AMDA: Publications - Caring for the Ages

New, enhanced nursing home quality indicators can now be found on the Centers for Medicare and Medicaid Services Nursing Home (NH) Compare Web site. The updates--announced Jan. 22--are intended to make the site simpler for consumers to use.

"By enhancing the quality measures, we can further improve our ability to provide valuable information to consumers," said Dennis G. Smith, former acting CMS administrator, "in turn helping them make more informed decisions when choosing nursing home care."

NH Compare is the most popular part of the Medicare Web site, according to CMS. It received 9.3 million page views in 2003. View it at www.medicare.gov/NHCompare.

The enhanced quality indicators are part of the national Nursing Home Quality Initiative (begun in November 2002) to provide consumers with additional information about the quality of nursing home care. CMS undertook to do that by providing a set of Minimum Data Set-based quality measures on Medicare's NH Compare Web site. CMS also provided assistance from state Quality Improvement Organizations.

Development of Enhanced Measures

The enhanced measures were developed under contract with Abt Associates (a for-profit government and business research and consulting firm) and were endorsed by the National Quality Forum (NQF), a voluntary standard setting, consensus-building organization representing providers, consumers, purchasers, and researchers.

At an April 2003 NQF meeting, its Nursing Home Steering Committee proposed revisions to the quality measures. Recommendations were then posted on the NQF Web site for public comment. Following the comment period, the quality measures were approved by the NQF Board and then forwarded to CMS.

Changes in Quality Measures

The 14 enhanced quality measures derive from the Minimum Data Set, which measures a nursing home resident's health, physical functioning, mental status, and general well-being at specified intervals. The enhanced quality measures build on the original 10 measures included in NH Compare. The enhancements largely reflect refinements in risk adjustments based on findings of a national validation test. As a result, the Facility Admission Profile (FAP) has been replaced with enhanced, individual-level risk adjustment, and other statistical adjustments have also been made.

Post-acute care: In terms of quality measures for post-acute care, the measure of short stay residents with delirium with an additional level of risk adjustment has been deleted--although the percent of short stay residents with delirium remains. The measure of walking ability has also been removed. A new indicator measuring the percent of short stay residents with pressure sores has been added.

Chronic care: Regarding measures for chronic care, the indicators for pressure sores have been revised to delete the FAP. Instead, the indicators measure the percent of high-risk and low-risk residents who have pressure sores. The measure of residents with infections has been deleted to focus instead on residents with urinary tract infections. Indicators for being bedfast or depressed, declining mobility, and continence have been added.

The quality measure scores for facilities are revised each quarter. NH Compare includes a nursing home's own quality measurements, as well as those for the state and nation. Thus, consumers--and other nursing homes--can compare one nursing home's score against another's.

The enhanced indicators reflect ongoing research, which all stakeholders agree needs to continue to in order to better measure quality care.

The Effects on LTC Physicians

For long-term care docs, the NH Compare Web site's popularity places additional importance on monitoring quality indicators in nursing homes. Medical directors should obtain their nursing home's quality data on an ongoing basis, but the quarterly updates will allow for comparison with other facilities in one's state and across the country.

One of the NH Compare Web site's goals is to encourage positive competition in improving quality, and medical directors are the instigators of quality improvements. Long-term care physicians may also be called upon to help interpret data that families or caregivers obtain from the Web site.

Web Site Features

The format for the NH Compare Web site has been revised to allow users to search for nursing homes by state, county, city, ZIP code, or nursing home name--or within a certain distance of the city or ZIP code they choose. Users can get maps and directions for the nursing homes they select.

The new format is more useful in helping consumers find a nursing home in a specific geographical area and presents quality measures in a more concise way. Unfortunately, it makes other useful information nearly impossible to find. The old format included text up front that helped explain each quality measure and why it was important. Now you have to hunt for that information (a challenge for this writer, who frequently uses the Web site).

Example: Regarding pressure sores, you have to search for information on what a pressure sore is, what it means to be at "high risk" or "low risk," why it is important to know about the prevalence of pressure sores in a nursing home, and what a nursing home can do to prevent them. Consumers will gain more streamlined information that may be more difficult to interpret without ready access to additional information. Better links to this interpretive information would greatly improve the new format.

QIOs Advise on Quality Improvement

Each state has a Quality Improvement Organization (QIO) currently under contract with CMS to provide quality improvement assistance to nursing homes, hospitals, physician offices, and home-health agencies.

According to CMS, approximately 2,500 of the nation's 17,000 nursing homes are working with QIOs on quality improvement efforts, and more than 60% of nursing homes have attended at least one QIO-sponsored workshop on the quality measures or on quality improvement techniques for nursing homes.

Effects of NH Compare on Quality

Health and Human Services Secretary Tommy G. Thompson called the Web site a "win-win situation" for the public and for nursing homes. "Not only have consumers become better informed," he said, "but nursing homes themselves have been taking steps to improve their quality of care."

According to CMS, many nursing homes have already made significant improvements in the care provided to residents by taking advantage of the NH Compare data and the support of QIOs. CMS credits the initiative with significant nationwide nursing home improvements, such as 15% fewer residents being physically restrained and 30% fewer residents experiencing chronic pain.

CMS noted, however, that the pressure ulcer measure has not improved significantly, and has, in fact, declined in 82% of states.

"This change may or may not mean that clinical care has deteriorated... . As clinicians focus on a given kind of care (such as skin care) they also become more accurate in measurement," CMS observed.

Influenza & Pneumococcal Vaccinations Endorsed

In addition to the enhanced quality measures, the NQF also recommended inclusion of measurements of pneumococcal polysaccharide vaccination for residents age 65 or older, as well as influenza vaccination for all nursing home residents. A disparity between the recommended reporting format and the available Minimum Data Set data may mean that including these measurements in NH Compare will be delayed, perhaps until the Minimum Data Set is revised.

Additional NQF Recommendations

Some of those improvements, such as the quality-of-life measures, require considerable development before specific proposals can be considered.

In January 2004 the NQF also endorsed two more nursing facility performance measures:

NQF consensus standards are independent of CMS, and CMS will choose whether or how to implement the standards.

Former & Enhanced Quality Measures

Nursing Home Compare Quality Measures: Post-Acute Care	Former QM	Enhanced QM
Percent of short stay residents who had moderate to severe pain.+	X	X
Percent of short stay residents with delirium.+	X	X
Percent of short stay residents with delirium with an additional level of risk adjustment (Facility Admission Profile).	X
Percent of short stay residents with pressure sores.+		X
Percent of short stay residents who walk as well or better on day 14 as on day five of their stay.	X
Nursing Home Compare Quality Measures: Chronic Care	Former QM	Enhanced QM
Percent of residents whose need for help with daily activities has increased.	X	X
Percent of residents who have moderate to severe pain.+	X	X
Percent of residents who were physically restrained.	X	X
Percent of residents with pressure sores. These were previously reported as one measure, with and without the Facility Admission Profile. Now they will be reported as a stratified measure for high-risk and low-risk residents.	X
Percent of residents with pressure sores with an additional level of risk adjustment (Facility Admission Profile). These were previously reported as one measure, with and without the Facility Admission Profile. Now they will be reported as a stratified measure for high-risk and low-risk residents.	X
Percent of high-risk residents who have pressure sores.**		X
Percent of low-risk residents who have pressure sores.**		X
Percent of residents with infections.	X
Percent of residents with a urinary tract infection. UTI was previously one of the infections reported as part of the Infections Quality Measure.		X
Percent of residents who spent most of their time in bed or in a chair.		X
Percent of residents who have become more depressed or anxious.+		X
Percent of low-risk residents who lose control of their bowels or bladder.		X
Percent of residents who have/had a catheter inserted and left in their bladder.**		X
Percent of residents whose ability to move about in and around their room got worse.**+		X
+ Measures with resident-level adjustments.
** In the enhanced set of measures, four of the measures are clinically related and grouped into two pairs. If one of the measures in a pair is selected, the other measure will also be displayed. The first set of paired measures is percent of low-risk residents who have pressure sores and percent of high-risk residents who have pressure sores. The second set of paired measures is percent of low-risk residents who lose control of their bowels or bladder and percent of residents who have/had a catheter inserted and left in their bladder. The latter two measures are linked to prevent introduction of a perverse incentive to inappropriately use catheters to improve performance in the area of continence.

New Indicators Headline NH Compare Web Site

An overview of the CMS' newly enhanced quality measures