Health and Disability

A group of Michigan providers convened to address their state’s looming care gap and formed the Kent County Health Field Collaborative (HFC). Its first project: a cooperative, flexible, and resourceful program that would directly address the barriers to sustained employment per the individual staffer.
John Oberlin

In 2004, a number of Michigan providers convened to address their state’s looming care gap and formed the Kent County Health Field Collaborative (HFC). Its first project: a cooperative, flexible, and resourceful program that would directly address the barriers to sustained employment per the individual staffer.

The Opportunity Partnership & Empowerment Network (OPEN) program has been a success and continues to expand its role and coverage area outside of Kent County. During a two-year pilot program, more than 80% of employees utilizing the program maintained their employment. All of these employees were considered at risk of losing their jobs because of inabilities to successfully manage personal challenges and work expectations. Also, two of the five participating employers cut turnover rates in half, while another company reported a drop from an average of 36% to 22%. Among the employers who initially made up the HFC, turnover rates ran as high as 58% before the program.

The program's collaborative structure keeps costs low. Collectively, the provider members, who all share the same problem of staff turnover, pay for one case worker’s salary and any expenses such as supplies and additional project work. Because the HFC is made up of long-term care, acute care, and rehab providers, payments are calculated through a utilization formula.

Nursing Home Quality, the national leader in Quality Indicator Survey (QIS) based quality assurance solutions for long-term care providers, announced the release of the latest version of abaqisTM, a web-based quality assurance system designed for use by nursing home providers to identify quality concerns and focus quality improvement efforts.

The QIS is a revised long-term care survey process utilized by the Centers for Medicare & Medicaid Services (CMS) that involves two stages of review. In Stage I, preliminary investigations are conducted through structured resident, family, and staff interviews, resident observations, record reviews, and analysis of Minimum Data Set (MDS) data.

These tasks, in combination with structured facility reviews, yield 162 Quality of Care and Quality of Life Indicators (QCIs) that are compared with defined thresholds to identify Care Areas for further investigation in Stage II of the QIS. The second stage involves in-depth quality investigations using Critical Element Pathways that address assessment, care planning, care provision, and reassessment.

The latest release of the abaqis TM system encompasses all six assessments conducted on site during Stage I of the QIS, with modules for family, staff, and resident interviews, resident observations, and census and admission record reviews. The system comprehensively guides the quality assurance efforts based on QIS concepts and processes, electronically manages the resident file, and even provides analysis of facility data based on national thresholds.

"I believe that the QIS has rendered the survey process more objective and more resident-centered," says Andrew Kramer, M.D., CEO of Nursing Home Quality. "However, the QIS software used in the survey process was developed solely for government surveyor use. The abaqis TM system is an affordable, user-friendly tool designed specifically for nursing home providers, allowing them to replicate the QIS for quality improvement purposes. At the end of the day, this system enables nursing homes to provide better care and quality of life to their residents."

A recently released study of Medicaid-financed nursing home use over 18 months in 2001 and 2002 finds that in states such as Oregon that have extensive community based long-term care services, Medicaid-covered nursing home stays were shorter than the national average. The numbers suggest that where seniors have alternatives, their nursing home stays are more likely to be for acute care following a hospitalization or for a shorter period at the end of life.

The study, "Medicaid-Financed Nursing Home Services: Characteristics of People Served and Their Patters of Care, 2001-2002," conducted by Matehematica Policy Research for the Office of Disability, Aging and Long-Term Care Policy for the U.S. Department of Health and Human Services, reports that over half of Medicaid-covered nursing home residents do not become eligible for benefits until after they move to a nursing home, with 29 percent obtaining coverage within six months of moving to the nursing home, 5 percent between six and 12 months, 7 percent between one and two years, and 9 percent after more than two years.

Last year, officials in the state of Ohio expressed concerns about the purchase of the "troubled family" known as HRC Manor by The Carlyle Group, a private equity firm that includes as its directors some of the most prominent names in American politics.

Toledo-based HCR Manor Care operates 44 nursing homes caring for 5,100 people in Ohio and has been under close watch by state authorities. Officials fear that recent problems could continue under the ownership of Carlyle, which owns Dunkin' Donuts and Hertz, but it's only health care related venture is Lifecare, a nationwide chain of 21 long-term care hospitals.

"These aren't the kind of nursing homes that they can just take over and keep status quo," said Beverly Laubert, long-term care ombudsman for the Ohio Department of Aging. "When you have facilities with such quality problems, someone is going to have to fix them."

State investigators have found instances in which residents at HRC Manor Care facilities did not receive proper care, including instances in which residents didn't receive physician-ordered lab tests or the proper treatment for incontinence, hampering their ability to progress toward using the bathroom on their own.

Michigan's own ombudsman for long-term care expressed the same kinds of reservations this week, but the response she got from one side of the aisle was scoffing. Via Gongwer:

On February 14, 2008, Senator Charles Grassley and Senator Herb Kohl introduced the Nursing Home Transparency and Improvement Act of 2008 (S.2641). According to a related Press Release, S.2641 aims to bring more transparency to consumers regarding nursing home quality, improve enforcement, and strengthen nursing home staff training requirements.

Among other things, S.2641 would reportedly require that "special focus facility" designations be placed on the Nursing Home Compare website. S.2641 would also require that CMS develop a standardized complaint form and require more uniform reporting of nursing staff levels so that comparisons can be made across nursing homes. S.2641 would also strengthen the available penalties. For instance, S.2641 would reportedly allow the Secretary to impose civil monetary penalties of up to $100,000 for a deficiency resulting in death, $3,000-$25,000 for deficiencies at the level of actual harm or immediate jeopardy, and not more than $3,000 for other deficiencies. Finally, S.2641 would attempt to improve staff training by including dementia management and abuse prevention training as part of pre-employment training.

Risk factors for hospital-acquired (HA) MRSA include:

Residing in a long-term care facility. MRSA is far more prevalent in these facilities than it is in hospitals. Carriers of MRSA have the ability to spread it, even if they're not sick themselves.

The Centers for Medicare & Medicaid Services (CMS) built upon historic action it took last November by making public more names of underperforming nursing homes across the country.

On November 29, 2007, the agency began publishing the names of Special Focus Facility (SFF) nursing homes that had failed to improve significantly after being given the opportunity to do so.

Once a facility is selected as an SFF, state survey agencies are responsible for conducting twice the number of standard surveys and will apply progressive enforcement until the nursing home either (a) significantly improves and is no longer identified as an SFF, (b) is granted additional time due to promising developments, or (c) is terminated from Medicare and/or Medicaid.

Last week the Centers for Medicare & Medicaid Services publicly identified over 4000 nursing homes - more than 25% of facilities nationwide - whose residents are physically restrained, or have pressure sores, or both, in excessive numbers. This should be a call to action to both Congress and the Centers for Medicare & Medicaid Services.

"What's needed to avoid pressure ulcers and physical restraints is a sufficient number of well-trained certified nurse assistants, accompanied and supervised by a sufficient number of registered nurses," said Senior Policy Attorney Toby S. Edelman with the Center for Medicare Advocacy. "With CMS reporting that more than 90% of nursing homes do not have sufficient staff to meet residents' needs, it is time for Congress to enact legislation mandating comprehensive and meaningful nurse staffing ratios," continued Edelman. "For its part, CMS needs to take stronger enforcement action whenever it finds facilities short-changing their residents and providing them with less care than they need."

On January 24, 2008, the Department of Health and Human Services' Office of Inspector General (OIG) published a Notice in Federal Register soliciting comments, recommendations and suggestions on how to best revise the nursing facility compliance program guidance. Specifically, the OIG is seeking comments addressing any changes to existing risk areas and introducing new risk areas. Comments must be delivered to the OIG by no later than 5 p.m. on February 25, 2008. The Notice explains how to submit any comments.