AMERICAN HEALTH CARE ASSOCIATION 2012 QUALITY REPORT

Transcription

1 AMERICAN HEALTH CARE ASSOCIATION 2012 QUALITY REPORT

2 Improving Lives by Offering Solutions for Quality Care. AHCA advocates for quality care and services for frail, elderly and disabled Americans, serving as the nation s largest association of long term and post-acute care providers. Our members provide essential care to approximately one million individuals in 8,690 not-for-profit and proprietary member facilities. AHCA represents the long term care community to the nation at large to government, business leaders and the general public. We serve as a force for change, providing information, education and administrative tools that enhance quality at every level.

3

4 A NEW DAWN IN AMERICA S SKILLED NURSING CARE CENTERS The long term and post-acute care profession is focused on providing quality care to America s seniors, individuals with disabilities and those who require post-acute care. Quality improvement is a journey involving an ongoing commitment to continually raising the bar on performance expectations. Skilled nursing care centers are no exception. We continue to look for new, better ways to enhance the lives of our residents and their experience in our facilities. This year the long term and post-acute care profession turned a new page on what it means to provide quality care. As the largest association representing our profession, the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) launched our own Quality Initiative. This bold, new effort is unlike any before. We have set specific, measurable targets for our members to meet over the course of the next three years. Our skilled nursing goals include: Safely Reduce Hospital Readmissions: By March 2015, reduce the number of hospital readmissions within 30 days during a skilled nursing facility (SNF) stay by 15 percent. The Quality Initiative builds upon much of the work facilities are already doing, but we wanted to further encourage centers nationwide to demonstrate progress through quantifiable goals. There is no single definition of quality care, but one crucial way to look at quality is through data. This report contains the most comprehensive and current data available about the quality of care in skilled nursing care centers. It sets the current benchmarks for our profession and allows us to analyze how we can improve moving forward. While the 2012 Quality Report paints a clear picture of the state of care, it is important to remember that behind the numbers and the charts are real people: our parents or grandparents, our heroes from the Greatest Generation and our friends living with disabilities. They have turned to a skilled nursing care center because they had needs that neither a hospital, nor family and friends, nor home- and community-based service providers could meet. We are honored to serve them and we look forward to continuing to improve the quality of care they receive in our centers each and every day. Increase Staff Stability: By March 2015, reduce turnover among nursing staff (RN, LPN/LVN, and CNA) by 15 percent. Increase Customer Satisfaction: By March 2015, increase the number of customers who would recommend the facility to others up to 90 percent. Safely Reduce the Off-Label Use of Antipsychotics: By December 2012, reduce the offlabel use of antipsychotic drugs by 15 percent. Neil Pruitt, Jr. Chair, AHCA Board of Governors When we achieve the goals of the AHCA/NCAL Quality Initiative, hundreds of thousands of lives will have been improved residents will have more fulfilling experiences and staff will be more empowered in their professions.

5 TABLE OF CONTENTS Executive Summary 2 The Long Term Care Community 7 Who We Care For 8 Workforce 11 Nursing Facility Staffing 12 Staff Turnover and Retention 12 American Health Care Association Members 16 AHCA Quality Initiative and Activities 17 AHCA Quality Initiative 17 Safely Reduce Hospital Readmissions 17 Increase Staff Stability 19 Increase Customer Satisfaction 21 Safely Reduce the Off-Label Use of Antipsychotics 21 AHCA Programs that Advance Performance 22 Long Term Care Trend Tracker 22 The Advancing Excellence in America s Nursing Homes Campaign 24 AHCA/NCAL National Quality Award Program 25 Trends in Quality 28 Skilled Nursing Facility Quality Measures 28 Regulatory Compliance Measures 29 Five-Star Rating 32 Customer Satisfaction 32 Employee Satisfaction 33 Trends in Payment for Quality 36 State Value-Based Purchasing Programs 36 Value-Based Purchasing Measurement 37 Tying Measurement to Incentive Payments 38 Managed Care 38 Skilled Nursing Reimbursement in Medicaid Managed Care 38 Medicare Advantage Prescription Drug Plans 39 Medicare Value-Based Purchasing Demonstration 40 Patient Protection and Affordable Care Act 40 Accountable Care Organizations and Bundled Payments 40 Medicare-Medicaid Integration 41 Outlook 41 The Year Ahead 43 Appendix 44 References 51

6 EXECUTIVE SUMMARY As the nation s largest association of long term and post-acute care providers, the American Health Care Association (AHCA) represents a diverse group of providers that care for persons across the health care continuum. AHCA represents two-thirds of all for-profit facilities, one-third of not-for-profit facilities and one-third of government facilities in the country. AHCA members are committed to a quality-driven, innovative and efficient healthcare system that meets the needs and preferences of the individuals in our care. In that spirit and in an effort to keep members, policymakers and the public informed about the advancements in quality care, AHCA publishes the annual Quality Report. Compiled from both government reporting and AHCA research, the Quality Report offers an overview of the latest national trends in the profession (including comparing AHCA members to nonmembers), updated information on how skilled nursing facilities are performing on governmental quality measures, and information on current and forthcoming payment models connected to quality care. The Quality Report also highlights ongoing efforts in the long term and post-acute care profession to improve quality care and reports on the current status of those programs and initiatives. Three major trends are notable in this report: Growth of short-term skilled rehabilitation Improvements in quality across spectrum of measures Expansion of value-based purchasing programs Shift from Long-Term Care to Short-Term Rehabilitation Today s skilled nursing facilities care for two distinct populations. Facilities have long been known for providing care to individuals who need long term care because they can no longer live independently at home or in assisted living. However, in recent years, there has been a shift in the types of individuals served in this setting. Now, the majority of individuals served in skilled nursing facilities are people who need rehabilitation or skilled nursing care to complete their course of care following an acute illness. Of the 3.7 million individuals who received care in a nursing facility in 2009, only 854,000 resided in the facility for at least a year. Of the remaining 2.9 million, 80 percent were admitted for short-term rehabilitation covered by Medicare. Individuals with short-term admissions, on average, have greater needs for assistance with Activities for Daily Living and are less likely to have dementia compared to long-stay individuals. As a result of this shift, both the range of services provided by skilled nursing facilities and the acuity of illness of persons served has significantly increased over time. Chronic medical conditions are present in at least onequarter to one-third of all individuals receiving skilled nursing care, with most of these individuals living with multiple chronic conditions. The average case-mix index (a measure of severity of illness) has increased in nursing facilities each year. At the same time, AHCA members continue to be the leading providers of care and services for the nearly one million individuals who do reside in nursing facilities for the long term. For the majority of these individuals, Medicaid is the principal payer for their care. Compared to non-members, AHCA members serve a greater percentage of Medicaid beneficiaries people with very low incomes and minimal assets. Approximately 65 percent of the residents in AHCA-member facilities rely on Medicaid as the principal payer for their care, compared to 61 percent of residents in non-member facilities. Only 20 percent of individuals in member facilities pay for their care out-of-pocket, compared to 24 percent in non-member facilities. Improvements in Quality Quality in skilled nursing facilities is measured by the Centers for Medicare and Medicaid Services (CMS), states and research organizations on the basis of indicators including compliance with regulations, clinical outcomes, staffing levels and consumer satisfaction. Clinical outcome quality measures (QMs) are computed quarterly by CMS and publicly reported on its Nursing Home Compare website. In skilled nursing facilities nationwide, the average performance has improved in 12 of the 15 total QMs over the last five years. The most dramatic improvements were seen in QMs for post-acute care patients, with 29 percent improvement in the proportion of individuals with pressure ulcers and 12 percent improvement in those with pain. For long-stay residents, there has been a 56 percent reduction in the use of physical restraints. In 2010, AHCA members had better scores than non-members for nine of the 15 QMs.

7

8 4 AHCA Quality Report Executive Summary Overall staffing trends also show a steady increase in the amount of direct care nursing time per resident day for all levels of nursing staff including Registered Nurses (RNs), Licensed Practical and Vocational Nurses (LPNs/LVNs) and Certified Nursing Assistants (CNAs). In addition, turnover has decreased for all nursing staff in direct care roles, as well as for nurses with administrative duties and for all nursing staff in the aggregate over the past several years. In order to take part in the Medicare and Medicaid programs, skilled nursing facilities must comply with federal regulations. Compliance is assessed by state surveyors contracted by CMS. All of the reported measures for regulatory compliance showed improvement over the last five years. The average number of deficiencies has steadily declined and the number of facilities cited for Substandard Quality of Care or Immediate Jeopardy also showed an overall downward trend. At the same time, the proportion of skilled nursing facilities with deficiency-free surveys has increased. CMS also rates skilled nursing facilities through its Five-Star Rating System, which is incorporated into the Nursing Home Compare website. Since the implementation of the rating system at the end of 2008, the percentage of facilities receiving an overall rating of four or five stars has steadily increased to 43 percent of facilities in these two categories combined. The proportion of facilities receiving a one or two star rating has correspondingly decreased. The improvement in overall ratings is attributable to increases in staffing levels and improvement in quality measure performance. Additional key measures of quality care include satisfaction rates among customers (both residents and family members) and nursing facility employees. Since 2008, customer satisfaction ratings for long-stay residents and their families have remained stable at 89 percent and 87 percent respectively. While short-stay patient satisfaction ratings have lagged behind those of their long-stay counterparts, short-stay customer ratings have increased nine percentage points since 2008, from 78 percent to 87 percent in Despite an improvement in employee satisfaction rates for nurses and nursing assistants since 2005, their rate of satisfaction only reached 67 percent in 2011, demonstrating significant room for improvement. Tying Reimbursement to Quality The historic method of purchasing skilled nursing facility care using fee-for-service payment structures rewards providers with higher costs and higher volume, regardless of the quality of outcomes. However, in recent years, reimbursement trends across health care settings for both Medicare and Medicaid have begun to shift from payments based on volume and type of services provided to payments based on outcomes and quality. Payment methods intended to foster specific provider behaviors and better outcomes are often referred to as pay-for-performance or value-based purchasing (VBP) arrangements. In an effort to provide additional resources to skilled nursing facilities and further emphasize quality care for Medicaid beneficiaries, many states are exploring VBP programs. In 2012, 12 states with AHCA affiliates were operating these arrangements. So far, states have tested a variety of approaches to VBP with mixed results. Both Medicare and Medicaid managed care are rapidly replacing traditional fee-for-service arrangements as the dominant payment and service delivery systems. Many states with existing managed care programs are aggressively pursuing managed long term care expansions. Eleven states were operating some form of Medicaid managed long term care statewide or regionally in By 2014, approximately 26 states will have some form of Medicaid managed long term care. However, it is unclear at this point if and how managed care will incorporate VBP models. The Patient Protection and Affordable Care Act (ACA) established three national efforts with implications for quality incentive payments: Accountable Care Organizations (ACOs), bundled payments and Medicare-Medicaid integration efforts. All three of these initiatives are still unfolding and little detail is available on how or whether quality incentives for skilled nursing facilities may be included. However, all three seek to facilitate and encourage coordinated and integrated care and reward providers who improve quality while lowering cost, very likely impacting long term and post-acute care. Through two new entities established within CMS the Medicare-Medicaid Coordination Office (MMCO) and the Center for Medicare and Medicaid Innovation the ACA aims to better integrate the two programs for individuals who are eligible for both. Currently, 28 states are working with MMCO on some form of Medicare- Medicaid integration initiative.

9 AHCA Quality Report Executive Summary 5 Through improvements in a majority of quality measures, declines in citations, increases in staffing levels and improvements in customer satisfaction rates, skilled nursing facilities have demonstrated their commitment to improving quality of care. Conclusions People who receive care in skilled nursing facilities and their families have increasingly higher expectations for the quality of services provided. They are rightfully demanding excellent outcomes and maximum value. Skilled nursing facilities are well on their way to transforming their operations to meet the quality and value demands of their customers and of government payers. Through improvements in a majority of quality measures, declines in citations, increases in staffing levels and improvements in customer satisfaction rates, skilled nursing facilities have demonstrated their commitment to improving quality of care. This commitment has been accelerated by new collaborative efforts of the profession in partnership with government and other stakeholders. The Advancing Excellence in America s Nursing Homes (AE) campaign brings together a variety of the profession s stakeholders to activate and support skilled nursing facilities as they improve their performance in key clinical and organizational areas. Through AHCA s software tool LTC Trend Tracker SM, independent and small regional providers now have easy access to the kinds of key quality and operational information needed to examine and benchmark performance that were previously only available to larger skilled nursing care center chains. Additionally, AHCA is driving quality improvement through the AHCA/NCAL Quality Awards Program which establishes criteria and pathways and provides peer recognition for providers on their journey toward performance excellence. Finally, earlier in 2012, AHCA/NCAL launched the Quality Initiative, a member-wide challenge to meet specific, measurable targets in hospital readmissions, staff stability, customer satisfaction and the off-label use of antipsychotics. Taken together, the Quality Initiative offers the potential to dramatically improve outcomes and satisfaction for hundreds of thousands of individuals in long term and postacute care, all the while reducing health care costs. Medicare and Medicaid budgetary pressure will continue to drive policymakers and skilled nursing care providers to explore payment methodologies which offer the promise of greater accountability and efficiency. The quality efforts already underway by the profession are preparing skilled nursing care providers for payment reforms that are currently being evaluated by government entities. By continuing to expand their capacity to effectively manage, measure and monitor specific areas of care, providers will be better equipped to adjust to payment models based on quality of services and new organizational structures within the health care system.

10

11 THE LONG TERM CARE COMMUNITY As the baby boomers age, demands for long term care services are expected to grow. While home- and communitybased services have expanded nationally to help meet this growing demand, many individuals will still need long term care in a skilled nursing facility. Simultaneously, the need for short-term rehabilitation following acute illness and hospitalization is growing as the elderly live longer and are hospitalized for a wide range of illnesses. This section of the report examines trends in nursing facilities in light of these circumstances. The total number of nursing facilities and the total number of beds has essentially remained static over the past five years at approximately 15,700 facilities and 1.7 million total beds. The number of not-for-profit facilities has decreased 9.5 percent while there has been a 2.9 percent increase in the number of for-profit facilities. While a majority of facilities are classified as Table 1.1 for-profit, publicly traded companies 1 control only 6.8 percent of skilled nursing facilities nationally. Detailed trends from 2007 to 2012 in the number and types of facilities nationally are reported in Table 1.1 and Table A1. Overall, 69 percent of skilled nursing facilities serve urban communities, while only 31 percent are located in rural areas. For-profit and not-for-profit facilities are largely located in urban areas. Of urban facilities, approximately two-thirds are classified as for-profit and onequarter are classified as not-for-profit. Government facilities are more evenly divided between urban and rural locations with 42 percent of government facilities in urban areas while 58 percent are located in rural areas. Approximately 72 percent of for-profit facilities are located in urban areas, while 28 percent are in rural areas. In not-for-profit facilities, 68 percent are in urban locations while 32 percent are in rural locations (Table A2). The number of Medicare-certified beds has remained essentially unchanged over the last six years, but the number of Medicaid-only certified beds has declined by 44 percent (Table A1). This trend likely represents the payment levels associated with the Medicare and Medicaid programs. The Medicare Payment Advisory Commission s (Med- PAC) annual reports have consistently shown positive Medicare margins for skilled nursing facilities while Medicaid margins are negative (MedPAC, 2012). Given the average $19.95 per Medicaid 1 There are nine publicly traded companies among the top 50 chains in the country and include Ensign Group, Extendicare, Kindred Healthcare, National Healthcare Corp, Skilled Healthcare, Sun Healthcare Group, Advocat Inc., Brookdale Senior Living and Five Star Quality Care, Inc. (Provider, 2012) Long Term Care Community National Overview Number of Facilities (Total) 15,866 15,772 15,718 15,694 15,693 15,690 For-Profit 10,521 10,581 10,607 10,641 10,758 10,832 Not-for-Profit 4,382 4,244 4,199 4,145 4,030 3,968 Government Total Beds 1,717,691 1,713,059 1,709,468 1,708,355 1,705,921 1,705,165 Average Number of Beds (All) Occupancy Rate 89.0% 88.6% 88.0% 87.5% 87.0% 86.6% Number of Persons Served at Any Given Time 1,431,134 1,420,735 1,411,054 1,400,484 1,395,832 1,387,727 AHCA Analysis, CMS CASPER Data, various years

12 8 AHCA Quality Report The Long Term Care Community While home- and community-based services have expanded nationally to help meet this growing demand, many individuals will still need long term care in a skilled nursing facility. patient day shortfall in Medicaid skilled nursing care payment rates (Eljay, 2011), the declining trend in Medicaid-only beds is of little surprise. The average number of beds per facility has remained unchanged at 108. Forprofits on average have more beds per facility than not-for-profits (Table 1.1). Approximately 20 percent of facilities are small, with less than 60 total beds, while 20 percent have more than 140 beds (CMS CASPER data, March 2012). There is essentially no difference in average beds per facility when comparing multi-facility ownership with independently-owned facilities. On any given day, the number of individuals in skilled nursing facilities averages 1.4 million (Table A1). That number has declined by three percent since This translates into a steady decline in occupancy rates over a six-year period, from 89 percent in 2007 to 86.6 percent in This decline may reflect the shift to greater use and financing of home- and community-based services and assisted living during this time period. At any single point in time, Medicaid is the major payer for care in a skilled nursing facility, with an average of 64 percent of individuals being Medicaid beneficiaries. Private pay individuals constitute 22 percent of the payer mix and Medicare is 14 percent (Figure 1.1). However, these percentages do not reflect the payer mix of all residents receiving services over time as they only reflect individuals in a facility on any given day rather than all individuals being admitted to a facility over time. For-profit facilities are more likely than not-for-profit facilities to provide services to Medicaid beneficiaries. In for-profit facilities, 59 percent of individuals are Medicaid beneficiaries, compared to 46 percent in not-for-profit facilities. Government facilities have the highest percentage of residents who are Medicaid beneficiaries, at 65 percent. For-profit facilities are also more likely to provide services to individuals whose stay is covered by Medicare. In for-profit facilities, 13.7 percent of individuals use Medicare as the primary payer compared to 11.3 percent of residents in not-forprofit facilities. For-profit facilities are significantly less likely to have individuals paying privately. In not-for-profit facilities, 25 percent of residents are classified as private pay compared with only 17 percent in for-profit facilities (Figure 1.1). Medicare covers up to a maximum of 100 days of skilled nursing facility care as long as the person continues to demonstrate improvement from Medicare covered services. Approximately 67 percent of individuals have Medicare coverage for less than 30 days (MedPAC, 2010). To qualify for this benefit, the individual must have had a three-day inpatient hospital stay within the last 30 days and require daily skilled nursing care, such as wound care or intravenous therapy, or rehabilitation services, such as physical, occupational or speech therapy. On average, about 25 percent of all individuals admitted to a skilled nursing facility for rehabilitation services are discharged to home. The remaining individuals stay in the facility and either pay for services privately or through Medicaid coverage (MedPAC, 2012). Since Medicare pays only for short-term, post-acute care, Medicaid often pays for long-term stays in skilled nursing facilities. This explains why, on any given day, only 14 percent of individuals in skilled nursing facilities have their stay paid for by Medicare while 64 percent are paid by Medicaid. However, when examining all 2.9 million admissions to skilled nursing facilities, 80 percent had Medicare reimburse some or all of their stay (Table 1.2). This demonstrates that facilities have high turnover of individuals covered by Medicare as compared to individuals covered by Medicaid, who are staying for longer periods of time. In fact, only 854,000 individuals remain in a facility for at least one year despite nearly 2.9 million individuals being admitted to skilled nursing facilities each year (Table 1.2). WHO WE CARE FOR In the past, skilled nursing facilities cared primarily for individuals who could no longer live at home independently (e.g., long-stay residents). However, with greater pressure to shorten

13 AHCA Quality Report The Long Term Care Community 9 Figure 1.1 Primary Payer of Services For-Profit Principal Payer of Services Not-for-Profit Principal Payer of Services Government Principal Payer of Services 17% 14% 25% 11% 24% 8% 59% 46% 65% AHCA Analysis, CMS CASPER Data, March 2012 Medicare Medicaid Other Figure 1.2 Age Distribution Medicare Admissions Non-Medicare Admissions Long Stay Residents ( >12 Months) 33.4% 10.4% 29.0% 29.6% 44.4% 14.9% 56.2% 41.4% 40.7% AHCA Analysis, CMS MDS 2.0 data, 2009 Less than 64 years Between 65 and 84 years Greater than 85 years

14 10 AHCA Quality Report The Long Term Care Community hospital lengths of stay as well as the development of assisted living and the expansion of home- and communitybased service options, the types of individuals cared for in skilled nursing facilities has changed. There are now two distinct populations cared for in America s skilled nursing facilities: (1) individuals who need rehabilitation or skilled nursing care to complete their course of care following an acute illness (2) individuals who need long term care because they can no longer live independently at home or in assisted living As a result of the changing populations in skilled nursing facilities, both the range of services provided by these facilities and the acuity of illness of persons served has significantly increased over time. Tables 1.2 and A3 compare 2009 Medicare, non-medicare and longstay admissions. Medicare admissions include those that were admitted from an acute care hospital. Non-Medicare admissions may be admitted from the community or after a non-qualifying Medicare hospital stay. Long-stay residents include individuals that reside in the facility for at least one year. Short-stay individuals admitted on Medicare are significantly older at admission than non-medicare admissions and are more likely to be female. Short-stay individuals on Medicare are, on average, 78.5 years old at admission compared to non-medicare individuals who are 73.4 years old. Long-stay individuals residing in a facility for at least one year averaged 79.5 years old at admission. Individuals under the age of 65 are more likely to be non-medicare admissions, and only 15 percent of long-stay individuals are on under age 65. More than three-quarters of residents are classified as Caucasian in both short- and long-stay populations. This reflects the demographic characteristics of this age cohort in the United States (U.S. Census, 2010). A large proportion of individuals in skilled nursing facilities for both short- and long-stays have impaired functional status (Table 1.2). Dementia and incontinence are the leading reasons for needing long term care in a skilled nursing facility. Nearly one-third of short-stay admissions are living with a cognitive impairment like dementia but, as expected, nearly two-thirds of those who stay in a facility long-term have dementia. Similarly, persons admitted for rehabilitation are far less likely to be incontinent compared to long-stay residents. Those without dementia or incontinence are more likely to be discharged home following their post-acute stay. Table 1.2 Characteristics of Individuals Receiving Services in Nursing Facilities Medicare Admissions Non-Medicare Admissions Long-stay Residents ( >12 months) Total # Individuals 2,329, , ,358 Age Category Age (Average) Gender Male 36.6% 39.5% 29.3% Female 63.3% 60.4% 70.7% Functional Status Dementia 29.5% 38.0% 63.7% ADL Dependence 4.4% 4.2% 4.1% Require Assistance with Walking 90.9% 80.6% 76.0% Incontinence of Bladder 35.8% 39.6% 66.4% Require Assistance with Eating 28.3% 28.0% 35.6% AHCA Analysis, CMS MDS 2.0 data, 2009

15 AHCA Quality Report The Long Term Care Community 11 Individuals admitted to a skilled nursing facility for a short-stay have higher levels of activities of daily living (ADL) dependence than long-stay residents. Activities of daily living include five activities: getting in and out of bed, bathing, eating, dressing and using the bathroom. Long-stay residents, on average, are dependent in 4.1 out of the five ADLs while short-stay, on average, are dependent in 4.4 at admission. Shortstay residents also require more assistance with walking in the hallways. While 76 percent of long-stay residents require assistance to walk, more than 90 percent of short-stay residents need assistance. This is consistent with what would be expected. Short-stay individuals are often admitted to skilled nursing facilities for rehabilitation services to improve ambulation following treatment for an acute illness in a hospital. The average degree of assistance needed with ADLs for individuals in skilled nursing facilities has steadily increased each year (Figure 1.3), as has the average case mix, a measure of severity of illness (Figure 1.4). This reflects the changing population in skilled nursing facilities and the increasing care needs of this population. Chronic medical conditions are common in skilled nursing facilities. At least one of these conditions is present in onequarter to one-third of all individuals in skilled nursing facilities (Table A3). However, most individuals are living with multiple chronic conditions. Reflecting the functional limitations discussed above, most individuals admitted to skilled nursing facilities from the hospital receive speech, occupational or physical therapy (Table 1.3). Figure 1.3 Average ADL Dependence Trends in Resident ADL Dependence Computed by AHCA using CMS Nursing Facility CASPER standard health survey data. This measure for ADLs is obtained by taking the sum of residents that are somewhat (assisted and dependent combined) or fully dependent on staff for the five ADLs (dressing, bathing, transferring, toileting and eating) divided by the total number of residents. Figure 1.4 Average case mix index Average Case Mix Index AHCA analysis of CMS SNF PPS claims data, various years. Nearly one in four individuals receives all three services. Most individuals admitted to a skilled nursing facility following a hospital admission also have recently received or are receiving an intravenous (IV) medication. Both rehabilitation services and IV services are rarely required for long-stay residents (Table A3). WORKFORCE According to data from the U.S. Bureau of Labor Statistics (BLS), approximately 1.7 million workers were employed at skilled nursing facilities across the United States in 2010 (this does not include other types of long term care facilities, such as assisted living and other residential care facilities). Approximately one million people, including Registered

16 12 AHCA Quality Report The Long Term Care Community Table 1.3 Therapies Therapies received during stay Any Therapy (Speech, OT, or PT) Nurses (RNs), Licensed Practical and Vocational Nurses (LPNs/LVNs) and Certified Nursing Assistants (CNAs), provided nursing care to residents. Of these workers, the majority were CNAs. From 2005 to 2010, nursing facilities have provided a growing source of employment nationwide in all labor categories (Table A4). Nursing Facility Staffing Often cited as a key indicator of quality of nursing facility care, staffing is typically expressed in terms of hours of staff time per resident day. Over the past five years, as shown in data from CMS in Table A5 and Figure 1.5, the overall staffing trend shows a steady increase in the amount of direct care nursing time per resident for all levels of nursing staff. Overall nursing staff time per resident day across all three categories is up almost nine percent from 2007 to Medicare Admissions Non-Medicare Admissions Long-stay Residents ( >12 months) 92.4% 61.6% 8.9% Speech Therapy 24.9% 14.8% 1.9% Occupational Therapy 86.4% 54.4% 4.2% Physical Therapy 89.6% 58.5% 5.2% Combination of therapies received Speech & OT 23.5% 13.1% 0.5% Speech & PT 23.6% 13.3% 0.5% OT & PT 84.4% 52.2% 1.8% Speech, OT & PT 23.0% 12.6% 0.3% AHCA Analysis, CMS MDS 2.0 data, 2009 As part of the CMS Five-Star Quality Rating System - which has been available on since the end of 2008, allowing consumers to access and compare information about nursing facilities - a rating of between one and five stars is assigned to each facility for their staffing levels. The ratings are determined based on the overall number of nursing staff as well as the number of RN staff per resident day. These staffing levels are adjusted to take into account the acuity of individuals served in each facility. As shown in Figure 1.6, from 2009 to 2011 there has been a 19 percent increase in the proportion of facilities receiving a staffing rating of four or five stars. In 2011, 47.9 percent of facilities received either a four or five star rating, compared to 40.3 percent in Correspondingly, 22 percent fewer facilities were rated as one or two stars, with 39.5 percent receiving one or two stars in 2009 and 31 percent receiving the same in Staff Turnover and Retention AHCA conducts periodic nationwide staffing surveys available to all Medicare and/or Medicaid-certified nursing facilities, collecting annual retention and turnover information for all employees (except temporary and contract staff) who work(ed) in skilled nursing facilities. In 2010, more than 3,700 nursing facilities from across the country (both AHCA members and non-members) participated in this survey. AHCA defines retention as the number of employees who have worked in a nursing facility for 12 months or longer divided by the number of current employees at the end of the calendar year. Turnover is defined as the number of terminations (voluntary and involuntary) in a given year divided by the total number of current employees at the end of the calendar year. From 2008 to 2010, turnover decreased for all nursing staff in direct care roles, as well as nurses with administrative duties and for all nursing staff in the aggregate (Figure 1.7). Nursing staff in direct care roles include CNAs, LPNs/LVNs and staff RNs. The retention rates in these same job categories increased slightly or remained relatively stable between 2008 and 2010 (Figure 1.8). Turnover rates for staff in administrative, food services and housekeeping positions improved from 2008 to 2010, while turnover increased for those working in therapy and social services roles (Figure 1.9). Retention shows positive trends in all of the non-nursing job categories over this same time period (Figure 1.10).

17 AHCA Quality Report The Long Term Care Community 13 Figure 1.5 Direct Care Nursing Hours per Resident Day CMS-CASPER/OSCAR Data, March various years RN LPN CNA TOTAL Figure 1.6 Trends in Five-Star Staffing Ratings 7.5% 32.8% Percent of Facilities 8.4% 37.0% 8.9% 39.0% The overall staffing trend shows a steady increase in the amount of direct care nursing time per resident for all levels of nursing staff. Figure 1.7 Trends in Nursing Staff Turnover from % 20.8% 21.1% Percent of Nurse Turnover 18.9% 20.6% Oct % 15.9% Oct % 13.6% Oct % 25.9% 26.0% 34.2% 36.3% 28.9% 42.8% 46.7% 41.0% 43.0% 41.8% 34.7% 53.5% 46.6% 42.6% 48.7% 45.2% 39.5% 5 Stars 4 Stars 3 Stars 2 Stars 1 Stars DONs ARNs RNs LPNs/LVNs CNAs All Nursing Source: Abt-Associates., 2012 AHCA Reports on staffing turnover surveys, various years. Available at

18 14 AHCA Quality Report The Long Term Care Community According to data from the U.S. Bureau of Labor Statistics, approximately 1.7 million workers were employed at skilled nursing facilities across the United States in Figure 1.8 Trends in Nursing Retention from Figure 1.9 Turnover Other Job Categories Percent Turnover Percent of Nurse Retention 20.5% 20.3% 18% 16.7% 30.8% 25.7% 45.7% 37.7% 33.7% 28.5% 28.0% 24.3% 19.5% 24.7% 22.5% Administrative Therapy Food Services Housekeeping Social Services & Activities AHCA Reports on staffing turnover surveys, various years. Available at Figure % 74.3% 75.4% 66.3% 70.0% 69.9% Retention Other Job Categories Percent Retention 82.1% 85.6% 84.8% 73.9% 77.9% 82.5% 69.6% 75.0% 73.9% 77.7% 81.4% 81.1% 77.9% 82.4% 81.4% 79.8% 82.2% 67.2% 71.7% 80.8% 71.7% 73.5% 72.5% 68.9% 69.7% 69.7% DONs ARNs RNs 71.7% LPNs/LVNs CNAs All Nursing Administrative Therapy Food Services Housekeeping Social Services & Activities AHCA analysis on 2008, 2009 and 2010 nursing facility staffing survey data AHCA analysis on 2008, 2009 and 2010 nursing facility staffing survey data

19

20 AMERICAN HEALTH CARE ASSOCIATION MEMBERS AHCA represents 55 percent of the more than 15,000 skilled nursing facilities in the United States today. AHCA members provide essential care to individuals in 8,690 not-for-profit, proprietary and government facilities. As of 2012, at any point in time, more than 770,000 individuals are receiving care in an AHCA member facility. As the nation s largest association of long term and post-acute care providers, the American Health Care Association (AHCA) represents a diverse group of providers that care for individuals across the long term and post-acute care continuum. AHCA represents 55 percent of the more than 15,000 skilled nursing facilities in the United States today. AHCA members provide essential care to individuals in 8,690 not-for-profit, proprietary and government facilities. As of 2012, at any point in time, more than 770,000 individuals are receiving care in an AHCA member facility. are part of smaller, regional multi-facility groups. Less than 12 percent of AHCA s members are part of a publicly traded company. Independently-owned and operated facilities account for 37 percent of AHCA s membership. Table 2.1 compares 2012 statistics on the number of facilities and facility types for AHCA members and non-members. AHCA member facilities comprise 930,011, or 55 percent, of all skilled Table 2.1 nursing facility beds in the United States. With the average bed size of an AHCA member facility 107 beds, member facilities are slightly smaller compared to the national average, 108 beds, as well as non-members, 110 beds. At an average of 93.5 beds, AHCA not-for-profit facilities also tend to have fewer beds than the national average, while proprietary member facilities average slightly higher at 110 beds. AHCA members tend to be slightly smaller when comparing bed count in government facilities as well. However, at 87.5 percent, the AHCA member occupancy rate is greater than the national average of 85 percent. As with the nation, AHCA members are more likely to be situated in urban areas than rural areas. However, when compared to non-members, AHCA members are less likely to be urban and more likely to be rural. Approximately 68 percent of AHCA members are located in urban areas, compared to 71 percent of non-members. At the same time, 33 percent of AHCA members are in rural locations while 29 percent of nonmembers are rural (Table A2). AHCA represents 64 percent of the nation s for-profit facilities, 36 percent of its not-for-profit facilities and 39 percent of its government facilities. AHCA member facilities include both those owned by multi-facility corporations and independently-operated facilities. Nearly two-thirds of AHCA s membership is comprised of facilities that are part of a multi-facility operation. Approximately half of these facilities are part of a large national chain and the remaining half Number of Facilities and Ownership Type Member Non-Member Total Total Number of Facilities 8,690 7,000 15,690 For-Profit Facilities 6,917 3,915 10,832 Not-for-Profit Facilities 1,428 2,540 3,968 Government Facilities Facility Type Multi-Owned Facilities 5,463 3,134 8,597 Independent Facilities 3,227 3,886 7,093 AHCA Analysis, CMS-CASPER data, March 2012

21 AHCA Quality Report American Health Care Association Members 17 Table 2.2 Bed Count and Certification Statistics Member Non-Member Total Total Beds 930, ,154 1,705,165 Medicare-Only Certified Beds 29,064 63,922 92,956 Medicare/Medicaid Certified Beds 861, ,832 1,487,422 Medicaid-Only Certified Beds 31,322 57,674 88,996 Average Number of Beds per Facility AHCA Analysis, CMS-CASPER data, March 2012 Quality Initiative embraces the Centers for Medicare and Medicaid Services (CMS) Triple Aim of Better Health, Better Care and Reduced Costs and incorporates the principle articulated by former CMS Administrator Dr. Donald Berwick that some is not a number and soon is not a time (Berwick, et al., 2006). AHCA s Quality Initiative, announced in February 2012, set four specific goals with measurable targets and deadlines for their achievement: Table 2.2 compares 2012 bed count and certification statistics for AHCA member facilities to non-members. A majority of the individuals receiving care in AHCA member facilities at any point in time rely on the Medicaid program to pay for their care. For more than half a million individuals receiving care in member facilities, or 65 percent of residents, Medicaid is their primary payer for their care. Compared to non-members which have 61 percent of residents relying on Medicaid, AHCA members serve a greater percentage of Medicaid beneficiaries. Only 20 percent of individuals in member facilities pay for their care out-of-pocket, compared to 24 percent in non-member facilities. The proportion of individuals having their skilled nursing care paid for by the Medicare program at any point in time is similar for both AHCA member and non-member facilities, at approximately 14 percent. As the principal payer for skilled nursing care services through the Medicare and Medicaid programs, the government has a strong interest in ensuring high-quality care. Nursing facilities that are certified to accept government payments under either of these programs must meet state licensure rules and federal regulations. A vast majority of AHCA members, 95 percent, are certified to accept both Medicare and Medicaid. Nearly all AHCA members, 98 percent, are certified for Medicaid, as compared to only 92 percent of non-members. Table 2.3 compares 2012 payer statistics for AHCA member facilities and non-members. AHCA QUALITY INITIATIVE AND ACTIVITIES AHCA Quality Initiative The AHCA Quality Initiative is an effort that builds upon existing work of the long term and post-acute care profession in advancing quality care by setting specific, measurable targets to further improve quality of care in America s skilled nursing facilities (SNF). The AHCA Safely Reduce Hospital Readmissions: By March 2015, reduce the number of hospital readmissions within 30 days during a SNF stay by 15 percent. Increase Staff Stability: By March 2015, reduce turnover among nursing staff (RN, LPN/LVN, CNA) by 15 percent. Increase Customer Satisfaction: By March 2015, increase the number of customers who would recommend the facility to others up to 90 percent. Safely Reduce the Off-Label Use of Antipsychotics: By December 2012, reduce the off-label use of antipsychotic drugs by 15 percent. Safely Reduce Hospital Readmissions Approximately one in five Medicare beneficiaries is discharged from a hospital to a skilled nursing facility (Mor et al., 2010). Nearly one in four of these individuals will be readmitted to the hospital within 30 days during their SNF stay. One in five long-stay residents will be sent to the hospital over the next six months (Figure 2.1). Hospitalization is disrupting to elderly individuals and puts them at greater risk for complications and

22 18 AHCA Quality Report American Health Care Association Members infections. Hospitalization also increases the likelihood of reduced functioning on return to the skilled nursing facility. Whenever safely possible, the facility should strive to minimize hospital transfers to avoid subjecting individuals to the exposures and risks associated with hospital readmissions. Hospital readmissions not only have the potential for negative physical, emotional and psychological impacts on individuals in skilled nursing care, but also cost the Medicare program billions of dollars. According to Brown University, the cost to the Medicare program of all hospital readmissions in 2006 was $4.34 billion (Mor et al., 2010). Preventing these events whenever possible has been identified by policymakers and providers as an opportunity to reduce overall health care system costs through improvements in quality. The issue has become a top priority for CMS and managed care programs over the past several years. Of particular emphasis today is reducing Table Payer Statistics Number of individuals served at a SNF at any point in time readmissions within the 30-day window following hospital discharge, with CMS now implementing payment reductions to hospitals with excess rates of readmissions as compared with their peers. Additionally, CMS recently announced a new initiative Better Care for Nursing Facility Residents through Enhanced Member Non-Member 773, ,431 Persons paid for by Medicare (%) 14.6% 14.1% Persons paid for by Medicaid (%) 65.1% 61.7% Persons paying privately (%) 20.2% 24.2% Figure 2.1 AHCA Analysis, CMS-CASPER/OSCAR data, March 2012 The Flow of Individuals from Hospitals Through SNFs HOSPITAL 20% 1 SNF HOME 35% 2 19% 4 ASSISTED LIVING 23% 1 NURSING HOME 20% 3 ER DEATH 1 Mor et al, MedPAC Commonwealth Jencks NEIM 2009

23 AHCA Quality Report American Health Care Association Members 19 Coordination Efforts and the creation of the Partnership for Patients with the stated goal of reducing all 30-day hospital readmissions by 20 percent over a three-year period. Further evidence of CMS focus on reducing hospital readmissions is the newlyimplemented Hospital Readmission Reduction Program. Under this program, enacted as part of the Affordable Care Act (ACA), beginning in October 2012, hospitals with high readmission rates will see reductions in their Medicare payments by as much as three percent over the next three years. MedPAC has recommended a similar program for nursing facilities and recent budget proposals from President Obama suggest a financial penalty for SNFs that continue to have high rates of hospital readmissions (MedPAC, 2012). In addition, CMS has incorporated review of readmissions into their new Quality Indicator Survey (QIS) process for nursing facilities. Given that the measures of hospital readmissions from the skilled nursing facility setting are currently calculated using claims data, these measures lag behind many others reported in this Quality Report due to the time involved in final settlement of claims before data are publicly available. In Table A9 and Figure 2.2, the trends in two measures for the period 2005 through 2009 are reported: (1) 30-day hospital readmissions among short-stay skilled nursing patients (2) six-month hospital readmission rates among long-stay skilled nursing residents Among both long- and short-stay individuals, changes in this measure have not been substantial over the past five years. Given that the measure is not risk-adjusted to account for any changes in underlying resident factors and acuity over this time period, it is unclear what the potential impact of this factor on expected hospitalization and hospital readmission rates may have been. In 2009, there was a one percentage-point decrease in the 30-day hospital readmission rate for short-stay patients from SNFs. Until further data points are available, it is premature to determine whether this signals the start of a positive trend. AHCA s goal of a 15 percent reduction in hospital readmissions over the next three years would result in 26,140 persons avoiding rehospitalization at an annual savings to Medicare of over $261.4 million dollars from AHCA member facilities. Figure 2.3 shows the distribution of AHCA members 30-day SNF hospital readmission rates. Figure 2.2 Percentage The median rate is 16.9 percent with a wide range of rehospitalization rates. This measure is not risk-adjusted, but regardless, demonstrates wide variation. Recognizing the fact that certain conditions (e.g., heart attacks, fractures and severe infections) arise making the prevention of all hospital readmissions unavoidable, facilities with the lowest rates (the lowest 20 th percentile of facilities) are not targeted for a reduction. AHCA is encouraging member facilities to do what is best for the patient and not be pressured to avoid sending an individual to the hospital who needs the care. Increase Staff Stability Skilled nursing facility staff who are familiar with the people for whom they care understand the individual preferences of each person. Regularly providing care to the same individuals allows staff to anticipate the person s needs and respond quickly and confidently. Trends in Skilled Nursing Facility Hospitalization and Hospital Readmission Rates 20% 15% 10% 5% 0% Source: "Long Term Care in America Project at Brown University funded in part by the National Institute on Aging (1P01AG027296)." Brown University, various years long stay hospitalization 30-day rehospitalization

24 20 AHCA Quality Report American Health Care Association Members Figure 2.3 AHCA Members 30-day SNF Hospital Readmission Rates Average: th Pecentile day hospital readmission rate Facilities targeted for 15% reduction People are more comfortable with caregivers they know, especially when the individual is living with dementia. In addition, the more familiar staff is with a person, the more likely they are to observe subtle signs that an individual is responding differently and may be experiencing a change in condition that requires a modification to care or medical attention. Numerous studies have found an association between staff stability (i.e., lower turnover, higher retention and less agency use) and quality of care. Higher staff turnover at all levels (clinical staff, administrator and DON) has been associated with lower quality of care (Castle, 2001; Castle & Engberg, 2005; Castle, Engberg, & Men 2007). When turnover and staffing levels are included together in an analysis of predictors of quality, both are predictive, but turnover more so (Castle & Anderson, 2011). Increased staff stability also has a beneficial effect on the operations of a skilled nursing care center by: (1) reducing the time and costs of advertising, interviewing, hiring and training new staff (2) reducing the need for and costs associated with using temporary workers (3) improving satisfaction of staff, resulting in staff members recruiting other good workers (4) fostering more interdisciplinary cooperation and planning (5) improving caregiver communication (6) resulting in better care for the patients AHCA s goal of a 15 percent reduction in nursing staff turnover over the next three years would mean 615,098 nursing staff would remain in their job each year. Figure 2.4 depicts the current nursing staff turnover rates based on AHCA s nationwide annual Nursing Facility Staffing Survey.

25 AHCA Quality Report American Health Care Association Members 21 Figure 2.4 Nursing Turnover % DONs 28.9% ARNs Increase Customer Satisfaction Customer satisfaction surveys provide valuable feedback to skilled nursing facilities on their performance across a range of quality of care and quality of life indicators. High ratings on customer satisfaction surveys are good indicators of quality care and generally reflect good health outcomes. In addition, when a satisfaction survey suggests areas of concern, the nursing facility has the opportunity to investigate the problem and institute processes to correct and improve the care that is provided. A critical indicator of overall performance is the customer s willingness to recommend the facility to others. Unpublished research suggests that facilities with the highest rates of satisfaction perform better in other organizational indicators including staff stability, staff retention, survey results, census and cash flow. There are a number of different satisfaction questionnaires in use in skilled nursing facilities, all of which Percent of Nursing Turnover 41.0% RNs 34.7% LPNs/LVNs AHCA Reports on staffing turnover surveys, Available at % CNAs 39.5% All Nursing are proprietary except for the Nursing Home Consumer Assessment of Health Providers and Systems (NH CAHPS) questionnaire developed by the Agency for Healthcare Research and Quality and endorsed by the National Quality Forum. However, the resident version of this instrument requires a face-toface interview, which has made it cost prohibitive to implement on a national scale. Nearly all survey questionnaires that AHCA has reviewed include two very similarly worded questions: 1. How satisfied were you overall with your experience at <insert facility name>? 2. Would you recommend this facility to (a friend or someone else)? Most care facilities administer their satisfaction survey by mail, but some do so by phone. Most commonly, the questions ask the resident or family member to rate the facility on a four or five point scale, while some use up to a 10 point scale. The AHCA Quality Initiative goal is for facilities to have greater than 90 percent of survey respondents willing to recommend it to someone else. Using data from one of the largest vendors measuring satisfaction in skilled nursing facilities in 2011, My InnerView, which collected data from 46 states and more than 4,600 facilities, 46 percent of facilities achieved greater than 90 percent of respondents being overall satisfied, and 45 percent of facilities had greater than 90 percent of respondents who would recommend the facility to a friend. If AHCA is successful in its goal, another 3,266 member facilities will have greater than 90 percent of residents and families recommending their facilities to others. Safely Reduce the Off-Label Use of Antipsychotics Antipsychotic medications have been approved by the Food and Drug Administration (FDA) principally for use treating schizophrenia and bipolar disorder. However, as with many FDA approved medications, clinicians often prescribe medications to treat other conditions. This is typically referred to as off-label use. Antipsychotics are commonly prescribed off-label for individuals living with dementia. While antipsychotics are commonly believed to be effective medications for individuals living with dementia, the evidence suggests that their effectiveness is minimal. Several metaanalyses show that these medications have a small benefit in some patients, but they are also associated with risks of serious, even life-threatening, harm for the elderly (Ballard, Waite, & Birks, 2011; Maher et al., 2011).

26 22 AHCA Quality Report American Health Care Association Members The intent of the AHCA Quality Initiative goal to reduce the off-label use of antipsychotics is to encourage alternative strategies for responding to challenging behavioral expressions in persons living with dementia before considering medications and to ensure that antipsychotic medications, when used, are as appropriate and safe as possible. A recent independent analysis of the published data on antipsychotic use in persons with dementia by Harvard physicians found that for every 100 individuals living with dementia who receive antipsychotics, only nine to 25 of them will derive some benefit, but one will die (Scheurer et al., 2012). Thus, the net positive impact of these medications is modest at best, particularly when used for long periods (e.g. greater than three to six months). Due to these findings, the FDA issued a black box warning in 2005 that states: Medical studies indicate that antipsychotic medications carry a significant risk of serious or even life-threatening adverse effects which can include heart attack, stroke, falls, blood clots and hospitalizations. CMS has also identified reducing the off-label use of antipsychotics among individuals in skilled nursing facilities as one of its priorities in 2012, setting a similar goal to AHCA s Quality Initiative goal of a 15 percent reduction by the end of 2012 (CMS Office of Public Affairs, 2012). Despite this data, the use of antipsychotics remains high in all settings (Eguale et al., 2012) with nearly half of all prescriptions being used for offlabel conditions. An Office of Inspector General (OIG) report in 2010 found that just over 80 percent of all antipsychotics prescribed in nursing facilities were for off-label conditions (OIG, 2010). Approximately 12.4 percent of all persons over the age of 65 admitted to a skilled nursing care center in 2009 were receiving an antipsychotic medication at the time of admission (AHCA analysis of MDS 2.0 data 2009). This indicates that nearly half of all individuals on antipsychotics in nursing facilities were admitted with a prescription for these medications already in place. CMS regulations promote the gradual dose reduction and/or withdrawal of these medications when clinically indicated. For these reasons, AHCA recommends two quality measures: (1) the percentage of individuals started on medications within the first 90 days following admission (2) the percentage of long-stay residents in a facility (for at least 90 days) who are receiving these medications The first measure reflects the practices within the facility (not the admissions to the center), and the second reflects both prescribing practices and the ability to gradually reduce the dose and discontinue the medications. Table 2.4 compares the off-label use of antipsychotic medications in 2011 between AHCA members and non-members using Minimum Data Set (MDS) 3.0 data. The data show that only a small percentage of patients (about three percent) are started on antipsychotic medication within the first 90 days following admission to a skilled nursing facility, while nearly one in four long-stay residents were receiving the medications. AHCA members were slightly, but not significantly, more likely to use antipsychotic medications compared to non-members in Using data from MDS 3.0 from the fourth quarter of 2011 provided by CMS, the national facility average rate of off-label use of antipsychotics for residents in a facility for at least 90 days was 24 percent. The distribution of all facilities off-label use of antipsychotics nationwide is shown in Figure 2.5. While more than 20 percent of facilities in the country have high rates of use (greater than 32 percent), an equal percentage have low rates (less than 14.5 percent). This suggests that lowering the use of these medications is achievable. AHCA s Quality Initiative goal to safely reduce of the off-label use of antipsychotic medications would result in 18,400 fewer individuals from receiving these drugs each year. AHCA Programs That Advance Performance AHCA believes that in order to advance and sustain high levels of performance it is critical to apply continuous quality improvement principles. AHCA encourages members to apply such principles by participating in three programs: LTC Trend Tracker SM, Advancing Excellence in America s Nursing Homes and AHCA/NCAL s National Quality Awards Program. Long Term Care Trend Tracker LTC Trend Tracker is an online tool available to all AHCA members free of charge that provides users access to performance reports to track, organize,

27 AHCA Quality Report American Health Care Association Members 23 Table 2.4 Off-Label Use of Antipsychotics 2011 First Quarter 2011 Second Quarter 2011 Third Quarter 2011 Fourth Quarter 2011 Starting antipsychotic after admission 2 AHCA Member 3.4% 3.3% 3.4% 3.4% Non-Member 3.1% 3.2% 3.3% 3.3% Prevalence among long-stay residents 3 AHCA-Member 23.9% 23.9% 24.0% 24.1% Non-Member 23.4% 23.6% 23.7% 23.8% AHCA Analysis, CMS MDS 2.0 data, 2009 Figure 2.5 Distribution of Facilities Off-Label Use of Antipsychotic Medications National Average: 24.0% >70 Percentage of off-label antipsychotic usage among long-stay residents in nursing facilities Source: CMS analysis of MDS 3.0 data, 4th Quarter Starting medications after admission was calculated using MDS 3.0 data for all individuals who were not admitted on an antipsychotic, but within the first 90 days had a subsequent MDS, indicating that an antipsychotic was prescribed excluding individuals with schizophrenia, Huntington s Disease, or Tourette s Syndrome. 3 Prevalence among long-stay residents (in the center for at least 90 days) was calculated using MDS 3.0 data from 2011 excluding individuals with schizophrenia, Huntington s Disease, or Tourette s Syndrome.

28 24 AHCA Quality Report American Health Care Association Members identify, benchmark, examine and compare a facility s clinical, quality and financial operations over time. LTC Trend Tracker works in conjunction with the AHCA Quality Initiative by providing the user the ability to benchmark their progress to that of their peer groups ranging from the local level to the national. LTC Trend Tracker uses the facility Medicare provider number to pull data into the tool. These data include Certification and Survey Provider Enhanced Reports (CASPER), Five-Star Ratings, Cost Reports, Quality Measures and hospital readmission information. Facilities can access up to 12 years worth of historical information and use this information to support operational decision-making. LTC Trend Tracker adoption has increased significantly in the last two years, from 3,241 facilities in March 2010 to 4,500 in March AHCA continues to enhance this program to facilitate members ability to quickly and easily assess and track their progress in multiple areas of their daily operations. The Advancing Excellence in America s Nursing Homes Campaign In 2006, AHCA joined with 13 organizations to establish the Advancing Excellence in America s Nursing Homes Campaign (Advancing Excellence). The campaign is a dynamic public-private partnership that has improved skilled nursing facility performance and established a rich learning community across the country. The purpose of Advancing Excellence is to accelerate and support skilled nursing facilities to improve their performance on a set of meaningful measures of clinical and organizational quality. The campaign is a voluntary learning collaborative, modeled on the Institutes for Health Care Improvement s 100,000 Lives Campaign. Participants have access to evidence-based tools and resources that are customized to improving performance in each of Advancing Excellence s goals. Skilled nursing facilities participating in the campaign are required to set performance targets and are provided with data to benchmark their progress; this includes tools to measure real-time progress and specific intervention strategies to help improve performance. AHCA champions Advancing Excellence because it is a catalyst for driving widespread change and is anchored in the application of continuous quality improvement processes. This directly aligns with AHCA s four Quality Initiative goals and supports member efforts to pursue AHCA s criteria-based Quality Award Program. Today, more than 50 percent of America s skilled nursing facilities (8,392 facilities) are enrolled in this voluntary campaign. AHCA members have actively embraced Advancing Excellence and represent 61 percent of all participants (Figure 2.6). As of 2012, the campaign has grown to include 30 stakeholder organizations as members. These organizations represent long term care providers, professionals, direct care staff, consumers, culture change leaders, researchers, governmental bodies and other organizations whose missions focus on high performance in the field Campaign Goals On January 10, 2012, the Board of Directors of Advancing Excellence announced new goals for the next two-year cycle that begins on November 1, These goals align with many priorities of CMS and other national long term care initiatives, including advancing the use of personcentered care, and are aligned with the AHCA Quality Initiative goals. Additionally, the new educational resources that are being developed will embed the elements of CMS Quality Assurance and Perfor- Figure 2.6 Advancing Excellence Participants 61.1% AHCA member participants Non AHCA member participants AHCA 8,392 Total Participants as of 4/10/2012 CMS MDS 2.0 data, %

29 AHCA Quality Report American Health Care Association Members 25 mance Improvement (QAPI) program, the quality performance program that will soon be required by the Department of Health and Human Services. The new Advancing Excellence goals are: Improve Staff Stability Increase Use of Consistent Assignment Increase Person-Centered Care Planning and Decision Making Safely Reduce Hospitalizations Use Medications Appropriately Increase Resident Mobility Reduce Pressure Ulcers Decrease Symptoms of Pain Prevent/Manage Infections Safely Local Area Networks of Excellence Local Area Networks of Excellence (LANEs) are one of the powerful features of Advancing Excellence. LANEs operate at the state level to support participants in achieving their performance targets. Just like the national steering committee, LANEs are comprised of a wide array of stakeholder groups that are vested in improvement at the local level. AHCA s state affiliate organizations participate in the LANEs and serve as the LANE conveners in several states. The LANEs are catalysts for skilled nursing facility improvement and are the go to networks for new ideas and approaches. LANEs also provide a regular forum for networking amongst the stakeholder groups which promotes additional opportunities. Furthermore, the network of state LANEs is a source for sharing success stories that can be replicated by their counterparts. Currently, all 50 states and the District of Columbia have established these stakeholder coalitions. Many LANEs have been working for four-plus years and have become formidable change agents within their states. AHCA/NCAL National Quality Award Program Initiated in 1996, the AHCA/NCAL National Quality Award Program is a progressive, three-step program based on the criteria of the Baldrige Performance Excellence program. The program encourages continuous learning and development of integrated quality systems to achieve performance excellence. Facilities may apply for recognition and awards at three levels: Bronze, Silver and Gold. Each level requires a more detailed and comprehensive demonstration of systematic quality. Facilities that move through the three levels of the program can expect to gain true insight into their organizations strengths and opportunities for improvement, as well as receive customized feedback to help improve their overall organizational effectiveness and capabilities. The number of applications for the AHCA/NCAL National Quality Award program has been steadily increasing over the past six years, a testament to members commitment to quality improvement. The rigor and high standards to achieve Silver or Gold awards is evidenced through the percentage of applicants receiving the awards. On average, 10 to 15 percent of silver and gold applicants receive award recognition. As of the 2011 award cycle, 18 percent of AHCA/NCAL s members have received a Quality Award at one of the three award levels. The application process delivers great benefits for participants. Facilities who receive the Silver and Gold awards are more likely than other skilled nursing facilities to have fewer survey deficiencies, including twice as likely to have a deficiency-free survey (Figure 2.9), better quality measures, like lower offlabel use of antipsychotics, and higher satisfaction scores. Nearly 75 percent of Silver and Gold award recipients achieve a four or five star rating in CMS s Five- Star Rating Program, compared to 43 percent for all other facilities nationally (Figure 2.10). Figure 2.10 Percent of Nursing Facilities with High (4 or 5) Five Star Overall Rating 71% Quality Award: Gold & Silver Quality Award: Gold & Silver All others 43% All others AHCA Analysis of CMS Five Star Nursing Home Compare data (March 2012)

30 26 AHCA Quality Report American Health Care Association Members Figure 2.7 Quality Award Applications by Year 700 Number of applicants Figure 2.8 bronze silver gold Quality Award Recipients by Year % of applicants receiving award 70% 60% 50% 40% 30% 20% 10% Figure 2.9 bronze silver gold Percent of Nursing Facilities with No Health Citations 8% 8% 8% 9% 9% 9% 9% 9% 9% 15% 17% 16% 14% 16% 19% 18% 16% 15% 2010 Q Q Q Q Q Q Q Q Q1 AHCA Analysis: CMS CASPER Data. Various years and quarters (Q) Quality Award: Gold & Silver All others

31 AHCA Quality Report American Healthcare Association Members 27

32 TRENDS IN QUALITY SKILLED NURSING FACILITY QUALITY MEASURES Skilled nursing facility Quality Measures (QMs) are computed and updated quarterly by the Centers for Medicare and Medicaid Services (CMS) and are publicly reported on the Nursing Home Compare website. The QMs are Figure 3.1 Percent of Residents with Condition derived from the Minimum Data Set (MDS), a comprehensive assessment that is completed on a periodic basis for each skilled nursing facility resident and are reported at the facility level. These measures report outcomes on 15 aspects of clinical care, three of which are specific to the post-acute population, while the remaining 12 are reported Trend in Nursing Facility Chronic Care Quality Measures: Physical Condition and Depression Related 20% 15% 10% 5% 0% AHCA Analysis CMS Nursing Home Compare March of various years Figure 3.2 depression pain physical restraints high risk pressure ulcer low risk pressure ulcer Trend in Nursing Facility Chronic Care Quality Measures: Physical Functioning and Weight Loss Related Percent of Residents with Condition 20% 15% 10% 5% 0% AHCA Analysis CMS Nursing Home Compare March of various years ADL Weight loss Locomotion Bedfast for long-stay skilled nursing facility residents. The set of measures shown below were endorsed by the National Quality Forum and have been reported by CMS beginning in late 2002 through the third quarter of 2010, the last period for which these data are available. In October 2010, CMS updated the MDS, transitioning from version 2.0 to version 3.0. A new set of QMs, based on information contained in MDS 3.0, has been endorsed by the National Quality Forum. CMS is currently in the process of transitioning their quality reporting to the new measures, which are expected to replace the MDS 2.0-based measures in July Subject to a number of measure-specific exclusions, the score for each facility-level QM is computed as the percentage by dividing the sum of persons in the facility with a particular condition by the sum of all eligible persons in the facility. Detailed descriptions of how the QMs are calculated can be found on the CMS website. Table A6 and Figures show average facility performance on the QMs over a five-year period ending with the most recently available data, which are from the third quarter of The data indicates that average performance nationwide has improved on 12 of the 15 QMs, with the most dramatic improvements seen for post-acute care patients in the area of pressure ulcers, decreasing from 17.7 percent to 12.5 percent, and for long- 4 The new CMS QMs had yet to be implemented at the time this report was set to print.

33 AHCA Quality Report Trends in Quality 29 stay skilled nursing facility residents in the area of physical restraints, which decreased from 6.3 percent to 2.8 percent. Rates were unchanged for two measures: persons with increasing depression or anxiety and prevalence of urinary tract infections. Average performance declined in only one measure prevalence of bowel and bladder incontinence among individuals at low risk. When compared to non-members in 2010, AHCA member facilities had better scores on average for six of 12 long-stay quality measures and all three short-stay quality measures (Table 3.1). REGULATORY COMPLIANCE MEASURES Facility compliance with regulatory requirements is based on findings from periodic inspections of nursing facilities, generally referred to as surveys. Federal law requires that every Medicare and Medicaid certified skilled nursing care center in America is surveyed at least once every 15 calendar months. Surveys are completed by state surveyors who are contracted by CMS to inspect and assess how well a facility is meeting federal regulations they must comply with in order to take part in the Medicare and Medicaid programs. The federal regulations address many aspects of the skilled nursing facility, including quality of patient care, quality of life, physical environment and safety. If a facility fails to comply with a particular regulation, a surveyor will assign that facility a citation. AHCA member facilities had better scores on average for six of the 12 long-stay quality measures and all three short-stay quality measures. Figure 3.3 Percent of Residents with Condition Percent of Residents with Condition Trend in Nursing Facility Chronic Care Quality Measures: Urinary System Related 40% 20% 0% Figure 3.4 Trends in Nursing Facility Post-Acute Quality Care Measures 20% 15% 10% 5% 0% AHCA Analysis CMS Nursing Home Compare March of various years AHCA Analysis CMS Nursing Home Compare March of various years Incontinence Pain UTIs Pressure ulcer 2010 Catheter Delirium

34 30 AHCA Quality Report Trends in Quality For each deficiency citation identified by surveyors, using a lettering system, a rating is assigned to its scope. The scope may be isolated, pattern or widespread. A rating also is assigned for severity and may include substantial compliance, potential for more than minimal harm, actual harm or immediate jeopardy. Some citations are considered to represent Substandard Quality of Care (SQC). 5 A finding of SQC indicates that the skilled nursing facility was found to have a significant deficiency or deficiencies, which the facility must address and correct quickly to protect the health and safety of individuals in its care. All survey data are available in CMS Certification and Survey Provider Enhanced Reporting (CASPER) system, previously known as Online Survey, Certification, and Reporting System (OSCAR). Summary data are also available on CMS Medicare website, Nursing Home Compare. Five-year trends for the period in four measures capturing safety concerns are reported in Table A7 and Figure 3.5. These measures are the percent of facilities receiving survey citations in the areas of medication Table 3.1 Quality Measure Rates: AHCA Members vs. Non-Members Quality measures Long-stay skilled nursing facility residents 2010 Member n= Non-Member n=7021 % with increasing depression or anxiety % with pressure ulcers (high risk) % with pressure ulcers (low risk) % physically restrained % with moderate to severe pain % with increased dependency in ADL % with worsened locomotion % with weight loss % bedfast % incontinent of bowel or bladder (low risk) % with urinary tract infection % with indwelling urinary catheter Post-acute skilled nursing facility patients % with moderate to severe pain % with pressure ulcers % with delirium Figure 3.5 AHCA analysis CMS Nursing Home Compare, Third Quarter of 2010 Trends in Nursing Facility Patient Safety Measures 40% 35% 30% 5 This is a technical regulatory term which means that one or more requirements under the federal regulations 42CFR (resident behavior and facility practices), 42CFR (quality of life), or 42CFR (quality of care) were not met, to a degree constituting either, (1) immediate jeopardy to resident health or safety, and a scope of pattern or widespread actual harm, or (2) a widespread potential for more than minimal harm. Percentage 25% 20% 15% 10% 5% 0% Source: CMS CASPER Data March of each year % of residents on antipsychotic medications % of facilities with infection control citation % of facilities with unnecessary drugs citation % of facilities with medication error citation

35 AHCA Quality Report Trends in Quality 31 errors, unnecessary drugs and infection control, and the percent of residents on antipsychotic medications. These data show that citations for medication errors have declined by more than three percentage points, with the absolute rate now at less than 10 percent of facilities receiving a citation in this area, Figure 3.6 Number of citations while unnecessary drugs and infection control are being cited more frequently over this time period. Prevalence of antipsychotic use has decreased slightly. To provide an overall picture of trends over the last five-year period with regard to regulatory compliance, Average Number of Deficiency Citations in Nursing Facilities AHCA Analysis of CMS Casper Data Figure 3.7 Percent of nursing facilities Percent of Nursing Facilities Cited at Level G or Above, with Immediate Jeopardy and Substandard Quality of Care 20% 15% 10% 5% 0% CMS CASPER Data March of various years % cited at level G or above % with substandard quality of care citations % with immediate jeopardy citations Table A8 and Figures report on a collection of measures of survey performance including: average number of deficiencies cited per facility; the percentage of facilities receiving a citation at the scope and severity level of G or above, which constitutes a finding of at least an isolated instance of actual harm; the percentage of facilities receiving a Substandard Quality of Care citation; the percentage of facilities receiving a citation at the Immediate Jeopardy (IJ) level of severity; and the percentage of facilities with citation-free surveys. Each of these compliance measures shows improvement over this time period: The average number of deficiencies has steadily declined, as has the percentage of facilities cited at level G or above. The percentage of facilities cited for Substandard Quality of Care and for Immediate Jeopardy has fluctuated but shows an overall downward trend. The proportion of facilities with deficiency-free surveys has increased. Compared to non-members, AHCA member facilities had essentially the same number of deficiencies in Members averaged 7.0 deficiencies while non-members averaged 6.9. However, AHCA members were significantly less likely to have substandard quality of care deficiencies than non-member facilities but were slightly more likely to have an immediate jeopardy citation. An equal proportion of AHCA members and nonmembers, 8.2 percent, had a deficiencyfree survey.

36 32 AHCA Quality Report Trends in Quality Figure 3.8 Percent of nursing facilities Percent of Nursing Facilities with Deficiency-Free Surveys 8.0% 6.0% 4.0% 2.0% AHCA Analysis of CMS Casper Data, March of various years Table 3.2 Regulatory Compliance Measures Average number of deficiency citations in nursing facilities % of nursing facilities cited at level G or above % of nursing facilities with substandard quality of care citations % of nursing facilities with immediate jeopardy citations % of nursing facilities with deficiency-free surveys FIVE-STAR RATING In December 2008, CMS incorporated a system of star-based ratings to the Nursing Home Compare website, assigning each skilled nursing facility a rating between one and five stars. Each facility receives an overall rating, which is a composite of individual star ratings calculated in three separate categories: AHCA member Non-member % 17.5% 4.7% 5.3% 4.3% 4.2% 8.2% 8.2% AHCA Analysis of CMS CASPER/OSCAR Health and Complaint Survey Results, March 2012 most recent data available from CMS 1) results of health inspections, 2) quality measures, and 3) staffing levels. The distribution of star ratings in the health inspections domain is fixed, with the top 10 percent of facilities in each state receiving five stars, the bottom 20 percent receiving one star, and the remaining categories evenly distributed. For more detail on how the individual and composite ratings are determined, see the Technical Users Guide available on the CMS website. Since the implementation of this rating system, the percentage of facilities receiving an overall rating of four or five stars has steadily increased, with 43 percent of facilities in these two categories combined as of the most recent period. The proportion of facilities receiving a one or two-star rating has correspondingly decreased. Given the fixed distribution of ratings in the health-inspection domain, the improvement in overall ratings is solely attributable to increases in staffing levels and improvement in quality measure performance. CUSTOMER SATISFACTION Customer satisfaction is one of the core measures that every organization uses to assess its level of quality performance. This is true for the field of long term care. Unpublished research suggests that high levels of customer satisfaction are correlated with better performance in other quality indicators, including staff stability, quality measure outcomes and performance in state and federal regulatory compliance requirements. In long term care the question that best captures the quality experienced by customers is their willingness to recommend their nursing home to others as a good place to receive care. Customer satisfaction ratings provide a rich source of information for people seeking long term care services for themselves or for a loved one. Many consumers already ask prospective facilities for their customer ratings, and the trend is moving toward greater public reporting.

37 AHCA Quality Report Trends in Quality 33 Several states publicly report customer satisfaction ratings, including Massachusetts, Minnesota, Ohio and Rhode Island. At the federal level, there is interest in including satisfaction ratings on Nursing Home Compare, though a feasible approach to national data collection to support public reporting has not yet been identified. Figure 3.10 provides data on national satisfaction rates for both long- and short-stay care. Since 2008, the ratings for long-stay residents and families of long-stay residents have remained stable at 89 percent and 87 percent respectively. Short-stay patient satisfaction ratings have lagged behind those of their long-stay counterparts. However, since 2008 their ratings have increased by nine percentage points, from 78 percent in 2008 to 87 percent in EMPLOYEE SATISFACTION Employee satisfaction is another key indicator of quality performance for long term care organizations. A key indicator of satisfaction is employee willingness to recommend their facility as a place to work. Figure 3.11 shows that the rates of satisfaction for nurses and nursing assistants have increased since For nursing assistants their satisfaction increased by eight percentage points, from 59 percent in 2005 to 67 percent in Nurse satisfaction increased by five percentage points over the same time period. While satisfaction rates have increased, there is still significant room for further improvement. Effective strategies for quality improvement must include a sustained commitment to those that provide direct care and communicate regularly with families, especially nursing assistants and nurses. Figure 3.9 Trends in Overall National 5-star Rating 11.6% 23.5% 21.1% 20.4% 22.3% Star 2 Stars Percent of Facilities 13.4% 25.4% 21.2% 20.2% 18.9% Stars 4 Stars 15.6% 26.8% 20.7% 20.1% 15.8% % 27.0% 20.9% 20.1% 15.2% Stars Source: CMS Nursing Home Compare March of year 2012 Since the implementation of this rating system, the percentage of facilities receiving an overall rating of four or five stars has steadily increased, with 43 percent of facilities in these two categories combined as of the most recent period. The proportion of facilities receiving a one or twostar rating has correspondingly decreased.

38 34 AHCA Quality Report Trends in Quality Figure 3.10 Customer Satisfaction: Willingness to Recommend the Facility as a Place for Care 95% Percentage of excellent/good 90% 85% 80% 75% 70% Long stay residents Families of long stay residents short stay patients Source: My InnerView National Surveys of Customer and Employee Satisfaction, *Scores are a combination of excellent and good *Residents who are not able to complete the survey on their own may have family members or staff assist them. In 2011, 94,704 long stay residents, 123,718 families of long stay residents, and 96,233 short stay patients participated in the My InnerView Surveys. Figure 3.11 Nurse and Nursing Assistant Satisfaction: Willingness to Recommend the Facility as a Place to Work 67% Percentage of excellent/good 65% 63% 61% 59% 57% 55% Source: My InnerView National Surveys of Customer and Employee Satisfaction, *Scores are a combination of excellent and good. In 2011, 133,666 individuals participated in the My InnerView surveys. SNF nurse SNF CNA

39

40 TRENDS IN PAYMENT FOR QUALITY Historically, public (Medicare and Medicaid) and private payers have purchased both short-stay and long-term care in a skilled nursing facility using a variety of fee-for-service (FFS) payment structures generally based on some measure of the cost of providing those services. 6 This method rewards providers with higher costs and higher volume of services regardless of the quality of outcomes. Highlighting rising costs of care, health care purchasers and policymakers have begun to pursue avenues to inculcate more accountability for the processes used to deliver care and, in some instances, related outcomes. Many researchers and analysts point to financial incentives as the most viable leverage for modifying health care provider behavior. Payment methods intended to foster specific provider behaviors and better outcomes are often referred to as pay-for-performance (P4P) or value-based purchasing (VBP) arrangements. 7 Other factors make it more viable to implement VBP arrangements now than in the past, including: availability of reliable measures of quality and outcomes; an expanded array of evidence-based practices which can be used by providers and offer consistent measurement; and advances in information technology for data collection and subsequent analysis. Thus, the trend in payment is shifting from a volume-based approach (e.g., FFS) to those based on outcomes or quality (e.g., VBP). The following section provides an overview of these trends to reimburse skilled nursing facilities related to state Medicaid VBP arrangements in FFS payment structures, Medicaid and Medicare managed care arrangements, and an overview of still nascent Patient Protection and Affordable Care Act (ACA) related models which also include VBP. STATE VALUE-BASED PURCHASING PROGRAMS In fiscal year 2010, state Medicaid expenditures on skilled nursing facility services were approximately $49.8 billion, a 2.8 percent decrease from Federal fiscal year Medicaid programs cover nearly two-thirds of all care in skilled nursing facilities, principally via FFS arrangements. Although Medicaid covers a large proportion of days of care for eligible beneficiaries, Medicaid payment levels are typically below both Medicare and private payment rates (MedPAC, 2012) as well as actual cost of care (Eljay, 2011). The disparity between Medicaid and other payers varies considerably by state (Eljay, 2011). In an effort to provide additional resources and further emphasize quality care for Medicaid beneficiaries, several states have explored VBP arrangements. Currently, the Centers for Medicare and Medicaid Services (CMS) has provided little to no guidance on Medicaid VBP. Thus, states have considerable discretion in developing Medicaid payment methods. Over the years, states have experimented with a variety of approaches. Typically, VBP incentive payments are amounts that are added on to a facility s base payment rate for achieving certain benchmarks. These approaches have produced mixed results. Furthermore, a number of VBP programs have been discontinued due to unclear outcomes or state budgetary challenges since the economic downturn. Based on a 2009 AHCA survey, eight states (CO, GA, IA, KS, MD, MN, OH and OK) had active VBP programs; three states were considering such programs (NC, NV and VA); while an additional five states had the authority for such arrangements, but the programs were inactive (CA, IL, MA, NY and TX). Budget challenges are the most common reason for a VBP program to become inactive. Other reasons for program inactivity are that VBP elements proved difficult to track or the state and the skilled nursing The trend in payment is shifting from a volume based approach (e.g., FFS) to those based on outcomes or quality (e.g., VBP). 6 A health care payer allows the health care provider to make almost all health care decisions independently. The provider submits claims to the state Medicaid agency, and receives payment if the service is covered by Medicaid, is within the parameters of the benefit and the person is Medicaid eligible. 7 State-based efforts typically are referred to as P4P programs, while Medicare and health plan efforts are generally called VBP strategies. For purposes of this document, we use VBP, only.

41 AHCA Quality Report Trends in Payment for Quality 37 facilities believe the measurement elements are not meaningful relative to measuring performance. Figure 4.1 States with Medicaid Value-Based Purchasing 2010 While eight states were operating or considering VBP programs in 2010, 12 states (CA, CO, GA, IA, KS, MA, NY, NV, OH, OK, UT and VT) were operating VBP programs by An additional two states (IN and VA) have proposed programs for North Carolina and Texas have program authority but have not yet implemented their programs. See Figures 4.1 and 4.2. VBP Measurement Financial incentives in VBP programs are typically based on a variety of measures including staffing, survey outcomes, resident satisfaction and clinical quality measures. Less common metrics include occupancy, efficiency, Medicaid utilization and implementation of culture change. 8 See Table A10 for an overview of metrics used in state Medicaid VBP programs. Such domains vary by the specific metrics. For example, Vermont s staffing measure is based on retention while other states may only focus on maintaining staffing ratios. Early in VBP program development, clinical quality measures were less common. However, as measurements and data collection methods have evolved, clinical quality measures have become more common. Source: Cheek et. al. (2012); AHCA state value-based purchasing survey, 2012 Figure 4.2 VBP program active VBP program proposed VBP program inactive No VBP program States with Medicaid Value-Based Purchasing In broad terms, the culture change movement focuses on making a variety of physical and operational changes in centers with the desired outcome of a home-like environment and implementation of person-centered care practices. Source: Cheek et. al. (2012); AHCA state value-based purchasing survey, 2012 VBP program active VBP program proposed VBP program inactive No VBP program

42 38 AHCA Quality Report Trends in Payment for Quality Other categories of measures include business performance measures, such as occupancy and efficiency as well as indicators of culture change. Tying Measurement to Incentive Payments Most states use a VBP approach in which points are scored for meeting benchmarks. Achievement of benchmarks is translated into per diem add-ons. Specifically, each facility is evaluated based on either its ranking compared to other facilities in the state or whether it has achieved facilityspecific target levels for performance. Points across the measures are summed and translated into a per diem add-on for Medicaid resident days. Add-on calculations vary from a fixed dollar amount to a percentage of a facility s specific rate. More recent efforts associated with Medicaid VBP approaches focus on embedding the incentive payment in the per diem rather than as an add-on to the per diem. In Ohio, the state recently increased the payment amount tied to quality measures which impacts the potentially achievable per diem. Skilled nursing facilities that fulfill at least five of 20 measures are rewarded by increasing their state s Medicaid bed-day rate by $16.44 from $ to $ Research has raised some concerns about current VBP arrangements (Briesacher et al., 2009). Specifically, researchers question whether the size of the incentive payments is sufficient to stimulate change by providers. Additionally, VBP arrangements that compare facilities to their peers create unattainable targets for low-ranking facilities even if they have improved quality or achieved accepted targets of quality. Therefore, lower performing facilities have less of an opportunity to receive a quality incentive payment, even when they show improvement. Still, other critics question whether the metrics used in VBP programs capture what matters most to consumers or drives costs. MANAGED CARE Both Medicare and Medicaid managed care are rapidly replacing traditional FFS arrangements as the dominant payment and service delivery systems. Until recently, skilled nursing facility services were not included in Medicaid managed care arrangements or only were included for what roughly equated to a post-acute care stay. 9 However, in recent years, a handful of states have significantly expanded Medicaid managed care including non-traditional populations (e.g., the elderly and individuals with disabilities) and nontraditional managed care services, specifically long term care. Hawaii, New Mexico and Tennessee include the full array of long term care in their Medicaid managed care arrangements, including long-stay skilled nursing care services. Arizona has the most experience with Medicaid managed care as well as inclusion of long-stay skilled nursing care services in managed long term care. Many states are aggressively pursuing managed long term care expansions in states with existing programs while other states are developing new managed long term care programs. In 2011, 11 states were operating some form of Medicaid managed long term care statewide or regionally. By 2014, approximately 26 states will have some form of Medicaid managed long term care. See Figure 4.3. The degree to which skilled nursing care is included in state Medicaid managed care programs is likely to continue to vary. However, the majority of states are indicating an interest in carving long-stay skilled nursing care into their managed care programs. Skilled Nursing Reimbursement in Medicaid Managed Care States typically use one of two methods of reimbursement in managed care. One, states may require plans to use FFS state-set provider rates for some or all providers who choose to contract with a plan and participate in their provider network. In this arrangement, states may build quality incentive payments into state-set rates following federal guidelines for incorporating such payments into capitation rates. The other method is where states may allow plans to negotiate FFS rates for some or all provider types. These plans may develop their own provider incentive payment arrangements as long as such requirements align with state plan performance standards and 9 Examples of states excluding skilled nursing care in managed care arrangements include Minnesota and Texas. New York s Medicaid managed long term care pilot program does not include skilled nursing at all.

43 AHCA Quality Report Trends in Payment for Quality 39 Figure 4.3 Medicaid Managed Long Term Care Expansion as of 2014 MEDICARE ADVANTAGE PRESCRIPTION DRUG PLANS By 2014, approximately 26 states likely will be operating MMLTC programs Source: Cheek et. al. (2012); AHCA state value-based purchasing survey, 2012 provider payment rate requirements. For example, states can establish plan performance requirements which make it necessary for plans to develop performance incentive arrangements for contracted providers. Plan measures roughly mirror state VBP arrangements but, typically, are more focused on clinical measures than FFS programs. States vary in how they require the MMLTC Discussion or planned implementation Current MMLTC program - regional or statewide incorporation of VBP for skilled nursing by managed care and leave the decision up to the managed care companies. Little research has been conducted on Medicaid managed long term care VBP arrangements. Other payment incentive arrangements include shared risk and savings agreements Plans are paid a capped amount per beneficiary and typically are expected to manage on average the costs of all enrollee needs to the capitation amount. Depending upon the state program, plans may be at varying degrees of risk for going over the capitation amounts (e.g., they must make up the difference), or they may accrue profits by keeping spending below the total capitation amount. In turn, plans may develop similar risk and shared savings arrangements with the providers. The Medicare Modernization Act established a new Part C in the Medicare program. Medicare Advantage Prescription Drug (MA- PD) plans are required to offer the full array of Medicare FFS benefits including skilled nursing care and the Part D drug benefit. Additionally, plans may offer extra benefits to enrollees. MA-PD plan enrollment has been expanding. The Kaiser Family Foundation (2011) reports that approximately one out of every four Medicare beneficiaries is enrolled in a MA-PD plan. CMS reimburses plans using a national benchmarking system which is used to set plan capitation rates. MA-PD plans, as well as other types of managed care plans, develop provider networks based upon provider participation criteria set by the plans and framed, for MA-PD, by federal guidelines. In terms of hospital readmissions, MA-PD plans have strong incentives to enroll hospital providers with low rates of avoidable hospital readmissions. Additionally, plans develop clinical guidelines and prior authorizations processes intended to guide enrollees to the most appropriate setting. In turn, MA-PD plans may offer incentive payments to skilled nursing providers. Specifically, MA-PD plans typically offer VBP arrangements for certain clinical outcomes, reduced lengths of stay and reduced hospital readmissions. Special Needs Plans (SNPs) are MA-PD plans targeted to specific populations

44 40 AHCA Quality Report Trends in Payment for Quality including people who are eligible for both Medicare and Medicaid (dual eligibles), people who are eligible for institutional services and people with chronic conditions. Due to the complex health care needs of their enrollees, SNP service coordination and efficient management of resources are critical. To aid in efficient and effective service delivery, many SNPs offer quality incentives to their providers, including skilled nursing facilities. Examples of quality measures, many based on the Consumer Assessment of Healthcare Providers and Systems, are reduced prevalence of pressure ulcers, weight changes, use of antipsychotic medications and reduced dehydration. MEDICARE VALUE-BASED PURCHASING DEMONSTRATION The Nursing Home Value-Based Purchasing Demonstration is the CMS pay-for-performance initiative to improve the quality of care furnished to all Medicare beneficiaries in skilled nursing facilities. Under this demonstration, CMS provided financial incentives to skilled nursing facilities that demonstrate delivery of high quality care or improvement in care. CMS anticipates that certain avoidable hospital readmissions would be reduced as a result of improvements in quality of care. This reduction and the subsequent reduction in skilled nursing facilities stays is expected to result in savings to Medicare that will be used to fund incentive payments. The demonstration includes all Medicare beneficiaries who are in a skilled nursing facility (i.e., those that receive only Part B benefits as well as those that receive Part A benefits, many of whom are also eligible for Medicaid). The approach will be to assess the performance of skilled nursing facilities based on selected quality measures, and then make performance payments to those facilities that achieve the best performance or the most improvement based on those measures. Performance is assessed in the following four domains: staffing, appropriate hospitalizations, outcome measures from the MDS and survey deficiencies from State health inspections. The demonstration included volunteer skilled nursing facilities in three host states: Arizona, New York and Wisconsin. A payment pool was determined each year for each State based on Medicare savings that resulted from reductions in the growth of Medicare expenditures, primarily from reductions in hospital readmissions. The demonstration has been completed; however, CMS has not released information from the VBP evaluation and preliminary analysis indicates mixed findings. The analysis shows somewhat positive intervention impacts in two states but limited impacts in the third demonstration state (White, n.d.). PATIENT PROTECTION AND AFFORDABLE CARE ACT The ACA established three national efforts with implications for quality incentive payments: Accountable Care Organizations (ACOs), Bundled Payments, and Medicare-Medicaid integration efforts. All three of these initiatives still are unfolding and little detail is available on how or whether quality incentives for skilled nursing facilities may be included. ACOs and Bundled Payments As discussed previously, the traditional FFS system is slowly being replaced by systems that pay for better outcomes and value rather than for the volume of services provided. Such strategies have been underway for many years in traditional managed care. The ACA will further reform the health care delivery system through the expansion of Medicare ACOs and Medicare bundled payments. ACOs and bundled payments both seek to facilitate and encourage coordinated and integrated care and reward providers that improve quality while also lowering costs. Medicare ACO initiatives seek to accomplish this by means of organizational structure reforms, whereas the Medicare bundled payment initiative uses payment reforms. The ACO model involves the measurement of savings and quality over a three-year period. The bundled payment model pertains to a bundle of services delivered within a given episode of care, such as the days spent in an acute care setting plus some period of post-acute care. The ACO Medicare Shared Savings Program will allow providers that voluntarily agree to work together to coordinate care. Those that meet certain quality standards will share in any savings they achieve for the Medicare program. ACOs which elect to become accountable for losses have the opportunity to share in greater sav-

45 AHCA Quality Report Trends in Payment for Quality 41 ings. In terms of measurement, ACOs will coordinate and integrate Medicare services across roughly 30 quality measures organized in four domains. These domains include patient experience, care coordination, patient safety, preventive health and services tailored to at-risk populations. The Bundled Payments for Care Improvement (Bundled Payments) initiative seeks to improve patient care by fostering coordination through four broadly-defined, patient-centered approaches. Three models involve a retrospective bundled payment arrangement, and one model would pay providers prospectively. Through the Bundled Payments initiative, providers have great flexibility in selecting conditions to bundle, developing the health care delivery structure and determining how payments will be allocated among participating providers. Participants in the Bundled Payments initiative must include a description of how they will address quality and efficiency in their applications. Incentive payments are paid to participants based on achieving savings and quality targets. Skilled nursing care providers may eventually play a much larger role under bundled payment initiatives than in ACO initiatives. This is due to the more limited scope of services skilled nursing facilities provide and the ability to create either a model that includes post-acute care services only, or one that includes both acute and post-acute care services. Specifically, models two and three have clear roles for post-acute care providers. Medicare-Medicaid Integration The ACA also established two new entities within CMS the Medicare- Medicaid Coordination Office (MMCO) and the Center for Medicare and Medicaid Innovation (CMMI). In terms of functionality, MMCO is charged with fostering the development of financial and organizational efforts to integrate Medicare and Medicaid services for people who are eligible for both programs (dual eligibles). CMMI has broad authority for testing an array of payment and service delivery models which may improve quality of care and produce efficiency. Specifically, CMMI has a broad new waiver authority for both Medicare and Medicaid as well as a substantial appropriation to test innovative concepts. Currently, 28 states are working with MMCO on some form of Medicare- Medicaid integration initiative. The vast majority are pursuing capitated, risk-based approaches which will use health plans to integrate Medicare and Medicaid benefits and financing. The plans will receive varying degrees of Medicare and Medicaid integrated capitation payments while all provider payments will be made by the plans for services delivered to dual eligibles. While details on how these integration models will be financed have yet to be defined, it is likely that plans will use existing quality incentive payment models currently in use in Medicaid and Medicare managed care. OUTLOOK Medicare and Medicaid budgetary pressure will continue to drive policymakers and skilled nursing care providers to explore payment methodologies which offer the promise of greater accountability and transparency. Two additional factors will foster continued interest in payment for quality. First, the long term and post-acute care profession, as well as many federal and state officials, increasingly recognize that regulatory and enforcement strategies are not effective in isolation as the sole mechanism for quality assurance. Second, traditional FFS Medicare and Medicaid reward volume and minimal compliance without regard for quality. Third, some current payment models incentivize practices that undermine quality efforts, such as the Medicare and Medicaid payment incentives to hospitalize beneficiaries receiving care at skilled nursing facilities. Public payers are increasingly recognizing that they have a responsibility to ensure public funds are spent on quality services. While the precise form of future VBP arrangements is unclear, purchasers and the profession will continue to move away from unmeasured performance with FFS payment to a new paradigm of performance measurement-driven payment.

46

47 THE YEAR AHEAD Long term and post-acute care providers are positioning themselves to be at the table to show the value that they provide to patients, other providers, and policymakers in achieving CMS Triple Aim: better health, better care and reduced costs. As demonstrated and discussed throughout this report, transformation is underway in the delivery of long term and post-acute care services to meet the quality and value demands of their customers. Meanwhile, the quality of care delivered in America s skilled nursing facilities is improving. On 12 of 15 publicly reported quality measures, skilled nursing facility performance has improved, particularly in regard to measures related to the delivery of post-acute care services. Regulatory compliance has also improved as the average number of citations, as well as their scope and severity, has declined dramatically over the past five years. Staffing levels in nursing facilities have increased as well, in part reflecting the need to improve quality but also reflecting the increasing acuity and frailty of individuals receiving services in today s skilled nursing facilities. This improvement in quality is further reflected in the satisfaction of persons served in these facilities, with overall customer satisfaction jumping by five percentage points to 87 percent between 2007 and Future trends are likely to include an expansion of publicly reported measures and an increased focus on measures that are meaningful to the different populations cared for in skilled nursing facilities across the country. Measures of quality specific to individuals receiving short-term rehabilitation will be added in the coming years, such as the percentage of individuals discharged back to home, the percentage of individuals who would recommend the facility to others and the percentage of individuals achieving improvement in mobility and self-care. Providers, consumers, payers and other stakeholders will continue to focus on quality and performance improvement in long term and post-acute care. In addition to its active regulatory and Quality Improvement Organizations program, the Centers for Medicare and Medicaid Services (CMS) will further encourage quality improvement through its new Quality Assurance/Performance Improvement requirements, which will add a proactive performance improvement component to the current reactive quality assurance-driven regulatory process. Long term and post-acute care stakeholders are also driving quality and performance improvement through campaigns such as Advancing Excellence in America s Nursing Homes and the AHCA/NCAL Quality Initiative. In tandem with regulatory quality assurance programs and partnerships to enhance performance, government and other payers are expected to continue realigning payment incentives to encourage further quality and performance improvement. The payment reforms currently being evaluated offer the potential for changing the role of government from payer for services to value-driven purchaser of quality outcomes. CMS, state governments and insurance companies are testing numerous alternative payment incentives and systems to improve quality and reduce costs. While all the various methods of valuebased purchasing are not yet known, consumers and payers of health care services have made clear that regulatory and financial incentives will be realigned to pay based on value and reward based on quality of services and measurable outcomes. Through participation in quality and performance improvement efforts, as well as through participation in payment reform initiatives, long term and post-acute care providers are positioning themselves to be at the table to show the value that they provide to patients, other providers, and policymakers in achieving CMS Triple Aim: better health, better care and reduced costs.

48 APPENDIX Table A1 LTC Community National Overview Number of Facilities (All) 15,866 15,772 15,718 15,694 15,693 15,690 For-Profit 10,521 10,581 10,607 10,641 10,758 10,832 Non-Profit 4,382 4,244 4,199 4,145 4,030 3,968 Government Percent of For-Profit Facilities 66.3% 67.1% 67.5% 67.8% 68.6% 69.0% Percent of Non-Profit Facilities 27.6% 26.9% 26.7% 26.4% 25.7% 25.3% Percent of Government Facilities 6.1% 6.0% 5.8% 5.8% 5.8% 5.7% NF Certification Status Medicare-only 5.2% 5.1% 5.0% 5.0% 5.0% 5.0% Medicaid-only 5.3% 4.8% 4.3% 4.1% 3.9% 3.7% Medicare/Medicaid 89.4% 90.0% 90.6% 90.9% 91.1% 91.4% Multi-Owned Facilities: # (%) 8, % 8, % 8, % 8, % 8, % 8, % Independent Facilities # (%) 7, % 7, % 7, % 7, % 7, % 7, % Total Beds 1,717,691 1,713,059 1,709,468 1,708,355 1,705,921 1,705,165 Total of Medicare-only Beds 80,255 83,575 87,397 89,819 92,789 92,986 Total Medicaid-only Beds 159, , , ,395 96,243 88,996 Total Medicare/Medicaid Beds 1,436,189 1,453,112 1,464,978 1,474,617 1,482,501 1,487,422 Total Bed Count in For-Profit Facilities 1,163,202 1,173,188 1,176,603 1,180,538 1,193,023 1,203,820 Total Bed Count in Non-Profit Facilities 441, , , , , ,495 Total Bed Count in Government Facilities 113, , , , , ,850 AHCA Analysis, CMS CASPER Data, various years

49 AHCA Quality Report Appendix 45 Table A1 (cont.) LTC Community National Overview Average Number of Beds (All) Average Bed Count in For-Profit Facilities Non-Profit Facilities Government Facilities Independent-Owned Facilities Multi-Owned Facilities Occupancy Rate 89.0% 88.6% 88.0% 87.5% 87.0% 86.6% Number of Persons Served at any Given Time 1,431,134 1,420,735 1,411,054 1,400,484 1,395,832 1,387,727 AHCA Analysis, CMS CASPER Data, various years Table A2 Facility Location Urban vs. Rural Number of Facilities Urban Rural # % # % National 15,690 10, % 4, % AHCA Member Facilities 8,690 5, % 2, % AHCA Non-Member Facilities 7,000 4, % 2, % AHCA Analysis, CMS CASPER Data, various years

50 46 AHCA Quality Report Appendix Table A3 Characteristics of Individuals Receiving Services in Nursing Facilities Medicare Admissions Non-Medicare Admissions Long Stay Residents (>12 months) Total # Individuals 2,329, , ,358 Age Category Age (average) Less than 65 years 10.4% 29.6% 14.9% Between 65 and 84 years 56.2% 41.4% 40.7% Greater than 85 years 33.4% 29.0% 44.4% Gender Male 36.6% 39.5% 29.3% Female 63.3% 60.4% 70.7% Race and Ethnicity American Indian 0.4% 0.6% 0.5% Asian 1.2% 2.2% 1.7% African-American 9.5% 13.9% 14.3% Hispanic 3.4% 6.5% 4.5% Caucasian 84.2% 75.2% 78.6% Functional Status Dementia 29.5% 38.0% 63.7% ADL dependence 4.4% 4.2% 4.1% Need Someone to Assist to Walk 90.9% 80.6% 76.0% Incontinence of bladder 35.8% 39.6% 66.4% Needing Assistance with Eating 28.3% 28.0% 35.6% Diagnoses Diabetes 34.5% 33.1% 32.0% Depression 31.5% 34.4% 54.9% Congestive Heart Failure 23.7% 17.6% 20.9% Hypertension 40.9% 69.3% 69.2% Chronic Obstructive Pulmonary Disease 22.4% 18.1% 17.5% Anemia 16.5% 25.5% 27.8% Osteoporosis 8.9% 14.1% 23.8% AHCA Analysis, CMS MDS 2.0 data, 2009

51 AHCA Quality Report Appendix 47 Table A3 (cont.) Characteristics of individuals Receiving Services in Nursing Facilities Medicare Admissions Non-Medicare Admissions Long Stay Residents (>12 months) Cancer 6.1% 11.2% 5.6% Stroke 14.1% 15.0% 21.8% Renal Failure 6.3% 9.0% 6.7% Heart Disease 14.8% 10.0% 12.6% Hip Fracture 7.7% 4.7% 1.7% Services ventilator or respirator 0.9% 1.1% 0.4% IV medication 70.0% 30.5% 1.4% Hospice 0.4% 6.4% 3.7% Pediatric 0.0% 0.2% 0.2% AHCA Analysis, CMS MDS 2.0 data, 2009 Table A4 Change in Nursing Facility Workforce 2005 to 2010 Occupational Category Percent Change RNs 120, , LPNs/LVNs 186, , CNAs 599, , Administrative & Other 618, , AHCA Analysis, US Department of Labor, Bureau of Labor Statistics, May 2005 and May 2011 National Industry-Specific Occupational Employment Estimates Table A5 Direct Care Nursing Hours Per Resident Day RNs LPN/LVN CNA Total AHCA Analysis CMS-CASPER/OSCAR Data, March various years

52 48 AHCA Quality Report Appendix Table A6 Quality Measure Performance QMs: Long-Stay Nursing Home Residents % with increasing symptoms of depression or anxiety between two assessment periods % with pressure ulcers (high risk) % with pressure ulcers (low risk) % physically restrained % with moderate pain daily or any instance of severe pain % with increased dependency in Activities of Daily Living between two assessment periods % with worsened locomotion between two assessment periods % with weight loss % bedfast % incontinent of bowel or bladder (low-risk) % with urinary tract infection % with indwelling urinary catheter QMs: Post-Acute Skilled Nursing Facility Patients % with moderate pain daily or any instance of severe pain % with pressure ulcers % with delirium AHCA analysis CMS Nursing Home Compare, 3rd quarter of each year

53 AHCA Quality Report Appendix 49 Table A7 Safety Measures % of Nursing Facilities with Medication Error Citation % of Nursing Facilities with Unnecessary Drugs Citation % of Nursing Facilities with Infection Control Citation % of Nursing Facility Residents on Antipsychotic Medications Table A8 Regulatory Compliance Measures Average number of deficiency citations in nursing facilities Source: CMS CASPER/OSCAR, March of various years Citation results for tags F332, F339 and F441 from CASPER standard health survey data Residents receiving Antipsychotic Medications data from CMS Resident Census and Conditions of Residents (672 Form) % of nursing facilities cited at level G or above % of nursing facilities with Substandard Quality of Care citations % of nursing facilities with Immediate Jeopardy citations % of nursing facilities with deficiency-free surveys AHCA Analysis CMS CASPER/OSCAR Health and Complaint Survey Results, March each year Table A9 (Re)Hospitalization of Nursing Facility Patients and Residents SNF 30-day re-hospitalization rate (%) NH facility long-stay 6-month hospitalization rate (%) Source - Long Term Care in America Project at Brown University funded in part by the National Institute on Aging. Brown University, various years

54 50 AHCA Quality Report Appendix Table A10 Overview of Value-Based Purchasing Quality Measures In Operation Proposed (See notes) Total Total Measures CA CO GA IA KS NV OH OK UT VT IN VA In Operation In Operation & Proposed Administrative cost/operating costs Chronic care pain Culture change Falls Home environment Hospitalization Immunizations Occupancy rate Person-centered/ residentdirected care Physical restraints Pressure Ulcers Quality measure scores/ indicators Quality program participation Rebalancing Satisfaction-- family Satisfaction-- resident Satisfaction-- staff Staff education Staff empowerment Staff stability/ turnover/ retention Staffing-- consistent assignment Staffing level/ratio State DOH score Survey UTI Indiana: Program is pending approval of CMS in the most recent SPA submission. Possible launch July Massachusetts: Program is small and focused on consistent assignment. Minnesota: State program supports provider-initiated projects aimed at improving the quality and efficiency of nursing home care. New York: The state is currently working on a new P4P system. The target is to have one set up by summer. North Carolina: State was looking at a P4P system at one time, but it was never implemented. Texas: Though a program exists, it has never been funded. Virginia: Program was develop in Virginia, but the initiative was shelved in 2008 due to the economic downturn.

55 REFERENCES (2011). Medicare health and prescription drug plan tracker. Kaiser Family Foundation. Retrieved August 10, 2012, from Abt Associates. (2012). Nursing home compare stakeholder meeting [PowerPoint slides]. Ballard, C.G., Waite, J., & Birks J. (2006). Atypical antipsychotics and psychosis in Alzheimer s disease. Cochrane Database of Systematic Reviews. Retrieved from: Berwick, D. M., Calkins, D.R., McCannon, C.J. & Hackbarth, A.D. (2006) The 100,000 lives campaign: Setting a goal and a deadline for improving health care quality. JAMA, 295, Briesacher, B.A., Field, T.S., Baril, J. & Gurwitz, J.H. (2009). Pay-for-performance in nursing homes. Health Care Financ Rev., 30, Castle, N.G. (2001). Administrator turnover and quality of care in nursing homes. The Gerontologist, 41, Castle, N.G., & Anderson, R.A. (2011). Caregiver staffing in nursing homes and their influence on quality of care. Medical Care, 49, Castle, N.G., & Engberg, J. (2005). Staff turnover and quality of care in nursing homes. Medical Care, 43, Castle, N.G., Engberg, J., & Men, A. (2007). Nursing home staff turnover: Impact on nursing home compare quality measures. The Gerontologist, 47, Centers for Medicare & Medicaid Services Office of Public Affairs. (2012). CMS announces partnership to improve dementia care in nursing homes [Press Release]. Retrieved from 368&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordTyp e=all&chknewstype=1%2c+2%2c+3%2c+4%2c+5&intpage=&showall=&pyear=&year=&desc=&cboorder=date Cheek, M., Finnan, L., Cho, E., Walls, J., Gifford, K., Fox-Grage, W., & Ujvari, K. (2012). On the verge: The transformation of long term care services and supports. AARP Public Policy Institute. Retrieved from health-care-reform/info /on-the-verge-the-transformation-of-long-term-services-and-supports-aarp-ppiltc.html Eguale, T., Buckeridge, D.L., Winslade, N.E., Benedetti, A., Hanely, J.A., & Tamblyn R. (2012). Drug, patient, and physician characteristics associated with off-label prescribing in primary care. Arch Intern Med, Eljay, LLC. (2011). A report on shortfalls in Medicaid funding for nursing home care. Retrieved from org/research_data/funding/documents/eljay%20medicaid%20shortfalls%20report% pdf Jencks, S.F., Williams, M.V., & Coleman, E.A. (2009). Rehospitalizations among patients in Medicare fee-for-service program. New England Journal of Medicine, 360, Laporte, Meg. (2012). Top 50 largest nursing home companies. Provider, 38 (6),

56 52 AHCA Quality Report References Maher, A.R., Maglione, M., Bagley, S., Suttorp, M., Hu, J., Ewing, B., Shekelle, P.G. (2011). Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults. JAMA, 306, Medicare Payment Advisory Commission. (2010). Report to The Congress: Medicare payment policy. Washington, DC: MedPAC. Medicare Payment Advisory Commission. (2012). Report to The Congress: Medicare payment policy. Washington, DC: MedPAC. Mor, V., Intrator, O., Feng, Z., & Grabowski D.C. (2010). The revolving door of rehospitalizations from skilled nursing facilities. Health Affairs, 29, Office of Inspector General. (2010). Medicare atypical antipsychotic drug claims for elderly nursing home residents (DHHS Publication No. OEI ). Washington, DC: U.S. Government Printing Office. Ouslander, J.G., Lamb, G., Tappen, R., Herndon, L., Diaz, S., Roos, B.A., Bonner, A. (2011). Interventions to reduce hospitalizations from nursing homes: Evaluation of the INTERACT II collaborative quality improvement project. Journal of the American Geriatrics Society, 59, Scheurer, D., Osser, D.N., Choudhry, N.K., Fischer, M.A. & Avorn, J. (2012). Restrained use of antipsychotic medications: Rational management of irrationality. Independent Drug Information Services. United States Census Bureau. (2010). Retrieved from US Department of Labor, Bureau of Labor Statistics. (2011). National Industry-Specific Occupational Employment Estimates. Retrieved from White., A. Nursing home value-based purchasing demonstration-1 year results [PowerPoint slides]. Retrieved from resources.leadingageny.org/nyahsa_org/special_reports/n pdf

57 The American Health Care Association / The National Center for Assisted Living 1201 L Street, NW Washington, DC