Impact of the Minnesota Performance-Based Incentive Payment Program (PIPP) on the Quality of Nursing Home Care

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1 Impact of the Minnesota Performance-Based Incentive Payment Program (PIPP) on the Quality of Nursing Home Care Academy Health Annual Research Meeting 2012 June 26, 2012 Teresa Lewis MN Department of Human Services

Care Academy Health Annual Research Meeting 2012 June

2 Co-Authors Greg Arling, PhD Indiana University Kathy Abrahamson, PhD, RN Western Kentucky University Valerie Cooke, BA, BS MN Dept. of Human Serv. Anthony Perkins, MS Indiana University Christine Mueller, PhD, RN, FAAN U of MN, School of Nursing

3 Background Traditional regulatory model not sufficient to improve NH quality Conventional pay-for-performance (P4P) may not be sufficient either Little evidence of effectiveness for regulatory or conventional P4P approaches New model of shared responsibility and collaboration Government agency cannot alone impact the quality of nursing home services Explore innovative strategies in partnership with nursing home providers

conventional P4P approaches New model of shared responsibility and collaboration Government agency cannot

4 Minnesota Performance-Based Incentive Payment Program (PIPP) Established by MN Legislature $18 Million annually ($6.7 Million state share) Administered by DHS Competitive application process Nursing homes design quality improvement projects: Identify problem Develop evidence-based intervention Receive up to 5% of per diem rate for 1 3 years (~$65,000/year in 100-bed facility) Achieve outcome goals for full payment Include sustainability plan

improvement projects: Identify problem Develop evidence-based intervention Receive up to 5% of per diem rate

5 PIPP Goals Provide better quality care more efficiently Encourage nursing facilities to experiment and innovate Equip facilities with organizational tools and expertise to improve their quality Motivate facilities to invest in better care Disseminate successful PIPP strategies throughout the nursing home industry

tools and expertise to improve their quality Motivate facilities to invest in

6 AHRQ Research & Demonstration Project Collaboration between Indiana University University of Minnesota Minnesota Department of Human Services Evaluation and dissemination in tandem Translation of research findings into practice

Minnesota Department of Human Services Evaluation and

7 Mixed Method Approach Qualitative analysis Site visits, interviews, surveys 18 Projects in 140 NHs Organizational assessment and business case analysis Quantitative analysis Cost effectiveness and potential cost savings PIPP participation Better care outcomes?

assessment and business case analysis Quantitative analysis Cost

8 Key Questions What NHs participate? What types of projects are they carrying out? Is PIPP elevating care quality? What are PIPP s impacts on NH organization and culture?

9 PIPP vs. Other MN NHs at Baseline (2006) Significant differences PIPP NHs larger, non-profit, heavier case mix, urban No difference in other facility characteristics Staffing, operating costs, reimbursement rates No difference in quality measures Quality of care, quality of life, regulatory deficiencies, staff retention

non-profit, heavier case mix, urban No difference in other facility

10 Many Project Foci # of Projects

11 Broad Range of Targeted Outcomes # of Projects

12 Did PIPP bend the quality curve? Interrupted time series Trends in NH care quality before and after PIPP Did PIPP NHs show greater improvement than comparison NHs? Did improvement coincide with PIPP participation?

13 Outcome for this Analysis MN Clinical Quality Indicators (QIs) QI-100 Score: 24 QIs across 10 domains Each domain = 10 points Range Extensively risk-adjusted Updated quarterly

10 domains Each domain = 10 points Range 0

14 QI-100 Score 10 Domains Psychosocial Restraints Psychotropic Meds Continence Infections Skin Care Nutrition Functioning Accidents Pain 24 QIs (Number per Domain) Behavior and Depression (3) Restraints (1) Anti-psychotics (1) Bowell & Bladder (6) UTI and Other infections (2) Pressure Sores (2) Weight loss (1) ADLs, Mobility, ROM (5) Falls & Other Accidents (2) Pain (1)

(3) Restraints (1) Anti-psychotics (1) Bowell & Bladder (6) UTI and Other infections (2)

15 Mixed Effect Growth Model Quarterly QI-100 score = Time (quarter) + Period (Pre/Post PIPP) + PIPP Category (PIPP, Non-PIPP, Project Type) + INTERACTIONS + Facility Random Effect Focus on 3-way interaction: Time X Pre/Post Implementation X PIPP category Control for facility covariates: non-profit, urban, case mix, size

Facility Random Effect Focus on 3-way interaction: Time X Pre/Post

16 Broad Impact across QI Domains 75 Average NH Quality Indicator Score (0-100) PIPP Start PIPP NHs Other NHs 66 65

17 Impact Matches Project Timelines 75 Average NH Quality Indicator Score (0-100) Round 1 Start Round 2 Start Round 1 NHs Round 2 NHs Other NHs

18 Clinical Projects Improve Multiple QIs Among 20 QIs in the QI-100 Non-PIPP facilities showed no improvement PIPP Facilities doing clinical projects improved in 6 QIs Other PIPP facilities improved in Behavior Problems Clinical Project Improvement (2007 vs. 2010) 9% 11% 7% 9% 9% 26%

clinical projects improved in 6 QIs Other PIPP facilities improved in

19 What have we learned? Significant PIPP impact on NH care quality across Multiple QI domains Variety of project types Different types of facilities

20 Early Qualitative Findings Facilitators Education Leadership Experimentation Communication Teamwork Better efficiency Seeing positive results/data Staff knowledge/competence Better relationships Teamwork Better efficiency Resident satisfaction Better quality of care/life Better public perception Successes Challenges Change New routines Perception of more work Communication Resources (time, staff, space) Quality measures Get leadership support Involve others from start Enlist enthusiastic staff Choose measures carefully Communicate widely/often Regularly evaluate progress Don t give up! Advice or Do-Overs

Successes Challenges Change New routines Perception of more work Communication Resources (time, staff, space) Quality measures Get leadership support

21 Challenges Administering PIPP Sustaining projects and achievements Expanding participation Demonstrating PIPP s fiscal impact

22 We re not afraid to go out and strive for something else something that we probably wouldn t have looked at before. Nursing home PIPP project staff member

23 For More Information Greg Arling, PhD Associate Professor of Medicine Scientist, Indiana University Center for Aging Research & Regenstrief Institute Valerie Cooke, BA, BS Nursing Facility Rates and Policy Division Minnesota Department of Human Services

Quality-Based Nursing Home. Issues and Opportunities

Quality-Based Nursing Home. Issues and Opportunities Quality-Based Nursing Home Reimbursement: Issues and Opportunities Greg Arling, PhD Associate Professor and Scientist School of Medicine Department of Medicine Division of General Internal Medicine and