Quality Assurance

The medical director of a nursing home has to include end-of-life care in the Quality Assurance (QA) process. As a result, several issues need to be evaluated, measured, and trended. These potential areas are listed to serve as ideas to be considered. Over a period of time, the data that are reported to the QA committee will help to establish benchmarks.

Pain Management
Pain has been defined as the 5th vital sign and can be measured by several different instruments. The choice of a visual acuity graph is not as challenging as the accurate assessment of pain. There continues to be a lot of concern on how best to accurately measure pain and discomfort, especially in the non-communicative and/or demented patient. Better, more comprehensive evaluation tools have been created, examples of which are included with this paper. (Appendix A)

Another useful measurement is the length of time it takes to control pain symptoms. Also, the utilization of the various pain medications as well as the various routes of administration could be measured. The committee could measure separately the management of different types of pain including chronic pain, acute pain, or pain found in actively dying patients.

A Pain Burden Scale is calculated by dividing the number of patients in the facility in pain by the total number of patients. (Appendix B) The QA committee could require this information from various hospice providers as well as monitor the data for their own facility.

Non-pain Symptom Management
Other symptoms can be monitored in much the same way as pain. Constipation, diarrhea, nausea, vomiting, confusion, depression, shortness of breath or other symptoms can be considered. Visual Acuity Graphs can be developed for monitoring. (Appendix C) As in pain management, the QA committee could require this information from various hospice providers as well as monitor the data for their own facility.

Hospice Utilization
Knowing the average length of stay for patients receiving hospice care within the facility, as well as the average length of stay of the hospice program for the city, state, or region could be beneficial. This would address some of the current concerns by many regarding the hospice/nursing home integration and the qualification for the patient's six month entitlement. The QA committee can monitor the percentage of patients on hospice in relation to the facility census. Furthermore, the number of patients on hospice in the facility can be measured against the total number of facility patients. The terminal patients are those who are in persistent vegetative state, those who have end stage medical condition, or whose death is imminent.

Bereavement
Bereavement in the nursing home includes the family, staff, friends, and fellow patients and is ongoing. Bereavement services includes routine support to those in need as well as memorial services. Documentation for these duties is needed. Several tools could be utilized to meet the facilities needs. (Appendix D)

Further Documentation
Some surveyors have requested documenting and reestablishing the surrogate's understanding of the patient's advance directives and the end-of-life care being provided. The issues such as malnutrition, tube feeding, pressure ulcers, or non-hospitalization needs to be discussed again and documented every 60 days. The hospice provider, nursing facility, and attending physician need to address these issues.

Surveys
Satisfaction surveys from the patients and families are useful and should include information regarding the nursing home staff, medical director, and attending physician. Performance surveys may be beneficial, where the proposed care plans can be compared with the care actually given. It is critical that the coordinated plan of care for these patients be written as specific as possible.

In-Service Education
Coordinated in-services need to be given to meet the specific educational needs of each facility.

Minimum Data Set (MDS) Whether the MDS is the most appropriate assessment tool in the nursing home has continued to be debated. The patient's care plan is produced from this assessment tool and the MDS triggers that refer to the appropriate Resident Assessment Protocols. The MDS is now electronically transmitted and it is now used to determine outcomes. Finally, PPS has utilized the MDS in establishing the reimbursement rate for the skilled units.

However, the MDS has shortcomings. It is designed as a functional assessment tool with expected outcomes for maintaining or improving function. With good end-of-life care, patients may decline in their ability to function. In addition, the MDS does not address all of the areas needed for end-of-life care including psychological, social, and spiritual issues.

The Hospice Subsection recommends that a separate instrument be developed utilizing the MDS format. The hospice provider should be responsible for the completion and utilization of this separate assessment tool, since the palliative care plan needs to be determined by those trained in palliative care, and not just acute and rehabilitative care. HCFA has now requested that such an instrument be developed. Several groups have already started on parts of this project including the National Hospice Organization and the Hospice Nursing Home Task Force.

Fraud
Several areas of potential fraud need to be addressed. Ethical concerns usually revolve around reimbursement issues. As a result, a chart has been developed to help answer most of these questions. (Appendix E)

Further reimbursement issues relate to medical director fees. As in any area of long term care, these rates are not in any way related to ability to refer patients, or tied to any performance clauses. There has been recent concern relating to dual medical directorships where a physician functions as both a nursing home medical director as well as a hospice medical director. If the purpose of the dual medical directorship is for referrals, then this remains unethical. If the purpose for dual responsibility is for education, integration, continuity of care, regulatory compliance, etc. then there are not any ethical issues.

The OIG has regularly published fraud alerts. Areas pertaining to long term care include concerns over inducements by hospice providers. Medicare skilled units were targeted because hospices provided free services to these residents in order for them to contract with the hospice when discharged. However, if a hospice patient has a hospitalization unrelated to the terminal diagnoses and qualifies for Medicare skilled care, they can remain on hospice related to their terminal diagnosis.

The National Hospice Organization's development of prognostication guidelines, especially of the non-malignant diseases has helped defray many of the eligibility concerns. Physicians can utilize these and other similar documents to avoid non-eligible admissions. (Appendix F)