Long Term Quality Measurement for Older Adults Tamara

Long Term Quality Measurement for Older Adults Tamara L. Burket, MS, GCNS-BC, ACNS-BC, CCRN Fellow Geriatric Nursing Leadership Academy

Resources n http: //www. cms. gov/Medicare/Quality. Initiatives-Patient-Assessment. Instruments/Nursing. Home. Quality. Inits/ index. html? redirect=/Nursing. Home. Qu ality. Inits/ 2

http: //www. newschool. edu/ltcc/pdf/tx. Back ground 03 -10 -05 FINAL. pdf 3

Objective – Discuss valid quality measures and their application in diverse gerontological settings throughout the community. 4

Points of Emphasis 1. Enhanced QOL as prime directive 2. History: Alphabet soup!! ACOVE /IOM/ CMS/ QI/ OBQI/ RAI… 3. Nursing Home Compare 4. Where do I start? 5

Target Population The Administration on Aging defines the older population as persons 65 and older (2004). The U. S. Census Bureau defines the older adult as “elderly” and includes persons 65 years of age and older (2001). 6

Young old =6575 n Old =75 -85 n Old old= 85+ n Centurions are now the fastest growing age group n 7

Target Population Statistics According to the U. S. Census Bureau: 1 in 8 Americans were elderly in 1994 & 1 in 5 or 20% will be elderly by the year 2030. The U. S. Census Bureau predicts the fastest growing portion of the elderly population is the “oldest old” (individuals 85 years of age and older). 8

Population Age Projections 2005 - 2050 9

Persons 65 and Over: - by age group - 1900 -2000 - projected 2010 -2050 10

Target Population: Complex Issues The elderly are living longer and they place increasing demands on the healthcare system and on medical and social services (CDC, 2005). Though we see the health of older Americans improving, many of these individuals are disabled or coping with chronic diseases/conditions (U. S. Census Bureau, 2006). Older adults are dealing with chronic diseases, diminished quality of life, and increased costs of healthcare (CDC, 2005). 11

Socioeconomic Issues n n 30%of the Medicare budget is spent on 6% of the Medicare population in the last year of life Federal spending in the elderly has double since 1960 Hospitals receive the majority of Medicare expenditures and nursing facilities receive the majority of Medicaid expenditures. Following retirement, income drops 50% on the average 12

Minority Elderly n 15%- 65+ – 8% Black – 2% Asian or Pacific Islanders – 1% Native American – 4% Hispanic 13

n n n 12% of Black population are elderly 13% of those are over 85 They are the fastest growing segment of the black population 14

Health Care Disparities http: //www. census. gov/Press-Release /www/releases/ archives/aging_population/006544. html http: //www. agingstats. gov/chartbook 2004/population. html http: //www. census. gov/population/www/pop-profile/elderlypop. html

Vulnerable Elders n ACOVE: – “community dwelling elders aged 65 and older who are at greater risk of death or functional decline over a 2 -year period. ” – JAGS 55: S 247 -S 252, 2007 16

Characteristics of Vulnerable Elders Patient Safety Concerns n Deficits In Quality of Care n Particular Care Needs of Older Persons n – JAGS 55: S 247 -S 252, 2007 n Iatrogenic Cascade 17

Complicated by: Multiple Medical Conditions n Chronicity n Ageism n Functional Status n Substantial Variation in Preferences n – Diversity 18

Top 4 Major Chronic Illnesses in Older Adults Asthma n Hypertension n Hearing Impairment n Heart Conditions n Robinson, D. , Kish, C. (2001) Advanced Practice Nursing. St. Louis, MO: Mosby, Inc. , 570 19

Geriatric Care Priorities n n n Medical Cognitive Affective Functional Social support/care giver 20

Elements Of Geriatric Assessment n n Economic Environmental Quality of life/well -being Advance Directives SPICES Sleep PO Incontinence Confusion Evidence of falls Skin breakdown 21

Legislation • • • 1935 -Social Security Act –Intended as “old-age” insurance 1965 -Older Americans Act established the foundation for the development of today’s senior centers. 1981 - Omnibus Budget Reconciliation Act (OBRA) reduced Medicaid eligibility for older Americans, care, set limits for health care services, established criteria for nursing home care 1983 -Prospective Payment System reduced reimbursement for home health services 1990 -OBRA provided direct reimbursement for NP’s 22 and specialists in rural areas…

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. . . “NEVER” EVENTS n 2008 - A list of 28 medical errors from the National Quality Forum: – Should never happen – Never getting paid n Among them: Death or disability related to – – – falls use of restraints or bedrails stage 3 or 4 pressure ulcers suicide or attempted suicide medication error sexual or physical assault while being cared for in a healthcare facility 24

Healthy People 2010 Physical activity n Overweight and obesity n Responsible sexual behavior n Injury and violence n Immunizations n Tobacco use n Substance abuse n Mental health n Environmental quality n Access to quality care n 25

“ 10 KEYS” TO HEALTHY AGING (From Healthy People 2020) • • • Lower Systolic Blood Pressure Stop Smoking Participate in Cancer Screening Get Immunized Regularly Regulate Blood Glucose Lower LDL Cholesterol Be Physically Active Prevent Bone Loss and Muscle Weakness Maintain Social Contact Combat Depression The Center for Healthy Aging University of Pittsburgh Graduate School of Public Health http: //www. healthyaging. pitt. edu/home. html# 26

Process Measures Timely initiation of care How often the home health team began their patients’ care in a timely manner. Influenza immunization received for current flu season How often the home health team determined whether patients received a flu shot for the current flu season. Pneumococcal polysaccharide vaccine ever received How often the home health team determined whether their patients received a pneumococcal vaccine (pneumonia shot). Heart failure symptoms during short-term episodes How often the home health team treated heart failure (weakening of the heart) patients’ symptoms. Diabetic foot care and patient education implemented during short-term episodes of care For patients with diabetes, how often the home health team got doctor’s orders, gave foot care, and taught patients about foot care. How often the home health team checked patients for pain. 27 Pain interventions implemented during short-term How often the home health team treated their episodes patients’ pain. Pain assessment conducted

More Process Measures Depression assessment conducted How often the home health team checked patients for depression. Drug education on all medications provided to patient/caregiver during short-term episodes How often the home health team taught patients (or their family caregivers) about their drugs. Multifactor fall risk assessment conducted for patients 65 and over Pressure ulcer risk conducted Pressure ulcer prevention included in the plan of care Pressure ulcer prevention implemented during short term episodes of care How often the home health team checked patients’ risk of falling. How often the home health team checked patients for the risk of developing pressure sores (bed sores). How often the home health team included treatments to prevent pressure sores (bed sores) in the plan of care. How often the home health team took doctor 28 ordered action to prevent pressure sores (bed sores).

Improvement Measures Improvement in ambulation How often patients got better at walking or moving around. Improvement in bed transfer How often patients got better at getting in and out of bed. Improvement in pain interfering with activity How often patients had less pain when moving around. Improvement in bathing How often patients got better at bathing. Improvement in management of oral medications How often patients got better at taking their drugs correctly by mouth. Improvement in dyspnea How often patients’ breathing improved. Improvement in status of surgical wounds 29 How often patients’ wounds improved or healed after an operation.

Healthcare utilization measures Acute care hospitalizations Emergency department use without hospitalization How often home health patients had to be admitted to the hospital. How often patients receiving home health care needed any urgent, unplanned care in the hospital emergency room – without being admitted to the hospital. 30

Impacting Quality Measures 31

Safety Evidence: Hospitals face mounting costs and decreased reimbursement based on indicators like injuries related to falls, pressure ulcers, and nosocomial infections. Nurses and other providers are challenged to define their contribution to patient safety in meeting regulatory requirements and standards. Teamwork Evidence: The Institute of Medicine (2008) supports interdisciplinary teamwork as evidenced in the review of 128 successful, innovative models for geriatric care. 32

Transdisciplinary Teamwork Population n Intervention n Comparison n Intervention n Plan n Do n Change n Assess n 33

Advocacy Evidence: Nurses have multiple opportunities within their organizations and communities to advocate for timely and just dispersal of increasingly sparse resources in the care of older adults. Rounds Evidence: The Studer Group recommends “Rounding for Outcomes” and the use of rounding logs and care plans to support nursing intervention, care coordination, and reward and recognition as patient and staff goals are achieved. 34

SPICES Sleep PO Incontinence Confusion Evidence of falls Skin breakdown 35

PICO P= Elder Trauma Victims over 65 years of age n I= Targeted Geriatric Rounding n C= Absence of targeted geriatric rounding n 0= Effects of intervention n 36

Sample PICO Question: Will targeted geriatric rounds provide measurable outcome improvements in nursing care for victims of injury patients over 65 years old?

Potential Qualitative Outcome Measures n n n Nurse Satisfaction Patient Satisfaction Quality of life Patient Safety/Compliance Data Nurse Sensitive Quality Indicators Geriatric Syndromes & Vulnerabilities 38

Qualitative n “Each time, those who espouse only evidence—without narratives about real people—struggle to control the debate. Typically, they lose. ” Jason Karlawish http: //scienceprogress. org/2011/11/the-importance-of-narrativein-communicating-evidence-based-science/ 39

10 Most Common Geriatric Consult Team Interventions 1. Confusion Assessment 2. Falls Assessment & Precautions 3. Polypharmacy Issues 4. Dehydration 5. Pain Management 6. Discharge Recommendations 7. Bowel Regimen 8. Blood Pressure Management 9. Urinary Sepsis Screening 10. Dysphagia Screening 40

Population of Nursing Care Plans Before & After Targeted Rounding 41

Examples: Nurse Satisfaction Data Before and After Rounding for Outcomes 42

Nurse Satisfaction Data Before and After Rounding for Outcomes 43

Patient Satisfaction Data KEY: Baseline: 3 Q 11 4 Q 11 1 Q 12 44

Quality Indicators per 1000 Patient/Device Days 45

FY 11 BOOST Results 30 -Day Related Cause Readmission Rates Comparison Groups FY 10 FY 11 11 Jul-Dec 11 Jan. June Organization 5. 2 5. 18 5. 26 5. 09 Internal Medicine 3. 48 4. 53 4. 86 4. 25 Family & Comm Med. 4. 2 4. 91 5. 68 4. 08 46

Additional Resources Penn State Milton S. Hershey Medical Center and Penn State College of Medicine. (2011). FY 11 Project BOOST results inform the FY 12 Care Transitions Project. Crescent. Hershey, PA. Sept. 14, 2011. Institute of Medicine. (2008). Retooling for an aging America: building the health care workforce. Washington, DC. The National Academies Press. Resnick, B. (2010). Function of older adults in acute care: optimizing an opportunity. In M. D. Foreman, K Milison & T. T. Fulmer (Eds. ), Critical Care Nursing of Older Adults: Best Practices (3 rd ed. , pp. 209 -238). New York: Springer. 47

http: //www. studergroup. com/dot. CMS/k nowledge. Asset. Detail? inode=111088 n http: //www. iom. edu/Global/News%20 A nnouncements/Crossing-the-Quality. Chasm-The-IOM-Health-Care-Quality. Initiat n http: //consultgerirn. org/searched? q=SP ICESive. aspx n 48