Background: In June, 2018, VHA began public reporting of its 135 Community Living Centers’ (CLCs’) overall quality using a five-star rating system based on data from the national quality measures captured in CLC Compare. In light of the private sector’s positive experience with report cards, this is a seminal moment for stimulating measurable quality improvements in CLCs. Yet public reporting of CLC Compare data raises substantial and immediate implications for CLCs. The report cards, for example, facilitate comparisons between CLCs and community nursing homes in which CLCs generally fare worse. This may lead to staff anxiety and potential unintended consequences (e.g., selective patient admissions—“cream skimming”). In addition, CLC Compare is designed to spur improvement, yet the motivating aspects of the report cards are unknown. Understanding staff attitudes and early responses is a critical first step in building the capacity for public reporting to spur quality. Specific Aims: We thus propose to adapt an existing community nursing home public reporting survey to reveal important leverage points to support CLCs’ quality improvement efforts. Our work will be grounded in a conceptual framework of strategic orientation and conducted in partnership with the VA Office of Geriatrics and Extended Care (GEC). We have 2 aims. 1. Qualitatively examine a sample of CLC staff reactions to CLC Compare. 2. Adapt and expand upon an extant community nursing home survey to capture a broad range of responses, then pilot the adapted survey in CLCs. Methods: Aim 1: We will conduct interviews with staff at 3 CLCs (one 1-star, one 3-star, and one 5-star) to identify (1) specific staff actions taken in response to their CLC’s public data, (2) staff commitment to/difficulties with using CLC Compare for quality improvement, and (3) factors that motivate staff to improve CLC quality. Aim 2: We will integrate these findings with our conceptual framework to adapt and expand a community nursing home survey to the current CLC environment. We will conduct cognitive interviews with staff in 1 CLC to refine survey items. We will then pilot the survey in 6 CLCs (two 1-star, two 3-star, and two 5-star) to assess survey feasibility, acceptability, and preliminary psychometric properties. Expected Results and Next Steps: We expect to develop a brief survey to be used in a future national administration to (1) identify system-wide responses to CLC Compare; (2) evaluate the impact of CLC Compare on Veterans’ clinical outcomes and satisfaction; and (3) develop, test, and disseminate interventions to support meaningful use of CLC Compare for quality improvement. Knowledge gained from this pilot and from future work will help GEC refine how CLC Compare is used, ensure that CLC staff understand and are motivated to use its quality data, and implement concrete actions to improve clinical quality. Products from this pilot will also facilitate studies of the effects of public reporting in other critical VHA clinical areas. Significance & Relevance to Veterans’ Health: This study responds to HSR&D’s Long-Term Care priority domain and the VHA priority of Greater Choice for Veterans. Just as public reporting of VHA hospital performance led to both positive and maladaptive responses, CLC Compare may have similar impacts on CLC staff and the 40,000 vulnerable Veterans they serve. This study seizes the opportunity to identify positive, as well as unintended and potentially maladaptive, early responses to CLC Compare to help improve VHA long-term care.
External Links for this Project
Grant Number: I21HX002765-01
Dimensions for VA
None at this time.
Mental, Cognitive and Behavioral Disorders, Aging, Older Veterans' Health and Care, Health Systems
Treatment - Comparative Effectiveness, TRL - Applied/Translational, TRL - Development
Caregiving, Outcomes - Patient
None at this time.