Program Goals
The Picker/Commonwealth Fund Long-Term Care Quality Improvement Program, part of the foundation's efforts in the field of delivery system improvement and innovation, aims to improve the quality of post-acute and long-term care services and supports, create linkages among them, and integrate this care with other health care services to serve patients better. Specifically, the program seeks to:
- identify, test, and spread measures, practices, models, and tools that will lead to person-centered, high-performing long-term care services;
- build strong networks among stakeholders to create a sense of common purpose and shared interest in improving performance;
- assess, track, and compare the elements of long-term care performance at the state and national levels; and
- ensure that long-term care is incorporated into payment, health information, and delivery system reforms.
The Issues
As our population ages, an increasing number of people live with multiple chronic conditions, in addition to whatever acute conditions may arise. Advancing age can also take a toll our ability to remain independent and often compromises our capacity to manage health care needs. Access to high-quality post-acute care and long-term care services and supports is therefore critical for patients trying to get well, stay well, and remain functional—especially for older adults who live alone.
Patients and their families know this, often from personal experience. Policymakers, on the other hand, have been slow to incorporate long-term care into plans for health system redesign. With the recent enactment of the Affordable Care Act, which included the Community Living Assistance Services and Supports (CLASS) Act, that seems to be changing. The Fund's Long-Term Care Quality Improvement Program is poised to support efforts to implement successfully the long-term care reforms included in these laws and to assist nursing homes and other providers that are striving to improve their performance.
Recent Projects
Advancing Excellence in America's Nursing Homes
Advancing Excellence in America's Nursing Homes is a national, public–private quality improvement campaign begun in 2006 with support from The Commonwealth Fund and the Centers for Medicare and Medicaid Services (CMS) to help nursing homes become good places to live, work, and visit. Led by a steering committee representing all major organizations that have a stake in high-quality nursing home care, the campaign is unique in encouraging the participation of not only organizational providers but also the individuals who staff facilities and the consumers they serve. To participate, nursing homes must agree to work on at least three of eight quality-related issues, such as reducing staff turnover—a problem endemic within the industry—or improving pain management, and set performance targets as well.
The campaign's Web site, www.nhqualitycampaign.org, is central to its work, providing a necessary tool for tracking improvement and comparing the performance of participating and non-participating facilities; serving as an efficient conduit for bringing evidence-based practices to the attention of nursing homes across the country; and giving consumers information they need to help them get good care in a nursing home.
Owing to its success in attracting participants—there are now more than 6,600 facilities, representing over 42 percent of all U.S. nursing homes—and in achieving measurable progress in meeting quality goals, the campaign has been extended beyond the original two-year commitment. In addition to updating the resources available on the Web site, in the past year new clinical goals have been added, such as improving advance care planning and staff satisfaction, and the metrics used to assess progress on organizational goals have been better defined.
Preserving Critical-Access Nursing Homes
The Commonwealth Fund's abiding interest in reducing disparities in health care for vulnerable populations has led to heightened attention on "safety net" health care providers. While the term typically refers to hospitals and primary care clinics, Brown University's Vincent Mor, Ph.D., and others have found a trend of nursing home closures in inner-city neighborhoods that points to the need to consider nursing homes as important elements of the safety-net system. Although the care provided by nursing homes in these communities is frequently of poor quality, these facilities are often the only source of post-acute and long-term care services that is accessible to residents.
With support from the Fund and CMS, a pilot project led by Carol Benner, national director of Advancing Excellence, is attempting to stabilize "critical access" nursing homes enough to forestall their closure and improve them sufficiently to warrant continued participation in the Medicare and Medicaid programs. The states of Georgia, Illinois, Indiana, and Ohio have been selected to test whether the Advancing Excellence campaign's state coalitions—know as Local Area Networks for Excellence, or LANEs—can build and sustain learning collaboratives among these nursing homes to improve organizational function, operational efficiency, and overall service delivery.
The Pioneer Network
In the vanguard of the nursing home "culture change" movement since 1997, the Pioneer Network reaches out to providers across the country that are seeking to become truly person-centered organizations. Pioneer, with support from The Commonwealth Fund, offers nursing homes training, practical tools, and access to a community of peers. Over the past year, CEO Bonnie Kantor, Sc.D., working closely with congressional staff and other federal policymakers, opened up exciting opportunities to spread person-centered care through the inclusion of specific language in the Affordable Care Act calling for a national demonstration of culture change projects. Other sections of the new law target workforce development, a critical concern for long-term care providers; allow for more creative use of civil monetary penalty funds; and encourage inclusion of incentives within payment reform efforts for delivering person-centered care.
In the coming year, the Pioneer Network will continue to work with policymakers to maximize the potential of these provisions to promote person-centered care in long-term care settings, as well as to address providers' concerns with the new changes.
Expanding Nursing Homes' Capacity to Improve Care
Just as health information technology (HIT) can improve the coordination of patient care in primary and acute care settings, it also has the potential to improve coordination in nursing homes, which increasingly serve patients that have been discharged from the hospital but are not yet ready to return home. Preliminary findings from a Fund-supported survey led by the University of Pittsburgh's Howard Degenholtz, Ph.D., suggest the nursing homes are considerably behind other health care sectors in the adoption of HIT systems, and that use is still largely confined to administrative functions like billing or submission of required resident assessment data to CMS. To help address this lag, a recently completed evaluation of New York State's nursing home HIT demonstration, jointly conducted by three separate research teams and cosponsored by the Fund and the state legislature, has provided policymakers and providers with many insights about the process and timing of HIT implementation, incentives and costs, factors that facilitate or impede adoption, implications for nursing home staff, and outcomes for residents. A Fund case study by Shana Lieberman Klinger and Scott White discusses the findings in detail.
Fund support also enabled Joseph Ouslander's team at Florida Atlantic University to develop INTERACT-II (Interventions to Reduce Acute Care Transfers), a set of clinical tools that assist nursing home staff in the early identification, assessment, communication, and documentation of acute changes in residents' health status. The goal is to help staff safely and appropriately manage acute illnesses in the nursing home, rather than automatically transferring residents to hospitals. The toolkit has been shared with the Institute for Healthcare Improvement's State Action on Avoidable Rehospitalizations (STAAR), an initiative sponsored by the Fund.
Long-Term Care Scorecard
The Affordable Care Act and CLASS Act will greatly expand the availability of Medicaid community-based long-term services and provide states with financial incentives intended to forge a better balance between nursing home care and home- and community-based services. As states embark on this new era in long-term care, they will need the means to assess progress in expanding access to a range of affordable, high-quality long-term care services. Following on the success of the Fund's national and state health system scorecards, Susan Reinhard, R.N., Ph.D., and her team from AARP is working with Fund staff and the SCAN Foundation to develop a state performance scorecard focused on long-term care. Over the coming year, a set of long-term care performance indicators will be finalized, and state policymakers will be surveyed to supplement information obtained from publically available data sets. The scorecard will be ready for public release in the summer of 2011.
New Directions
In addition to finalizing the Fund's new state scorecard on long-term care performance and continuing its support of the Pioneer Network to foster person-centered long-term care, the Long-Term Care Quality Improvement program is supporting a number of other projects. For example, Harvard Medical School's David Grabowski, M.D., has begun to explore the promise of telemedicine as a safe, cost-effective way to reduce hospitalizations of nursing home residents—which occur frequently and are often associated with negative health outcomes. Telemedicine allows nursing home staff to consult with off-site physicians, who can then assess residents' need for hospital care and recommend treatments that the home might be able to provide at lower cost.
Another project, meanwhile, is seeking to improve coordination of care between hospitals and home health care settings and reduce costly hospital readmissions. A team led by Penny Hollander Feldman, Ph.D., of the Visiting Nurse Service of New York will determine whether home health care agencies can effectively use the Care Transitions Measure, a brief patient questionnaire that was developed by Eric Coleman, M.D., with earlier Fund support to assess the adequacy of instructions that hospitals provide their patients prior to discharge, The study will test whether home health agencies and other post-acute care providers can use the tool to assess how well a hospital prepares patients for home care, predict the level of resources new patients will require, tailor services to patients' individual needs, and provide hospitals with feedback on their transitional care. The project team will also develop a version of the Care Transitions Measure capable of assessing how well home health care agencies prepare their patients for discharge.