Transcript Long Term Quality Measurement for Older Adults

Long Term Quality
Measurement for Older
Adults
Tamara L. Burket, MS, GCNS-BC,
ACNS-BC, CCRN
Fellow Geriatric Nursing
Leadership Academy
Resources
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http://www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/
index.html?redirect=/NursingHomeQu
alityInits/
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http://www.newschool.edu/ltcc/pdf/txBack
ground03-10-05FINAL.pdf
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Objective
–Discuss valid quality measures
and their application in diverse
gerontological settings throughout
the community.
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Points of Emphasis
1. Enhanced
QOL as prime directive
2. History:
Alphabet soup!!
ACOVE /IOM/ CMS/
QI/ OBQI/ RAI…
3.
4.
Nursing Home Compare
Where do I start?
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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).
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Young old =6575
Old =75-85
Old old= 85+
Centurions are
now the fastest
growing age
group
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Target Population Statistics
According to the U.S. Census Bureau:
1 in 8 Americans were elderly in 1994 & 1in 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).
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Population Age Projections
2005 - 2050
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Persons 65 and Over:
- by age group
- 1900-2000
- projected 2010-2050
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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).
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Socioeconomic Issues
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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
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Minority Elderly
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15%- 65+
– 8% Black
– 2% Asian or
Pacific
Islanders
– 1% Native
American
– 4% Hispanic
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12% of Black
population are
elderly
13% of those are
over 85
They are the fastest
growing segment of
the black
population
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Health Care Disparities
http://www.census.gov/Press-Release /www/releases/
archives/aging_population/006544.html
http://www.agingstats.gov/chartbook2004/population.html
http://www.census.gov/population/www/pop-profile/elderlypop.html
Vulnerable Elders
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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:S247-S252, 2007
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Characteristics of
Vulnerable Elders
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Patient Safety Concerns
Deficits In Quality of Care
Particular Care Needs of Older Persons
– JAGS 55:S247-S252, 2007
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Iatrogenic Cascade
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Complicated by:
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Multiple Medical Conditions
Chronicity
Ageism
Functional Status
Substantial Variation in Preferences
– Diversity
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Top 4 Major Chronic
Illnesses in Older Adults
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Asthma
Hypertension
Hearing Impairment
Heart Conditions
Robinson, D., Kish, C. (2001) Advanced Practice Nursing. St. Louis,
MO: Mosby, Inc., 570
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Geriatric Care Priorities
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Medical
Cognitive
Affective
Functional
Social support/care giver
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Elements Of Geriatric
Assessment
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Economic
Environmental
Quality of
life/well-being
Advance
Directives
SPICES
Sleep
PO
Incontinence
Confusion
Evidence of falls
Skin breakdown
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Legislation
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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
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and specialists in rural areas…
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...“NEVER” EVENTS
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2008- A list of 28 medical errors from the
National Quality Forum:
– Should never happen
– Never getting paid
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Among them: Death or disability related to
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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
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Healthy People 2010
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Physical activity
Overweight and obesity
Responsible sexual behavior
Injury and violence
Immunizations
Tobacco use
Substance abuse
Mental health
Environmental quality
Access to quality care
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“10 KEYS” TO HEALTHY AGING
(From Healthy People 2020)
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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#
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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.
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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 doctor28
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
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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.
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Impacting Quality
Measures
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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.
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Transdisciplinary
Teamwork
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Population
Intervention
Comparison
Intervention
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Plan
Do
Change
Assess
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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.
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SPICES
Sleep
PO
Incontinence
Confusion
Evidence of falls
Skin breakdown
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PICO
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P= Elder Trauma Victims over 65
years of age
I= Targeted Geriatric Rounding
C= Absence of targeted geriatric
rounding
0= Effects of intervention
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Sample PICO Question:
Will targeted geriatric
rounds provide measurable
outcome improvements in
nursing care for victims of
injury patients over 65 years
old?
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Potential Qualitative
Outcome Measures
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Nurse Satisfaction
Patient Satisfaction
Quality of life
Patient
Safety/Compliance
Data
Nurse Sensitive
Quality Indicators
Geriatric Syndromes
&
Vulnerabilities
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Qualitative
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“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/
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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
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Population of Nursing Care Plans
Before & After Targeted Rounding
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Examples:
Nurse Satisfaction Data Before and After
Rounding for Outcomes
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Nurse Satisfaction Data Before and
After Rounding for Outcomes
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Patient Satisfaction Data
KEY: Baseline: 3Q11 4Q11 1Q12
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Quality Indicators per
1000 Patient/Device Days
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FY11 BOOST Results
30-Day Related Cause Readmission Rates
Comparison
Groups
FY10
FY11
11 Jul-Dec
11 JanJune
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
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Additional Resources
Penn State Milton S. Hershey Medical Center and Penn State College of
Medicine.(2011). FY11 Project BOOST results inform the FY12 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 (3rd ed., pp. 209-238). New
York: Springer.
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http://www.studergroup.com/dotCMS/k
nowledgeAssetDetail?inode=111088
http://www.iom.edu/Global/News%20A
nnouncements/Crossing-the-QualityChasm-The-IOM-Health-Care-QualityInitiat
http://consultgerirn.org/searched?q=SP
ICESive.aspx
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