In the Literature
The long-term care sector—like the health care industry overall—has begun to recognize the importance of collecting and using data to improve the quality and outcomes of care. According to a comprehensive study of work completed in the last 20 years, the current crop of quality measures and information systems has already begun to transform nursing homes and home health agencies, though there is still much room for improvement.
In Improving the Quality of Long-Term Care With Better Information, (Milbank Quarterly, September 2005) Vincent Mor, Ph.D., of the Brown University School of Medicine, argues that measurement of long-term health care quality needs to be more consistent; easier to monitor and measure using objective standards; less prone to error; and more reliable. After examining the work of long-term care advocates, consumers, practitioners, insurers, and regulators, Mor concludes that further research is still needed to learn how consumers use quality information and how these efforts could improve the outcomes of care.
As hospital stays grow shorter, nursing homes and home health agencies are taking on a greater share of the long-term care of ill and elderly Americans. Mor reviews the current literature on this subject, with an eye to answering the following questions: How reliable and valid are the data used to develop quality measures? How applicable are these measures to the diverse populations served? If providers improve care, will outcomes improve as well? Are the current quality measures consistent with consumers' interests? How can we establish benchmarks of quality?
In the Beginning
Quality improvement in long-term care really got off the ground during the mid-1980s and early 90s. Nursing home research conducted by the Institute of Medicine (IOM), under the leadership of Sidney Katz, led to 1987's Nursing Home Reform Act, which mandated clinical assessments that would provide guidelines for the care of nursing home residents.
The resulting minimum data set (MDS), introduced nationally in 1991 and upgraded in 1996, was the first standardized, nationally applied instrument for clinical care planning in nursing homes. It was a product of the work of hundreds of experts from academia, geriatrics, psychiatry, nursing, physical and occupational therapies, nutrition, social work, and residents' rights groups.
At the same time, researchers at the University of Colorado delved into quality among home health agencies, developing a system for monitoring quality of care called the Outcome and Assessment Information Set (OASIS) data set. In 1999, OASIS was adopted by Medicare to record uniformly information about all Medicare beneficiaries using home health services.
Despite these advances, a 2001 IOM report noted a distinct lack of progress in improving care in nursing homes, and raised questions regarding the adequacy of data used to make measurements. In fact, according to Mor, the whole idea of extrapolating quality from the data gathered is still problematic. Differences in measured quality among facilities may indicate substantive differences in patient experience—or they could be the result of variation in data collection methods.
Furthermore, it is difficult to document detailed care processes solely in written records, and Mor cites researchers who repeatedly found that care observed in nursing homes did not necessarily match the data found in records. One method of reducing variations, Mor suggests, is to provide better training for staffers who perform the MDS and OASIS evaluations and to audit records systematically and observe care being delivered.
Putting Long-Term Care Data to Work
Despite these problems, the IOM recommended promoting public reporting of quality information as an inducement to improvement. This led the Centers for Medicare and Medicaid Services to create the Nursing Home Compare Web site in 2002 and the Home Health Compare site in 2004. While both sites make the data available and accessible, many clinicians and consumer advocates say they do not capture essential information, like quality-of-life or the level of satisfaction experienced.
Mor also finds that while there is substantial interest in this kind of quality information, it is still unclear who is looking at the Web sites and whether, or how, the information informs consumer decision-making. Another important audience for the sites, says Mor, is hospital discharge planners. As most patients are admitted to nursing homes and home health agencies directly from hospitals, having valid quality information could influence transfer and treatment plans and help to reduce readmission to the hospital.
The adoption of uniform, clinically relevant patient information systems has already begun to transform the nursing home and home health agency industries, says Mor. By continually feeding back quality performance data, long-term care leaders can examine, change, and improve their current practices. In addition, by publicly reporting this information, even more providers are motivated to improve—prompted by either local competition or fear of what consumers might discover on public Web sites. Nursing home chains are also using quality improvement approaches and competition to stimulate action. Leaders in the nursing home industry, says Mor, are beginning to believe they have the necessary tools to make changes and improve quality of care.
Facts and Figures:
- Standardized, mandatory, patient assessment systems are computerized in all U.S. nursing homes and home health agencies serving Medicare and Medicaid beneficiaries.
- Almost all states' quality improvement organizations have created or adapted quality improvement training materials for the nursing home industry (Kissam et al. 2003).
- Hospital discharge planners could facilitate patients' transition from hospital to long-term care facility by making greater use of quality data. One study found that predischarge assessment, education, and appropriate follow-up reduced hospital readmission by 12 to 75 percent (Ben-bassat and Taragin 2000).