Charlene Harrington, Ph.D. RN, Professor University of California San Francisco

Charlene Harrington, Ph.D. RN, Professor University of California San Francisco

Eliminated ICFs all meet NF standards Developed new regulations and ratings for scope and severity of deficiencies Established sanction procedures Implemented the MDS assessment system Developed quality measures Adopted QIS survey process Testing NH value purchasing

Facility characteristics location, size, ownership 1.State in-person annual inspection and complaint surveys with federal requirements Quality (scope and severity of violations Life safety violations 2.Nurse staffing hours RNs, LVNs, NAs, total hours Adjusted for resident case mix 3.Resident Quality Measures - MDS 3.0/RAI 18 measures

8 7 6 5 4 3 2 7.2 5.2 6.1 7.2 6.2 6.8 1 0 Harrington et al., CASPER and CMS NH Compare, 2014 1994 1998 2002 2006 2010 2014

30% Harrington et al. CASPER Data 25% 20% 15% 10% 25% 26% 28% 26% 23% 22% 5% 0% 2003 2005 2006 2008 2010 2011

33% of Medicare nursing home residents had adverse events or harm during their SNF stays in 2013 59% of those were preventable due to substandard treatment, inadequate resident monitoring and failure or delay in care. Over 50% with harm returned to a hospital with a cost of $2.8 billion http://oig.hhs.gov/oei/reports/oei-06-11-00370.asp 25% of Medicare nursing home residents were readmitted to a hospital in FY 2011 cost $14.3 billion for septicemia and other common problems http://oig.hhs.gov/oei/reports/oei-06-11-00040.asp Recent research shows stronger state enforcement improves quality outcomes (Mukamel et al. 2012, Health Services Research)

Harrington, et al 2011 & CMS CASPER 2014 4.5 4 3.5 3.7 3.6 3.5 3.8 3.9 4.1 3 2.5 2 1.5 1 0.5 0 2.5 2.1 2.3 2.4 2.4 2.3 0.7 0.7 0.7 0.8 0.8 0.8 0.7 0.7 0.6 0.6 0.7 0.8 1996 2000 2004 2008 2010 2014 CNAs LPNs RNs

6.00 5.00 4.00 3.39 LVN/NA RN 3.57 3.59 4.04 4.28 4.28 3.00 2.00 1.00 0.00 0.56 0.54 0.52 0.85 0.89 0.81 Top 10 Other FP Chain FP NonChain NP Chain NP NonChain Government Harrington, Olney, Carrillo, & Kang. 2011 HSR

Long Stay Measures Falls with major injury Urinary Track Infection Moderate to severe pain Pressure ulcers high risk Incontinence low risk Catheter Physical restraints Need for help increased Weight loss Depression Flu vaccinations Pneumonia vaccinations Antipsychotic RX Short Stay Measures Moderate to severe pain Pressure ulcers Flu vaccination Pneumonia vaccination Antipsychotic Rx CMS 5-Star NH Compare 2014

30% 25% 20% 15% 10% 5% 24% 21% Impacts 14,000 to 300,000 residents MDS data Medicare NH Compare 11% 8% 7% 7% 6% 6% 4% 1% 8% 6% 2012 2014 14% 15% 0%

Nurses often not trained to conduct assessments and don t value and use the MDS Ascertainment bias staff in better facilities are more likely to identify negative outcomes Incentive to inflate Medicare payment items to increase their revenues (Medpac 2012) Incentive to under report poor quality items to inflate their quality ratings MDS data are not audited so quality measures are not very accurate

1999 - Medicare-certified HHAs must assess residents & submit OASIS data for payment 2010: Major revision implemented and new HH quality measures being developed Medicare Home Health Compare Has quality measures (not audited) Home Health Consumer Assessment of Health Care Providers and Services (HHCAHPS) No deficiency and complaint data Infrequent state inspections of HHAs CMS 5-Star Medicare Home Health Compare 2014 12

80% 70% 60% CMS CMS OASIS data 2014 2004 2009 2014 50% 40% 30% 20% 10% 28% 22% 16% 60% 64% 68% 61% 51% 43% 46% 38% 37% 0% Admitted to Had less pain Better at taking Better at hospital meds walking/moving

Quality Indicator Overall Quality Process of care Outcome of care Improvement For-Profit HHAs 77.18% 85.99 56.87 Nonprofit HHAs 78.71% 87.37 60.13 Avoidance of hospitalization Avoidance of more bedsores 71.64 73.53 99.61 99.51 Number of Visits 37.6 23.7 Profit margins 15% 6.4% Cabin, Himmelstein, Siman, Woolhandler, 2014 Health Affairs.

Beds have doubled in past 12 years Serious quality problems & scandals Services generally are not eligible for Medicare & Medicaid payment Regulated by states few standards for personnel, client assessment & services No nursing staff required Minimal state oversight & sanctions No data reporting and no quality measures

No federal quality regulatory system New CMS efforts to develop quality measures and CAHPS surveys for HCBS Minimal state regulations for personnel, client assessment, and service delivery Minimal state oversight & sanctions No state data on quality Clients may not complain -fear of losing their provider or services

Major effort is needed to improve regulatory oversight and quality for all LTSS Quality measures are needed for residential care and HCBS Data reporting needs to be improved in terms of availability and accuracy for LTSS quality measures