qualtity of care in nursing homes

Introduction

Interpretive guidelines (of federal regulations) broadly define the responsibilities of the medical director. Thus, the medical director is responsible tor ensuring quality of care in the facility.

Regulatory responsibilities:

• implementation of resident care policies
  • admissions, transfers, discharges
  • infection control
  • use of restraints
  • physician privileges & practices
  • ancillary services
• coordination role
  • monitoring & ensuring implementation of resident care policies
  • providing oversight & supervision of physician services
  • overseeing overall clinical care to ensure adequacy

Clinical care includes:

• medical care provided by physicians
• care provided by ancillary services
• direct care provided by nursing
  • skin assessment: prevention & treatment of pressure ulcers
  • fall risk assessment & falls prevention
  • prevention & assessment of undernutriton & dehydration
  • physical & chemical restraint reduction
  • assessment & treatment of incontinence
  • prevention & treatment of nosocomial infections
  • clinical implementation of resident assessment protocols (RAPs) & other clinical practice guidelines (CPGs)

Problems with assessing quality of care in nursing homes

• typical philosophy is that quality = absence of bad results
• focus on surveys with resulting paperwork compliance & diversion from direct care
• poplulation is complex with multiple chronic conditions & medications
• lack of evidence from controlled trials applicable to this population
• unclear link between best practices & quality of outcomes

Monitoring quality, processes & outcomes:

• systematic method where every event is identified
  • tracking of selected indicators (reviewed weekly)
    • hospitalizations
    • ER visits
    • readmissions
    • isolation status
    • supportive services, do not hospitalize, hospice status
    • pressure ulcers
    • falls
    • residents with medical issues
    • residents with mental health issues
    • indwelling catheters
    • G tubes, NG tubes
  • incident reports: as they occur; reviewed monthly in QA
    • skin injuries
    • falls
    • medication errors
    • ADEs ?? adverse drug events ??
  • nursing indicators - reviewed monthly in QA
    • pressure ulcers
    • physical restraints
    • chemical restraints
  • facility quality indicator profile: reviewed monthly in QA
  • special QA projects, eg. pain control
    • reviewed monthly or periodically in QA
  • nosocomial infection surveillance reports
    • as they occure; reviewed monthly in QA
  • infection culture isolates & antibiograms
    • reviewed every 3 months in QA
  • consultant pharmacist reports
    • reported every 3 months in QA
• audit process - selected resideents reviewed in task force & reported to QA

Monitoring quality, the importance of good data

• critical to capture every event in timely manner
  • forms simple, easy to complete & readily available
• critical that forms are completely & accurately completed
  • LVN fills out initial form
  • nursing supervisor checks accuracy & completeness in a timely manner
• data entered into database in a timely manner
  • data validation to prevent entry error
  • data needs to be cross-checked to make sure it is consistent
• achieving these aims depends on the culture of the facility, which is highly dependent upon the director of nursing

Once an outcome is identified as a target for intervention

• define process of care
  • process must be under the control of nursing home staff
  • variation in the process should affect outcomes
• process operationalized & approved in policy & procedure
• policy & procedure implemented
• process monitored
• process evaluated
• process altered (if needed)
• repeat cycle

The medical director should be involved in each step. In general, most tracked indicators should have associated policy & procedure.

Focus on process measures

• process
  • appropriateness - doing the right thing
    • most applicable type of indicator for measuring quality of care
    • almost all evidence extropolated from younger populations
    • consensus opinion may simply represent prevalent beliefs
    • one goal is to reduce variance standardizing practice
    • usual methoiod of standardizing practice is through use of clinical guidelines
    • medical complexity in nursing home population makes standardized approaches difficult
    • risk of standardizing practice is suppressing innovation
  • skill - doing it well; not directly accessible
• outcomes - issues
  • most meaningful & only important indicators in the long run
  • in nursing home population, good outcomes are defined as doing as well or better than reasonably expected
    • improvement is not necessarily expected
  • long-term proposition - not useful for short-term analyses
  • no evidence-based data on what good outcomes or best practices are in the nursing home population

Goals:

• standardization of care using best available evidence
  • minimizing both undertreatment & overtreatment, both of which lead to iatrogenic (possibly preventable) negative outcomes
  • minimizing variations in care

Problems associated with medication prescribing in nursing homes

• multiple chronic medical conditions treated with multiple medications
• increased potential for side effects, interactions & adverse outcomes, with need for increased monitoring
• significant number of bad outcomes due to inappropriate prescribing
• high liability risks

Goals of optimizing medication use are improved outcomes

• decreased adverse drug reactions & bad outcomes
• improved health consequences by secondary prevention & treatment
• improved risk management
  • bad outcomes are common in the nursing home population
  • when they occur, the care preceding the bad outcome is frequently looked at in detail
  • liability risk if facility has had documented deficiency in area in question

Methods:

• development of clinical guidelines covering assessment & treatment of the most common conditions & those with uncertain or unsafe risk/benefit ratios, as well as the most commonly used medications
• systematic evaluation of individual medication regimens & therapeutic dilemmas as educational exercise
• development of appropriateness indicators
• implicit review using appropriateness indicators for individual medication regimens
• focused review & education based on appropriateness indicators

Medications

• chronic conditions (underuse)
• medications including PRNs used > 4 time/week (overuse)
• appropriateness (misuse)
  • alternative non pharmacologic treatments used
  • indication (generalizability from controlled studies)
  • allergies
  • side effects
  • collateral side-effects
  • collateral benefits
  • duplicative treatment
  • schedule of dosing
  • dosage (renal, hepatic) adjustment
  • drug-drug intgeraactions
    • absorption
    • specific & non-specific cyt P450 interactions
  • drug-food interactions (absorption)
  • drug-disease interactions
  • institutional feasibility
  • cost/formulary issues
  • regulations - unnecessary medications
    • psychotropics
    • duplicative treatment
• risk/benefit ratio (should it be used)
  • goals of care
  • degree of risk (takes priority over expected benefit)
  • expected benefit vs competing risk
  • burden of treatment
• monitoring (how & when)
  • predictable side-effects - review of systems
  • therapeutic drug monitoring & other testing
  • benefits - symptoms; other monitoring
  • trials of medication withdrawal

Comparison of for-profit with non-profit nursing homes

• non-profit nursing homes with
  • higher quality staffing (ratio of effect 1.11)
  • lower pressure ulcer prevalence (HR= 0.91)
  • lower use of physical restraints (HR= 0.93) (not satistically significant)
  • fewer deficiencies in governmental regulatory assessments (ratio of effect 0.90) (not satistically significant)

Additional terms

• Nursing home compare
• quality indicators in nursing homes (MDS-based)