Strategic Implementation of Quality Initiatives

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Running head: WHITE PAPER 1

Deliverable Two: Cost, Quality and Access of Care

LaToya T. Benson

Rasmussen University Online

Healthcare Quality Management

January 29, 2023

Dr. Ide

Cover Letter

January 29, 2023

To: Professor Dawn Ide, Chief Medical Officer (CMO)

From: LaToya T. Benson, Senior Clinical Analyst

Re: Cost, Quality, Access of Care of Nursing Homes

Enclosed is the white paper on the quality improvement initiative for the next fiscal year. After further evaluating Oakridge Health Systems' last year's annual survey findings compared to the state and national healthcare data statistics, these are this report's three main focal points:

(1) Quality measures are tools that help us measure patient outcomes, perceptions, and organizational structure and systems associated with the ability to provide high-quality health care and that relate to one or more quality goals for health care.

(2) Improving healthcare quality and safety is a growing focus for the nursing field and healthcare systems, as medical institutions aim to achieve efficiency, reduce healthcare costs and ensure high-quality patient outcomes.

(3) Bedsores are a severe healthcare problem and the target of care quality reform. Taking some simple steps can reduce the chance of pressure ulcers developing. Bedsores are a crucial indicator of the quality and experience of care.

I would like to will schedule a meeting so that we can further discuss the report. Please respond by end of the next business day.

Sincerely,

LaToya T. Benson, Senior Clinical Analyst

Executive Summary

Nursing facilities are part of the long-term care delivery system that includes home and community-based services (Harrington, 2018). Still, their relatively high cost has led them to be the focus of much attention from policymakers. As the COVID-19 pandemic continues to ravage the country, widespread financial challenges loom over many long-term care facilities (Harrington, 2018). One of the root causes of these challenges is Medicaid underfunding. Medicaid plays a significant role in financing nursing facility care in the United States. Policy proposals to limit federal financing for Medicaid may lead to cuts in eligibility or scope of coverage for long-term care services (Harrington, 2018). With Medicaid as the primary payer for most nursing facility residents, policy and payment for nursing facility care is a priority policy area for state and federal governments that finance it. Changes to federal Medicaid financing could have repercussions for states' ability to maintain Medicaid spending for long-term services and support. In addition, regulations effective November 2016 aimed to address longstanding challenges in quality and safety in nursing facilities (Harrington, 2018). As the demand for long-term care continues to increase and policy proposals and regulations unfold, facilities' characteristics, capacity, and care quality remain subjects of concern among consumers and policymakers. Nursing facilities provide care to prevent problems and address residents' needs, but sometimes care must meet established standards. State surveyors assess the process and the outcomes of nursing facility care for individual requirements across significant areas. When a facility fails to meet a requirement, a citation is given to the facility for that requirement. This report analyzes the state of Illinois and national healthcare quality based on health deficiencies in the most recent year of data reported by the Centers for Medicare & Medicaid Services with supporting examples. Along with the recommendation for an initiative based on deficiencies and an evaluation of the quality measure outcomes.

Background/Explanation of the problem

The COVID-19 pandemic has put longstanding problems in Illinois nursing homes into the spotlight. Since the pandemic started, Illinois skilled nursing and residential care facilities have lost at least 14% of the workforce, and violations have increased (“Miletich,”.n.d.). According to a new report from an advocacy group, Illinois is the third worst state in the country for nursing home quality (“Nursing home report cards,” n.d.). According to the report, about 97 percent of nursing homes in Illinois had federal deficiencies or citations, and nearly 28 percent had severe shortcomings (“Nursing home report cards,” n.d.). According to a recent Families for Better Care report in 2019, Illinois ranks 42nd out of the fifty states in the U.S., with an overall grade of “F” because of its poor nursing home conditions. See the image below:

The Illinois Medicaid program pays for the care of about 70 percent of all the nursing home residents in the state, or roughly 45,000 seniors and disabled individuals (“Nursing home report cards,” n.d.). Many Illinois nursing homes, however, are challenged by low payments from Medicaid. Nursing homes hope the state's newly adopted budget will offer relief. The budget includes another $240 million for Medicaid funding for nursing homes, including $70 million for staffing. It also has potential financial penalties for nursing homes that fail to meet staffing requirements.

Discussion/Analysis

A nursing home’s failure to meet a federal participation requirement is defined as a deficiency (“Nursing home enforcement,”.n.d.). Deficiencies range in scope and severity from isolated violations with no actual harm to residents to widespread violations that cause injuries or put residents in immediate jeopardy of harm (“Nursing home enforcement,”.n.d.). Deficiencies may be cited because of an on-site inspection or evaluation of written reports or documentation. Some examples of deficiencies include:

· A nursing home did not provide a fluid and potassium-restricted diet to a resident who had end-stage renal disease.

· A resident reported to multiple nursing home staff that another resident had made threats to return to the nursing home to shoot and stab nursing home staff once he was discharged. The nursing home did not report the threat to a law enforcement entity and take other appropriate actions.

· A doctor ordered that a nursing home should not give medications to a resident when the resident’s systolic and diastolic blood pressures were less than 100 and 60, respectively. However, for 14 days in a month, the nursing home gave the medications to the resident when the resident’s systolic blood pressure fell below the ordered parameter of 60.

According to the state and national data set in the Centers for Medicare & Medicaid Services for the quality measure, staffing, and the number of deficiencies, Illinois's health deficiencies are more significant than the nation. In Cycle 1, the nation averaged 8.4 health deficiencies, and Illinois had 11.5 health deficiencies. In Cycle 2, the nation averaged 8.6 health deficiencies, and Illinois had 10.8. In Cycle 3, the nation averaged 8.1, and Illinois had 9.4. Although health deficiencies were declining from Cycle 1-3, Illinois's numbers remained more significant than the nation. See the figure below:

The data set does not describe Illinois's type of health deficiencies. However, according to Medicare.gov, within a 5-50-mile radius in Illinois, the most common deficiency in nursing homes is abuse (“Medicare.gov,”.n.d.). Therefore, the number of health deficiencies in Illinois could represent abuse. Neglect is a form of abuse. For example, a resident can develop severe bedsores when left in their feces due to neglect. Another example is medication errors. The nursing staff may make mistakes when giving medications to residents, such as administering the wrong medication. Another example is dehydration and malnutrition. Nursing home staff members may not provide enough food or water to residents. Based on this analysis, one quality measure initiative I recommend for Oakridge Health System is decreasing bedsores/bedsore prevention. Bedsores are a crucial indicator of the quality and experience of care (“Bedsores associated with Nursing Home Abuse and neglect,”. n.d.). According to the Centers for Disease Control (CDC), as many as one out of 10 residents in nursing homes currently suffer from bedsores, and studies show that they get them twice as often as hospital patients (Centers for Disease Control and Prevention, 2015). Preventing bedsores is essential to protect patients from harm and reduce the costs of caring for them (“Bedsores associated with Nursing Home Abuse and neglect,”. n.d.) Bedsores can also lead to bodily sepsis, nerve damage, dehydration, malnourishment, and even death.

Recommendations

The primary focus of quality improvement in healthcare is promoting patient safety and avoiding patient injuries. Therefore, since bedsores are one of the most common but severe complications in nursing homes, I recommend that Oakridge Health Systems develop a Bedsore Prevention Program to reduce the prevalence of bedsores. Preventing this problem is essential to protect patients from harm and reduce the costs of caring for them. This program will consist of the following:

1. Skin Assessment: A skincare assessment will be completed for new nursing home residents within 14 days of admission to the facility to help determine what factors may put the resident at risk for developing bed sores (“What are nursing homes required to do to prevent bed sore,”.n.d.) Identifying specific risk factors helps the nursing home staff determine which preventative measures should be for each resident.

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II. Repositioning and Reduction: If a resident is identified as at risk for a bedsore development or a bedsore risk assessment score indicates that the person is at stake, then a preventive intervention addressing repositioning needs and pressure reduction must be instituted (“What are nursing homes required to do to prevent bed sore,”.n.d.) Within 12 hours, reducing or eliminating risk factors can prevent pressure ulcer formation.

Stop Pressure Injuries - Free SSKIN Poster – Active Healthcare

III. Nutrition: If a resident is identified as at risk for pressure ulcer development and has malnutrition (involuntary weight loss of ≥ 10% over one year or low albumin or albumin levels), then nutritional intervention or dietary consultation should be instituted because a poor diet, deficient dietary protein intake, is an independent predictor of pressure ulcer development (“What are nursing homes required to do to prevent bed sore,”.n.d.)

Nutrition Management in Diabetic Patients With Pressure Injuries | WoundSource

IV. Increase Nursing Staff: Higher nurse staff levels in nursing homes are one of the essential things a facility can do to improve the quality of care and life (“Nurse-patient ratios as a patient safety strategy,”.n.d.) When the nursing staff is overworked and caring for too many patients, they may be forced to prioritize what they do and who they help (“Nurse-patient ratios as a patient safety strategy,”.n.d.). Therefore, they can be left in one position for too long and develop bedsore that rapidly worsens and triggers a cascade of complications such as infection, hospitalization, and disability.

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V. Staff Education: Healthcare staff should be educated on stopping and managing pressure sores. If they hold the knowledge, it could be one way of helping to care for the patient. Also, educating healthcare professionals on pressure ulcer prevention may lead to better patient care.

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Conclusion

Bedsores are significant health issues and one of the biggest challenges nursing homes faces on a day-to-day basis. Aside from the high cost of treatment, bedsores also significantly impact patients’ lives and the provider’s ability to render appropriate care to patients. Preventing bedsores has always been a challenge for caregivers and the healthcare industry as a whole because the epidemiology of bedsores varies by clinical setting and is a potentially preventable condition. The development of pressure ulcers or injuries can interfere with the patient’s functional recovery, may be complicated by pain and infection, and can contribute to more extended hospital stays. Between deficiencies, treatment costs, and financial losses, there are incentives for nursing homes to improve the quality of care and prevent the creation of pressure sores in patients.

References

Bedsores associated with Nursing Home Abuse and neglect. Hupy and Abraham, S.C. (n.d.). Retrieved January 29, 2023, from https://www.hupy.com/library/bedsores-associated-with-nursing-home-abuse-and-neglect.cfm.

Charlene Harrington, H. C. (2018, April 3). Nursing facilities, staffing, residents and facility deficiencies, 2009 through 2016. KFF. Retrieved January 29, 2023, from https://www.kff.org/medicaid/report/nursing-facilities-staffing-residents-and-facility-deficiencies-2009-through-2016/.

Centers for Disease Control and Prevention. (2015, November 6). Products - data briefs - number 14 - February 2009. Centers for Disease Control and Prevention. Retrieved January 29, 2023, from https://www.cdc.gov/nchs/products/databriefs/db14.htm.

Medicare.gov. (n.d.). Retrieved January 29, 2023, from https://www.medicare.gov/care-compare/results?searchType=NursingHome&page=3&city=Hazel+Crest&state=IL&zipcode=60429&radius=25&sort=closest.

Miletich, M. (n.d.). Patients matter most: Illinois could drastically change struggling nursing home system. https://www.25newsnow.com. Retrieved January 29, 2023, from https://www.25newsnow.com/2021/11/22/patients-matter-most-illinois-could-drastically-change-struggling-nursing-home-system/.

Nursing home enforcement. CMS. (n.d.). Retrieved January 29, 2023, from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationEnforcement/Nursing-Home-Enforcement.

Nursing home report cards. Nursing Home Report Cards Families For Better Care. (n.d.). Retrieved January 29, 2023, from https://familiesforbettercare.com/index.php/report-cards.

PG;, S. (n.d.). Nurse-patient ratios as a patient safety strategy: A systematic review. Annals of internal medicine. Retrieved January 29, 2023, from https://pubmed.ncbi.nlm.nih.gov/23460097/.

What are nursing homes required to do to prevent bed sores? What are nursing homes required to do to prevent bed sores? - Nursing Home Law Center. (n.d.). Retrieved January 29, 2023, from https://www.nursinghomelawcenter.org/what-are-nursing-homes-required-to-do-to-prevent-bed-sores.html.