Objectives: The National Academies of Sciences, Engineering, and Medicine (NASEM) Nursing Home Quality report recommends that states “develop and operate state-based…technical assistance programs…to help nursing homes…improve care and…operations.” The Quality Improvement Program for Missouri (QIPMO) is one such program. This longitudinal evaluation examined and compared differences in quality measures (QMs) and nursing home (NH) characteristics based on intensity of QIPMO services used.

Design: A descriptive study compared key QMs of clinical care, facility-level characteristics, and differing QIPMO service intensity use. QIPMO services include on-site clinical consultation by expert nurses; evidence-based practice information; teaching NHs use of quality improvement (QI) methods; and guiding their use of Centers for Medicare and Medicaid Services (CMS)-prepared QM comparative feedback reports to improve care.

Setting and Participants: All Missouri NHs (n = 510) have access to QIPMO services at no charge. All used some level of service during the study, 2020–2022.
Methods QM data were drawn from CMS’s publicly available website (Refresh April 2023) and NH characteristics data from other public websites. Service intensity was calculated using data from facility contacts (on-site visits, phone calls, texts, emails, webinars). NHs were divided into quartiles based on service intensity.

Results:All groups had different beginning QM scores and improved ending scores. Group 2, moderate resource intensity use, started with “worse” overall score and improved to best performing by the end. Group 4, most resource intensity use, improved least but required highest service intensity.

Conclusions and Implications: This longitudinal evaluation of QIPMO, a statewide QI technical assistance and support program, provides evidence of programmatic stimulation of statewide NH quality improvements. It provides insight into intensity of services needed to help facilities improve. Other states should consider QIPMO success and develop their own programs, as recommended by the NASEM report so their NHs can embrace QI and “initiate fundamental change” for better care for our nation’s older adults.

Rantz, M.J., Martin, C., Zaniletti, I., Mueller, J., Galambos, C., Vogelsmeier, A., Popejoy, L., Thompson, R.A., & Crecelius, C. (2024). Longitudinal evaluation of a statewide Quality Improvement Program for Nursing Homes. Journal of the American Medical Directors Association. Published online January 31, 2024.

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Background: Nursing home residents with end-stage renal disease (ESRD) are an understudied, yet growing population within nursing homes.

Purpose: To describe hospital transfers for nursing home residents diagnosed with ESRD and receiving hemodialysis.

Methods: Data were analyzed for residents with ESRD transferred to the hospital between October 2016 and September 2020 (n = 219). Descriptive statistics, bivariate  analyses, logistic regression, and content analysis were used for analysis. (more…)

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Injuries, infections, behavioral incidents and family insistence often drive hospital admissions among nursing home residents, and a new study finds many of those transfers may be unavoidable.

Researchers: More hospital admissions are ‘unavoidable’ than previously thought – McKnight’s Long-Term Care News

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The way the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, inequitable, fragmented, and unsustainable. The failings of the US healthcare system regarding nursing homes are reflected in poor resident outcomes, substantial government spending, pervasive inequities, and an underpaid and demoralized workforce (Konetzka, Yan, & Werner, 2021; Sloane et al., 2021; Travers, Agarwal, et al., 2021; Travers, Teitelman, et al., 2020; Yang, Yong, & Scott, 2022). Between the years of 2013 and 2017, 82% of nursing homes were cited for an infection prevention and control deficiency (U.S. Government Accountability Office, 2020). Consequently, it is no surprise residents and those working in the nursing home sector suffered greatly under the weight of the coronavirus disease 2019 (COVID-19) pandemic. Images of isolated residents languishing day after day, reports of infections fomented by lack of personal protective equipment, the deaths of over 150,000 residents, and stories of underpaid staff working in unsafe conditions with little respite, recognition, or support, have plagued news feeds for over 2 years. And yet, many underlying problems related to how the United States finances and regulates nursing home care have existed for decades in nursing homes without timely and critical legislative intervention. Four reports produced by the Institute of Medicine, now the National Academies of Sciences, Engineering, and Medicine (NASEM), proposed solutions for improving care delivery in nursing homes (Instituteof Medicine [IOM] Committee on Nursing Home Regulation, 1986; IOM Committee on Improving Quality in Long-Term Care, Wunderlich, & Kohler, 2001; IOM Committee on the Adequacy of Nursing Staff in Hospitals and Nursing Homes, Wunderlich, Sloan, & Davis, 1996; IOM Committee on the Future Health Care Workforce for Older Americans, 2008). Some led to significant changes, such as the passage of OBRA 1987, and promulgation of new standards; however, none have resulted in change that eradicated these fundamental problems. Immediate action to initiate meaningful change is necessary.

Travers, J.L., Alexander, G., Bergh, M., Bonner, A., Degenholtz, H.B., Ersek, M., Ferrell, B., Grabowski, D.C., Longobardi, I., McMullen, T., Mueller, C., Rantz, M., Saliba, D., Sloane, P., & Stevenson, D.G. (2023). 2022 NASEM quality of nursing home report: moving recommendations to action. Public Policy & Aging Report. 33(S1), S1-S4.

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The National Academies of Sciences, Engineering, and Medicine (NASEM) Committee on the Quality of Care in Nursing Homes had a broad mandate: to examine how the United States“delivers, finances, measures, and regulates the quality of nursing home care”(National Academies of Sciences, Engineering, and Medicine,2022,p. xvii). The resultant goals and associated recommendations encompass a broad array of strategies and actors needed to improve the quality of care. At their core are a vision and guiding principles that, if enacted, the Committee asserts will transform the day-to-day delivery of care: “nursing home residents receive care in a safe environment that honors their values and preferences, addresses goals of care, promotes equity, and assesses benefits and risks of care and treatments”(NationalAcademies of Sciences, Engineering, and Medicine,2022,p. 498i). Care delivery must be person-centered: that is, care that meets the unique needs, goals, values, and preferences of residents

Rantz, M. & Ersek, M. (2023). Care delivery, quality measurement, and quality improvement in nursing homes: Issues and recommendations from the National Academies’ report on the quality of care in nursing homes. Journal of the American Geriatrics Society, 71(2), 329-334.

Rantz, M. & Ersek, M. (2023). Care delivery, quality measurement, and quality improvement in nursing homes: Issues and recommendations from the National Academies’ report on the quality of care in nursing homes. Public Policy & Aging Report, 33(S1), S11-S15.

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Mueller, C.A., Alexander, G., Ersek, M., Ferrell, B., Rantz, M., & Travers, J. (2023). Calling all Nurses – Now is the time to take action on improving the quality of care in nursing homes. Nursing Outlook. Published online: January 6, 2023.

For a number of decades, nurses have raised concerns about nursing-related issues in nursing homes (NH) such as inadequate registered nurse (RN) staffing, insufficient RN and advanced practice registered nurse (APRN) gerontological expertise, and lack of RN leadership competencies. The NASEM Committee on the Quality of Care in Nursing Homes illuminated the long-standing issues and concerns affecting the quality of care in nursing homes and proposed seven goals and associated recommendations intended to achieve the Committee’s vision: Nursing home residents receive care in a safe environment that honors their values and preferences, addresses goals of care, promotes equity, and assesses the benefits and risks of care and treatments. This paper outlines concrete and specific actions nurses and nursing organizations can take to ensure the recommendations are implemented.

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Context: In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only).

Methods: Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality.

Findings: Three key components were necessary for successful implementation of the Initiative—staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations.

Conclusions: Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations.Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve

Tyler, D.A., Feng, Z., Grabowski, D.C., Bercaw, L., Segelman, M., Khatutsky, G., Wang, J., Gasdaska, A., & Ingber, M.J. (2022). CMS initiative to reduce potentially avoidable hospitalizations among long‐stay nursing facility residents: lessons learnedThe Milbank Quarterly, 100(4), 1243-1278.

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Purpose: To identify leadership styles and staffing strategies in Missouri long-term care (LTC) facilities that stood out among their peers as “positive deviants” with regard to COVID-19 infections and staffing shortages.

Methods: Statewide survey of all LTC facilities to identify exemplar facilities with stable staffing and low rates of COVID-19. Interviews with senior leaders were conducted in 10 facilities in the state to understand the strategies employed that led to these “positive outliers.” A result-based educational program was designed to describe their actions and staff reactions.

Results: Exemplar leaders used transformational leadership style. Top reasons for their success were as follows: (1) trusting and supportive staff relationships; (2) positive presence and communication; and (3) use of consistent staffing assignments. Strong statewide participation was noted in the educational programs.

Martin, N., Frank, B., Farrell, D., Brady, C., Dixon-Hall, J., Mueller, J., & Rantz, M. (2022). Sharing lessons from successes – long-term care facilities that weathered the storm of COVID-19 and staffing crises. Journal of Nursing Care Quality, 38(1), 19-25.

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The National Academies of Sciences, Engineering, and Medicine (NASEM) convened a committee in Fall 2020 to address the quality of nursing home care with three specific tasks: (1) examine how our nation delivers, regulates, finances, and measures the quality of nursing home care; (2) delineate a framework and general principles for improving the quality of care in nursing homes; and (3) consider the impact of the coronavirus disease 2019 (COVID-19) pandemic on nursing home care. The Committee comprised 17 members, including six nurses. Over a period of 18 months, the Committee held numerous meetings, including public forums with key stakeholders, conducted extensive reviews of the evidence, and produced a report with seven goals along with recommendations specific to those goals. The complete report is available in print and online (NASEM, 2022). The following discussion describes the seven goals, which address Tasks 1 and 2. With regard to Task 3, the Committee’s conclusion was that the COVID-19 pandemic made evident the long-standing deficiencies in nursing home care in the United States. As a family caregiver stated in her testimony to the committee, “The pandemic has lifted the veil on what has been an invisible social ill for decades.” The pandemic resulted in high rates of mortality for residents and staff and shed light on each area described in the Committee’s recommendations.

Alexander, G.L., Travers, J., Galambos, C., Rantz, M., Ferrell, B., & Stevenson, D. (2022). Strategic recommendations for higher quality nursing home care in the United States: The NASEM report. Journal of Gerontological Nursing, 48(11), 3-6.

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Study also found those with ‘full-code’ status regarding end-of-life care more likely to have repeat transfers than those with ‘do-not-resuscitate’ status.

Nursing homes transfer roughly 25% of their residents to the hospital at least once, at a cost of $14.3 billion to Medicare, according to a federal report by the Office of Inspector General.

But a new study by the University of Missouri discovered the number of repeat transfers are much higher for Black nursing home residents and those under age 65.

In one of the few studies to analyze the demographics of nursing home residents who get repeatedly transferred to the hospital, Amy Vogelsmeier, an associate professor in the MU Sinclair School of Nursing, found that Black nursing home residents, those under age 65 and those with “full-code” status were significantly more likely to be transferred to the hospital, at least four times or more in a given year.

“Black Nursing Home Residents, Those under Age 65 More Likely to Have Repeat Transfers to Hospital, MU Study Finds.” ShowMeMizzou, 1 July 2022, https://showme.missouri.edu/2022/black-nursing-home-residents-those-under-age-65-more-likely-to-have-repeat-transfers-to-hospital-mu-study-finds/. Accessed 5 July 2022.

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