Proceedings from the Quality Colloquium: Evidence-Based Medicine and Long-Term Care
March / April 2005
Evidence-Based Medicine
Proceedings from the Quality Colloquium
Evidence-Based Medicine and Long-Term Care
Pennsylvania, which has the third largest senior population in the United States, is in a unique position to lead in setting the standard of long-term care quality. Overseeing more than 90,000 residents in over 700 nursing facilities, the Penn. Department of Health sought to go beyond its survey and regulatory functions by initiating the Nursing Care Facilities Best Practices Project in April 2001. The goals of the project are to:
- evaluate quality of care across multiple domains in Pennsylvania nursing facilities;
- develop and implement best-practice protocols to improve the quality of care, minimize the risk of care problems occurring or reverse care problems; and,
- evaluate the effectiveness of protocols in improving quality of care and provide tools for project replication in all Pennsylvania nursing homes.
“The department is committed to reaching beyond our regulatory function and finding ways to improve the quality of life for older Pennsylvanians,” said Dr. Calvin B. Johnson, secretary of the Penn. Department of Health.
More than 100 nursing home facilities in Pennsylvania volunteered to participate in the project, and facilities were selected for participation in part based on CMS Quality Indicator results and the facility’s capability to support the project. During Phase I, 10 facilities served as test sites and 10 as controls. During Phase II, 33 facilities are serving as test sites and 27 as controls. “The Department of Health’s overall goal for the project is to provide Pennsylvania nursing homes with proven best practices to improve the quality of care for residents.”
Morrison Informatics, Inc., a healthcare consulting firm, managed the project, and Hebrew Rehabilitation Center for Aged Research and Training Institute developed the best-practice protocols and evaluated the project’s outcomes. Nurse educators from The Kendal Corporation worked with nursing homes to implement the protocols, providing ongoing training and support. The nurse educators also worked with facilities to implement a quality assurance process in order to monitor the consistency of protocol implementation and resident enrollment in the program and to ensure that resident care was provided as outlined in protocol guidelines.
At each nursing home, the nurse educator, in conjunction with the administrator and director of nursing, set up an advisory panel consisting of department heads (or representatives) from physical or occupational therapy, recreation, social services, dietary services, and supervisory and direct nursing staff (usually nursing assistants). This advisory panel serves as the steering committee to oversee interdisciplinary implementation of protocols, to solve facility-specific challenges in implementation, and to review significant resident care planning issues. Best-practices protocol training was provided for all staff of all shifts to assure full implementation of protocols. Following the initial training of facility staff, the nurse educator conducted weekly onsite visits, which gradually decreased to one or two a month as the protocols became integrated into care processes at the nursing homes.
The use of best-practices protocols does not require any additional nursing home staff. Rather, the best-practice programs were designed to gradually replace former care practices and lead to efficient and effective improvements in quality of care. However, adoption of the best-practices program did require commitment of initial time and resources from administrative, nursing, clinical, therapy, and housekeeping staff. Throughout the program implementation, all disciplines become more knowledgeable about how other departments function and, as a group, become more cohesive, strengthening the communications that result in a stronger interdisciplinary team. As a result of the project, more resident referrals are made to physicians, dieticians, therapists, and social workers. This results in more comprehensive use of appropriate services, and is reflected in more thorough care planning. Staff satisfaction increases as staff members see their efforts improve care, increase resident independence and self-esteem, and improve resident quality of life.
Outcomes
Outcomes resulting from the best-practices protocol at the facility level were examined using quality indicators derived from computerized longitudinal Minimum Data Set (MDS) Version 2.0 resident assessments completed by facility staff. The following are the primary outcomes from the analysis:
Activities of Daily Living (ADLs)
An ADL quality improvement area, either dressing or eating, was selected for each resident. Using MDS data, the “ADL late loss worsening” quality indicator was reviewed.
- Test sites using the ADL protocol slowed rates of ADL decline four times more than the control facilities providing usual care.
- Test sites improved their quality indicators by 30 to 40%, whereas control sites experienced a lower rate of improvement or stayed the same.
Pain Management
Pain affects 50 to 60% of residents in long-term care facilities and affects quality of life. Six quality indicators were reviewed: inadequate pain management, pain worsening, behavior problems, behavior problem-high risk, behavior problem-low risk, and depressed/anxious mood worsening.
- Pain protocol test facilities had a 26% improvement in rates for inappropriate behaviors, compared to an 8% decline in the control sites.
- Test sites improved 20 to 40% in the area of behavior QIs, while control sites indicator rates declined or stayed the same.
- Test sites also improved 7% in depressed/anxious mood QI rates, while the control sites declined by 4%.
Depression
Quality indicators included depressed/anxious mood worsening, little or no activities, cognition worsening, communication worsening, new/persistent delirium, weight loss, and inadequate pain management.
- Test sites showed an 8% improvement in depression QI rates vs. an 18% decline among control sites.
- Test sites showed a 22% improvement in combined quality indicator rates vs. a 15% decline among control sites.
- The most significant improvement for test sites was a 69% improvement for resident involvement in activities programming and a 61% improvement in pain management.
- Both test and control sites improved their rates for inadequate pain management, a 61% improvement in test sites and 12% improvement in control sites.
- Control sites declined in two areas, 42% in communication worsening and 100% in weight loss.
Conclusions
Through the use of evidence-based protocols, the Nursing Care Facilities Best Practices Project has provided best-practices protocols that improve quality of care for residents of nursing homes. In addition, the project has demonstrated the necessity for using standardized and validated protocol guidelines and the requirement for sustained support from nurse educators for up to six months during the initial implementation period.
- Systematic and standardized implementation of best-practices protocols in nursing homes improves the quality of care.
- Success requires support of facility administrators and staff at every level and for all daily shifts of nursing facility operations.
- Knowledgeable support provided to facilities by trained nurse educators working one-on-one with facility staff and monitoring implementation during the introductory period is required.
- Best-practices protocols for individual quality improvement areas can result in improvements in other related areas.
- Use of protocols improves facility performance and leads to increased staff satisfaction.
Results of the analysis of QI data indicate that implementation of best-practice protocols, with intensive initial and regular weekly support from trained nurse educators, is an effective method for improving the quality of care that nursing facilities provide to residents. In addition, best practices can be interrelated and lead to quality improvement in multiple areas.
Further Development and Implementations
Pennsylvania nursing homes have requested development of additional best-practices protocols in major areas of resident care and are interested in implementing multiple protocols to improve overall resident quality of care and facility quality performance. Outcomes demonstrated both an immediate impact on the quality of care at nursing facilities and a demand for additional best-practice protocols. Based on the positive results achieved, the Pennsylvania Department of Health has extended the Nursing Care Facilities Best Practices Project demonstration through 2005. This extension includes continuing nurse educator support for the first group of test facilities for the original protocols, release of the pain protocol for use by Pennsylvania nursing homes, and development and implementation of two new protocols for pressure ulcers and urinary incontinence. The project will also study the retention of quality improvement results, the effects of using multiple protocols, and the results of protocols for pressure ulcers and incontinence. In addition, plans are under way to provide best-practices protocol implementation to all Pennsylvania nursing homes during 2005 to 2007.
Acknowledgements
This project is funded by the Penn. Department of Health. The Pennsylvania Nursing Care Facilities Best Practices Project is directed by Secretary of Health Calvin B. Johnson, MD, MPH, and Deputy Secretary of Quality of Assurance Richard H. Lee, MPA. Two advisory groups, the Executive Advisory Group and the Stakeholders Work Group, which provide input on project developments, implementation and evaluation, have supported the project. These groups include representatives of the Penn. Health Care Association, the Penn. County Affiliated Homes, the Penn. Association of Non-Profit Homes for the Aging, the Hospital and Healthcare Association of Penn., the Penn. Health Law Project, the Center for Advocacy for the Rights and Interests of the Elderly, consumers and family representatives, staff from the Centers for Medicare and Medicaid Services Central and Region III offices, the Penn. Long Term Care Council, the Departments of Health and Public Welfare, and residents and family members.
Morrison Informatics, Inc., a healthcare consulting company based in Mechanicsburg, Pennsylvania, conducts the project for the Department of Health. The project team includes nationally known, qualified, and experienced professionals with experience in developing, implementing, and measuring effective best-practices quality improvement models in nursing homes. The team includes Malcolm H. Morrison, PhD, Antony M. Grigonis, PhD, and Ruth Cheng, MBA. Best-practices protocol implementation is being conducted under the direction of Beryl Goldman, RN, MS, NHA, of The Kendal Corporation, Kennett Square, Pennsylvania, with the support of project nurse educators Sabita Balgobin, RN, MSN, and Ruth Bish, RN. Best-practices protocol development, data analysis, protocol development, and evaluation are being conducted by John Morris, PhD, Sue Nonemaker, RN, MS, and the staff of the Hebrew Rehabilitation Center for Aged Research and Training Institute, Roslindale, Massachusetts. Brant Fries, PhD, of the University of Michigan Institute of Gerontology is assisting in these tasks. Barry Fogel, MD, MBA, principal and executive vice president of LTCQ, Inc., was the moderator of the “Evidence-Based Medicine and Long-Term Care” session presented to The Quality Colloquium, Harvard University, August 23, 2004.
Other members of the team include nationally recognized experts in long-term care services and quality improvement. Technical assistance is provided by Sally McCue, MBA, of Clifton Gunderson LLP, an accounting firm in Calverton, Maryland; and public information services are being provided under the direction of Nancy Sacunas, APR, of Sacunas Stoessel, a public relations firm in Harrisburg, Pennsylvania.
The Penn. Department of Health specifically disclaims responsibility for any analyses, interpretations, or conclusions. To learn more about results of the Pennsylvania Nursing Care Facilities Best Practices Project, contact the Penn. Department of Health at 1-877-PA-HEALTH or visit the Web site: www.health.state.pa.us.
Richard Lee is deputy secretary for the Penn. Department of Health. Malcolm Morrison is president and CEO of Morrison Informatics, Inc., in Mechanicsburg, Pennsylvania. Beryl Goldman is director of Kendal Outreach, LLC, at The Kendal Corporation in Kennett Square, Pennsylvania. Sue Nonemaker is a senior research associates at the Hebrew Rehabilitation Center for Aged Research and Training Institute in Roslindale, Massachusetts. Barry Fogel is principal and executive vice president of LTCQ, Inc., in Lexington, Massachusetts. Ruth Cheng is director of special projects at Morrison Informatics. For further information, contact Cheng at 717-795-8410 or informatic@informaticinc.com.