Advancing Excellence In America’s Nursing Homes: Overview, April 2009

1. Advancing Excellence In America’s Nursing Homes: Overview, April 2009 Mary Jane Koren, MD, MPHAssistant VP, The Commonwealth FundChair, AE Steering CommitteeStefan Gravenstein, MD, MPHProfessor of Medicine, Brown UniversityClinical Director, Quality Partners of Rhode IslandCarol Benner, Sc.M.Field Director, AE

2. Campaign Mission To help nursing homes achieve excellence in the quality of care and quality of life for the more than 1.5 million residents of America’s nursing homes by: • Establishing and supporting an infrastructure of local QI networks • Strengthening the workforce • Improving clinical and organizational outcomes

3. What the Campaign Does Advancing Excellence is helping nursing homes make a difference in the lives of residents and staff.  Advancing Excellence provides free, practical and evidence-based resources to support quality improvement efforts in America’s nursing homes. Advancing Excellence is committed to providing support to those on the frontlines of nursing home care.  Advancing Excellence promotes open communication and transparency among families, residents, and nursing home staff. 3

4. Campaign History • 2005 - 2006 • Stakeholders come together to plan Campaign • Campaign launch • Website developed • Steering Committee and Work Groups formed • 2007 • Process frameworks developed • Commonwealth Fund grant awarded • Field Director hired (October) • First national LANE Conference (December) • First data suggesting success

5. Campaign History (continued) • 2008 • National Webinars (Pain, Pressure Ulcers, Consistent Assignment, Staff Stability) • Monthly newsletter • Consumer fact sheets • AHRQ Grant for Interchange 2008 awarded • Top Ten Guides for Front Line Workers • Second National LANE Conference: Dallas,TX 12/1/08

6. Campaign History (continued) • 2009 • More Webinars • Resident Satisfaction, Restraints, Adult Learning (May 12) • Hired second person • Videos on Website • New CMS contract (coming) • Focusing on more communication - brochure about resources • Phase II of Campaign • Nursing Homes can update profiles • New Goals (Staff Satisfaction and Advance Care Planning) • Website Revisions (Best Practices, Easier TA Tools)

7. Founding Organizations Alliance for Quality Nursing Home Care American Association of Homes and Services for the Aging (AAHSA) American Association of Nurse Assessment Coordinators (AANAC) American College of Health Care Administrators (ACHCA) American Health Care Association (AHCA) American Medical Directors Association (AMDA) Centers for Medicare & Medicaid Services (CMS) and its contractors, the Quality Improvement Organizations (QIOs) and State Survey Agencies National Association of Health Care Assistants (NAHCA) NCCNHR: National Consumer Voice for Long Term Care The Commonwealth Fund The Evangelical Lutheran Good Samaritan Society 7

8. Steering Committee (continued) Agency for Healthcare Research and Quality (AHRQ) Alzheimer’s Association American Academy of Nursing -- Expert Panel on Aging American Association for Long Term Care Nursing (AALTC) American Health Quality Association (AHQA) Association of Health Facility Survey Agencies (AHFSA) Centers for Disease Control and Prevention (CDC) Foundation of the National Association of Boards of Examiners of Long Term Care Administrators Hartford Institute for Geriatric Nursing Institute for Healthcare Improvement (IHI) National Association of Directors of Nursing Administration in Long Term Care (NADONA/LTC) National Association of State Long-Term Care Ombudsman Programs (NASOP) National Conference of Gerontological Nurse Practitioners (NCGNP) National Gerontological Nursing Association (NGNA) PHI Pioneer Network Service Employees International Union (SEIU) 8

9. National Learning Network • Engages Leaders • Shared aims or goals • Welcomes everyone and harnesses energy • Self-conscious – participants are a part of the whole • Non-linear • Devolves control/bottom-up learning • Manages knowledge with agility • Seeks critical mass – not total coverage • Values asking, not merely sharing McCannon and Perla, JQPS, May, 2009

10. Advancing Excellence Campaign Communications Workgroup Results Workgroup Campaign Steering Committee Technical Assistance Workgroup Organizational Chart Staffing Workgroup Recruitment Workgroup Consumer Workgroup Goals Taskforce Local Area Networks for Excellence (LANEs) Nursing Homes Consumers LTC Professionals and Frontline Staff

11. Who Does What • Steering Committee ( meets bi-weekly) Work Groups • Governance, Policy, National meetings – the “Interchange”, Communications, Technical Assistance • CMS Support through its Nursing Home QIO Special Study • Website. data analysis, STAR target setting web site, limited administrative support • Commonwealth Grant • Supports Local Area Networks of Excellence (LANEs), Webinars, Technical Assistance, Outreach

12. The Eight Goal Areas Clinical Quality Goals 1) To reduce high risk pressure ulcers; 2) To reduce the use of daily physical restraints; 3) To improve pain management for longer term nursing home residents; and 4)To improve pain management for short stay, post-acute nursing home residents. Organizational Goals 5) To establish individual targets for improving quality (STAR); 6) To assess resident and family “satisfaction” for quality of care; 7) To increase staff retention; and 8) To improve consistent assignment of nursing home staff, so that residents regularly receive care from the same caregivers.

13. Using the Goals for Success 1. Lay the organizational groundwork for improvement • Stabilize your workforce: Increase staff retention (Goal 7); • Improve efficiency by letting your staff get to know their residents: use consistent assignment so that residents regularly receive care from the same caregivers (Goal 8); and • Know where you’re headed: use STAR (on the CMS web-site) to set QI targets (Goal 5).

14. Using the Goals for Success 2. Work on the really important problems • Reduce the use of daily physical restraints (Goal 1); • Reduce high risk pressure ulcers (Goal 2); • Be sure people in your home aren’t “hurting”: Improve pain management for short and long stay residents (Goals 3 & 4).

15. Using the Goals for Success 3. Find out what your “customers” think Ask residents and families to tell you how you’re doing: measure experience with care (“satisfaction”) (Goal 6).

16. Major Accomplishments • More than 7,200 (45%) nursing homes and 2100 consumers • National coalition of government, providers, workers, professionals and consumers • LANEs in 49 states • Robust web site • Evidenced – based technical assistance/ Webinars • Consumer Fact Sheets for each goal • Guide to engage nursing home front-line staff

17. Benefits of a National Campaign • Increased staff retention and focus • Cost savings because of improved quality and staff retention • Improved customer satisfaction • Preparation for Pay-for-Performance • Advances standards development • Fosters Quality Improvement and Data Culture • Stakeholders at the table – now and in the future

18. NH Participation in Advancing Excellence (December 2008) RI DC Percent Participation 0% – 25% 26% – 50% 51% – 75% 76% – 100%

19. LANE Roles and Responsibilities • Provide statewide leadership • Raise awareness about the campaign • Recruit nursing homes • Pull stakeholders together • Provide technical assistance • Communicate key campaign messages • Respond to critical issues

20. Core LANE Members • Nursing home associations (AHCA and AAHSA affiliates) • Quality Improvement Organizations (QIOs) • State Survey Agencies • Ombudsmen • Consumer Advocacy Groups • Others • DONs, Medical Directors, Administrators, CNAs

21. Attributes of Successful LANEs • Regular meetings • Inclusion of statewide leaders • Good attendance • Shared goals • Regular agenda that includes reviews progress and plans next steps • Celebration and recognition

22. Characteristics of Coalitions • Trust • Buy-in • Inclusion • Creativity • Communication • Sharing of Resources • Synergy • Win – Win • Success • Satisfaction

23. “If men of good will wish to come together for the purpose of upholding reason and establishing a rational society, they should begin by following the example of the cowboys in Western movies when the sheriff tells them at the door to a conference room: 'Gentlemen, leave your guns outside.‘” Ayn Rand, 1961

24. Coming together is a beginning; keeping together is progress; working together is success. …Henry Ford

25. Alone we do so little; together we do so much. Helen Keller

26. Characteristics of Coalitions • Trust • Buy-in • Inclusion • Creativity • Communication • Sharing of Resources • Synergy • Win – Win • Success • Satisfaction

27. Five Coalition Myths • The only agenda is the coalition’s Agenda… • Coalitions don’t get stuck... • Coalitions are about love, joy, peace, brotherhood….. • Coalitions don’t accomplish anything… • Coalitions are easy…

28. LANEs • 49 States have LANEs • Different as night and day • January 2008 – 80% QIO conveners • NY – four provider associations • WA, CA – ombudsman • MD, FL, IN, OK – provider associations • Core members include SSA, ombudsman, provider association representatives, QIO representatives • May also include AMDA, NADONA, CAG, hospital reps, culture change coalition, nursing groups

29. The Relative and Absolute Number of Residents at High Risk for Developing Pressure Ulcers is Increasing

30. Presure Ulcers

31. Restraints

32. Chronic Pain

33. Pain -Acute

34. Progress Toward Goals Progress Toward National Goal, By Participation and Target-Setting (Campaign results after year 1) Goal Source: This material was prepared by Quality Partners of Rhode Island, the Medicare Quality Improvement Organization for Rhode Island, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health & Human Services. The contents presented do not necessarily reflect CMS policy. Data through one year (four quarters).

35. Campaign Progress • Campaign participants have improved faster than non-participants in all things measured. • Campaign participants improved faster in the goals they selected to work on in every case. • Those homes for which targets were set for improvement improved fastest

36. Summary - Oklahoma Data is from the AE Campaign website (www.nhqualitycampaign.org and the CMS list of 4000 nursing homes used by QIOs in the 9thSOW. Clinical measures are QMs from Q3 2008. The pressure ulcer QM is for residents at high risk for developing pressure ulcers. Recruitment is from the real-time clickable map and was extracted in March 2009. For the clinical measures, lower numbers are better; for recruitment and target setting, higher numbers are better. A rank score of “1” for each of the categories is the best.

37. Summary – South Dakota Data is from the AE Campaign website (www.nhqualitycampaign.org and the CMS list of 4000 nursing homes used by QIOs in the 9thSOW. Clinical measures are QMs from Q3 2008. The pressure ulcer QM is for residents at high risk for developing pressure ulcers. Recruitment is from the real-time clickable map and was extracted in March 2009. For the clinical measures, lower numbers are better; for recruitment and target setting, higher numbers are better. A rank score of “1” for each of the categories is the best.

38. Summary – Arkansas Data is from the AE Campaign website (www.nhqualitycampaign.org and the CMS list of 4000 nursing homes used by QIOs in the 9thSOW. Clinical measures are QMs from Q3 2008. The pressure ulcer QM is for residents at high risk for developing pressure ulcers. Recruitment is from the real-time clickable map and was extracted in March 2009. For the clinical measures, lower numbers are better; for recruitment and target setting, higher numbers are better. A rank score of “1” for each of the categories is the best.

39. Arkansas Restraint RateQ3 2005 through Q3 2008 13.6 6.2 5.9 4.1

40. How did they do it? • A strong LANE • 100% Recruitment in Campaign • 2 rounds of regional educational programs (12 total) • Used AE resources from the web: • Process frameworks • Clinical practice information

41. Describing Your Results • Gather your data • Decide on presentation messages • Organize data for that message • For example: is message how well we are doing, or how much better we must do, or something of both

42. Finding Your Results • www.nhqualitycampaign.org • Click on Campaign Progress • Select national or state progress • National gives graphs like the ones just shown (presently updated to 2008 Q1) • State data is linked to a live update engine, and should give most current data (presently updated to 2008 Q3)

43. AE Resources • Care Guides • Flow diagrams, best practices, evidenced-based • Audio Recordings from Webinars • National speakers, success stories, based on Care Guides • Consumer Fact Sheets • Easy to understand language • Downloadable Web-based Videos • National speakers, best practices

44. AE Resources • Ten Ideas for Staff Involvement in Advancing Excellence • Ideas, worksheets, and templates to involve CNAs in QI • Planning a campaign kickoff • Suggested articles for newsletters • Templates for showing staff how their efforts are paying off • Consumer Guide • Educational materials about nursing home care • Suggestions for consumers to actively participate in the care planning and QI

45. AE Resources Consistent Assignment Resident Satisfaction Staff Retention Pressure Ulcers Restraints Target Setting Pain X X X X X X X X X X X X X X X X X X X X X X X X

46. How to Use AE Resources Use Audio Recording with all staff Reinforce with Care Guide Distribute Consumer Fact Sheets Reinforce with Video Monitor success • Choose an AE Goal • Look at your Data • Set a Target • Involve staff to develop a plan • Review AE resources • Finalize Plan

47. To Join the Campaign • Go to www.nhqualitycampaign.org • Upper right hand corner under Action Links select Join the Campaign • Need your Medicare/Medicaid Provider No. • Choose three goals: • 1 clinical • 1 organizational • One other goal, either clinical or organizational

48. Reasons to Join the Campaign • Campaign provides resources to succeed • Campaign identifies areas that need improvement • Campaigns provides technical assistance tools • Campaign provides guidance to meet goals • Good care costs less • Reduction/elimination of pressure ulcers saves money • Reducing staff turnover and consistent assignment is efficient • “Value based purchasing” will be rewarding high performance • Consumers are more knowledgeable, expect good care • Successes (Arkansas!) • It’s the right thing to do

49. Moving Ahead: the Campaign Continues • Eliminate target setting as a separate goal and require target setting for all goals. • Add statewide (LANE) target “No state will have a pressure ulcer rate higher than 15%”. • Lower national target for physical restraints to 3%. • Combine 2 pain goals into one. • Clarify definition and measurement of consistent assignment, resident satisfaction and staff turnover. • Add goal that focuses on staff satisfaction. • Add a new goal that focuses on “advance care planning”.

50. Thank you!