Archived: Long Term Care Quality Improvement

This program is now closed.

Program Goals

The Picker/Commonwealth Fund Program on Long-Term Care Quality Improvement, a key component of the foundation’s efforts to improve health care delivery and spur innovation, aims to raise the quality of postacute and long-term care services and supports, and to improve care transitions for patients by integrating these services with the other care they receive. 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 stakeholder networks to create a sense of common purpose and shared interest in improving performance and coordinating care
  • assess, track, and compare the performance of long-term services and supports at the state and national levels
  • ensure that long-term care services are an integral part of any care system and are incorporated into provider payment, health information technology, and delivery system reforms.

The program also oversees a Commonwealth Fund initiative targeting the particularly vulnerable group of individuals who are enrolled in both the Medicare and Medicaid programs—the so-called “dual eligibles.” The effort seeks to bring about better care, improved care experiences, and reduced costs for these beneficiaries through better coordination of services.

The Issues

As our population ages, an increasing number of people live with multiple chronic conditions, compromised physical function, and, sometimes, dementia. These problems not only can complicate our ability to manage our health care needs but can also jeopardize our ability to remain independent.

That’s why access to high-quality, affordable postacute care and long-term services and supports (LTSS) is so critical. Patients and their families know it is one of the keys to getting well, staying well, and remaining functional. Policymakers, however, have generally been slow to recognize how integral LTSS are to an effective and efficient health care system.

As implementation of the Affordable Care Act proceeds, The Commonwealth Fund’s Program on Long-Term Care Quality Improvement is supporting work with nursing homes and other long-term care providers to ensure successful care transitions and better patient outcomes overall.

Recent Projects

Advancing Excellence in America's Nursing Homes
Advancing Excellence in America’s Nursing Homes is a national, voluntary quality improvement campaign to help nursing homes become good places to live, work, and visit. Launched in 2006 with support from The Commonwealth Fund and the Centers for Medicare and Medicaid Services (CMS), Advancing Excellence is unique in encouraging the participation of not only nursing home providers but also the individuals who staff facilities and the consumers they serve. To join, nursing homes must agree to work on important quality-related issues such as reducing staff turnover—a problem endemic within the industry and a barrier to high performance—or improving the care planning process to address patients’ goals for care. Participating providers must also set performance targets and measure change. The campaign works with stakeholder coalitions in each state, called Local Area Networks for Excellence, or LANEs, which help keep nursing homes engaged and moving forward.

Advancing Excellence has achieved great success in attracting nursing homes—now more than 8,800, representing over 56 percent of all U.S. nursing facilities—and in making measurable progress toward quality goals. Through the campaign’s Web site, nhqualitycampaign.org, nursing homes can access free tools for tracking improvement and comparing facilities’ performance, such as in safely reducing hospitalizations and addressing inappropriate use of antipsychotic medications in people with dementia. Nursing home leaders can also learn about evidence-based practices through training webinars. Consumers, meanwhile, can find information that will help them get good care.

The Fund’s longstanding commitment to person-centered long-term care, particularly in nursing homes, is evident in a number of other recent grants. For example:

  • Fund support to the Pioneer Network, a leading force behind culture change in nursing homes and the move to person-centered care, has enabled the coalition to advise state and federal agencies on nursing home payment and policy. Pioneer leaders have been working with CMS to implement a provision of the Affordable Care Act designed to strengthen quality assurance and performance improvement efforts in nursing homes. They have also worked with officials in Colorado, Kansas, and New Hampshire on pay-for-performance mechanisms that promote culture change.
  • The University of Wisconsin’s Barbara Bowers, Ph.D., investigated the lack of strong evidence to support consistent nurse assignment in facilities, despite general acceptance of this practice as a key to person-centered care. Bowers concluded that previous studies failed to define consistent assignment objectively—thus complicating attempts to quantifiably measure it—and applied it in variable ways.
  • In collaboration with the National Center for Assisted Living, Sheryl Zimmerman, Ph.D., of the University of North Carolina convened 37 stakeholder organizations to recommend ways of optimizing the seven psychosocial components of the new version of the nursing home resident assessment tool known as the Minimum Data Set.
  • Mathy Mezey, Ed.D., of the Hartford Center for Geriatric Nursing at New York University developed recommendations for academic nurse training programs to incorporate the principles of person-centered care into their curricula.
  • Edward Miller, Ph.D., of the University of Massachusetts and Cynthia Rudder, Ph.D., of the Long-Term Care Community Coalition conducted a case study of consumer participation in the formulation of Medicaid nursing home payment policies in New York and Minnesota. The researchers also developed informational materials for consumers in other states.

Long-Term Services and Supports State Scorecard
With the growing demand for LTSS and continuing pressures on government budgets, states are being forced to do more with less. One solution is to establish a better balance between nursing home care and services delivered in the home or through community-based providers, such as adult day health care programs. As states embark on this new era in long-term care, they will need the means to assess progress in making affordable, high-quality services and supports available to all who need them.

Following on the success of The Commonwealth Fund’s national and state health system scorecards, Susan Reinhard, R.N., Ph.D., and her team from AARP collaborated with the Fund and the SCAN Foundation to develop the first-ever state performance scorecard focused on long-term services and supports. The report, Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers, examined four key dimensions of performance—affordability and access, choice of setting and provider, quality of life and quality of care, and support for family caregivers—and assessed each state’s performance overall as well as on the 25 individual indicators within the four domains. It found that all states have a long way to go to create a high-performing LTSS system, and that state Medicaid policies dramatically affect consumer choice and affordability. One of the most sobering findings is that the cost of LTSS, especially those provided in nursing homes, is unaffordable for most middle-income families. The scorecard, along with related state case studies, has served as a blueprint for action, with many states now working to address problem areas.

The Dual Eligibles Initiative
About 9 million Americans are eligible for benefits from Medicare, the federal program that provides health coverage for older adults and younger people with severe disabilities, as well as Medicaid, the joint federal–state program that pays for both medical care and long-term services and supports for low-income individuals. Often referred to as the “dual eligibles,” this group represents a relatively small share of Medicare and Medicaid beneficiaries (16% and 15%, respectively). Because of their needs for a mix of medical care, behavioral health, and long-term care services, however, dual eligibles incur exceptionally high costs and account for disproportionate shares of spending in both programs. Some of the costs result not just from high use of services but also from inefficiencies caused by a lack of coordination in both payment and service delivery.

The Medicare–Medicaid Coordination Office within CMS, in conjunction with the new Center for Medicare and Medicaid Innovation, is authorized to study and address issues pertaining to dual eligibles. Its aim is to serve these beneficiaries better, assist health care providers, and help states develop an integrated approach to delivering and paying for the complex care beneficiaries need.

The Commonwealth Fund has also launched an initiative to help dual eligibles, with the goals of improving quality of care and care experiences and reducing overall costs. Several projects are already under way. Under the leadership of Eric Carlson, J.D., the National Senior Citizens Law Center is examining the experiences of states that received a waiver from the federal government so they may use Medicaid funds to pay for assisted-living services for dual eligibles. While the waivers are intended to allow beneficiaries to avoid the institutionalized settings of nursing homes, there are considerable downsides. Most important is that federal nursing home standards do not apply to assisted-living facilities, meaning consumer protections are comparatively slight. In an article in ElderLaw Report (Dec. 2011), Carlson outlined strategies that elder law attorneys can use to advocate for assisted-living clients when their rights are compromised, such as when facilities require residents to pay the private-pay rate for a period before accepting Medicaid reimbursement—a clear violation of federal Medicaid law.

With support from The Commonwealth Fund and the SCAN Foundation, the Center for Health Care Strategies is continuing to provide technical assistance to 12 states as they develop plans for an integrated system of care for dual-eligible beneficiaries and submit them for CMS approval. Through face-to-face meetings, conference calls, and Web-based educational sessions, state officials are able to share ideas, discuss common challenges, and learn about ways to deliver seamless care.

A number of states are turning to capitated managed care as a way to contain costs and integrate care systems for dual eligibles. While the potential for better care coordination is significant, an already vulnerable population may be at risk if strong beneficiary protections for independence and choice of service setting are lacking. Recognizing the importance of consumer input, CMS requires states to involve consumers in the implementation of managed care programs. Fund grantee Kevin Prindeville, from the National Senior Citizens Law Center, has created a Web site (www.dualsdemoadvocacy.org) to provide consumer groups with informational resources and concrete recommendations that will enable them to engage constructively with state governments to ensure adequate safeguards.

Future Directions

In addition to continuing its support for person-centered care and performance improvement in nursing homes, the Fund’s Program on Long-Term Care Quality Improvement is supporting a number of projects aimed at improving care coordination and transitions for patients. For example:

  • David Casserett, M.D., of the University of Pennsylvania is working with 14 hospices to identify best practices in the care of seriously ill nursing home residents. His goal is to pinpoint strategies and methods that strengthen the nursing home–hospice relationship and ensure that residents receive the best care possible, without being transferred to a hospital.
  • Over the next year, the Fund will closely coordinate its work on dual eligibles with the Medicare–Medicaid Coordination Office, the Center for Medicare and Medicaid Innovation, and individual states in order to identify, evaluate, and spread innovations that improve care and lower costs—without putting beneficiaries in jeopardy. Attention will be given to smaller providers that are recognized for delivering high-quality care; keeping the essential features of these high-performing plans intact while they are brought to scale may represent the most feasible way to improve dual-eligible care and lower its cost. Carol Raphael, former CEO of the Visiting Nurse Service of New York, and Penny Feldman, Ph.D., director of its Center for Home Care Policy, will form a learning collaborative for plan and provider leaders to address the organizational challenges that must be resolved for this to occur.