate of hemoglobin A1c (HbA1c) blood testing, which is used to prevent the complication of diabetes. The project regularly convened representatives from nursing facilities across the state to review best practices and develop a conceptual model for quality improvement. Health Care Excel staff conducted diabetes education sessions with administration and staff, providing information on symptoms, risk factors, testing, and complications. Health Care Excel also provided posters explaining the HbA1c test for display to staff, residents, and family members. These efforts showed an increase in the rate of the HbA1c testing in six out of seven active facilities. Data also showed that the aggregate HbA1c rate improved from 57% in May 2001 to 87% in February 2002. Contact Karin Kennedy: 812-234-1499. Immunization Projects Each year, 20,000 elderly die from flu and pneumonia that can be prevented by vaccination. QIOs in Alaska, Arizona, Colorado, the District of Columbia, Florida, Hawaii, Idaho, Kansas, Kentucky, Massachusetts, Minnesota, Mississippi, Montana, New Mexico, Oregon, Washington, West Virginia, and Wyoming have teamed with skilled nursing facilities in a range of projects designed to increase vaccinations. In Arizona, a project by Health Services Advisory Group has demonstrated that a collaborative community approach can make a difference in the pneumococcal polyvalent vaccine (PPV) rates in nursing homes. HSAG designed the project in partnership with the state Medicaid agency, with 127 nursing facilities participating. Results show 75% of all beneficiaries in nursing facilities were immunized for pneumococcal pneumonia, compared to 52.5% at baseline. Contact Patricia Dubick at 602-263-6382. In Massachusetts, MassPRO began in 2000 to promote the implementation of procedures for routine screening and immunization of all new nursing home patients; to promote annual screening and vaccination of staff and patients; and to promote institution-wide baseline reviews of immunization records for needed vaccinations. The project is conducting informational campaigns, distribution of immunization kits, educational workshops, and technical assistance designed to reach all of the state’s 500 nursing homes. By April 2002, 216 participating facilities reported making more than 700 system changes to implement standing orders for immunizations. These included new or revised policies or procedures, standing orders and physician-directed orders, and improved documentation. Contact Sue Kelman: 781-890-0011. Seattle-based Qualis Health conducted a project that improved pneumococcal vaccination rate from 53% to 74% in 26 long-term care facilities in Alaska. In Idaho, Qualis Health helped increase influenza and pneumococcal immunization rates among nursing home residents by implementing standing orders, distributing provider toolkits, hosting educational videoconferences, educating staff, providing tracking software, and disseminating information on mass billing for vaccination. Among the 1,500 residents of 38 participating facilities, the flu immunization rate increased from 65% in 2000 to 73% in 2001 and the pneumococcal rate increased from 43% to 58%. In Washington, Qualis Health is working to increase immunization in 300 long-term care facilities (1999-2002). Results show an increase of facilities with standing orders in place for pneumococcal vaccinations from 58% to 72%. Residents receiving pneumococcal vaccinations increased to 61% from 47%. Contact: Evan Stults 206-368-2401. The Kansas Foundation for Medical Care conducted an intervention to improve vaccination rates for flu and pneumonia in 20 nursing facilities during the flu season of 1999. Interventions consisted of sample standing orders, clinical pathways, and immunization policies and procedures. Results showed improvement in the aggregate vaccination rates for pneumococcal pneumonia (57% baseline-65% re-measurement.) The project identified a number of barriers to greater improvement, including constant facility staff turnover and lack of time to collect data. Contact: Lisa Williams, 785-273-2552. New Mexico Medical Review Association is collaborating with the Centers for Disease Control on a two-year project to evaluate best practices for promoting Standing Orders Protocol for vaccinations in nursing homes. Almost three-quarters of the skilled nursing facilities in New Mexico are involved in the project which includes interventions directed at increasing staff immunization rates— developed in response to indications that nursing home residents are more likely to accept immunizations if providers were immunized. Interventions involved staff training and the distribution of informational material. Data is currently being collected. Contact: Joanne Branyon-Ward, 505-998-9746. The Virginia Health Quality Center conducted an 18-month Nursing Home Immunization Project that helped to increase the immunization rates for influenza and pneumonia in 15 participating nursing homes. Completed in September 2001, the project worked to implement administration of vaccines for influenza and pneumonia to patients in each facility through improved clinical procedures, such as standing orders. Results from the project showed that utilization of standing orders is effective for increasing influenza and pneumococcal immunization in long-term care facilities. Post-project results indicate that influenza vaccination rates increased from 75.5% to 82.3% and pneumococcal vaccinations rates more than doubled from 26.1% to 52.3%. Contact Robin Weil at 804.289.5320. The West Virginia Medical Institute conducted an influenza and pneumococcal immunization project in nursing homes of southwestern West Virginia. Half of the 22 facilities in the area participated in the project, which featured the distribution of immunization toolkits at regional meetings. The toolkits included resident vaccination records, chart stickers to record vaccinations, and standing orders allowing staff to administer vaccinations to patients without a physician order in their medical records. The interventions increased the proportion of residents receiving annual flu vaccines from 78.8% to 81.4% and the proportion of residents receiving pneumococcal pneumonia vaccines from 37.5% to 40.4%. Contact Becky Cochran at (304) 346-9864. Colorado Foundation for Medical Care increased the rates of pneumococcal vaccination, tuberculosis screening and annual influenza vaccinations among nursing home residents from 1995-1998. Through a set of interventions consisting of staff training, educational videos, sample policies, and other education materials for residents and their families, residents were significantly more likely to receive all three preventive services. The project helped increase the percentage of nursing home residents receiving flu shots from 84% to 89%; pneumococcal vaccinations from 16% to 48%; and tuberculosis screening from 59% to 83%. Contact Kam Valentine at (303) 695-3300. Improving Anticoagulant Use QIOs in Iowa, Nebraska, and Illinois are working to improve the use of anticoagulants with patients who are admitted to hospital-based skilled nursing facilities with atrial fibrillation One example: The Iowa Foundation for Medical Care is providing technical assistance to 10 nursing facilities by developing system-oriented changes that facilities can build into their internal processes. These include posters featuring quality indicators, beneficiary education cards, medical record stickers, physician pocket cards for quick reference, and clinical pathways in electronic format. In addition, IFMC has facilitated the sharing of existing interventions among participating SNF facilities. Following data collection and abstraction, feedback reports are provided to the quality improvement staff at each facility. Contact Laurie Poole at 515-223-2900. Improving Screening and Management of Depression Approximately 30-50% of nursing home residents are depressed. Because many suffering from depression go unrecognized and untreated, the Michigan QIO (MPRO) is conducting a special study to improve screening and management. MPRO is collaborating with 14 skilled nursing facilities to implement process changes that provide improved care to residents with depression. MPRO convened trade organizations and conducted focus groups to develop intervention strategies that focus on conducting provider, staff, and family educational sessions, distribution of a depression toolkit, and technical assistance for project implementation. Reducing Inappropriate Use of Restraints The Colorado Foundation for Medical Care, in collaboration with the Colorado Department of Public Health and Environment-Health Facilities Division, participated in a project funded by CMS to reduce the inappropriate use of physical restraints in long-term care facilities. An expert study group working on the project created a patient assessment tool, entitled "Assessment Log/Intervention Care Plan". The tool is designed to: meet the intent of the regulations relative to the use of restraints; assist facilities in examining incidents that lead to restraint use; promote least restrictive device use and highest level of functioning for the resident; promote alternatives to restraints identify trends and patterns in events or behaviors; promote evaluations and re-evaluations of interventions implemented by facilities. This tool, which was reviewed and accepted by both state and federal surveyors, highlights assessments and interventions for falls, behavior problems, wandering, and medical necessity. Eighty-two percent of Colorado’s 214 long-term care facilities reported that the education materials were "very useful." Facilities also reported greater success in reducing restraint use and a corresponding public awareness campaign reached 500,000 people. Addressing Antibiotic-Resistant Bacteria Qualis Health, the Idaho QIO, has helped nursing homes in the state address the growing problem of antibiotic-resistant bacteria. Qualis helped 17 facilities implement an infection surveillance system, which is particularly helpful for tracking urinary tract infections—the most common type of infection among nursing home residents. The system, along with the use of clinical methods for diagnosis and treatment of infections, is intended to improve physicians’ use of antibiotics with the goal of slowing the emergence of resistant bacteria. Results of the project will be available this winter. Contact John Ballenot at (208) 389-5024.