Nursing Home Quality Incentives

Person-centered care is becoming a way of life in Ohio. This means that we are creating environments where people can live and work with meaning and purpose. It involves residents, their family and friends, and the caregivers who work every day to support the resident's preferences and needs. Everyone engaging together makes the place a home.

The quality incentive measures are intended to stimulate practices that support residents in five general areas: nursing home performance, choice, staffing, clinical practice and environment. The goal is for all nursing homes to achieve the quality incentive measures. To that end, this website provides valuable resources to assist nursing homes. We will point you to resources for each of the twenty measures, including professionals who have experience that can help.

Background

Technical Assistance

Facilities must submit no later than May 31, 2014 to be considered for the state fiscal year 2015 rate-setting. 

The Incentive Measures

Use the menu below to begin learning how your facility can meet - or already is meeting - the quality incentives. This site will constantly evolve, so visit often. If you have questions about the measures or this website, please contact us.

 

Performance

To raise the bar for quality long-term care, nursing homes are challenged to meet overall performance goals by achieving high overall consumer satisfaction, meeting state survey standards and participating in the Advancing Excellence in America’s Nursing Homes Campaign. These four measures reflect a nursing home’s overall commitment to customer service and quality and a desire to improve performance:

 

Satisfaction Survey Overall Scores

Satisfaction survey data is available on LTCOhio.orgTo receive the quality incentive point for this measure, the facility's overall score on the resident satisfaction survey initiated in 2013 must be at least 87.5, and the facility's overall score on the family satisfaction survey initiated in 2014 must be at least 85.9.  The score from the resident survey initated in calendar year (CY) 2013 will be used for the state fiscal year (SFY) 2015 rate; the scores from the family survey initiated in CY 2014 will be used for SFY 2016 rate.

The facility must participate in the Ohio Resident Satisfaction Survey and the Ohio Family Satisfaction Survey conducted by the Ohio Department of Aging in accordance with ORC 173.47. The facility must receive sufficient resident/family responses to meet the survey's required margin of error. 

In preparation for the 2014 Nursing Home Family Satisfaction Survey, please ensure you have the current address of each resident's most interested family member or legal representative. Instructions for participation will be sent in late spring or summer of 2014.

The Department of Aging will report scores for the incentive calculation for the purposes of reimbursement; no reporting action by the facility is necessary.  Results from the 2013 Nursing Home Resident Satisfaction Survey are available here:  2013 Nursing Home Resident Satisfaction Survey - Overall Scores.  Results from the 2013 Residential Care Facility Resident Satisfaction Survey are available here:  2013 Residential Care Facility Resident Satisfaction Survey - Overall Scores.  The results of the 2012 Nursing Home Family Satisfaction Survey are available here:  2012 Family Satisfaction Survey - Overall Scores.

Relative Advantage

An emphasis on improving satisfaction survey performance may result in higher occupancy and revenue because a higher level of satisfaction among residents and their families indicates a better quality of life for those living in and visiting the facility. "According to the survey vendor My InnerView, more than 60 percent of families choose a nursing home based on the recommendation of others." (Source: Long-Term Care Improvement Guide)

In Ohio, approximately 4,500 visitors a month use the Ohio Long-Term Care Consumer Guide website to find long-term care for themselves or their loved ones. Visitors can find overall satisfaction, survey performance and facility-provided information on facilities' services. Research indicates a correlation between satisfaction and quality of a facility's operation. Efforts to improve overall satisfaction may be reflected in the quality information that people making long-term care decisions will see. "According to My InnerView, long-term care settings consistently rated highly by customers are bound to measure up as high quality operations on any criterion. In other words, surveys mirror quality." (Source: Long-Term Care Improvement Guide).

Compatibility

The Quality Indicator Survey (QIS) and MDS 3.0 have dramatically increased the input of residents into the assessment and survey processes. For example, the Ohio Department of Health has implemented the QIS in all their surveys. In the traditional survey, just five residents and two family members might be interviewed in a 100-bed facility. With QIS, Department of Health surveyors review 40 residents and interview any able residents and families.

Residents and families have come to expect their input to be taken into account by facility staff and surveyors through formal means; the satisfaction survey makes those inputs available to the public as quality indicators to those needing information for facility selection.

Measuring resident and family satisfaction is one of the goals of the Advancing Excellence in America's Nursing Homes Campaign. Participation in the campaign is another quality incentive for Ohio's Medicaid reimbursement system, so choosing satisfaction as one of your targeted goals improves the likelihood of achieving improvement in both measures.

Simplicity

Reviewing the overall score to see if it meets the minimum threshold for the quality incentive will not improve your facility's outcome the following year. It is critical to focus on domains in which your facility is not meeting your consumers' needs.

Review the columns for "hardly ever" and "never." Begin your quality improvement efforts in the areas where your residents or their family members find your facility unacceptable. Look for trends, even across domains, that indicate a common problem or underlying issue. Are there communication gaps between what administration or social services promise and what occurs at the direct care level? Would additional staff or consistently assigned staff make a difference in consumer perceptions?

Look for differences between your scores and the statewide averages. Some areas of nursing facility life may have common complaints across facilities. For instance, meals and dining receive lower scores on many satisfaction surveys; preparing and serving meals to dozens of people with diverse tastes are daunting tasks even in the best of facilities. If your facility has a particular deficiency compared to your peers, there may be standards of care or quality of life that you may be able to improve.

Review the satisfaction survey report with key staff members, including leaders at all staff levels. Ask them to discuss how the facility might improve based on the family or resident feedback. Identify staff members who can contribute to quality improvement efforts. Develop resident and family council topics around your quality improvement needs. Ask them to assist in the development of specific follow-up questions to address weaknesses. If the survey showed that the food is not "tasty," ask for input into which foods could change their opinion. If activities offered are not things that the residents like to do, ask them specifically which activities they would choose. Ask residents and families to focus on one domain or survey question at a time. Build improvement teams around specific needs. Ask for ideas and solutions and report your progress back to the council(s). Print your results in your newsletters and ask for feedback from families and residents who may not have been surveyed. Address their comments in the next edition.

Ask for outside assistance as needed. Invite the ombudsman and state survey staff to work with you in your efforts. The Ohio Department of Health's Technical Assistance Program is available for staff in-services. Ombudsmen are available for help with resident and family council development and other person-centered care efforts. Corporate quality improvement consultants, the Ohio Advancing Excellence in Nursing Home campaign, Ohio KePro and others are able and willing to assist. Some members of the Person-Centered Care Coalition have volunteered to serve as mentors to other facilities interested in improving their care.

Trialability

Barbara Frank and Cathie Brady (B&F Consulting), on behalf of the Critical Access Nursing Home project through the Advancing Excellence campaign, created the Self-Discovery Assignments for Administrator and DNS. Use the results of your findings to prioritize areas of weakness that are reflected in your family and resident satisfaction survey scores.

Create opportunities for families and residents to speak to the administrator in person. In 2008, Scripps Gerontology Center reported that family members who reported that they "always" talk to the administrator showed an average mean score of 95.6 on the "Would you recommend" question, and a mean of 96.0 on their overall liking of the facility. Those who "never" talked to the administrator showed mean scores of 87.1 and 88.4 on those two items.

Develop consistent assignment among staff and residents. Consistent assignment means the same caregivers (RNs, LPNs and STNAs) consistently provide care for the same residents almost every time they are on duty (85 percent of their shifts). A goal of the Advancing Excellence Campaign, this commitment to fewer caregivers providing care for each resident increases the quality of care in facilities in which it has been adopted. An implementation guide is available on the campaign's website.

Observability

The Advancing Excellence in America's Nursing Homes Campaign, in support of its goal on measuring resident and family satisfaction, offers a four-part webinar on resident satisfaction. The first part of the webinar features Ohio's State Long-Term Care Ombudsman, Beverley Laubert, and other experts in the field.

Resources

Sign on to the Advancing Excellence in America's Nursing Homes Campaign. For assistance in registration, please see the Advancing Excellence quality incentive measure. One of the campaign's previous goals was to measure resident and family satisfaction. The Campaign's newer goals, particularly the Person-Centered Care goal, reflect in satisfaction.

Join the Person-Centered Care Coalition. The Coalition is made up of committed stakeholders in the long-term care industry. Through shared resources, mentoring and various educational events, the coalition influences and supports transformational culture change in long-term care environments where all individuals can experience meaning and purpose.

Participation in the Advancing Excellence in America's Nursing Homes campaign

To receive the quality incentive point for this measure, the facility must satisfy the requirements for participation in the Advancing Excellence in America's Nursing Homes campaign. The facility must have enrolled and selected goals by December 31, 2014 to be awarded points for state fiscal year 2016.  One of the goals must be clinical and the facility must submit data for six consecutive months on a "process" goal by December 31, 2014.

Nursing home participation has been verified by the Advancing Excellence in America's Nursing Homes campaign.  Please view an updated list of verified homes that participated in the Advancing Excellence campaign in CY2013

Active participation can be verified only if the nursing home has agreed to share its goal selection with the Local Area Network for Excellence (LANE).  See instructions  for sharing goal selection. 

Relative Advantage

The Advancing Excellence in America's Nursing Homes Campaign is a major initiative of the Advancing Excellence in Long-term Care Collaborative. The Collaborative assists all stakeholders of long-term care supports and services to achieve the highest practicable level of physical, mental and psychosocial well-being for all individuals receiving long-term care services. Participation in the campaign gives nursing homes access to educational tools and quality improvement resources, as well as methods for monitoring their progress in each of the campaign goals.

Compatibility

The Campaign goals are consistent with state and federal priorities for nursing homes. The majority of nursing homes in Ohio are currently registered for the campaign; most nursing homes already address the campaign goals in the facility quality assurance plan, so participation in the campaign and progress on the goals does not necessarily require additional effort.

Simplicity

Confirm your facility is an active participant in the campaign.

  • If your facility is currently registered, visit www.nhqualitycampaign.org, log in and update your facility profile, enter data and track your progress.  Selection of two goals (at least one clinical), sharing your goals with the LANE and six months of consecutive data entry prior to December 31, 2014 is required for 'active participation.'  [UPDATE:  for calendar year 2013, the LANE confirmed participation with two months of consecutive data entry prior to February 2014.  CY 2014 participation will be verified with 6 months of consecutive data entry.]  
      
  • If your facility has never registered in the campaign, submit your facility's registration now to ensure eligibility for the next fiscal year. Registrations require a Medicare provider number, the facility name and facility contact person. Registrations are not final until two goals have been selected.
     

Trialability

To incrementally adopt this measure:

  1. Complete (or update) your facility profile.
  2. Select (or review) your facility goals.
  3. Enter data for your selected goals.

Observability

The following graphs show Quality Measure trends in Ohio (2008 - 2010) for the campaign's clinical goals. The trend lines illustrate that campaign participants selecting a particular goal improve faster in that goal than non-participants. SOURCE: Advancing Excellence in America's Nursing Homes Quality Campaign, State Results: Ohio, November 15, 2010

Data regarding participants and their goal selections reflect the nursing homes' website registrations and goal selections as of April 28, 2010.

Ohio: Quarterly Trends of Campaign Nursing Home Group Means - Physical Restraints

Ohio: Quarterly Trends of Campaign Nursing Home Means - Chronic Care Pain

Ohio: Quarterly Trends of Campaign Nursing Home Means - Post Acute Care Pain

Ohio: Quarterly Trends of Campaign Nursing Home Means - High Risk Pressure Ulcers

Resources

Advancing Excellence in America's Nursing Homes

Download these Excellent Ideas, one-page fact sheets on important Campaign topics:

For username and password assistance:  Leasa Novak, HSAG, LNovak@hsag.com or (614)  301-2261.

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Resident Review Compliance

To receive the quality incentive point for this measure, the facility must achieve a 95% compliance rate with requesting resident reviews in a timely manner for individuals admitted under a hospital exemption.

The facility must report the compliance rate with requesting resident reviews to the Ohio Department of Medicaid. Facilities must report using the Quality Incentive Data Submission Tool no later than May 31, 2014 to be considered for the state fiscal year 2015 rate-setting. Please review the submission instructions.

Relative Advantage

Pre-Admission Screening and Resident Review (PASRR) works to ensure that people are in the appropriate environment when they need intensive treatment and services.

Compatibility

Federal and state laws require compliance with PASRR requirements.

To help ensure that individuals were not inappropriately placed in nursing facilities (NFs), the Omnibus Budget Reconciliation Act of 1987 (OBRA 87, Pub. L. 100-203) introduced Preadmission Screening and Resident Review (PASRR). PASRR requires that all applicants to a Medicaid-certified nursing facility are evaluated for mental illness (MI) and/or mental retardation or related conditions (MR); are placed in the most appropriate setting (whether in the NF or in the community); and receive assessments that identify the services they need in those settings. (Centers for Medicare and Medicaid Services, May 1, 2012.)

In 1994, regulations governing PASRR were incorporated into the Code of Federal Regulations at 42 CFR 483.100-138.

Simplicity

Hospital exemptions are now available for electronic submission through the Hospital Exemption Notification System (HENS).  HENS allows hospitals to complete the hospital exemption form on-line and send it electronically to the nursing home and the PAA. The system meets federal electronic certification requirements, eliminating the need for a physician's signature. The information then is easily uploaded into the state's computer system. Answers to three key questions in HENS will automatically refer the form to either the Ohio Department of Mental Health or the Department of Developmental Disabilities to determine if follow-up contact with the individual is needed or desired.

HENS User Guides

Microsoft Word and PDF fillable forms are also available for use by nursing facilities.

Trialability

Content forthcoming

Observability

During the month of March, 2012, the Ohio Department of Medicaid (formerly the Ohio Department of Job and Family Services) conducted a series of training Webinars called "New Medicaid Level of Care Rule Changes."

A number of webinars, tools and presentation materials are available from the Ohio Department of Mental Health and Addiction Services to demonstrate scenarios and answer frequently asked questions.

Resources

Please contact the PASSR Office or visit the website of the Ohio Department of Mental Health and Addiction Services for further questions about PASSR requirements.

PASRR Office
30 East Broad Street, 7th Floor, Columbus OH 43215
(614) 466-1063
Fax: (614) 485-9746

 

Standard and Complaint Survey Performance

Having a positive survey history has multiple advantagesTo receive the quality incentive point for this measure, the facility must have had neither of the following on the facility's most recent standard survey or any complaint surveys conducted not later than the last day of the calendar year preceding the fiscal year for which the point is to be awarded:

  • A health deficiency with a scope and severity greater than F.
  • A deficiency that constitutes a substandard quality of care.*

Homes designated as a Special Focus Facility by the Centers for Medicare & Medicaid Services (CMS) with no improvement for 18 months are not eligible for this measure. Reporting for standard and complaint surveys will be done by the Ohio Department of Health; no reporting action by the facility is needed.

*"Substandard quality of care" means one or more deficiencies related to participation requirements under 42 CFR 483.13, resident behavior and facility practices; 42 CFR 483.15, quality of life, or 42 CFR 483.25, quliaty of care, that constitute either immediate jeopardy to resident health or safety (level J, K, or L); a pattern of or widespread actual harm that is not immediate jeopardy (level H or I); or a widespread potential for more than minimal harm, but less than immediate jeopardy, with no actual harm (level F). (42 CFR 488.301)

Relative Advantage

Having a positive survey history has multiple advantages, including:

  • Improvements in health outcomes, survey results and customer satisfaction;
  • Cost savings and enhanced marketing and community perception/rating as a result of excellent survey results;
  • Possibility of the facility becoming a mentor facility;
  • Prevention of civil money penalties generated from citations;
  • Preservation of facility reputation and staff morale; and
  • Meeting standards of practice

Compatibility

Achieving this measure will increase the facility's regulatory compliance and serves as evidence of the level and quality of care provided there. The measure corresponds to facility policy and procedures for quality care and meets professional standards of practice for quality care. Also, this measure meets facility goals of best care practices delivery found in the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities

Simplicity

Facilities should evaluate their current quality assessment and assurance issues to determine and address the areas that would most benefit their facility. They can implement and use existing quality assurance strategies based on tools, policies, procedures and staff training, making revisions as necessary.

For success, management should ensure that direct care staff is aware of and understands the facility's overall goals and directives for the delivery of care and services to residents. In addition, management should provide education in regard to resident care procedures and processes that is consistent with current standards of practice and facility policies.

Make facility policies and procedures (i.e., fall intervention protocols and isolation protocols) easily accessible to all staff. Develop a strong quality assessment and assurance committee that identifies and addresses quality issues, implements corrective action plans and revises them when needed.

Have the medical director take an active role in coordination of facility-wide medical concerns and attend quality assurance meetings. Disseminate current identified concerns from the quality assurance committee to the direct care staff. Develop a mechanism for all staff (i.e., direct care staff, housekeeping and maintenance) to provide input on identified concerns.Educate both administrative and direct care staff about federal and state regulations. Having regulations available to all staff will help ensure better compliance through better understanding of rationale. Observe competency and monitor direct care staff to determine any deficient care practices. Develop additional training as necessary. Routinely review and fine tune internal policy and procedures.

Educate staff in major care areas: safety/fall prevention, hydration, skin care, weight loss prevention and infection control. Design "triggers" into assessments and develop specific quick and easy monitoring tools. Individualize resident care, address concerns and implement and revise interventions as needed.

Trialability

The nursing facility should determine care area needs, and then adopt interventions on one wing or unit while evaluating the outcomes associated with their interventions. Use facility quality assurance information to assess for problem areas; use pilot projects for unit or floor of facility or affected residents.Review MDS 3.0 national/state ranges for areas where your facility requires improvement. Review past citations to determine if policy or procedures and care delivery are still in place. Educate administrative staff in regard to regulations and interpretive guidelines.Adopt certain identified care areas targeted by the facility's quality assurance process and medical director. Educate staff about regulations, best care practices and facility steps needed to deliver quality care in skin, fall prevention, hydration, weight loss prevention, and restorative and infection control.

Observability

You can see this practice in action at mentor facilities, through on-site visits to mentor facilities to observe practice, by viewing outcome measurements and using monitoring tool data for areas that need improvement.

Resources

CMS: Regulations and Interpretive Guidelines

Ohio Department of Health state rules for nursing homes

Ohio Department of Health Technical Assistance Program

The Agency for Healthcare Research and Quality

The Centers for Disease Control and Prevention

Advancing Excellence in America's Nursing Homes

Ohio Person-Center Care Coalition

Ohio KePRO

Ohio Long Term Care Ombudsman

Pioneer Network

 

Choice

Honoring choice in how consumers live their lives is critical to raising the bar for quality long-term care. Nursing homes are challenged to put culture change in motion through policies and practices that reflect true consumer choice in dining, bathing, and rising and retiring and honoring consumers’ wishes through participation in care planning. The Advancing Excellence in America's Nursing Homes Campaign has added person-centered care as a priority goal for nursing home seeking to honor choice. These four measures reflect a nursing home’s overall commitment to consumer choice:

 

Choice in Dining

To receive the quality incentive point for this measure, a facility must offer at least 50 percent of its residents a minimum of one of the following dining choices for at least two meals each day:

  • Restaurant-style dining in which food is brought from the food preparation area to residents per the residents' orders;
  • Buffet-style dining in which residents obtain their own food or have the facility's staff bring food to them, per the residents' directions, from the buffet;
  • Family-style dining in which food is customarily served on a platter and shared by residents;
  • Open dining in which residents have at least a two-hour period to choose when to have a meal;
  • Twenty-four-hour dining in which residents may order meals from the facility any time of the day.

The point will be awarded to providers who indicate on the Quality Incentive Data Submission Tool that at least 50 percent of their residents are offered choice of meals (as defined above). Facilities must complete the submission no later than May 31, 2014 to be considered for the state fiscal year 2015 rate-setting.  Please review the submission instructions.

Relative Advantage

Providing choice in dining has a positive impact on quality.Providing choice in dining has a positive impact on quality. Research supports that liberalized diets enhance the quality of life and nutritional status of adults in a nursing home setting.

Residents given choice in dining experience reduced weight loss, increased protein and energy intake, reduced supplement use (more "real food" intake) and decreased nutrition and hydration related clinical conditions (e.g., pressure ulcers, urinary tract infections). See the discussion of positive outcomes in The Food and Dining Side of the Culture Change Movement: Identifying Barriers and Potential Solutions to Furthering Innovation in Nursing Homes, beginning on page 16.

Residents with cognitive impairments may benefit the most from the adoption of home-like dining options. A study published by the Journal of the American Dietetic Association reported that residents with cognitive impairments with low body mass index, which makes them most at risk for malnutrition, benefit more from home-like dining options other than traditional tray service.

Cost calculations may daunt facility administration when considering adoption of additional dining choices, but research indicates that they may experience lower food costs, reduced food waste, less money spent on cost of nutritional supplements and more consistent food temperatures. See the discussion of cost considerations in The Food and Dining Side of the Culture Change Movement: Identifying Barriers and Potential Solutions to Furthering Innovation in Nursing Homes, beginning on page 17.

Additional meal options provide residents a home-like dining experience rather than an institutional one. It is also imperative in a facility's efforts to allow residents to sleep as long as they like. By allowing 24-hour meal services, residents' needs can be met whenever they feel like eating.

Dining options also support snacking as an important food intake option. The generation typically served in a nursing home has been found to "snack" at a high rate (84 percent). "Snackers" have higher intakes of energy, protein, carbohydrates and total fat and may be less susceptible to undesired weight loss according to the Journal of the American Dietetic Association.

Increased participation and communication (especially in persons with dementia) in their dining experience can only increase residents' satisfaction with dining.

These and other outcomes are extensively covered in Creating Home in the Nursing Home II, an online symposium. A joint effort by Pioneer Network and Centers for Medicare and Medicaid Services (CMS), the symposium addressed the importance of dining to the overall person-centered care movement.

Compatibility

Many facilities already offer dining choice. "Figures from a 2004 survey of nursing facilities conducted by the Centers for Disease Control and Prevention show that 89 percent of facilities in the United States used a pre-plated, tray-style food delivery service - that is, food prepared in kitchens, placed on trays and delivered to residents. Six years later, the Commonwealth survey revealed that 29 percent of nursing facilities had implemented less institutional approaches to dining, such as restaurant, family and buffet styles, and provided more dining times. (Source: Provider magazine August 2010)

As person-centered care influences dining choice offered in nursing facilities, CMS has worked with providers and advocates to address the regulations that may impact liberalization of diets and schedules. The Creating Home II symposium yielded two relevant resources:

  • Survey Interpretation of the Regulations - A paper and webinar by Linda Handy, MS, RD, Consultant, Retired Specialty/Trainer Surveyor CDPH
  • The Food Code and the CDC Infection Control Guidelines - Webinars by Glenda Lewis, MSPH, FDA Office of Food Safety and Nimalie Stone, MD, CDC

Resident Choice in Meal Times: The Interpretive Guidelines, issued by CMS, oblige facilities to respect residents' rights to self-determination and participation in choosing schedules and making choices about aspects of life in the facility that are significant to the resident. Importantly, the Guidelines oblige the facility to gather information about the residents' choices over the schedules that are important to them, including daily eating schedules, in order to assist them in fulfilling them.

Simplicity

Section three of the Long-Term Care Improvement Guide, "Practical Approaches for Building a Resident-Centered Culture" has real world examples of the adoption of dining choices in the "Culinary Engagement" section.

The New Dining Practice Standards includes a number of principles for adopting less restricted diet and meal times in nursing facilities. Most importantly, the standards emphasize that diet is to be determined with the person in accordance with choices and preferences rather than by diagnosis.

Trialability

Facilities should review their family and resident satisfaction survey scores with an eye to the questions on meals and dining. An internal survey developed to measure the residents' satisfaction with the facility's current serving and schedule processes could reveal suggestions for improvements. Results of this survey can be discussed with the Resident Council, sharing the person-centered care (PCC) dining options and how the facility might test each option for resident input.

Test and evaluate. Utilize one or more of the PCC dining options for a specified time period or for one area of the facility, i.e., a wing or floor. Evaluate residents' response to the options for satisfaction, meal intake, cost and sustainability. Develop a post-survey for satisfaction.

Observability

Read Providers Revamp Dining to Please the Palette: Choices and flexibility lead to better outcomes for a description of facilities that have adopted new dining choices.

Resources

Artifacts of Culture Change (See item #1)

The Creating Home in the Nursing Home symposium on culture change and the food and dining requirements, co-sponsored by CMS and the Pioneer Network (symposium background paper).

"The Deep Seated Issue of Choice," by Linda Bump

Food and Dining Standards

Additional articles on the long-term care environment, focused on dining and meals

The California Culture Change Coalition's Person-Directed Dining Practice Package

"Enjoyable Dining: Can We Build an Evidence Base?" Debra Wood, R.N., Leading Age Magazine, November/December 2011

"Providers Revamp Dining To Please The Palette: Choices and flexibility lead to better outcomes," Meg LaPorte, Provider, August 2010

Choice in Bathing

To receive the quality incentive point for this measure, at least 50 percent of the facility's residents must be able to take a bath or shower as often as they choose.

The point will be awarded to providers who indicate on the Quality Incentive Data Submission Tool that at least 50 percent of their residents are able to take a bath or shower as often as they choose. Facilities must complete the submission no later than May 31, 2014 to be considered for the state fiscal year 2015 rate-setting.  Please review the submission instructions.

Relative Advantage

The barriers to overhauling the bathing experience are few and the rewards are great.According to the Quality Partners of Rhode Island: "The barriers to overhauling the bathing experience are few and the rewards are great." Ideas that speak to the bathing experience include addressing both the physical environment and soliciting and addressing the resident's individual preferences. Both have the potential to increase resident engagement and increase resident and family satisfaction. According to My InnerView's 2010/2011 National Survey of Customer and Employee Satisfaction in Nursing Homes report, choice/preferences is one of the top five drivers most correlated with recommending the nursing facility to others. They also can decrease residents' negative responses to bathing. This in turn may decrease incidents and injury to both the resident and the caregiver, while building positive, trusting relationships between them.

Compatibility

The Interpretive Guidelines issued by CMS oblige facilities to respect residents' rights to self-determination and participation in choosing schedules and making choices about aspects of life in the facility that are significant to the resident. Importantly, the guidelines oblige the facility to gather information about the residents' choices in order to assist them in fulfilling them.

A facility's inability to take resident choice into account could lead to finding of deficiencies in:

  • F242 Self-Determination and Participation: The resident has the right to choose activities, schedules and health care consistent with his or her interests, assessments and plans of care; and make choices about aspects of his or her life in the facility that are significant to the resident.
     
  • F272 Resident Assessment: Also provides support for structuring care giving around the preferences and routines of each individual resident.
     
  • F240 Quality of Life: Specifies the facilities responsibility toward creating and sustaining an environment that humanizes and individualizes each resident.
     
  • F246 Accommodation of Needs: The facility's physical environment and staff behaviors should be directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preferences.
     
  • F252 Environment: Nursing homes are to provide "a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible". The regulatory guidelines published in 2009 describes this requirement by stating "For purposes of this requirement, 'environment' refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A determination of "homelike" should include the resident's opinion of the living environment."
     

Surveyor guidance includes:

Determine what time the resident awakens and goes to sleep, and whether this is the resident's preferred time. Also determine whether the facility is honoring the resident's preferences regarding the timing (morning, afternoon, evening and how many times a week) for bathing and also the method (shower, bath or in-bed bathing). Obtain further information as necessary from observations and staff interviews. If the resident is unaware of the right to make such choices, determine whether the facility has actively sought information from the resident and/or family (for a resident unable to express choices) regarding preferences and whether these choices have been made known to caregivers.

Simplicity

View "Bathing without a Battle" by Joanne Rader, RN, FAAN of B&F Consulting.

See "A Pleasant Bathing Experience", Quality Partners of Rhode Island

Trialability

For environmental changes, begin by conducting learning circles and asking residents and staff members in one hallway or neighborhood to share one way they feel the tub/shower room at the facility is different from the bathrooms they have/had at home. Also ask them to offer one small thing that they could do that might make the tub/shower room feel more like home or like a spa? Give an example, such as playing soft music in the background, or having warm towels, etc. Ask for volunteers to work on a team that would come up with a cost effective plan that could transform the tub/shower room into a spa room. See Pioneer Network's "Design on a Dollar" for additional ideas. Then, transform the room. When one hall is successful, transform all tub/shower rooms similarly.

When it comes to determining personal preference, begin small. Target one hall or a section of one hall to ask residents their preference of when they would like to bathe, how often they would like to bathe, how they prefer to bathe (shower, bath, sponge bath) and possibly what products they prefer. This information may and should already exist in the care plan and MDS 3.0. With information in hand, ask the team or caregivers of those residents how these preferences can be accommodated. With the input from the direct caregivers established, and preferences offered by the resident, establish schedules. Revisit these schedules as needed or during care conferences to assure resident preferences remain the same. When bathing according to personal preference becomes successful in one area, begin another area.

To target bathing challenges, determine which residents have been unhappy with bathing care. Then, view "Bathing without a Battle" and begin using the techniques demonstrated in this video.

Observability

"Bathing without a Battle," by Joanne Rader, RN, FAAN of B&F Consulting. CMS sent this video to every nursing home in the country.

Resources

Artifacts of Change See item #11

Bathing Without a Battle

Health Centric Advisors (formerly Quality Partners of Rhode Island)

Choice in Rising and Retiring

To receive the quality incentive point for this measure, the facility must have at least the minimum scores noted below for the following topics on its resident satisfaction survey (initiated in odd years):

  • Residents' ability to choose when to go to bed in the evening; minimum score: 89
  • Residents' ability to choose when to get out of bed in the morning; minimum score: 76

To receive the quality incentive point for this measure, the facility must have at least the minimum scores noted below for the following topics on its family satisfaction survey (initiated in even years):

  • Residents' ability to choose when to go to bed in the evening; minimum score: 88
  • Residents' ability to choose when to get out of bed in the morning; minimum score: 75

The facility must participate in the Ohio Resident Satisfaction Survey and the Ohio Family Satisfaction Survey conducted by the Ohio Department of Aging and receive sufficient resident and family responses to meet the required margin of error.  The scores from the resident survey initated in calendar year (CY) 2013 will be used for the state fiscal year (SFY) 2015 rate; the scores from the family survey initiated in CY 2014 will be used for SFY 2016 rate.

In preparation for the 2014 Nursing Home Family Satisfaction Survey, please ensure you have the current address of each resident's most interested family member or legal representative. Instructions for participation will be sent in late spring or summer of 2014.

The Department of Aging will report scores for the incentive calculation; no reporting action by the facility is needed.  The results of the 2013 Nursing Home Resident Satisfaction Survey are available here: 2013 Resident Satisfaction Survey - Choice in Rising & Retiring.  The results of the 2012 Nursing Home Family Satisfaction Survey are available here:  2012 Family Satisfaction Survey - Choice in Rising & Retiring.

Relative Advantage

56 percent of residents reported choice and control regarding getting up in the morning "very importantWhen residents are awakened, and put to bed according to facility and staff convenience, residents' sleep patterns are often compromised and sleep deprivation may occur. Typical outcomes may include lethargy, loss of appetite, depression, anxiety, agitation and combative behavior. Such declines may equate to increased staff time, frustration of both caregiver and resident, increased medication, increased falls and weight loss.

Resident satisfaction is related to the choice and control they have over everyday matters, such as deciding when to get up in the morning or go to bed at night. A study by Dr. Rosalie Kane, et al, found that 56 percent of residents reported choice and control regarding getting up in the morning "very important," and 51 percent of residents reported that choice and control regarding going to bed was "very important."

In addition, according to My InnerView's 2010/2011 National Survey of Customer and Employee Satisfaction in Nursing Homes report, choice/preferences is one of the top five drivers most correlated with recommending a nursing facility to others.

Compatibility

The Interpretive Guidelines issued by the Centers for Medicare and Medicaid (CMS) oblige facilities to respect residents' rights to self-determination and participation in choosing schedules and making choices about aspects of life in the facility that are significant to the resident. Importantly, the guidelines oblige the facility to gather information about the residents' choices in order to assist them in fulfilling them.

A facility's inability to take resident choice into account could lead to finding of deficiencies in:

  • F242 Self Determination and Participation, which states the resident has the right to: choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care; and make choices about aspects of his or her life in the facility that are significant to the resident;
  • F272 Resident Assessment, which provides support for structuring care giving around the preferences and routines or each individual resident; and
  • F240 Quality of Life, which specifies the facilities' responsibility toward creating and sustaining an environment that humanizes and individualizes each resident.

Please note: F368 - Frequency of Meals is not contradictive of residents awakening and retiring according to their choice.

Simplicity

Begin by understanding the effects of the medical model nursing home work patterns have on the sleep experience of residents.

Trialability

To introduce this subject, form a learning circle. Ask "What happens at the facility that is disruptive to a person's good night sleep?" Then ask the team to share one thing that the facility could do differently so that these disruptions wouldn't happen.

Workplace practices may include waking up residents or putting residents to bed at times that are convenient to the caregiver. However, these times may not be what the resident prefers. Have caregivers ask each resident what time they prefer to go to bed at night, and what time they prefer to be awakened each morning, or if they prefer to wake up on their own without any prompting. (These preferences should be reflected in the MDS 3.0 and Care Plan). You may choose to do this in one area of the building, or with one group of residents.

Honoring resident rising and retiring preferences may affect medication administration times. It is important to have a facility's medical director's buy-in and involvement in this change. In addition, medication orders may need to be changed to reflect medication administration "upon rising" or at times that complement the residents' choice in sleeping schedules.

Form a team that includes staff and residents to create a plan that removes workplace practices that are disruptive to sleep. Consider practices such as implementing quiet voices and banning equipment use until after 9 a.m. The team might choose to quit routine floor cleaning during the night and then address filling water pitchers during the night, etc. These habits, tasks and staff schedules may be addressed one at a time or in one area of the building.

As the facility experiences success in one area of the building, or with one group of residents, repeat the above processes until all resident preferences are honored, and the entire facility provides an environment that is conducive to a good night's sleep.

Observability

The Pioneer Network has published case studies of facilities that have undergone culture change transformations, including changes in the waking and sleeping schedules of residents.

Facilities found that honoring choice in waking times impacted numerous other care areas:

Honoring choice in waking times impacted numerous other care areas, such as dietary, housekeeping, activities, direct care and clinical.

Resources

None

Advance Care Planning

To receive the quality incentive point for this measure, at least 75 percent of the facility's residents have the opportunity, following admission to the facility and before completing or quarterly updating their individual plans of care, to discuss their goals for the care they are to receive at the facility, including their preferences for advance care planning, with a member of the residents' healthcare teams that the facility, residents and residents' sponsors consider appropriate.  The facility must record the residents' care goals, including advance care preferences in their medical records and use them in the development of the residents' individual plans of care.

The point will be awarded to providers who indicate on the Quality Incentive Data Submission Tool that they have met the measure (as defined above).   Facilities must complete the submission no later than May 31, 2014 to be considered for the state fiscal year 2015 rate-setting.  Please review the submission instructions.

Relative Advantage

Resident choices in regard to their health care and advance care plan must be known and honored by facility staff.Resident participation in the care planning process ensures that the comprehensive care plan is inclusive and is built upon the resident's choices for their medical and personal care. Resident choices in regard to their health care and advance care plan must be known and honored by facility staff. Having information about the resident's wishes enables the nursing home to respect the residents' choices and provides the resident with the care they have chosen in advance. Staff who know the resident's preferences can be more efficient in providing care because they can anticipate needs and plan their work around the resident's schedule.

Advance care planning also alleviates anxiety of residents by assuring them that their wishes for their medical care and quality of life will be honored. Spending time up front getting to know the resident's preferences will save time during care processes and will increase the satisfaction of the resident.

The Agency for Healthcare Research and Quality found that "residents who have talked with their families or physicians about their preferences for end-of-life care:

  • Had less fear and anxiety;
  • Felt they had more ability to influence and direct their medical care;
  • Believed that their physicians had a better understanding of their wishes; and
  • Indicated a greater understanding and comfort level than they had before the discussion.

Compatibility

Residents have a right to participate in care planning. Residents have the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the state, to participate in care planning and treatment or changes in care and treatment.

Failure to include residents' wishes in the care planning process may result in citations under F280 Resident Participation in Care Plans.

Simplicity

Resident participation in care planning is the outgrowth of an ongoing conversation between staff and residents about their needs and preferences. Utilizing the My Personal Directions template with residents is an easily implemented method of obtaining information regarding the residents' choices.

When caregivers spend time getting to know resident preferences, relationships begin to develop that lead to optimal quality of life for both staff and residents. "Conversations that Light the Way" is a useful guide to facilitate caring communications.

Advance Care Planning. Caring Connections, a program of the National Hospice and Palliative Care Organization, offers an Ohio specific guide to advance directives with consumer-friendly descriptions of the types of advance directives and forms to complete.

Person-Centered Care Planning.  The Quality of Life Structured Resident Interview and Care Plan is a system for creating individualized, person-centered care plans in the nursing home. This interview-based approach to care planning generates the information staff need to tailor a resident's care plan to their preferences, as well as quantitative measurement of individual and facility-level outcomes. Please visit http://www.improvingqol.pitt.edu/home to register as a user and learn more.

Trialability

Utilize the Implementation Guide from the Advancing Excellence in America's Nursing Homes Campaign's goal on Advance Care Planning. The campaign's website also includes a sample advance care plan and a tracking tool for tracking and reporting purposes.

Contact Ohio KePRO for assistance in signing up for Advance Care Planning as a facility goal or utilizing the tracking tool.

Observability

The Advancing Excellence in America's Nursing Homes campaign's implementation guide to advance care planning includes monitoring and evaluation processes for ensuring residents' advance care plans are created and honored.

Resources

The Advancing Excellence in America's Nursing Homes campaign's materials on Advance Care Planning includes: Implementation Guide, Tool for Tracking, Fact Sheets.

Caring Connections, a program of the National Hospice and Palliative Care Organization, offers an Ohio specific guide to Advance Directives.

The Ohio End of Life Collaborative involved a broad group of professionals to develop Conversations that Light the Way, a workbook that provides a place for individuals to document their preferences.

Having Your Say: Advance Directives, American Health Care Association

Advance Directives, Medlineplus.gov

Quality of Life Structured Resident Interview and Care Plan System, A system for creating individualized, person-centered care plans in the nursing home

 

Clinical

To raise the bar for quality long-term care, nursing homes must commit to improvement in clinical areas affecting their consumers. Nursing homes are challenged to reduce the use of restraints, improve reported pain, and incidences of urinary tract infections and pressure ulcers and to track hospital admissions. These six measures reflect a nursing home’s overall commitment to improving the quality of care their residents receive:

 

Pain

To receive the quality incentive point for this measure, not more than 13.35% of the facility's long-stay residents may report severe to moderate pain during the minimum data set assessment process.

The facility's MDS score will be verified; no reporting action by the facility is needed.

Relative Advantage

Advances in pain management will improve the residents quality of life, increase cost savings for the facility and more.Advances in pain management will not only improve the residents quality of life and increase cost savings for the facility, they will also result in:

  • Improved health outcomes;
  • Improved survey performance;
  • Improved resident satisfaction;
  • Increased resident socialization;
  • Increased resident ambulation/mobilization;
  • Decreased pain for residents;
  • Decreased hands on care required;
  • Decreased falls; and
  • Decreased agitation and resident behaviors.

Compatibility

In compliance with F309 Quality of Care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Prioritizing resident comfort levels allows for the best outcome for the resident.

Simplicity

The facility should evaluate their current quality measures to determine how to improve upon pain management. The facility may consider developing a screening tool upon admission that follows the residents' care needs throughout their stay. Consider the following:

  • Evaluate the existing tools the provider has in place.
  • Identify pain during the admission nursing assessment.
  • Evaluate the medication administration record - pain measurement/medication provided/effectiveness of pain medication.
  • Validate pain tool adoption and place on medication administration book for quick reference/assessment for cognitive and cognitively impaired.
  • Observe residents daily for new pain identification.
  • Use a pain tracking tool consistently and proactively for screening and assessments in order to validate severity of pain, duration of pain and the residents' ability to ask for medication.
  • Recognize residents' verbalization and staff recognition of nonverbal residents' pain.
  • Raise awareness of pain issues, especially in confused or non-verbal residents.

Trialability

The nursing facility should determine their pain management needs, then adopt interventions on one wing or unit while evaluating the outcomes. The facility can then roll out what they have learned incrementally to the rest of the facility. Consider the following:

  • Start with residents who are currently on pain medication.
  • Rate pain levels for those on pain medication to identify ineffective relief.
  • Conduct a survey of residents who are not on pain medication who report pain.
  • Determine/develop a list of pain medication alternatives known to decrease pain.
  • Use pharmacological and non-pharmacological interventions together.
  • Observe residents to identify new pain or ineffective control of pain.
  • Use a consistent pain tool throughout the facility.
  • Educate staff in regard to consistent and proactive screening.
  • Adopt a special program/protocol for pain management for residents with moderate to severe pain.
  • Ensure the analgesic used is specific for the pain diagnosis, when pharmacological interventions are implemented.

Observability

Ways to observe the effects of this measure include:

  • MDS 3.0 data, use of medication administration records, pain relief results in quality assurance and quality improvement data.
  • Observation of residents.
  • Pharmacy review and recommendations for those with ineffective relief.
  • Review of PRN (as needed) pain medication.
  • Review of medication administration records for documented effective pain relief.
  • Individual resident review of pain meds given per standing orders.

Resources

The Advancing Excellence in America's Nursing Homes campaign's materials on Reducing Pain, includes an implementation guide, tool for tracking, webinar, fact sheets

NQF measure 677 National Quality Forum (NQF), National Voluntary Consensus Standards for Nursing Homes: A Consensus Report, Washington, DC: NQF; 2011.

Prevalence and Management of Pain, Center for Disease Control and Prevention

Pain assessments for older adults

Tools - Setting : Nursing Home Condition, PainPrimaris (Quality Improvement Organization for Missouri

Clinical Practice Guideline: Pharmacological Management of Persistent Pain in Older Persons, American Geriatrics Society

Pain Management in the Long-Term Care Setting (2003), American Medical Directors Association (AMDA) Clinical Practice Guideline

American Academy of Hospice and Palliative Medicine

American Academy of Pain Medicine

American Pain Society

Pain and Physical Symptoms Toolkit, Brown University

Hospice and Palliative Nurses Association

"Try This" series, John A Hartford Institute for Geriatric Nursing

National Initiative on Pain Control

Partners Against Pain®

Quality Improvement Organizations

Beth Israel Medical Center Resource Center for Pain Medicine and Palliative Care

Ohio Department of Health Technical Assistance Program

Pressure Ulcers

To receive the quality incentive point for this measure, not more than 5.16% of the facility's long-stay, high-risk residents may have been assessed as having one or more stage two, three or four pressure ulcers during the minimum data set assessment process.

The facility's MDS score will be verified. No reporting action by the facility is needed.

Relative Advantage

Health outcomes for nursing homes residents include reduction in pain and suffering, reduced risk of infection and sepsis, and Improved quality of life and dignity.

Outcomes also include savings to the health care system (wound care supplies and staff time to assess, document and treat wounds). "AHRQ estimates that the average pressure ulcer-related hospital stay extends to between 13 and 14 days and costs between $16,755 and $20,430, depending on medical circumstances." - "Positive Outcomes of Culture Change - The Case for Adoption," Tools for Change, vol.1, no 2, April 2011, the Pioneer Network

This measure also can improve survey performance (less margin for citation with fewer pressure ulcers) and satisfaction score improvement. Clinical practice, expert opinions and published literature indicate that most, but not all, pressure ulcers can be prevented (consensus statement from NPUAP

Compatibility

Achieving this measure maintains compliance with survey regulations, corporate monitoring systems and quality indicators and quality measures.

Simplicity

Reducing the number of pressure ulcers in high-risk residents requires a systemic approach to quality improvement:

 

  • Implement clear protocols for risk assessment and skin inspection.
  • Individualize care plans (with front-line staff input) based on identified risk areas.
  • Implement clear protocols for risk assessment and skin inspection. Refer to these resources for help.
  • Implement clear protocols for communicating care plans and risk status to front-line staff.
  • Provide effective education for new staff; annual in-servicing and competency testing for nursing department.
  • Increase use of consistent assignment and improved staff retention.
  • Improve supervision and monitoring of hands-on care (e.g. turn schedules, incontinence care, etc.).
  • Conduct root cause analysis of all facility-acquired pressure ulcers.
  • Implement clear protocols for treatment of existing pressure ulcers.

Trialability

Review policies and procedures. Involve staff in improvement efforts and individualized care planning. Focus on communication and interdisciplinary involvement.

Observability

Mentor nursing facility .

Resources

The Advancing Excellence in America's Nursing Homes campaign's materials on Pressure Ulcer Reduction (LINK:  http://www.nhqualitycampaign.org/star_index.aspx?controls=pressureulcersexploregoal) includes an implementation guide, tool for tracking, webinars, fact sheets and more.

Pathway for Prediction, Prevention and Treatment of Pressure Ulcers in Nursing Homes, Ohio KePRO

Gauging Pressure Ulcers: A Nursing Home's Guide to Prevention and Treatment, Primaris

Reducing Pressure Ulcers in Nursing Homes: An Interdisciplinary Process Framework (Audio file), Advancing Excellence in America's Nursing Homes Campaign

Quick Reference Guide for Prevention, National Pressure Ulcer Advisory Panel (NPUAP)

A Handbook for Nurses, Chapter 12. Pressure Ulcers: A Patient Safety Issue, Agency for Healthcare Research & Quality Patient Safety and Quality

Pressure Points Poster, Ohio KePRO

Pressure Ulcer Staging, National Pressure Ulcer Advisory Panel (NPUAP)

Quick Reference Guides for and Treatment, National Pressure Ulcer Advisory Panel (NPUAP)

Pressure Ulcer Prevention Points, National Pressure Ulcer Advisory Panel (NPUAP)

Pressure Ulcer Scale for Healing (PUSH) Tool, National Pressure Ulcer Advisory Panel (NPUAP)

Skin Care Posters - Set I, Ohio KePRO

Skin Care Posters - Set II, Ohio KePRO

Skin Care Posters - Set III, Ohio KePRO

Skin Care Posters - Set IV, Ohio KePRO

Pressure Ulcer Quality Measure Poster, Ohio KePRO

Electronic PUSH Tool, Ohio KePRO

Pressure Ulcer-Free Calendar, Ohio KePRO

Pressure Ulcer Overview, Ohio KePRO

Positive Outcomes of Culture Change, The Pioneer Network

State Operations Manual Appendix PP, FTag 314, The Centers for Medicare & Medicaid Services.

NCHS Data Brief: Pressure Ulcers Among Nursing Home Residents, 2004, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics

Restraints

To receive the quality incentive point for this measure, not more than 1.52% of the facility's long-stay residents may be physically restrained as reported during the minimum data set assessment process.

The facility's MDS score will be verified. No reporting action by the facility is needed.

Relative Advantage

Meeting this measure can lead to improved health outcomes for nursing homes residents (less risk for unintended adverse outcomes, such as pressure ulcers or contractures, less risk of injury or entrapment, and improved dignity), as indicated by:

Compatibility

This measure maintains compliance with survey regulations, corporate monitoring systems and quality indicators and quality measures.

Simplicity

Remember that restraints cannot be added without a physician order, and that they must be used to address a medical symptom. Adopt a "restraint keeper" policy so that plans to add new restraints must be filtered through one person (i.e. director of nursing or restorative nurse).

For residents currently in restraints, identify the common reasons restraints are used: history of falls, positioning, behaviors or other common reasons. Begin quality improvement efforts to improve outcomes in these areas. For example, revitalize your facility's fall prevention program or meet with physical/occupational therapists for seating or positioning issues. Discuss restraint reduction with medical director and physicians, families and staff; focus on the dangers of restraint use.

Commit to a restraint-free philosophy. See the Advancing Excellence in America's Nursing Homes Campaign Fact Sheet for Consumers and the Fact Sheet for Staff. See also the Ohio Department of Health Restraint Brochure.

Engage therapy department in restraint reduction for individual residents (for PT/OT/ST physical therapy, occupational therapy and speech therapy assessments, seating/positioning needs and, functional improvements).

Trialability

Ensure that all staff (i.e. floor staff, MDS coordinator, restorative, therapy, director of nursing, administrator, etc.) understand the definition of a restraint. See the CMS memo. Limit the accessibility of restraints for all front-line staff, and appoint a "Restraint Keeper" to coordinate new restraint orders.

Systematically review all existing restraints and begin to trial a reduction process. See Ohio Department of Health Restraint Guidelines. Remove for short periods of time to assess resident response. Use restraint alternatives as appropriate. Be sure all staff is aware of restraint alternatives.

Observability

None

Resources

Implementation Guide, Advancing Excellence in America's Nursing Homes Campaign

Interventions Table, Advancing Excellence in America's Nursing Homes Campaign

Restraint Tracking Tool, Advancing Excellence in America's Nursing Homes Campaign

Webinars and other materials on Restraints, Advancing Excellence in America's Nursing Homes Campaign

Working Together for Safer Care: Reducing Restraint Use, Ohio KePRO

Conducting Effective Restraint Reduction Meetings, Ohio KePRO

Improving Quality Measures: Physical Restraints, Ohio KePRO

Quality Measures Explained: Physical Restraints, Ohio KePRO

Restraint Alternatives Guide, Ohio KePRO

Restraint Determination Flowchart, Ohio KePRO

Restraint Reduction Flowchart, Ohio KePRO

Restraint Reduction Planning Form, Ohio KePRO

Facility Assessment Checklist, Ohio KePRO

Fact sheet on restraints, Ohio KePRO

Restraint Crossword Puzzle, Ohio KePRO

Restraint Poster, Ohio KePRO

Restraint Dashboard (blank), Ohio KePRO

Restraint Dashboard (sample), Ohio KePRO

Fact sheet on fall prevention, Ohio KePRO

Handout on Behavior Management, Ohio KePRO

State Operations Manual Appendix PP, F-Tag 221, The Centers for Medicare & Medicaid Services. This regulation helps to ensure that residents are not restrained for reasons of discipline or staff convenience, or not used to treat a medical symptom.

Ohio Administrative Code, Ohio Department of Health

FDA Guide to Bed Safety

FDA Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment

Urinary Tract Infections

To receive the quality incentive point for this measure, less than 7.0% of the facility's long-stay residents may have had a urinary tract infection as reported during the minimum data set assessment process.

The facility's MDS score will be verified. No reporting action by the facility is needed.

Relative Advantage

There are multiple advantages to decreasing urinary tract infections, including:

  • Improved resident/family satisfaction
  • Improved resident health
  • Improved regulatory compliance
  • Improved reputation of facility care in community
  • Improved health outcomes as evidenced by no bacteremia or septicemia related to, or as a result of, urinary tract infections
  • Improved survey results
  • Better resident outcomes
  • Cost savings from decreased antibiotic usage and repeat lab tests
  • Improved staff morale

Compatibility

In compliance with F315 Urinary Incontinence, Residents are not catheterized unless medically necessary. Incontinent residents receive services to prevent urinary tract infections and treatment to restore bladder function as possible.

The measure may lead to increased regulatory compliance and serve as evidence of level and quality of care provided. It also may lead to increased knowledge of and ability to recognize the scope and severity of urinary tract infections. In addition, it helps meet additional regulations with the overall goal of maintaining resident's highest practicable well-being. When incorporated into care planning/assessments, standards of practice, restorative care, infection control and hydration practices and staff competencies, it leads to increased health of residents.

Simplicity

The nursing facility should evaluate their current quality assurance measures and policy and procedure to determine if any revisions are needed. The facility may also consider a screening tool to determine which individuals require increased monitoring. The nursing facility should consider:

  • Proper implementation of quality measures, policies and procedures.
  • Staff training, which is updated as necessary.
  • Having floor nurses monitor front line staff to ensure proper peri care is given, proper hydration is offered via in room fluids and meal fluids.
  • Adding programs such as restorative, bowel/bladder, hydration, skin and infection control.
  • Adding risk and prevention of urinary tract infections information to new hire orientation, admission assessment for "risk" identification and staff competencies.

Trialability

The nursing facility should determine care area needs then adopt interventions on one wing or unit while evaluating the outcomes. Attempt this practice on one floor or wing of the facility, then adopt it for residents or staff that fit a profile determined by the facility. Implement and use existing quality assurance based tools, policies, procedures, staff training and make revisions as necessary.

Educate floor nurses in regard to the importance of direct monitoring of core floor staff. Enable floor nurses to give instant education and feedback during observed peri care. Enable and empower floor nurses to be part of the continual monitoring teaching process and to give positive feedback - especially in regard to newly trained STNAs.

Implement a written and accountable monitoring system to randomly spot check peri-care for all staff. This can be added to the admission/readmission and nursing assessment forms. Identify residents with current urinary tract infections on infection control forms. Identify residents with catheters or other identified risk factors for urinary tract infections, such as decreased hydration, etc.

Observability

Conduct on-site visits to observe practice. This could be another facility or within a facility where the trial practice was successful. Focus on your own facility resident success stories.

You can view this practice at selected mentor facilities who are willing to share information gathered in their quality assurance process in regard to all aspects of urinary tract infections, investigations, results, training, monitoring, etc.

Examine lab results and facility surveillance rounds for appropriate perineal, catheter care/tubing control, implementation of toileting programs and appropriate hand washing.

Make available videos or webinars on prevention of urinary tract infections. Make weekly/monthly and quality calculations for urinary tract infections by unit.

Resources

Appendix PP - Guidance to Surveyors for Long Term Care Facilities

Ohio KePRO

Facility's medical director and contracted pharmacy in-services

F315 Urinary Incontinence with corresponding interpretive guideline (urinary tract infections)

The Agency for Healthcare Research and Quality

Guideline for Prevention of Catheter-associated Urinary Tract Infection, The Centers for Disease Control and Prevention

National Kidney & Urologic Diseases Information Clearinghouse (NKKUDIC)

National Association For Continence, Charleston, South Carolina

Mayo Clinic

Ohio Department of Health Technical Assistance Program for free facility education

Hospital Admission Tracking

To receive the quality incentive point for this measure, the facility must use a tool for tracking residents' admissions to hospitals and must annually report hospital admission by month. 

The nursing facility must submit data by May 31, 2014 to be awarded points for fiscal year 2015.

Relative Advantage

Tracking residents' admissions to hospitals may lead to better relationships with referring hospitals.Tracking residents' admissions to hospitals may reveal care practice improvement needs and lead to better relationships with referring hospital(s) to improve care transitions. CMS recommends strong relationships between care providers as seen by the Accountable Care Organization (ACO) opportunity. ACOs create incentives for health care providers to work together to treat an individual patient across care settings - including doctor's offices, hospitals and long-term care facilities.

Better use of evidence-based practices results in better patient outcomes and reduces the cost of care. Transfers to and from the hospital cause disruptions in care continuity. There are potential costs in medication stabilization, transportation and resulting transfer trauma to the resident.

Compatibility

The Quality Indicator Survey (QIS) triggers investigation in the area of hospitalization if thresholds for readmissions are exceeded in the Phase I review. The following F tags can be cited if resident care results in hospitalization:

  • F272: Comprehensive Assessment;
  • F274: Resident Assessment When Required;
  • F279: Comprehensive Care Plan;
  • F282: Care Plan Implementation by Qualified Persons;
  • F309: Provision of Care and Services;
  • F157: Notification of Changes;
  • F241: Dignity;
  • F271: Admission Orders;
  • F278: Accuracy of Assessments;
  • F281: Professional Standards of Quality;
  • F242: Self-Determination and Participation;
  • F353: Nursing Services;
  • F385: Physician Supervision;
  • F501: Medical Director; and
  • F514: Clinical Records.

Hospitals will seek cooperation from area nursing homes to avoid the new rehospitalization penalties included in the Patient Protection and Affordable Care Act of 2010. Nursing facilities seeking to improve transitions from hospitals to nursing care will have motivated partners in their efforts.

"As pay-for-performance initiatives begin to be implemented, both hospitals and payers will be quickly looking to their clinical practitioners to develop programs to improve the transition outcomes. The key elements to the transition of care are as follows:

  • Develop comprehensive discharge plans that screen for risk factors, and engage the patient/family in the self-management skills and goal setting needed to launch a successful transition of care.
  • Deploy home follow-up protocols, including home chronic disease professionals, to follow the patient at home.
  • Create disease-specific programs that measure the risks of a readmit, develop action plans to resolve those risks, and monitor the progress via data collection to better understand future performance."

(Paying the Price for Rehospitalizations, Robert McCoy, BS, RRT, FAARC and Dan Easley, BS)

Homes are encouraged to enter summary data gleaned from INTERACT into the Advancing Excellence in America's Nursing Homes campaign tool to monitor progress.  Regular entry of data will help the home meet data submission requirements for the Advancing Excellence quality incentive measure.  Instructions and resources are provided here:  http://www.nhqualitycampaign.org/files/GettingStartedPracticum3sn8-1-13.pdf

 

Simplicity

A number of tracking tools are available from public and private vendor sources. Ohio KePRO's website has a list of some of the best known.

Trialability

A number of programs on care transitions have documented positive outcomes for both patients and providers.

Observability

The Ohio KePRO, Ohio's Quality Improvement Organization, under contract with CMS, is working with health care providers to improve the quality of care for individuals who transition between care settings. A number of multidimensional programs for improving care transitions have documented success in patient outcomes. A description of those programs may be found in the Ohio KePRO fact sheet on the Integrating Care for Populations and Communities project.

Resources

The Advancing Excellence in America's Nursing Homes campaign has added a new goal on Reducting Hospitalizations, which includes an implementation guide, tool for tracking, webinars, fact sheets and more.

"QIS System Addresses Hospital Readmissions," Andy Kramer, MD, Provider, June 2011

National Quality Forum Webinar: Reducing Readmissions through Care Transitions

The RARE (Reducing Avoidable Readmissions Effectively) Campaign

Interventions to Reduce Acute Care Transfers (INTERACT)

Health Care Leader Action Guide to Reduce Avoidable Readmissions

Readmission rates for hospitals

Transitional care processes and outcomes among adult recipients of long-term services and supports, Long Term Quality Alliance

Building Innovative Communities: Promoting Health Reform Principles through Community-based Learning and Collective Action, Long Term Quality Alliance

"Reducing Heart Failure Hospital Readmissions from Skilled Nursing Facilities," Professional Case Management, Vol. 16, No. 1, 18-24

Immunizations

To receive the quality incentive point for this measure, at least 95% of the facility's long-stay residents must be given pneumococcal vaccine and at least 93% of long-stay residents are given seasonal influenza vaccine.

The facility's MDS score will be verified. No reporting action by the facility is needed.

Relative Advantage

There are multiple advantages to immunizing against pneumococcal and influenza infections, including:

  • Residents have lower risk of illness and serious complications related to infections.
  • Residents live in an environment with decreased transmission of disease.
  • Residents live in an environment with decreased transmission of disease.
  • Residents are able to freely participate in activities within the nursing home or in the larger community.
  • Residents and families gain knowledge about prevention of infections.
  • Residents may have reduced exposure to unnecessary antibiotics which may assist in C. diff prevention efforts.

FLU

The "flu" (also called influenza) is a very contagious respiratory infection. Flu is spread very easily from person to person. People are usually infected when a person coughs or sneezes.

The flu shot (influenza vaccination) can prevent residents from getting the flu or reduce the risk of becoming seriously ill from the flu. People who are age 65 and older are at higher risk for developing serious life-threatening medical complications from the flu.

Residents should be given a flu shot during the flu season (October through March). Residents should not get another flu shot if they have already received a flu shot at another place, or if there is a medical reason why they should not receive it. (CMS's Nursing Home Compare)

PNEUMONIA

The pneumococcal shot (pneumococcal vaccination) may help prevent, or lower the risk of seriously illness from pneumonia caused by bacteria. It may also help prevent future infections.

Residents should be asked if they have been vaccinated for pneumonia, and if not, should be given the pneumococcal shot unless there is a medical reason why they should not receive it.

Compatibility

Since October 2005, the Centers for Medicare and Medicaid Services (CMS) has required nursing homes participating in Medicare and Medicaid programs to offer all residents influenza and pneumococcal vaccines and to document the results. According to requirements, each resident is to be vaccinated unless contraindicated medically, the resident or legal representative refuses vaccination, or the vaccine is not available because of storage.

Simplicity

The facility should review its currently reported rate of influenza and pneumococcal immunization rate submitted using the MDS. Determine whether current procedures enable to the home to meet the measure - at least 95% of the facility's long-stay residents must be given pneumococcal vaccine and at least 93% of long-stay residents are given seasonal influenza vaccine.

New residents: implement clear protocols for evaluating the need for immunizations at intake.

Existing residents: focus efforts on existing residents prior to the fall immunization season.

See Resources, below, for implementation tools.

Trialability

The nursing facility should evaluate their current quality assurance measures and policy and procedure to determine if any revisions to address immunization rates are needed.

Create or adapt consumer friendly materials emphasizing the need for immunizations in the nursing home population.

Observability

The Centers for Disease Controls'Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities has indicators for testing, surveillance and transmission precautions available for use by all long-term care facilities.

Resources

Ohio KePRO's Improving Health and for Populations and Communities project, featuring resources and information regarding Flu and Pneumonia Immunizations, including an Immunization Toolkit.

Ohio Department of Health's ImpactSISS, an interactive system for recording and tracking immunizations.

Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities

The Minnesota Department of Health's FluSafe program features preparatory activities a nursing home can implement to address vaccination schedules.

Mossad, Sherif B., "Influenza in long-term care facilities: Preventable, detectable, treatable."

"Ohio Immunization Laws" Members Only, Legislative Service Commission Brief, vol. 128, Issue 5, April 10, 2009.

 

Environment

Raising the bar in long-term care requires the transformation of the "facility" into a "home." To be more than an institution, nursing homes are challenged to eliminate the use of overhead paging, provide accessible bathrooms, encourage the personalization of resident rooms, and offer private rooms. These two measures reflect a nursing home’s overall commitment to the physical transformation inherent in culture change:

 

Private Rooms

To receive the quality incentive point for this measure, an average of at least 50 percent of the facility's Medicaid-certified beds must be in private rooms or semiprivate rooms to which all of the following apply:

  • Each room provides a distinct territory for each resident occupying the room;
  • Each distinct territory has a window and is separated by a substantial wall from the other distinct territories in the room;
  • Each resident is able to enter and exit the distinct territory of the resident's room without entering or exiting another resident's distinct territory; and
  • Complete visual privacy for each distinct territory may be obtained by drawing a curtain or other screen.

The facility must report the number of Medicaid certified beds in private rooms or semiprivate rooms meeting the above criteria on the first day of each month of the calendar year preceding the fiscal year for which the Medicaid rate will be paid and on the last day of the fiscal year for which the Medicaid rate will be paid.  Facilities must report using the Quality Incentive Data Submission Tool no later than May 31, 2014 to be considered for the state fiscal year 2015 rate-setting. Please review the submission instructions.

Relative Advantage

Utilizing private rooms may reduce costs for the facility and the health care system.Studies in both nursing facilities and hospitals have found that residents in shared rooms are at significantly higher risk of nosocomial infections, including C-Diff and MRSA, than those in private rooms. The Commonwealth Fund-supported study, "Exploring the Cost and Value of Private Versus Shared Bedrooms in Nursing Homes, "(The Gerontologist, Apr. 2007), found that 84 percent of the nursing home residents who developed acute nonbacterial gastroenteritis during an outbreak had a roommate. Only 16 percent of those who became ill had a private room.

Utilizing private rooms to lower the infection transmittal rate also may reduce costs for the facility and the health care system. The same study reported that "... infections (primarily pneumonia and influenza A) account for almost 1/4 of hospitalizations of nursing home residents ... Finally, a study conducted in 1994 estimated that the average cost of hospitalizing a nursing home resident to treat pneumonia to be $7,500 (Lave, Lin, Hughes-Cromwick & Fine, 1999). Since most of these infections are difficult and expensive to treat, and increase risk of mortality, this is a particularly significant issue for both patients and the health care system at large."

The marketing of private rooms for residents also may result in revenue gain. With new construction, private rooms are more expensive to build. However, one study found a $23 cost differential in the amount able to be charged for a private room, making it possible to recoup upfront costs in less than four years. "The business case for private rooms is even more compelling if nursing homes have trouble filling beds in shared rooms. It can take less than seven months to recoup the cost of construction and debt service for two private rooms versus one shared room if the second bed in the shared room is vacant," Margaret P. Calkins, Ph.D..

Additional advantages found to result from the use of private rooms, as reported Dr. Calkins:

  • Improved sleep, which leads to fewer falls;
  • Less anxiety;
  • Improved continence;
  • Ease in hosting visitors, especially at end of life;
  • More control over personal territory; and
  • Less staff time managing roommate conflict.

Compatibility

Facilities often utilize empty space to allow for private rooms for residents for whom a private room is desirable due to illness, level of activity or risk of infection. The practice may aid facilities in meeting residents' needs for privacy and dignity. Private rooms may enable residents to make their rooms more homelike and personalized, leading to higher overall satisfaction with the facility.

Simplicity

Use of empty rooms and rearrangement of existing resident facilities often utilize empty space to allow for private rooms for residents for whom a private room is desirable due to illness, level of activity or risk of infection. With occupancy rates in the mid-80 percentiles, facilities with lower census may find it easier to commit to providing private rooms to more residents.

In 2005, the typical nursing home was 29 years old. Many nursing homes will have to be replaced or renovated in the next decade.

"After analyzing 189 bedroom plans and developing a detailed cost analysis, the average cost of construction plus capital costs (debt) of a traditional, side-by-side shared room was found to be $41,012 or $20,506 per person, while the average cost of a private room was $36,515 (2005 dollars). Thus, it costs $16,009 more per person to build private versus traditional shared rooms. Stated another way, it costs $32,018 more to build two private rooms than one shared room. This would seem to support those who say that private rooms are too expensive to build. But taking a life-cycle costing approach, it can be demonstrated that this difference in construction cost is not as great as it might appear. Based on a large national study, the average daily cost of a private room in a nursing home is $23 more than a shared room. If the beds are all occupied, assuming a $23 dollar a day difference, it would take 1.9 years to recoup the cost differential of building 2 private rooms versus 1 shared room. However, if the facility cannot fill a bed in a shared room, the lost revenue is not $23, but $167 per day -the average daily cost of a shared bedroom. At $167 a day it takes only 6.4 months to recoup the construction and debt differential" (Calkins & Cassella, 2007). ("Exploring the Cost and Value of Private Versus Shared Bedrooms in Nursing Homes," The Gerontologist, Apr. 2007)

Trialability

A facility may assign private rooms to residents for whom a private room may be most helpful: those with infections or at highest risk if they were to acquire an infection; residents who prefer a different waking/sleeping schedule than the majority; and those whose speaking or wandering may be disruptive to a roommate.

Observability

Some facilities are built to offer only private rooms. As an Ohio facility administrator described the decision to make their rooms private, "We were built that way to meet the needs of the Boomer population. Shared rooms just won't be acceptable." Others have been renovated or existing rooms have been repurposed. An Ohio facility described their use of previously shared rooms as private rooms as "using a low census and a commitment to private rooms. It wasn't strategic; it just happened. Overall, it's much better."

Resources

Calculating loss of revenue from a semi-private to a private room. These rates are private pay, but give an idea of the revenue stream differential and how it may be applied to residents paying with Medicaid.

  Avg. Daily Nursing Home Rate
Private
Avg. Daily Nursing Home Rate
Semi-private
Cincinnati $222 $191
Cleveland $240 $206
Columbus $218 $196
Rest of State $206 $189
State Average $218 &194

Source: 2010 MetLife Market Survey of Long-Term Care Costs

State Averages: MetLife provides a "State Average" for each type of long-term care service in each state-the average of all rates for all sampled services in the state. In the states where MetLife includes average rates for one or more cities or areas within a state, these averages are specific to those areas.

"Exploring the Cost and Value of Private Versus Shared Bedrooms in Nursing Homes," The Gerontologist; April 2007 ; 47(2):169-83. With Christine Cassella.

"Envisioning your future in a nursing home," Paper presented to the Creating Home in the Nursing Home symposium hosted by CMS and the Pioneer Network in April 2008.

Some of the most extensive research on the use of private rooms in a nursing home setting has been done by Margaret P. Calkins, Ph.D., President of IDEAS Inc., Board Chair of IDEAS Institute and Founding member and Board Member of SAGE.

Eliminate Overhead Paging

To receive the quality incentive point for this measure, the facility must maintain a written policy that prohibits the use of overhead paging systems or limits the use of overhead paging systems to emergencies, as defined in the policy. The facility must communicate the policy to its staff, residents and families of residents.

The point will be awarded to facilities that indicate on the Quality Incentive Data Submission Tool they have adopted such a policy and communicated it to staff, residents and families of residents. Facilities must complete the submission no later than May 31, 2014 to be considered for the state fiscal year 2015 rate-setting. Please review the submission instructions.

Relative Advantage

>Using overhead paging for emergencies only or not at all creates a homelike environment.Using overhead paging for emergencies only or not at all creates a homelike environment. Few personal homes would come equipped with such an institutional feature as an overhead paging system. Noise from overhead paging contributes to sleep disruption and workplace stress. According to Karen Schoeneman and Carmen S. Bowman, in their report, Development of the Artifacts of Culture Change Tool, facilities that have eliminated overhead paging report that "It significantly decreases the white noise throughout the facility, decreases resident agitation - especially for those dealing with dementia, improves the working environment, creates a more 'normal' living environment in the households and increases privacy."

Compatibility

The Interpretive Guidelines: §483.15(h)(1) issued by CMS oblige facilities to provide a safe, clean, comfortable and home-like environment. Importantly, the guidelines call the elimination of overhead paging and piped-in music among the "good practices that serve to decrease the institutional character of the environment." Wireless systems or "other electronic systems" are included in the intent language of the revision to address homes that do not have nurse's stations or use wireless systems.

Simplicity

When a facility adopts consistent assignment of staff (the same caregivers are assigned to the same residents on a permanent basis), the ability of staff to predict and respond to residents' needs is enhanced, limiting the reliance on overhead paging for alerts. One facility eliminating overhead paging said they did so, "... cold turkey. When you have consistent assignments you shouldn't have to page CNAs."

A number of vendors offer electronic paging systems that allow staff members to be summoned by residents or co-workers. See the Pioneer Network's Design on a Dollar for information on inexpensive means of creating homelike environments.

Trialability

Have staff track overhead paging use for a day or a week, including overnight. What kinds of messages are being conveyed and how often? Meet with staff and residents to discuss the possibility of eliminating overhead paging. Ask staff and management about their personal use of overhead paging. What messages are considered critical? How could they be otherwise communicated? What overhead messages could be reduced or eliminated through other means? What should an "emergency use only" policy include? What portable electronic means of communication has staff used (either at your facility or others in the area)? What did they like or not like about those systems?

Ask residents how they reacted to the overhead paging system when they first moved into the nursing home? Are their activities, conversation or rest interrupted by overhead paging?

"[t]ake a 'no overhead paging' holiday and see what happens. How did people adapt? Did they take messages rather than paging overhead for every call? Two-way radios and walkie talkies are inexpensive and readily available for this exercise." - Pioneer Network, Design on a Dollar

Observability

Visit nursing homes where overhead paging has been eliminated. The Person-Centered Care Coalition has solicited mentor facilities through its efforts toward making a more homelike environment available for residents. Sign up for the Coalition's listserv and ask for assistance in making the transition.

"Noise reduction: environments that foster peace and comfort" includes a success story, California Culture Change Coalition.

Resources

Design on a Dollar

Artifacts of Culture Change See items 39 and 40.

"Shh-People Thinking," presented to the National Consumer Voice for Quality Long-Term Care 2009 Annual Meeting & Conference on reducing noise.

 

Staffing Measures

Commitment to the "boots on the ground" – the long-term care workforce - raises the bar for quality long-term care. Nursing homes are challenged to adopt staffing practices that promote the consistent assignment of staff to residents, retention of staff, and the reduction of staff turnover and to empower the staff who have the most interaction with residents to participate in their care planning. These four measures reflect a facility’s overall commitment to a high-quality, stable and empowered workforce:

 

Consistent Assignment

To receive the quality incentive point for this measure, the facility must do both of the following:

  • Maintain a written policy that requires consistent assignment of nurse aides and specify the goal of having a resident receive nurse aide care from not more than twelve different nurse aides during a 30-day period; and
  • Communicate the policy to its staff, residents and families of residents.

The point will be awarded to providers who indicate on the Quality Incentive Data Submission Tool that they have adopted such a policy (as defined above). Facilities must complete the submission no later than May 31, 2014 to be considered for the state fiscal year 2015 rate-setting.  Please review the submission instructions.

Relative Advantage

Consistent assignments also allow staff to get to know the usual condition or status of the residents.Consistent assignments allow staff to get to know the residents, their wants and needs and preferences for daily routines. This allows staff to more easily plan their workload and schedule during their shift and anticipate the residents' needs.

Consistent assignments also allow staff to get to know the usual condition or status of the residents. This can help staff to pick up on subtle changes in a resident's condition before a crisis occurs, reducing the chance that a change in resident condition can occur without the staff's knowledge.

Many nursing homes use the practice of rotating assignments, citing issues of fairness and preventing burnout ("A Case for Consistent Assignment," Farrell et al, Provider magazine). While burnout is an important consideration, the cause of burnout must be understood if it is to be addressed. According to Dr. Bill Thomas, "The true cause of burnout is the deadening effect of closing one's emotions to people who are in obvious need of a human connection." ( "What Are Old People For? How Elders Will Save The World" William H. Thomas, Vanderwyk & Burnham, 2004). When staff assignments are rotated, it is difficult for them to have a "set routine" for individual residents. The workflow changes with each new assignment. Consequently, rotated staff try to get through basic care and compliance with facility procedures for documentation, and there is often not enough time in a shift to make a "human connection" with the residents This can lead to burnout, which can further lead to staff turnover, increased tardiness and call-offs, low staff morale, etc.

A high degree of consistent staff assignment is associated with "lower citations on quality of life deficiency citations (resident), quality of life deficiency citations (staffing), quality of life deficiency citations (facility) and quality of care deficiency citations." ) The Influence of Consistent Assignment on Nursing Home Deficiency Citations, Nicholas G. Castle, PhD, The Gerontologist, November 2011)

Compatibility

Some nursing homes are already using a model of staffing that allows consistent assignments or consistent assignments on some units (i.e. dementia unit or skilled unit).

Simplicity

As with any improvement process, begin by assessing the current practice of the facility. Does any area of the facility currently use consistent assignments (i.e. dementia unit)? Find out what is working and what isn't working, then make a plan to begin implementation of the new process.

Sample Method 1

  • Meet with staff by shift to discuss benefits of consistent assignment.
  • Allow STNAs to select their own assignments. Use post-it notes or index cards to determine the level of assistance that each resident needs.
  • Continue meeting every three months, or more frequently if needed.

Sample Method 2

  • Form a team.
  • Hold learning sessions with staff, residents and families.
  • Convene a meeting of direct-care staff.
  • Design a process to measure the impact of consistent assignment.
  • Compare baseline data with future data collections.
  • Empower staff to make adjustments.
  • Celebrate successes.

The Advancing Excellence in America's Nursing Homes campaign goal for consistent assignment has numerous resources for implementing consistent assignment, including:

In addition, Consistent Assignment: A Key Step to Individualized Care from the California HealthCare Foundation provides a simple step by step guide to implementation.

Trialability

Find out which staff members already have relationships with residents, particularly the residents with high acuity. Begin by implementing on one unit or on one shift. Hire and schedule with consistent assignment as the goal.

Observability

The Pioneer Network's Case Studies in Person-Centered Care offer examples of consistent assignment. The Ohio Person-Centered Care Coalition offers the opportunity to network with facilities that have implemented consistent assignment.

Resources

Advancing Excellence in America's Nursing Homes campaign's extensive guide to Consistent Assignment (LINK TO:  http://www.nhqualitycampaign.org/star_index.aspx?controls=consistentassignmentexploregoal)  including fact sheets, tracking tools, implementation guides and webinars.

Consistent Assignment webinar, Ohio Person Centered Care Coalition

Consistent Assignment, Ohio Person Centered Care Coalition

Artifact of Culture Change Tool

"Predictable Scheduling" by Mary Jane Koren, Advancing Excellence in America's Nursing Homes campaign

"Keystone for Excellence," David Ferrell and Barbara Frank, Provider Magazine

"A Case for consistent assignment," David Ferrell et al., Provider Magazine

Staff Retention

To receive the quality incentive point for this measure, the facility's staff retention rate must be at least 75 percent. The facility must meet the accountability measure in the calendar year preceding the fiscal year for which the point is to be awarded.

The point will be awarded based on the filed Medicaid cost report; no reporting action by the facility is needed. 

Relative Advantage

The turnover cost of a single STNA can be as high as $2,000 to $4,000.There is a significant financial incentive in reducing the cost of staff turnover by increasing retention of existing staff. The loss of an employee increases direct costs in advertising, background checks, physical exams and vaccinations, as well as staff time for interviewing, training and new staff orientations. The turnover cost of a single STNA can be as high as $2,000 to $4,000. ("An exploration of nursing home organizational processes," Forbes-Thompson S, et al. West J Nurs Res. 2006 Dec;28(8):935-54.)

Other benefits to the facility include improvements in resident and staff relationships, increased job satisfaction and more consistent staff assignment to residents.

Compatibility

Retention and turnover of staff are almost universal issues among long-term care providers. The American Health Care Association (AHCA) has reported that the "retention rate for nursing facility employees was 55 percent. Retention rates among staff registered nurses, licensed practical nurses and certified nurse assistants ranged from 49 to 56 percent. Turnover rate for all nursing facility employees was 35 percent. The turnover rate for certified nurse assistants was higher than other nursing staff, at 43 percent." From the October 2010 "Report of Findings: Nursing Facility Staffing Survey"

In Ohio, the AHCA report found that retention of "all nursing facility employees" was the highest nationally at 72.9 percent. Retention of nursing staff (which includes RNs and LPNs) in Ohio was approximately equal to the national average at 51.5 percent.

Table showing retention, turnover and vacancy rates by NF job category, 2010

Simplicity

Use the Staff Stability Toolkit, published by Quality Partners of Rhode Island, which incorporates experiences and lessons learned in more than 400 nursing homes. It is a resource for homes starting to reverse turnover, as well as employers who have already started to address recruitment and retention and need further assistance in a specific area.

The toolkit walks administrators through self-discovery assignments to determine their current employment status and discusses workplace practices that positively and negatively impact staff retention and turnover. Hiring well, good new staff orientation, effective use of monetary incentives and other factors impacting staff retention are critical.

Trialability

A number of interventions have been attempted to increase staff retention. The Advancing Excellence in America's Nursing Homes Campaign described a number of approaches that contribute to staff retention in an interventions guide. Among them are:

  • Consistent Assignment: Some resulting observations were that staff on consistent or permanent assignment was found to have higher job satisfaction and lower staff turnover. Residents had better outcomes in pressure ulcers, discharge to lower levels of care and mortality death rates.
  • Employment Benefits: Results indicate staff with health insurance had increased tenure and reported benefits to be of more value to them than higher wages.
  • Management Style: Managers with a 'consensus' management style by which they seek input from their workgroups and allow them to have input into decision-making have lower staff turnover.

In general, facilities should focus on:

  • Screening and recruitment (i.e. reviewing their hiring practices to ensure they are only hiring quality candidates);
  • Processes related to new hires (i.e. providing a quality orientation, providing effective support for new staff such as a mentor program and conducting new staff hire surveys); and
  • Processes related to staff development (i.e. career ladders, specialized training, team building, mentor/supervisor training, etc.).

Observability

View the webinar, Staff Stability: Learn to Manage your Resources and Improve Staff Retention, Advancing Excellence in America's Nursing Homes, PowerPoint or PDF, with separate audio.

MOLANE, a consortium of long-term-care partners, is sponsoring a series of six, one-hour seminars that can help you acquire and retain staff, titled Nursing Home Staff Retention Webinar Series: January - April 2012. Materials from past webinars are available on the site.

Resources

Advancing Excellence in America's Nursing Homes campaign's extensive guide to Staff Stability, including fact sheets, tracking tools, implementation guides and webinars.

Improving Nursing Home Culture: Final report of a pilot project sponsored by Centers for Medicare and Medicaid for nursing home quality improvement

Retaining Caregivers, Improving Care, Catholic Health Association of the United States

Nursing Home Staff Retention Webinar Series: January - April 2012

FastFacts: Staff Retention. California Health Care Association

"Nursing Workforce: Recruitment and Retention of Nurses and Nurse Aides is a Growing Concern." General Accounting Office

"Positive Outcomes of Culture Change - The Case for Adoption," Tools for Change, vol.1, no 2, April 2011, the Pioneer Network

Nursing Home Staff Turnover and Retention: An Analysis of National Level Data. Christopher Donoghue. Kean University, Union, NJ

Stayers, Leavers and Switchers Among Certified Nursing Assistants in Nursing Homes: A Longitudinal Investigation of Turnover Intent, Staff Retention, and Turnover. Jules Rosen, MD, Emily M. Stiehl, BA, Vikas Mittal, PhD, and Carrie R. Leana, PhD

A Facility Specialist Model for Improving Retention of Nursing Home Staff: Results From a Randomized, Controlled Study. Karl Pillemer, PhD. Rhoda Meador, MS. Charles Henderson, Jr., MA. Julie Robison, PhD. Carol Hegeman, MS. Edwin Graham and Leslie Schultz

Staff Turnover

To receive the quality incentive point for this measure, the facility's staff turnover rate for nurse aides must not be higher than 65 percent. The point will be awarded to providers who indicate on the Quality Incentive Data Submission Tool that they have met the measure (as defined above). Facilities must complete the submission no later than May 31, 2014 to be considered for the state fiscal year 2015 rate-setting.  Please review the submission instructions.

Relative Advantage

There is a significant financial incentive in reducing the cost of staff turnover.There is a significant financial incentive in reducing the cost of staff turnover. The loss of a certified nurse aide (State-Tested Nurse Aide in Ohio) increases direct costs in advertising, background checks, physical exams and vaccinations as well as staff time for interviewing, training and new staff orientations. The turnover cost of a single STNA can be as high as $2,000 to $4,000. (An exploration of nursing home organizational processes. Forbes-Thompson S, et al. West J Nurs Res. 2006 Dec;28(8):935-54.)

Improvements in resident and staff relationships, increased job satisfaction and more consistent assignment of staff to residents are other benefits to the facility.

Work on reducing staff turnover overlaps with the Advancing Excellence in America's Nursing Homes campaign goal of reducing staff turnover. Since participation in the campaign is one of the quality incentive measures identified for Ohio's Medicaid reimbursement system, working to reduce staff turnover assists a facility in meeting both measures.

Compatibility

Retention and turnover of staff are almost universal issues among long-term care providers. The American Health Care Association has reported that the "retention rate for nursing facility employees was 55 percent. Retention rates among staff registered nurses (RN), licensed practical nurses (LPN) and certified nurse assistants ranged from 49 to 56 percent. Turnover rate for all nursing facility employees was 35 percent. The turnover rate for certified nurse assistants was higher than other nursing staff, at 43 percent." From the October 2010 "Report of Findings: Nursing Facility Staffing Survey"

In Ohio, the AHCA report found that turnover of "all nursing facility employees" was 32.7 percent. Turnover of nursing staff (which includes RNs and LPNs) in Ohio was 37.3 percent.

Table showing retention, turnover and vacancy rates by NF job category, 2010

Simplicity

Use the Staff Stability Toolkit, published by Quality Partners of Rhode Island, which incorporates experiences and lessons learned in more than 400 nursing homes. It is a resource for homes starting to reverse turnover, as well as employers who have already started to address recruitment and retention and need further assistance in a specific area.

The toolkit walks administrators through self-discovery assignments to determine their current employment status and discusses workplace practices that positively and negatively impact staff retention and turnover. Hiring well, good new staff orientation, effective use of monetary incentives and other factors impacting staff retention are critical.

Trialability

A nursing facility must first determine their current turnover rate to learn how to develop strategies to reduce it. The Advancing Excellence in America's Nursing Homes Campaign has published a tool for calculating staff stability

A number of interventions have been attempted to increase staff retention. The Advancing Excellence in America's Nursing Homes campaign described a number of approaches that contribute to staff retention in an interventions guide. Among them are:

  • Consistent Assignment: Some resulting observations were that staff on consistent or permanent assignment was found to have higher job satisfaction and lower staff turnover. Residents had better outcomes in pressure ulcers, discharge to lower levels of care and mortality death rates.
  • Employment Benefits: Results indicate staff with health insurance had increased tenure and reported benefits to be of more value to them than higher wages.
  • Management Style: Managers with a 'consensus' management style by which they seek input from their workgroups and allow them to have input into decision-making have lower staff turnover.

In general, facilities should focus on:

  • Screening and recruitment (i.e. reviewing their hiring practices to ensure they are only hiring quality candidates);
  • Processes related to new hires (i.e. providing a quality orientation, providing effective support for new staff such as a mentor program and conducting new staff hire surveys); and
  • Processes related to staff development (i.e. career ladders, specialized training, team building, mentor/supervisor training, etc.).

Observability

View the webinar, Staff Stability: Learn to Manage your Resources and Improve Staff Retention, Advancing Excellence in America's Nursing Homes, PowerPoint or PDF, with separate audio.

MOLANE, a consortium of long-term-care partners, is sponsoring a series of six, one-hour seminars that can help you acquire and retain staff. Nursing Home Staff Retention Webinar Series: January - April 2012. Materials from past webinars are available on the site.

Resources

Advancing Excellence in America's Nursing Homes campaign's extensive guide to Staff Stability, including fact sheets, tracking tools, implementation guides and webinars.

Improving Nursing Home Culture: Final report of a pilot project sponsored by Centers for Medicare and Medicaid for nursing home quality improvement that addresses workforce retention processes and improvement strategies

Retaining Caregivers, Improving Care, Catholic Health Association of the United States

Nursing Home Staff Retention Webinar Series: January - April 2012 MOLANE, a consortium of long-term-care partners, is sponsoring a series of six, one-hour seminars that can help you acquire and retain staff. Materials from past webinars are available on the site.

FastFacts: Staff Retention. California Health Care Association

A Facility Specialist Model for Improving Retention of Nursing Home Staff: Results From a Randomized, Controlled Study. Karl Pillemer, PhD. Rhoda Meador, MS. Charles Henderson, Jr., MA. Julie Robison, PhD. Carol Hegeman, MS. Edwin Graham and Leslie Schultz

Artifacts of Culture Change See item 72

University of North Carolina Institute on Aging Turnover calculator

"Nursing Workforce: Recruitment and Retention of Nurses and Nurse Aides is a Growing Concern." General Accounting Office

"Positive Outcomes of Culture Change - The Case for Adoption," Tools for Change, vol.1, no 2, April 2011, the Pioneer Network

Nursing Home Staff Turnover and Retention: An Analysis of National Level Data. Christopher Donoghue. Kean University, Union, NJ

Stayers, Leavers and Switchers Among Certified Nursing Assistants in Nursing Homes: A Longitudinal Investigation of Turnover Intent, Staff Retention, and Turnover. Jules Rosen, MD, Emily M. Stiehl, BA, Vikas Mittal, PhD, and Carrie R. Leana, PhD

A Facility Specialist Model for Improving Retention of Nursing Home Staff: Results From a Randomized, Controlled Study. Karl Pillemer, PhD. Rhoda Meador, MS. Charles Henderson, Jr., MA. Julie Robison, PhD. Carol Hegeman, MS. Edwin Graham and Leslie Schultz

Aide Participation in Care Conferences

To receive the quality incentive point for this measure, for at least 50 percent of the resident care conferences in the facility, a nurse aide who is a primary caregiver for the resident attends and participates in the conference.

The point will be awarded to providers who indicate on the Quality Incentive Data Submission Tool that they have met the measure (as defined above). Facilities must complete the submission no later than May 31, 2014 to be considered for the state fiscal year 2015 rate-setting. Please review the submission instructions.

Relative Advantage

The nursing assistant is the front line employee.Aside from the residents themselves, the nursing assistants are often the most knowledgeable about the resident's daily life and care needs. Nursing assistant participation in care conferences involves the aide in the resident's goal setting and ensures that everyone - including the resident, aides, nursing staff, therapy and others - are in accord with the resident's choices and care needs.

The nursing assistant is the front line employee who, other than the resident himself, may have the most knowledge of what the resident wants to be able to accomplish for himself and has the knowledge of what the resident is capable of accomplishing for himself. By participating in the care conference, the nursing assistant is more aware of what should be reported in regard to how the resident is doing in achieving the goals set forth for him. The nursing assistant also is more aware of risks that may need to be identified in certain situations for the resident.

The participation of the nursing assistant in care conferences improves communication between the resident, family and facility staff regarding how the resident is performing toward the goals set for the resident. In addition, participation improves resident satisfaction surveys and family surveys.

Aide participation in care conferences may reduce staff turnover because staff feel involved and empowered. ("An Exploratory Study of Certified Nursing Assistants' Intent to Leave," U.S. Department of Health and Human Services)

Resident assistants or nurse aides are often the most knowledgeable about the residents' daily life and care needs but are not included in care plan meetings. ("Everyday matters in the lives of nursing home residents: wish for and perception of choice and control," Dr. Rosalie Kane, et al)

Compatibility

The practice of involving aides in care conferences is in compliance with survey regulations and enhances quality of care for the resident. It also empowers the nursing assistant to believe what they do on a day-to-day basis matters to the team and that he or she, in collaboration with the resident and family, is an integral part of developing the care plan. Participation also ensures the resident, family and the facility staff are working together to develop a care plan that is individualized for each resident residing the nursing facility.

Simplicity

Prioritize aide involvement when scheduling care conferences so that the most involved nursing aide is invited and available to attend. This may require coverage of the aide's responsibilities during the conference or a flexible work schedule so the aide may attend if the resident and the resident's family prefer to schedule outside that aide's normal work schedule.

Ensure that aides are familiar with residents' care plans. If they are newly assigned as a caregiver for a resident, ask the resident and caregiver to complete the My Personal Directions for Quality Living form. Future caregivers should review the My Personal Directions with the resident when assigned.

Consistent assignment of staff to residents is imperative. The involvement of aides in care conferences would be meaningless if the aides are not familiar enough with the residents' abilities, preferences and goals to be useful to the meeting.

Create opportunities for the aide to speak up in the care conferences. Give the aide a role in introducing the resident's recent experiences, barriers and abilities, particularly for residents with cognitive impairments that limit their ability to do so themselves.

Trialability

Identify residents with cognitive impairments that limit their ability to participate in conferences themselves and for whom family members do not typically participate. Prioritize scheduling aides for participation in the care conferences for residents that meet these criteria.

Ask aides to identify residents about whom they are most knowledgeable as a result of a particularly good relationship or a longer tenure as their caregiver. Ask the resident (or resident's family) and caregiver to complete the complete the My Personal Directions for Quality Living form together.

Observability

A number of nursing homes have adopted aide participation in care conferences. The Person-Centered Care Coalition has solicited mentor facilities through its efforts in promoting person-centered care. Sign up for the Coalition's listserv and ask for assistance in making the transition.

Resources

Artifacts of Culture Change tool, See item 48

Assessment and Care Planning: The Key to Quality Care

My Personal Directions for Quality Living