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IIR 07-114 – HSR&D Study

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IIR 07-114
VA Nursing Homes: Medical Staff Models and Care Correlates
Gary G Kochersberger MD
Canandaigua VA Medical Center, Canandaigua, NY
Canandaigua, NY
Funding Period: June 2008 - May 2011

BACKGROUND/RATIONALE:
The Veteran Health Administration (VHA) provides care to over 10,000 veterans in its 133 community living centers (CLCs). Medical staff organization in nursing homes have not been well described but have been shown to impact on quality of nursing home care. It is therefore important to describe the medical staff providing care to this frail and costly population, and whether the organization of this care is related to the quality of care provided in CLCs.

OBJECTIVE(S):
To conduct a national survey of VA CLC medical directors, quantified the medical structure and organization in CLCs and its relationship to health care outcomes. Understanding how medical staffs are organized within VA nursing home care units is a prerequisite to managing a workforce that best meets the needs of an aging veteran population within a system characterized by increasing resource constraints.


METHODS:
Sample and data:
Survey content was based on prior work with medical staff organization in community facilities, adapated to the VA with input from a VA provider expert panel.
Results of the returned CLC medical directors' survey responses were compared to responses of a parallel survey of medical directors who were members of the American Medical Directors' Association (AMDA). The AMDA survey was of a random sample of medical directors, conducted by the investigators in 2006-2007.
Minimum Data Set (MDS) resident assessment data from all CLCs for 2008-2009 was made available to the study.

Outcome measures: Quality Outcome measures are based on MDS responses and were obtained from the CLC data cube in the VSSC. Four health-related outcomes (prevalence of indwelling catheters, prevalence of anti-psychotic use in the absence of psychotic or related conditions, prevalence of daily physical restraint use, and prevalence of stage 1-4 pressure ulcers among low-risk residents) from the 1st quarter of 2009 were used.

CLC Characteristics: Information on CLC physician and mid level providers staffing levels, leadership turnover and medical director education, training, and activities was collected in the survey. Aggregated MDS data measures were created to characterize the veterans served in each CLC.

Medical Staff Organization: The dimensions of MSO were the key independent variables of interest. Each of these dimensions was constructed by averaging the scores of the related survey items. The dimensions as described in our previous publication in JAMDA (2009) included
Formal appointment process;
Commitment -physician cohesiveness ;
Commitment -leadership turnover ;
Departmentalization -physician supervision ;
Departmentalization - interdisciplinary involvement ;
Formal review process ;
Informal dynamics/ interpersonal relationships.

Relationship of Medical Staff Organization and CLC Quality Indicators:
To examine the association of medical staff organization and resident outcomes we conducted ordinary least square (OLS) regression analyses.
For the purpose of comparing regression coefficients of variables on different scales, we standardized some variables including, nursing case-mix index, ADL score, number of beds in the facility, proportion of residents who receive hospice or palliative care, and physician FTE per bed.


FINDINGS/RESULTS:
CLC vs. Freestanding Nursing Homes (FSNH) vs. Hospital-based Nursing Homes (HBNH)

We highlight the most interesting findings. The average CLC had less total attending physicians practicing at the facility than either FSNHs of HBNHs (2.44, 10.2, 10.3 physicians, respectively), but there were more physician FTEs in the CLC than either NH setting (1.78, 0.5, 0.8, respectively). About the same proportion of CLCs used nurse practitioners (NP) as FSNHs and HBNHs. More CLC medical directors reported having additional certifications in geriatrics (68.6% in CLCs vs. 38.8% in FSNHs and 50% in HBNHs).
Medical directors' time obligations were very different between the facilities. CLC medical directors reported spending much less time doing clinical work than either the FSNH or the HBNH (CLC = 49.0%, FSNH =73.2%, HBNH =40.0%). The second largest time obligation was administrative work which accounted for 35.23%,25.5%, and 10.0% of CLC, FSNH and HBNH medical directors' time, respectively.

Commitment to the facility was defined by physician cohesiveness and leadership turnover. Physician cohesiveness was similar across all three facility types. While the number of reported administrators over a the past 5 years was similarly (about 2), the turnover of nursing leaders was much lower in CLCs (on average 1.6 leaders in CLCs vs.2.6 and 2.1 in FSNHs and HBNHs, respectively)..

Departmentalization of the medical staff as measured by physician supervision and physician autonomy were similar across settings, however, interdisciplinary involvement was higher in CLCs (on average, 0.7) than in FSNHs and HBNHs (0.4, 0.5, respectively).


Outcomes:
In 2009, the average score for indwelling catheters among all CLCs was about 17.5%, antipsychotic quality indicator (QI) score average was about 15%. The average QI score for pressure ulcers among residents at low-risk of developing them was about 6%, and the average QI score of daily restraint use was about 0.5%.

Risk adjustors: The average ADL among CLCs was 9 (interquartile range 6-13). On average, 15% of the CLC residents had moderately cognitive impairment (CPS=3 or 4) and 10% were severely cognitively impairment (CPS=5 or 6). On average, the proportion of residents who received hospice or palliative care was 13%.

Regression Analyses of the Association of CLC Medical Staff Organization (MSO) and Quality Indicators:

Facility MSO and physician workload did not seem to be correlated with the prevalence of indwelling catheters, antipsychotic use, or daily restraints.

Prevalence of stage 1-4 pressure ulcers (PUs) among low-risk residents: Higher nursing case-mix level and lower ADCs were related to higher prevalence of pressure ulcers (1SD higher nursing case-mix index level was related to 2.4% higher prevalence of pressure ulcers, and 1SD higher daily census was related to 2.1% point lower prevalence of PUs). While higher levels of physician supervision was related to lower prevalence of PUs, physician cohesiveness and formal review process were related to higher prevalence of pressure ulcers. A facility with more than 80% residents cared by one physician had lower prevalence of pressure ulcers, and CLCs with higher physician FTEs had a higher prevalence of PUs. The higher case mix and clinical acuity associated with higher PUs may be driving the need for more medical staff.


IMPACT:
By defining CLC medical staff organizational models and their relationship to patient outcomes this study lays groundwork for future investigation on the ways CLC organization can lead to better quality of care, reduced health care costs and a more stable and productive nursing home workforce. The following products result from successful completion of the project: 1) Database describing structural and medical staffing characteristics of CLCs; 2) Tool to quantify medical staff organization in CLCs; 3) Initial evidence on the impact of medical staff organization on quality outcomes; 4) Comparison of CLCs and community based NHs.

PUBLICATIONS:
None at this time.


DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: none
Keywords: Long-term care, Management, Management and Human Factors, Models of Care, Organizational Structure, Quality assurance, improvement, Quality Improvement
MeSH Terms: none

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