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Background
Clinical
experts described successful
interventions for improving
quality of care in
nursing homes at a
two-day conference
in Baltimore, hosted
by the American Health
Quality Association.
The conference, Partnerships
for Success: The Federal
Initiative on Quality
Improvement and Public
Reporting in Nursing
Facilities, was
co-sponsored by the
American Association
of Homes and Services
for the Aging, the
American Health Care
Association, and Quality Partners of Rhode Island.
The
July 24-25 meeting
brought together nursing
home providers, administrators,
ombudsmen, medical
directors, quality
experts, and consumer
advocates to discuss
lessons learned from
a six-state quality
improvement effort,
a pilot for the forthcoming
a national nursing
home quality initiative.
Sponsored by the Centers
for Medicare and Medicaid
Services, the national
initiative calls for
Quality Improvement
Organizations to work
with nursing homes
to improve outcomes
in core measures of
resident care.
Interventions
Avoiding
Loss of Daily Living
Functions
Genesis
Health Ventures, one
of the nation’s largest
nursing home companies,
provided details on
its At-Risk Meeting
program, designed to
consistently address
and monitor residents
at risk for decline
in daily living functions.
The program, being
implemented company-wide,
involves a weekly meeting
among facilities’ medical
directors, nursing
directors and unit
managers that often
includes consultant
pharmacists, rehabilitation
specialists, and nutrition
specialists. The At-Risk
Meeting standardizes
the process for improving
clinical outcomes by
addressing at-risk
residents’ health in
a pro-active manner.
The At-Risk Meeting
also builds strong
working relationships
among medical staff
and allows medical
directors to provide
informal training.
Results
of the program are
reviewed on a regular
basis by individual
facilities and by the
corporation’s quality
improvement committee.
Presenters: Irene Fleshner,
senior vice president
for clinical practice
at Genesis Health Ventures.
Dr. Robert Kaplan,
vice president of medical
affairs for the Southern
Region of Genesis ElderCare.
Karen Robbins, vice
president for clinical
services for the Southern
Region of Genesis.
Results:
The program has reduced
the number of patients
who suffer unintended
decline in daily living
function, use of restraints,
the number of hospital
readmissions, the number
of care-related complaints,
and improved patient
and family satisfaction.
The At-Risk Meetings
have required spending
no additional resources
and saved caregiver
time by efficiently
and effectively addressing
patient health problems.
Pain
Management
Quality Partners of Rhode Island,
the state’s QIO, discussed
its program to manage
pain among nursing
home residents. The
QIO recruited 21 nursing
homes and provided
staff with a toolkit
on pain management
that incorporated guidelines
established by the
American Medical Directors
Association. Each facility
attended six workshops
devoted to pain management
education, principles
and techniques for
applying continuous
quality improvement
and the sharing of
lessons among nursing
homes. Then, a nurse
was assigned to apply
the continuous quality
improvement principles
at each home. Based
on the project, RIQP
concluded that nursing
homes can improve processes
of care but need an
outside group to help
facilitate the process.
Presenter: Dr. David
Gifford, principal
clinical coordinator
for Quality Partners of Rhode Island, focuses on
evaluating and improving
the quality of care
in long-term care settings.
Results:
One year following
the intervention, a
study of 20 residents
with pain found that
residents with a complete
pain assessment increased
and the number of residents
who did not require
pain medication increased
by about 40 percentage
points.
Pressure
Ulcers
Clinical
researchers from Abbott
Laboratories demonstrated
the PINpoint program,
which educates long-term
care facilities on
a comprehensive approach
to preventing pressure
ulcers by following
four research-based
protocols for at-risk
patients. PINPoint
implementation includes
two-day trainings for
staff leaders, inservice
education for direct
care staff, easy to
use documentation forms,
as well as a web-based
tracking system to
rapidly monitor medical
outcomes. Presenters:
Dr. Anne Coble
Voss, senior research
scientist for Ross
Products Division,
Abbott Laboratories.
Abby Cook, clinical
projects leader for
Ross Products Division.
Results:
A pilot test of the
program improved resident
quality of care, reduced
pressure ulcer treatment
costs, decreased the
risk of litigation
and survey deficiencies
and increased homes’
marketing potential.
Besides showing a dramatic
reduction in pressure
ulcers,. PINpoint reduced
Stage II pressure ulcers
by 67% in its first
30 days of implementation.
In addition, the program
decreased the number
of residents experiencing
weight loss by 75%
and increased the number
of residents participating
in turning and repositioning
programs by 36%. The
program resulted in
an overall savings
of $1.51 per resident,
per day. All facilities
participating in the
pilot sustained improvements
for more than 12 months.
Nutrition
A
representative of the
Benedictine Health
System’s Nutritional
Center of Excellence
described its innovative
dietary services program
that increases nursing
home residents’ appetites
and reduces unexpected
weight loss. Featuring
a pleasant dining experience
and a variety of freshly
prepared menu options—85%
of which are made from
scratch—the program
addresses the relationship
between poor diets
and health conditions
such as weight loss,
dehydration, and pressure
sores. A model alternative
to tray service, residents
also receive a la carte
breakfast meals that
maintain hydration
and provide essential
nutrients. The nutritional
care program also is
sensitive to nursing
home budget constraints
and fosters an environment
that motivates dietary
and nursing staff in
facilities.
The
program is based on
a philosophy that 90%
of weight and appetite
problems can be resolved
without use of commercial
supplements. Presenter:
Rich Daehn, director
of the Benedictine
Health Systems Nutritional
Centers for Excellence,
has more than 18 years
of experience in long-term
care foodservice.
Results:
The program has demonstrated
food service cost savings
and ensures that appetites
increase by 15%, unexpected
weight loss remains
below 2%, customer
satisfaction rates
remain above 92% and
there are few incidences
of dehydration.
Staff
Turnover
One
of the greatest challenges
nursing homes face
is rampant staff disaffection
and turnover. The Mather
Institute on Aging
and Life Services Network
briefed the conference
on a workforce initiative
that improves care
delivery through efforts
to increase job satisfaction.
The LEAP quality initiative
helps nursing home
staff learn to use
tools and resources
that improve quality
and empowers staff
to provide person-centered
care for residents.
The program trains
high-performing nurses
and nurse assistants,
who then instruct coworkers
to develop positive
relationships with
residents and families,
sharpen assessment
skills, and cultivate
leadership characteristics.
Presenters: Linda
Hollinger-Smith, director
of research for Mather
LifeWays in Evanston,
IL, and Anna Ortigara,
vice president of program
development for Life
Services, have both
presented the LEAP
findings at numerous
conferences and authored
articles on LEAP and
related topics.
Results:
The initial pilot site
that tested the program
from 1999-2001 showed
a reduction in nursing
staff (RNs and CNAs)
turnover rates from
62% in 1999 to 20%
in 2001, as well as
increases in measures
of staff empowerment,
leadership behaviors,
job satisfaction and
perceptions of organizational
climate.
Staff
Development
Good
Shepherd Services,
a nonprofit health
care services organization
in rural Wisconsin,
outlined its "Wellspring"
model—the first long-term
care provider alliance
to focus on cost-effective
quality care by changing
the organizational
culture, empowering
staff, and creating
staff resource teams
that facilitate clinical
education. Wellspring-participating
nursing homes become
part of an alliance,
which uses integrated
federal quality indicators
and scientifically
proven clinical practices
to improve staff efficiency
and resident outcomes.
Through
education on best clinical
practices, nursing
teams at Wellspring
facilities foster an
organizational culture
change. Staff also
are taught to think
critically in order
to analyze clinical
information gathered
through data collection.
Following implementation,
resident outcomes are
measured daily in individual
homes and across the
Wellspring alliance.
Based on those reports,
staff make appropriate
quality improvements.
Presenters: Mary Ann
Kehoe, executive director
of Good Shepherd Services,
which co-founded Wellspring
in 1994, is a registered
nurse and nursing home
administrator. Robyn
Stone, executive director
of the Institute for
the Future of Aging
Services, is an authority
on health care policy.
Results:
In 2000, a Commonwealth
Fund report found that
Wellspring homes had
higher immunization
rates, lower incontinence
rates, less restraint
use and less staff
turnover compared to
other nonprofit homes.
Wellspring facilities
experienced significantly
fewer health deficiencies
than other facilities.
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