Physician Practice in the Nursing Home: Measuring Performance and Assuring Quality Care - PowerPoint Presentation

Physician Practice in the Nursing Home: Measuring Performance and Assuring Quality Care Paul R. Katz, MD, CMD Professor of Medicine Department of Geriatrics College of Medicine Florida State University

Interdisciplinary care is the underpinning of quality in the nursing home (NH)Nurses contribute the majority of “person hours” of care in the NH In addition to nurses, physicians are among the key players in the interdisciplinary team Nurse practitioners and physician assistants are also important contributors to medical care delivery in the NH Understand the Context

Families often don’t get an informed choicePlacement driven by:Medical needs Psychiatric/behavioral needs Payment source Location of nursing home Relationships between nursing home and hospital Hospital and nursing home bed supplyFamily advocacyHospital clinicians often unaware of nursing home capacity and quality Choosing a Nursing Home

Evidence based considerationsNurse staffing ratiosSurvey deficienciesPerformance on publically reported quality measures Administrator/Director of Nursing leadership style and turnover rates For profit v not-for profit Philosophy of care (i.e. person centered/culture change) Focus on quality improvement (i.e. INTERACT)Choosing a Nursing Home

The link between physician care and NH quality Approaches to measuring physician performanceSetting a research agenda Is There a Doctor in the House?

1.4 million residents in US 46% chance of being admitted to a NH after the age of 65Post-acute patients receiving SNF care account for 20% of total NH days (US) New payment models focus on enhanced care coordination and transitions of care with reduced re-hospitalization rates Nursing Homes (NH)

In the U.S. only one in five primary care physicians engages in the care of nursing home residents (JAGS 45: 911, 1997)The majority spend 2 hours or less per week in NH care In Ontario (2005), 1190 physicians engage in NH care out of 10,317 (12%); of these 628 (53%) cared for 90% of all residents. Between 1990 and 2000 there was a 5% decline in proportion of general practitioners providing services to LTC homes (CMAJ 19:429, 2002) Nursing Home Physicians in North America (historical)

Teno JM et al. Research Letter: Temporal Trends in the Number of Skilled Nursing Facility Specialists from 2007 through 2014. Published online: July 10, 2017.doi:10.1001/jamainternmed.2017.2136

Ryskina KL, Polsky D, Werner RM. Research Letter: Physicians and advanced practitioners specializing in nursing home care, 2012-2015. JAMA Nov 28, 2017 Vol 318 (20)

Baseline and Projected Geriatrician National Supply and Demand, 2013 and 2025 US DHHS, HRSA-Bureau of Health Workforce, April 2017 Estimated supply 2013: 3590 New entrants 2013-2025: 2640 Attrition 2013-2025: -690Change in average work hours: -20Projected supply: 6230

Baseline and Projected Geriatrician National Supply and Demand, 2013 and 2025 Demand: Estimated demand 2013: 22,940 Changing demographic impact: 10,260 Insurance coverage impact: -------Projected demand: 33,200Projected supply minus demand: -26,980

Credibility GapJ Am Med Dir Assoc 14(2):83-84, 2013 Physicians practicing in NHs have low credibility/respect compared to their peers Skill set not recognized or appreciated Acute care is the center of the health care universe reflecting predominance of the medical modelDisease focusedCure at all costs Technology

Optimal physician practice translates into desirable outcomes:Clinical quality Efficiency/cost effectiveness Patient and family satisfaction Quality of life Is this Assumption True?

A Model for Nursing Home Physicians: Linking Practice to Quality Ann Intern Med 2009; 150:411-413 Three critical dimensions… Commitment conceptualized as percentage of the physician's practice devoted to NH care and the amount of time, on average, spent per NH patient encounter. Physician NH practice competency defined by specialized training and experience necessary to handle the complex medical care in a highly regulated, interdisciplinary care context that is the contemporary NH. Organizational structure reflects the cohesive integration of the medical providers into the culture of the facility.

Clinical and Nonclinical Factors Associated with Potentially Preventable Hospitalizations Among Nursing Home Residents in New York State (JAMDA 12: 364-371, 2011) 147 randomly selected NHs Outcomes derived from DON survey, MDS and SPARCS (patient level data related to hospitalizations) 2007-8 Nursing Home Medical Staff Organization

ResultsFour factors significantly associated with reduction in ambulatory care sensitive (ACS) conditions Nursing staff trained to effectively communicate with physicians regarding a resident’s condition Physicians treat residents within the nursing home and admit to hospital as a last resort NHs that provide better information and support to nurses and aides surrounding end-of-life care Easy access to stat lab results in <4hrs on weekends Nursing Home Medical Staff Organization

Treatment of Pain in European Nursing Homes: Results from the SHELTER StudyJAMDA online: www.jamda.com/article/S1525-8610(13)00250-8/fulltext Cross sectional study of pharmacological and non-pharmacological pain management involving 4156 residents Assessed with interRAI instrument for LTCF7 countries involved: Czech Republic, England, Finland, France, Germany, Italy, Netherlands and Israel High turnover of regular staff and low to moderate physician availability were negatively associated with pharmacological pain management

6275 residents of 175 nursing homes included as part of larger IQUARE study in southwestern FranceThe number of GPs working at each home varied from 1 to 42 with mean of 13.8Residents in NHs with 20 GPs or more/100 beds had more inappropriate prescribing than in NHs with less than10 GPs/100 beds (OR 1.8) Organizational Factors Associated with Inappropriate Neuroleptic Drug Prescribing In Nursing Homes (J Am Med Dir Assoc 2015;16:590-597)

Unplanned transfer to emergency departments for frail elderly residents of aged care facilities: A review of patient and organizational factors (J Am Med Direc Assoc 2015;16:551-562): Literature review of observational studies (N=78) Meta-analysis not possible given heterogeneity of studies36% of studies included some prospective data54% from US;12% Australia;10% Canada Organizational Determinants of Transfers from Residential Aged Care Facilities

Lower rates of hospitalizations if:Greater involvement of medical staff through full time appointmentsGreater availability of facility medical director Greater availability of primary care physicians Increased physician hours per resident More formal structured appointment process for physician Organizational Determinants of Transfers from Residential Aged Care Facilities

Rysinka KL, Yuan Y, Werner RM. Health Serv Res. 2019;1-11.Data sources: Medicare claims and NH assessments for 2,118.941 hospital discharges to 14,526 SNFs Jan 2012-October 2014 Nursing home specialist’s (MD/NP) patients were:Less likely to be rehospitalized (14.71% v 16.23%) More likely to be successfully discharged to community (56.33% v 55.49%) Nursing home specialists had higher 60-day Medicare payments ($31,628 v $31,292) Impact of NH Specialists on Postacute Care Outcomes and Cost

What metrics do we use to measure physician performance?Should they be based on productivity and financial performance ORShould they be based on measures that exemplify a special skill set and it’s application at the bedside? If Physician practice relates to quality then……

Measures of productivity and financial performance, while important, DO NOT necessarily measure good clinical care The skill set necessary to practice high quality care is defined by attending physician competencies specific to the nursing home Metrics to measure physician performance

Competencies for Physicians Practicing in the NH: Rationale Nursing Home practice demands a unique skill set Competencies linked to relevant clinical outcomes/quality Credibility of physicians predicated, in large part, on specialization Impetus to set the bar independently or allow government to determine performance metricsHelps inform new curriculum development

“Preparing for Better Health for an Aging Population” ( nam.edu /VitalDirections) Physician and nurse training in all settings where older adults receive care, including nursing homes, assisted-living facilities, and patients’ homes. Demonstration of competence in the care of older adults as a criterion for all licensure, certification, and maintenance of certification for health care professionals. Enhanced reimbursement for clinical services delivered by practitioners who have a certification of special expertise in geriatrics National Academy of Medicine Priorities

Foundational (ethics, professionalism and communications)Medical Care Delivery ProcessSystemsNursing Home Medical Knowledge Personal QAPI (quality assurance and professional improvement) Competencies for Post-Acute and LTC Attending Physicians http:// www.amda.com /strategic-initiatives/ competencies.cfm

Domain I: Foundation (Ethics, Professionalism and Communication) Module 1.1 Application of Ethical Principles in Clinical Decision-Making Module 1.2 Clinical Implications of Legal and Regulatory Requirements Module 1.3 Recognizing and Adapting to Patient Limitations and Impairments Module 1.4 Optimizing Communication with Patients and Families Module 1.5 Culturally Sensitive Interactions with Patients, Families and Staff Module 1.6 Elements of Appropriate and Timely Practitioner Performance

Domain II: Medical Care Delivery Process Module 2.1 Applying the Care Delivery Process to Patient Care Module 2.2 Developing a Person-Centered Evidence-Based Medical Care Plan Module 2.3 Identifying and Incorporating Prognosis into Care Decisions Module 2.4 Principles of Palliative and End-of-Life CareModule 2.5 Developing Effective Palliative and End-of-Life Care Plans

Domain III: Systems Module 3.1 Providing Prudent and Minimally Disruptive Care Module 3.2 Using Patient Databases in Clinical Practice Module 3.3 Determining Appropriate Levels of Care Module 3.4 Optimal Management of Care TransitionsModule 3.5 Working Effectively with the Interdisciplinary Care Team Module 3.6 Understanding and Explaining the Impact of Finances on Care Decisions

Domain IV: Medical Knowledge Module 4.1 Identifying and Managing Changes in Condition Module 4.2 Formulating a Pertinent and Adequate Differential Diagnosis Module 4.3 Identifying and Developing a Person-centered Medical Plan Module 4.4 Minimizing Risk and Optimizing Patient SafetyModule 4.5 Managing Pain Safely and Effectively Module 4.6 Prescribing Medications Prudently and Effectively

Domain V: Personal Professional Development in PA-LTC Module 5.1 Developing a Personal Professional Development Plan Module 5.2 Utilizing Quality-Related Information to Improve Care Module 5.3 Using Patient Outcomes to Improve Practice

Competencies Curriculum Online Course Web-based Asynchronous Case studies Pre- and post-test questionsEvaluations Certificates

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Donabedian conceptualized quality along 3 dimensions:Structure (organizational characteristics)Process (what is done in practice) Outcome (the final product) Logic: Good structure (i.e. high nurse staffing ratios) facilitates good process ( i.e performing medication reconciliation) Good process facilitates good outcomes(i.e. reduced rates of re-hospitalization) Metrics to measure physician performance (Castle N, Ferguson JC. The Gerontologist 50: 426, 2010)

Provision of Care in the Nursing Home Structure NH Staff - Training - Number - Stability Organization NH layout Policies NH Ownership - Profit - Not-for-profit Expenditures RAND Health Process Steps of care provided by N ursing aides LVNs Registered Nurses Therapists Physicians Nurse Practitioner Pharmacists Policy Implementation Fall rates Rates of restraint use Functional decline Deficiencies Outcomes

ProStructure: Data available and easy to measureProcess: Describes what is done to the resident Outcome: The desired state for the resident Con Structure: Variable link to quality of care (“necessary but not sufficient”) Process: Does not necessarily describe appropriateness of what is done; documentation vs actual care; often requires chart reviewOutcome: Dependent on multiple inputs and often inevitable in frail NH residents (majority of MDS measures) Metrics to measure physician performance (Castle N, Ferguson JC. The Gerontologist 50: 426, 2010)

Development of Quality Indicators for NH Primary Care Providers (Phase I) Grant support from the Morris Justein Family Charitable Foundation Focus on PROCESS measures that operationalize the AMDA competencies I d e n t i f y t h e s t e p s o f c a r e t h a t a r e i n f l u e n c e d b y t h e p r i m a r y c a r e p rov i d er ( p h y s i c i a n o r a d v a n c e p r a c t i c e nu r s e/PA ) . Mitigates need for complicated risk adjustments Allows for more “discipline specific” focus Ideally reflects best practices

U C L A B o r u n C e n t e r F O R G E R O N T OLO G I CA L R E S E A R C H T E A M M E M B E R S

Methodology Reviewed and adapted existing indicators A C O V E 3 Q u a li ty Ind i c a t o r s 200 7 N H Q u a li ty I nd i c a t o r s 200 4 N H R e s i d e n t i a l C a r e Q u a li ty I nd i c a t o r s ( 2002 ) A G S /AMDA C h oo s i n g W i s e l y T h e E u r o p e a n H e a r t R h y t h m A ss o c ia t i o n g u i d e li n e s SGIM-AMDA-AGS Consensus Best Practice Recommendations for Care Transitions

Technical expert panel convenedModified Delphi Process (Rand) Pre-meeting ratings In-person discussion (June 2017) G oa l i s c la r i f i c a t i o n N o t f o r c i n g a g r ee m e n t R e - r a t e a ft e r d i s c u ss i o n Methodology

I N S T RUCTI O NS M o s t o f t h e Q I s a r e c o n s t r uc t e d a s I F a n d T H E N s t a t e m e n t s : “ I F ” s t a t e m e n t d e s c r i b e s t h e r e s i d e n t s t o w h o m t h e i nd i c a t o r a pp li e s “ T H E N ” s t a t e m e n t d e s c r i b e s t h e p r o c e s s o f c ar e t h a t s h o u l d o r s hou l d no t b e a pp li e d u nd e r t h e s e c i r c u ms t a n c e s R a t e t h e v alidi t y a n d f e a s ibi l i t y o f indi c a t o r s o n a 1- 9 poin t s cal e wh e r e 9 = m o s t hi g hl y v ali d a n d 1 = no t a t al l v ali d 1- 3 = no t v a li d ; n o t f e a s i b l e t o i m p l e m e n t 4- 6 = v a r i a t i o n i n v a li d i t y ; v a r i a t i o n i n f e a s i b ili ty 7- 9 = v a li d ; f e a s i b l e t o p e r f o r m t h e p r o c e s s W h e r e t h e r e a r e m ul t ipl e o p t ion s , v o t e e ac h ind e p e nd e n t l y .

V A L I DITY W e d e f i n e a n i nd i c a t o r t o b e v a li d i f : T h e qu a li t y i nd i c a t o r is c l e a r a n d e x p li c i t . A d e qu a t e s c i e n t i f i c e v i d e n c e or p r o f e ss i o n a l c o n s e n s u s e x i s t s t o s upp o r t a s t r o n g li n k b e t w ee n t h e p e r f o r m a n ce o f s p e c i f i e d c a r e a n d o u t c o m e s . I m p r o v e d qu a li t y o f li f e is c o n s i d e r e d a n o u t c o m e . A p r o v i d er w i t h s i g n i f i c a n t l y h i g h er r a t e s o f a dh e r e n c e t o a n i nd i c a t o r w o u ld b e c o n s i d e r e d a h i g h er qu a li t y p r o v i d e r . A m a j o r i t y o f f a c t o r s t h a t d e t e r m i n e a dh e r e n c e t o a n i nd i c a t o r a r e und er t h e i n f l u e n c e o f t h e p r o v i d er ( o r a r e s ub j ect t o i n f l u e n c e, s u c h a s s upp o r t o f c a r e g i v e rs ) .

F E A S IBILI T Y F e a s i b ili t y of i m p l e m ent a t i on s h o u ld b e r a t e d b a s e d o n a n a v e r a g e nu rs i n g h o m e t r yi n g t o d e li v er h i g h qu a li t y c a r e . C o n s i d er s t a ff i n g r e s o u r c e s , ph y s i c i a n r e s o u r c e s , e x p e n s e .

IF the NH staff attempts to contact the PCP by phone or pager for an acute change in a nursing home resident (NHR),THEN there should be documentation that the PCP returned the call within 60 minutes.(Note: acute change in condition includes a critical lab) NH Quality Measure

IF a NHR is admitted with a diagnosis of dementia, THEN the PCP should assess the resident’s diagnosis, prognosis and associated behavioral symptoms.IF a NHR has advanced dementia, THEN the PCP should NOT recommend the insertion of a percutaneous feeding tube. NH Quality Measure

IF a NHR has a suspected or definite diagnosis of delirium, acute confusional state, or reduced level of consciousness, THEN there should be a documented attempt to identify a potential etiology IF a NHR is admitted with the intention of a short stay (i.e., rehabilitation, hospice, respite) THEN the PCP should see the NHR to initiate a comprehensive assessment within 3 days NH Quality Measure

All NHRs should be offered immunizations, as per national immunization guidelinesIF an individual is admitted to the NH, THEN within 6-8 weeks of admission, the patient’s chart should document a discussion regarding preferences for life-sustaining treatments or a reason that discussion did not occur. NH Quality Measure

Researcher-Clinician Partnership grant through the Center for Aging, Brain Health and Innovation Goal: Refine, validate, and operationalize newly developed primary care provider-specific QMs to calculate a “Primary Care Provider Quality Score” (PQS). DEVELOPMENT OF A PRIMARY CARE PROVIDER QUALITY SCORE (PQS) FOR PERSONS IN LONG-TERM CARE (Phase II)

Team Members Researcher-Clinician Partnership Program

Quality Measures

Recruit 8 nursing homes in Canada and the US that are members of the Senior Quality Leap Initiative With input from the participating site medical directors, specify the selected 37 quality indicators Pilot test the QI’s at Schlegel and Baycrest and then apply at all sitesBased on performance of the measures, comprise a “Primary Care Provider Quality Score” Phase II Methodology

Next StepsCorrelate the PQS to: System level quality indicators and clinical outcomes (MDS) Medical staff organizational variables Determine the optimum medical provider:resident ratio for PA-LTCDevelop and publish an online PQS toolkit for broad dissemination

Employ artificial intelligence to simplify collection of process based quality measures Influence policy based on research evidence Next Steps

Questions/Discussion