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IIR 06-260
Identifying and Characterizing High Performing VHA Nursing Homes
Michael Shwartz, PhD MBA BA VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA Boston, MA Funding Period: July 2008 - September 2011 Portfolio Assignment: Long Term Care and Aging |
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BACKGROUND/RATIONALE:
As part of its commitment to provide the highest quality to those in VA Community Living Centers (CLCs), the VA Office of Geriatrics and Extended Care (GEC) monitors and provides performance data to CLCs on 28 quality indicators (QIs) calculated from the Minimum Data Set (MDS). In addition, GEC launched a major effort to implement Patient Centered Care (PCC) practices, which it monitors using the Artifacts of Culture Change Tool. OBJECTIVE(S): 1) To develop composite measures of quality from the 28 MDS-based QIs and use these to identify high and low performing facilities; 2) To analyze the relationship between quality and job satisfaction, workgroup functioning and organizational culture as assessed by the All-Employee Survey (AES); 3) To analyze the relationship between quality and the extent of implementation of PCC practices; and 4) To analyze the relationship between quality and CLC costs. METHODS: We selected 112 of the 132 CLCs in which, in FY07, at least one-third of their residents were long-stay (over 90 days) and there were at least 10 long-stay residents. We primarily focused on FY05 to FY07 MDS data, although we also used data from FY03-FY07 to develop risk-adjustment models and data from FY08 to analyze PCC implementation. We considered two sets of QIs: 1) The MDS-based 28 QIs, which were our main focus; and 2) 5 incidence-based risk-adjusted QIs calculated from risk-adjustment models developed from MDS variables. We used several approaches to calculate composite measures. First, we used opportunity-based weights (OBWs) to combine observed rates for each indicator into a composite measure. OBWs, the approach used by the Centers for Medicare and Medicaid Services (CMS) in its pay-for-performance programs, gives equal weight to each type of QI event measured by the QIs. Second, we used a Bayesian multivariate normal model to calculate "shrunken" rates for each of the QIs, which were then combined using OBWs. Shrunken rates adjust for differences across QIs and facilities in the reliability of observed rates due to differences in sample sizes. Third, we used two Benefit-of-the-Doubt (BOD) approaches, simple linear programming models (SLP) and Data Envelopment Analysis (DEA). These approaches, which are based on the assumption that a facility's performance on individual QIs indicates its revealed preferences about the relative importance of the indicator, adjust weights within specified constraints to optimize performance. We profiled facilities using these different approaches, concentrating on those facilities identified as being in the top and bottom quintiles. Using the shrunken rate composite (for which interval estimates are available), we were able to identify a set of high performing facilities that were statistically different than a set of underperforming facilities (significance was based on the absence of overlap between their respective 95% Bayesian credible intervals). GEC uses the Artifacts Tool (developed by CMS) to measure implementation of PCC. Although the individual items that make up this instrument have face validity, scoring of the Artifacts Tool has not been validated. We considered 3 scoring methods: 1) the current method; 2) a method that sums standardized domain scores; and 3) a method that assigns optimal weights to domains to maximize the PCC/quality relationship. We examined the relationship between MDS-based quality and PCC using both multiple regression models and latent variable models. To analyze the quality/CLC cost relationship, we merged data from the VA Decision Support System with MDS data. We examined several generalized estimating equations (GEE) models with dependent variable total facility costs (for FY05, FY06 and FY07) and the following independent variables (by year): total patient days, RUGs score (a case-mix severity measure), year and the shrunken composite measure of quality. FINDINGS/RESULTS: 1) In FY2007, CLC composite scores, which reflect the chance of any QI event, ranged from 0.066 to 0.190 (0.068 to 0.184 using shrunken rates). Facilities in the top and bottom quintile were quite similar (agreement on 19 or more of 22 facilities) using the observed-rate composite, the shrunken-rate composite and the SLP BOD composite. Based on the shrunken rate composite, there were 27 high performing CLCs that were statistically distinguishable from 28 underperforming facilities. 2) Prediction errors when using shrunken rates were generally (though not exclusively) lower than when using observed rates. 3) Using each of the Artifacts scoring methods, the coefficient linking PCC implementation to quality was statistically significant. When the Artifacts Total Score was calculated from standardized domain scores, CLCs one standard deviation (SD) below the mean had a prevalence of 8.2/1000 more QI events than CLCs one SD above the mean. Using the latent variable model and standardized domain scores, there were 13 high performing facilities in terms of PCC implementation that were clearly distinguishable from 18 underperforming facilities. 4) In the GEE model, the coefficient linking quality to cost was 1.09 (95% CI 0.174 to 2.011). A facility with a quality score one SD below the mean (high quality) had about 5% lower costs than a facility with a score one SD above the mean. 5) Five incidence-based risk-adjustment models were developed (validated c statistics in parentheses): pressure ulcers (0.75), functional decline (0.67), behavioral decline (0.69), 6-month mortality (0.75) and 6-month preventable hospitalization (0.75). 6) We found no consistent relationship between any of the composite measures and any of the AES scales or individual questions we examined. IMPACT: VA is currently implementing PCC in CLCs. By demonstrating that more extensive implementation of PCC practices is associated with better quality and that better quality is associated with lower costs, our findings provide empirical support for the VA PCC movement. Over the longer term, by identifying a set of high performing facilities in terms of quality and PCC implementation, we provide a basis for learning and sharing best practices; by identifying a set of underperforming facilities, we highlight areas for targeting interventions in order to improve quality of care. External Links for this ProjectDimensions for VA Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects. Learn more about Dimensions for VA. VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project PUBLICATIONS:Journal Articles
DRA:
Aging, Older Veterans' Health and Care, Health Systems Science
DRE: Epidemiology Keywords: Management, Organizational issues, Quality assessment MeSH Terms: none |
