5 measurable quality initiatives form core of CMS Action Plan

CMS recently issued its 2012 Action Plan for Further Improvement of Nursing Home Quality. The Action Plan, which was distributed to state survey agency directors, highlights the continued movement by CMS toward empirically based healthcare and outcome management. As nursing homes compete in the post-reform environment for new direct patient admissions and more hospital discharges, several data-driven tools—from Five Star rankings to hospital readmission benchmarks—that form the core of CMS’ focus on quality will be critical to nursing homes’ success. The Action Plan details CMS’ efforts to continue to improve nursing home safety and quality, organized into the following five actionable strategies:

1. Enhance consumer engagement
2. Strengthen survey processes, standards and enforcement
3. Promote quality improvement
4. Create strategic approaches through partnerships
5. Advancing quality through innovation and demonstration

Several key aspects of each of these action items—many of which have already been implemented—are discussed in more detail below.

ENHANCE CONSUMER ENGAGEMENT

As part of its continued efforts to involve individuals as active and informed participants in their care, CMS has redesigned the Nursing Home Compare website to make it easier to use and understand. Seven quality measures derived from MDS 3.0 data will be added to the website. Additionally, CMS will evaluate other quality measures for inclusion on the website, focusing particularly on measures of hospitalization, discharge to community and functional status improvement. CMS will also post on the Nursing Home Compare website nursing home staffing data taken from payroll reporting, and CMS will develop a prototype system for the collection of payroll-based staffing data. Utilizing the new transparency reporting requirements under the Affordable Care Act, CMS has posted nursing home ownership information as well. For a summary of the redesigns that have already been implemented this year, see CMS’ July 19, 2012 notice.

STRENGTHEN SURVEY PROCESS, STANDARDS AND ENFORCEMENT

CMS is planning several initiatives to improve the effectiveness of annual nursing home surveys and complaint investigations. The State Operations Manual and the Interpretive Guidance to Surveyors for Long Term Care Facilities continue to be revised. In 2012, new guidance will be released for feeding tubes, end of life and advance directive tags. 

To address a one percent decrease in the percentage of surveys being completed under the State Performance Standards System during 2010 and 2011, CMS is generating a quarterly report on performance to help regional offices identify states that are in the early stages of falling behind on the completion of surveys, so that early interventions can be initiated.

Also, in the winter of 2012, CMS plans to publish final guidance regarding the collection of civil money penalties prior to appeal. In that same timeframe, CMS will conduct a data analysis of the frequency and amounts of penalties to determine trends and outliers.

Finally, a program for conducting state and national background checks on job applicants who will have direct access to residents is ongoing and is scheduled to be evaluated by the Office of Inspector General in 2013. 

PROMOTE QUALITY IMPROVEMENT

CMS’ initiative to broaden quality activities in nursing homes continues with the national rollout of the Quality Assurance Performance Improvement (QAPI) program. Tools and technical assistance are now available to all nursing homes via an online resource library, which will help facilities upgrade their current QAPI programs.

The high incidence of healthcare-acquired infections is an area of ongoing concern, and CMS plans to address this issue on several fronts. In 2012, CMS, in partnership with the Centers for Disease Control, will conduct an in-depth study to identify infection control initiatives in each state and to use this information to train nursing home surveyors. 

CMS has also targeted initiatives in 2012 to address the use of antipsychotic medications in nursing homes. These include (i) the publication of rates of antipsychotic drug use on Nursing Home Compare, (ii) training for surveyors, providers, and prescribers, and (iii) the revision of guidance for surveyors. This effort began in May with CMS’ announcement of its Partnership to Improve Dementia Care.

CREATE STRATEGIC APPROACHES THROUGH PARTNERSHIPS

According to CMS, quality care is best achieved when there is collaboration among the many individuals and organizations working to attain that goal. To that end, in August 2012, CMS launched a National Nursing Home Quality Care Collaborative focused on preventable healthcare-acquired conditions. Other activities in this arena are ongoing and include: quarterly meetings with states; active participation in the Advancing Excellence in America’s Nursing Homes Campaign; and collaboration with Medicaid and community-based partners on LTC rebalancing. 

ADVANCING QUALITY THROUGH INNOVATION AND DEMONSTRATION

The Nursing Home Value Bases Purchasing (NHVBP) Demonstration Project began in July 2009. Calculations from the first year of the project have been completed and, as a result, incentive payments were awarded to 30 nursing homes. CMS is currently making performance calculations for the second year of the project. 

In August, CMS began an Initiative to Reduce Avoidable Hospitalizations Among Nursing Home Residents. In carrying out this initiative, CMS is partnering with independent, non-nursing facility organizations to implement evidence-based interventions that reduce avoidable hospitalizations. The initiative is expected to last until August 2016. 

CONCLUSION

For nursing home providers, the time to focus on measurable quality indicators is now. As its Action Plan makes clear, CMS is targeting empirical, data-driven care as part of its survey, rankings and payment programs. Like nursing home ownership information, this data will be transparent and available to consumers and hospital discharge planners. With hospitals potentially being penalized for avoidable readmissions, it is clear that those nursing homes with the best measurable quality care will be the winners in this post-reform system.

Jason Bring

Jason E. Bring, Esq., is a member of the Healthcare Group of Arnall Golden Gregory LLP. Bring defends nursing facilities in medical liability and False Claims Act cases, as well as assists them in regulatory and reimbursement issues.