Under the microscope

October 1, 2002
George Hradecky

George Hradecky is a former editor in chief of Pharmaceutical Representative magazine.

Pharmaceutical Representative

Now long-term care facilities must report quality data to the public.

Starting on October 15, 2002, long-term care facilities across the United States will begin reporting data on 10 quality measures (see sidebar on this page) as part of a quality initiative from the Centers for Medicare and Medicaid Services. The data from the measures will be reported at www.medicare.gov/nhcompare/home.asp. Though nursing homes have always reported quality data, the new initiative is a "particularizing and focusing of a system that's already in place," in the words of John Gillan, director of community relations at the Washington-based American Health Care Association. "When Tommy Thompson came in, he was talking right away about getting a better handle on quality care, payment for care," says Gillan. "So he came at it very broadly and it just seemed to particularize itself in these quality initiatives."

The initiative was announced in November 2001 and met with considerable support from the industry. "Quality matters, and because we know that performance differs among nursing homes, it is essential that we identify true measures of quality care that, uniformly applied and easily understood, can be used as a tool both for improving nursing home performance and educating consumers," said Larry Minnix Jr., president and chief executive officer of the Washington-based American Association of Homes and Services for the Ageing, at the time of the announcement. "It is time for the public to have reliable, meaningful data to help make informed long-term care decisions, and it is time for nursing homes and government to come together to give the public that information."

Support and concerns

Industry support for the initiative has continued from the launch of the six-state pilot program in April to the present, but associations have raised concerns about how accurate a picture of care the indicators provide consumers. Some fear outside factors could give people the wrong impression. "Patients in one nursing facility may be older and sicker than patients in another facility," says Gillan. "If your facility has many more people with complex conditions, it's going to exacerbate the whole thing. For example, those people are going to be more solidly bedridden than others, which increases the chance for more pressure ulcers, which is one of the measures. So the average person on the street reads this and they say: 'This facility doesn't take care of people, look at the pressure ulcer incidence. Boy, that sure tells you they aren't doing a good job.' It's a complex thing today, to comparatively evaluate long-term care facilities, because of that acuity level, because of all sorts of things that the average person on the street doesn't understand."

Minnix advises consumers not to base their entire decision about care on the quality numbers. "AAHSA encourages consumers to view the published measures and ratings as a starting point for asking further questions about a nursing home's quality of care," he says. "It is important, for example, to ask the older person's physician about the type of nursing home that would be most suitable. Then, ask around. What kind of reputation for care does the home have? What do doctors, clergy and other families think of the home? Is the atmosphere clean, pleasant and inviting? Does the staff make you feel welcome? What kind of interaction do you see between the residents and staff? Is the staff open to answering all your questions?"

To address concerns about quality measures being unfairly weighted, the CMS has included risk adjustments in three of the measures (residents with pressure sores in the chronic measures, and residents with delirium and residents who improve in walking in the post-acute measures) that take into account a faculty admission profile that considers patients' condition when they are admitted to a facility.

But even still, the quality initiative as it is formatted when it launches in October is not likely to be the absolute, final configuration. Gillan sees the project as a work in progress. "We have been supportive of the CMS program from the beginning and will continue to be, but will continue to work closely with them on measurements," he says. "That's the key - if the measurements can be made as complete and well-based as possible, and reported as well as possible to the consumer, we can't ask for much more than that. But a lot of folks are looking at October as a silver bullet time as if CMS is going to roll out the program and say, 'OK, this is it, this is intact and this is the way the program is going to be forever.' Not even they believe that. We certainly don't believe it. It's going to be a continuing involvement to arrive at optimum care for patients in nursing facilities."

Opportunities for reps

Because medications play a huge role in treating elderly populations, the quality initiatives can present selling opportunities for reps calling on either long-term care facilities or the doctors who work in them. When it comes to the quality initiatives, medications can either be the primary method of treatment (as with infection and pain management), or have an indirect effect (as with delirium and improvement in walking).

"Any change in a patient or resident's condition should first be considered as a potential medication adverse effect before anything else," says Mark Sey, a principle in the Woodbridge, CA-based pharmacy consulting firm Mark Sey and Associates. "There's a significant potential for medications to contribute negatively."

Keeping an eye on medication side effects can go a long way toward managing a facility's quality measures. Often, the side effects of a drug being used to treat one of the measures can have a negative impact on one or more of the other measures.

Concern about the impact of side effects on quality measures should not be used to reduce treatment that is otherwise working. "The challenge is going to be to manage the patient's pain or conditions with medication on the one hand, but on the other hand, try to avoid producing the serious adverse effects or side effects that are going to inhibit functioning or contribute to other issues," says Tom Clark, director of professional affairs for the Alexandria, VA-based American Society of Consultant Pharmacists. "It can only be done by looking at each patient on a case-by-case basis."

One danger facilities face in dealing with quality scores is to look at the overall data and use it as a guideline for treating an entire population of patients. "What we don't want to do is treat the facility's scores instead of looking at the information and then applying it from a population base into individual care," says Sey. "Constant reminders are necessary to move away from that and say 'OK, this is population data and now we need to filter that out and look at the individuals who are contributing to that population data and make sure we are treating these people appropriately.'"

Despite the importance of looking at patients individually, nursing homes should also have facility-wide programs in place for dealing with each of the quality initiatives. "A system-wide strategy needs to be in place for things like education, tracking, monitoring, revision of facility protocols or policies, and procedures in response to weaknesses or problems that have been identified," says Clark. "So there is a role for both the system-wide approach as well as the individual patient basis for more in-depth customized evaluation or treatment to balance the disease in that particular resident." PR

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