National Perspective on Assisted Living & Quality

The National Perspective on
Assisted Living & Quality
Dave Kyllo

Texas Health Care Association
Austin, Texas
November 5, 2013

dkyllo@ncal.org

1

National Survey of Residential Care
Facilities (NSRCF)
Includes
•Assisted living
•Board and care homes
•Congregate care
•Enriched housing programs
•Homes for the aged
•Personal care homes
•Shared housing

Source: U.S. Dept. of HHS 2010 National Survey of Residential Care Facilities
http://www.cdc.gov/nchs/data/databriefs/db78.htm

Facilities: Key Findings
•31,100 facilities
•971,900 licensed beds
•733,200 residents
•19% of residents covered by Medicaid
•43% of facilities with at least one resident receiving
Medicaid LTC services

Facilities: Facility Size
While about half of facilities are small, most residents
live in larger communities.
Facility Size

Percentage of Residents

Extra Large (100+ beds)

29%

Large (26-100 beds)

52%

Medium (11-25 beds)

9%

Small (4-10 beds)

10%


Facilities: Regional Variation
Residential care facility beds per 1,000 persons aged 85 and over, by region
Region

Beds/1,000 persons 85+

West

245

South

164

Midwest

177

Northeast

131

Total: United States

177


Percent of facilities offering selected
services, and residents using them


Assisted Living Residents
Data from ALFA, ASHA, AAHSA, NCAL & NIC
2009 Overview of Assisted Living
•Average Age = 86.9
•Average Age at Move-in = 84.6
•73.6% Female; 26.4% Male
•Average Income = $27,260
•Average Assets (including home) = $431,020
•Median Income = $18,972
•Median Assets (including home) = $205,000

Common Chronic Conditions

Caffrey, C. Sengupta M., Park-Lee E, et al. Residents living in residential care facilities: United States, 2010. NCHS data brief, no 91.
Hyattsville, MD: National Center for Health Statistics. 2012.

Activities of Daily Living

Caffrey, C. Sengupta M., Park-Lee E, et al. Residents living in residential care facilities: United States, 2010. NCHS data brief, no 91.
Hyattsville, MD: National Center for Health Statistics. 2012.

Facilities: Other Health-Related
Characteristics
∗ 19.9 % bowel incontinent in last 7 days
∗ 36.6% urinary incontinent in last 7 days
∗ 77.1% need help with medications
∗ 38% receive help with 3+ADLs
∗ 24% admitted to a hospital in last 12 months
∗ 35% treated in hospital ED in last 12 months
∗ 14% fell in last 12 months resulting in injuries other
than hip fractures

National Survey of Residential Care Facilities:
Residents’Cognitive Abilities

∗ 48.7% experience confusion
∗ 46% experienced difficulty with short term memory in the last
7 days
∗ 28% experienced difficulty with long term memory in the last
7 days
∗ 18% could not find apartment
∗ 21% could not recognize staff names & faces
∗ 15% don’t know they are in a facility
∗ 22% don’t know what season it is


NCAL’s Policy Priorities
• Keep Regulation at the state level
• Keep Assisted Living Included in CMS’ definition
of Medicaid HCB settings
• Protect, Improve Medicaid Coverage
• Ensure that AL thrives in an episodic
payment/ACO Environment
• Help Members navigate health care reform
• Make the move to EHRs
• Demonstrate that we can manage quality
• Get residents’ diabetic testing strips delivered

Federal Regulation of AL
∗ Over the past years, the U.S. Senate Aging Committee has
focused several hearings on AL quality of oversight.
∗ In 2012, Sen. Bill Nelson (D-FL) considered introducing
disclosure legislation after Florida legislature failed to act
following a breakdown in the state’s AL regulatory system
detailed by Miami Herald series.
∗ Sen. Nelson now chair of Aging Committee and AL likely to
be a focal point of committee attention.
∗ “Frontline” investigative report on AL aired July 30 and may
increase scrutiny by the media.
13

Navigating the New Alphabet Soup
•
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ACO
MCO
OIG
ACA
HIT
EHR
EMR
HIE
HIE (but now you call me “HIX” if you mean insurance)
LTSS

• Response: (LOL, OMG,)

Accountable Care Organizations
Advice from Hospital Sector Analysts…

• Engage Early
• Bring Data

• Hospital Discharges
• Discharges to their Hospital
• DRGs (Resident conditions)

• Make an Investment (time & money)
ACOs will narrow who they work with and increase volume
with their partners

Medicaid & Assisted Living
Major Challenges include:
∗Rates often inadequate.
∗Payment for AL Incomplete (housing, food, utilities not
covered; SSI check insufficient to fill gap).
∗States shifting to managed care.
∗Many recent federal initiatives tend to exclude AL,
including CMS proposed rules defining HCBS settings.
16

Home & Community-based Services (HCBS) as a % of
Medicaid LTC Spending

State

Percent
HCBS

New Mex.

83.2%

Iowa

39.8%

Texas

46.9%

Minn.

67.9%

Miss.

14.4%

Source: CMS Percentage of LTSS Spending for HCBS Usinig FFY 2009 Data)“State Medicaid
Reimbursement Policies and Practices in Assisted Living,” Robert Mollica, National Center for
Assisted Living/AHCA, September 2009. Available at www.ncal.org.

CMS Proposed Rules Defining HCBS
Settings
CMS has published a series of proposed rules intending
to enforce Olmstead decision in Medicaid communitybased settings.
∗Concepts being promoted include: community
integration, resident-centered care, home-like settings,
and individual autonomy.
∗Raises issue of whether assisted living is too
institutional in nature.
∗Possible consequence: exclusion of AL from Medicaid.
18

CMS Issues Revised Proposed Rules
Defining HCBS Settings in 2012
∗ In April and May, 2012, CMS published a revised
definition of Medicaid HCBS settings in final rule
implementing Community First Choice program and
proposed rules implementing revisions to 1915i
program.
∗ While improved, the proposed definition still could
exclude some AL communities.

19

Revised Proposed Definition of HCBS
Settings
In the latest proposed rules, CMS states:
“…home and community-based settings shall have all of the
following qualities, and such other qualities as the Secretary
determines to be appropriate, based on the needs of the
individual as indicated in their person-centered service plan:
The setting is integrated in, and facilitates the individual’s full
access to, the greater community, including opportunities to
seek employment and work in competitive integrated settings,
engage in community life, control personal resources, and
receive services in the community, in the same manner as
individuals without disabilities;
20

Settings (2)
• The setting is selected by the individual from among all
available alternatives and is identified in the personcentered service plan;
• An individual’s essential personal rights of privacy, dignity
and respect, and freedom from coercion and restraint are
protected;
• Individual initiative, autonomy, and independence in
making life choices, including but not limited to, daily
activities, physical environment, and with whom to
interact are optimized and not regimented;
• Individual choice regarding services and supports, and who
provides them, is facilitated.;
21

Settings (3)
• In a provider-owned or controlled residential setting, the following
additional conditions must be met. Any modification of the
conditions, for example, to address the safety needs of an individual
with dementia, must be supported by a specific assessed need and
documented in the person-centered service plan:

∗ The unit or room is a specific physical place that can be
owned, rented or occupied under another legally
enforceable agreement by the individual receiving services,
and the individual has, at a minimum, the same
responsibilities and protections from eviction that tenants
have under the landlord tenant law of the State, county, city
or other designated entity;
22

Settings (4)
∗ Each individual has privacy in their sleeping or living unit:

-- Units have lockable entrance doors, with appropriate staff having
keys to doors;
--Individuals share units only at the individual’s choice; and
--Individuals have the freedom to furnish and decorate their sleeping
or living units;

∗ Individuals have the freedom and support to control their own
schedules and activities, and have access to food at any time;
∗ Individuals are able to have visitors of their choosing at any
time; and
∗ The setting is physically accessible to the individual.
23

Settings (5)
We also plan to propose that home and communitybased settings do not include the following:
1) A nursing facility;
2) An institution for mental diseases;
3) An intermediate care facility for the mentally
retarded;
4) A hospital providing long-term care services; or
5) Any other locations that have qualities of an
institutional setting, as determined by the
Secretary.
24

Settings (6)
∗ The Secretary will apply a rebuttable presumption
that a setting is not a home and community-based
setting, and engage in heightened scrutiny, for any
setting that is located in a building that is also a
publicly or privately operated facility that provides
inpatient institutional treatment in a building on the
grounds of, or immediately adjacent to, a public
institution or disability-specific housing complex...”
25

AHCA/NCAL Issues with Latest CMS Proposed
Rule Defining HCBS Settings

NCAL & AHCA asks CMS to:
∗Strike the “rebuttable presumption” that certain provider-controlled
settings are institutional (those on or near institutional settings or
disability-specific housing complexes);
∗Use care planning process to ensure resident-centered care, not arbitrary
definitions related to facility location;
∗Make sure eviction procedures accommodate state standards for
residential care/assisted living facilities;
∗Make sure that standards for sharing units are workable and realistic
about economic constraints facing states; and,
∗Permit secure perimeters (locked units) for residents with dementia.

26

OIG Finds Deficiencies in State Regulation of AL
Communities Providing Medicaid Services

∗ In December 2012, HHS’ OIG released a report today documenting
deficiencies in meeting state and federal requirements for assisted
living facilities (ALFs) providing Medicaid services.

∗ Examined data, inspection reports, and provider care plans for 2009 in
the seven states with the most assisted living Medicaid beneficiaries:
Georgia, Illinois, Minnesota, New Jersey, Oregon, Texas, and
Washington.
∗ The study encompassed many types of facilities including private
residences where beneficiaries were taken care of by relatives; singlefamily homes that served six or fewer individuals; and multi-unit
residences, some serving more than 200 individuals.
The report, Home and Community-Based Services in Assisted Living Facilities,
can be found at: https://oig.hhs.gov/oei/reports/oei-09-08-00360.pdf.

27

OIG Report on State Enforcement
of Medicaid Standards
Report Findings: Greatest area of concern is meeting
care plan standards.
∗77 percent of beneficiaries receiving HCBS resided in ALFs cited for at
least one deficiency or noncompliance with state licensure or certification
standards.
∗Nine percent of beneficiaries’ records did not include care plans required
by the states and federal government.
∗Forty two percent of the care plans did not include the frequency of
HCBS furnished, as required.
∗In five of the seven states that also required (as a state option) care plans
to specify the beneficiaries’ goals and the interventions to meet them, 69
of 105 care plans did not meet that requirement.
∗In two of the seven states that required care plans to be signed by
beneficiaries or their representatives, 12 of 25 care plans did not meet that
28
requirement.

Differences between Facilities Serving Medicaid
Beneficiaries and Those That Do Not

RTI study presented in November 2012 found that AL
facilities accepting Medicaid payment were similar in many
ways to those that do not:
∗ In general, found that Medicaid facilities are “not that
different” from non-Medicaid facilities.”
∗Levels of services provided and staffing generally similar.
Source: “Do Residential Care Facilities That Serve Medicaid Beneficiaries Differ From
Those That Do Not?” Angela Greene, Galina Khatutsky, Joshua Wiener & Ruby
Johnson, slides, Gerontological Society annual meeting, Nov. 17, 2012
29

RTI Medicaid study (2)
RTI study found some differences between Medicaid and
non-Medicaid facilities:
∗More Medicaid residential care facilities (RCFs) are smaller (4-25 beds).
∗More non-Medicaid RCFs have dementia or Alzheimer's units.
∗Higher proportion of Medicaid RCFs provide skilled nursing care.
∗A slightly higher mean number of LPN hours for direct care per resident are
provided in the non-Medicaid facilities and the mean number of hours of direct care
per person provided by administrators in Medicaid facilities is higher.
∗Non-Medicaid RCFs have higher monthly base rate.

30

RTI Medicaid study (3)
∗ Resident profiles in Medicaid facilities differ from
those in non-Medicaid facilities:
∗ Medicaid residents tend to be younger (under 65) and a higher
proportion are minorities.
∗ Higher proportion of Medicaid residents have diabetes.
∗ Higher proportion of non-Medicaid residents are female and a
higher proportion have Alzheimer’s disease or other dementias.
∗ Higher proportion of Medicaid residents are intellectually
disabled or have a serious mental illness.
∗ Higher proportion of Medicaid residents exhibit problem
behaviors such as wandering, and being verbally and physically
abusive.
31

Resident Living Arrangements
∗ Another recent RTI study attempting to explore whether
AL/residential care is more “community-based” or
institutional in nature found differences between Medicaid
and non-Medicaid residents living arrangements.
∗ However, the study found that, with exception of living
arrangements and visitors, Medicaid facilities are roughly
comparable to non-Medicaid facilities.
Source: “Are Residential Care Facilities ‘Community Services’?,” Joshua Wiener,
Galina Khatutsky, Ruby Johnson, Angela Greene, slides, Gerontological Society
annual meeting, Nov. 17, 2012
32

Resident Living Arrangements
Non-Medicaid residents more likely to have single
room or apartment.
Type of Living
Arrangement

Total
Residents (%)

Non-Medicaid
Residents (%)

Medicaid
Residents (%)

Room designed
for 2 or more
persons

26.9

22.5

45.5

Room designed
for 1 person

31.6

32.8

26.6

Apartment

41.5

44.7

27.9

33

Source: “Are Residential Care Facilities ‘Community Services’?,” Joshua Wiener, Galina
Khatutsky, Ruby Johnson, Angela Greene, slides, Gerontological Society annual

Issue: Single Rooms for AL Medicaid
Beneficiaries?
∗ Most states currently allow sharing of rooms/units for AL
Medicaid services providers.
∗ Medicaid does not pay for room and board.
∗ If CMS is going to require single rooms, then a funding
mechanism needs to be found to pay for them (HUD
vouchers?). This might save government dollars if
structured properly by substituting AL for more expensive
institutional settings.
∗ If CMS requires single rooms w/o funding, then ironically
many AL Medicaid residents will end up in institutional
settings sharing rooms at a greater public cost.
34

State Regulatory Trends
∗ In 2012, at least 18 states made AL
legislative/regulatory changes (January 2012-January
2013).
∗ Many states made major changes.
∗ In recent years focal points of change include: Staff
education/training, more focused surveys,
disclosure, fire safety, infection control/TB testing,
medication management.
35

Source: NCAL 2013 State Regulatory Review

Innovative Survey Models
∗ Colorado: On Jan. 1, 2013, the Assisted Living Residence
(ALR ) program began conducting risk-based re-licensure
inspections, initially on a pilot basis.
∗ Under the new system, ALRs meeting the following criteria
will be eligible for an extended survey cycle: licensed for at
least three years, and, within that prior three years, having
had no enforcement activity, no pattern of deficient practice,
and no significant deficiency cited in response to a complaint
that negatively affected the life, health, or safety of residents.

36

Innovative Survey Models (2)
∗ New Jersey: In 2012, the state Department of Health (DOH)
collaborated with The Health Care Association of New Jersey
Foundation to create a voluntary program titled Advanced Standing.
To receive the department’s distinction of Advanced Standing, a
facility must comply with all applicable local, state, and federal
regulations as well as submit quality data that reaches benchmarks
established by a peer review panel.

∗ A facility participating in the program does not receive a routine survey
by DOH. However, any time a facility falls below DOH standards, such as
poor performance on a complaint investigation, that facility can be
removed for cause from the program by DOH. In addition, DOH provides
follow-up surveys based on a random sample of facilities that participate
in the program. The program is open to all licensed assisted living
residences and comprehensive personal care homes.
37

Innovative Survey Models (3)
Other Innovative Assisted Living State Oversight Models:
∗North Carolina recently extended survey cycle to two years
for “Four-Star” assisted living facilities. Those with highest
rating can be inspected every two years instead of annually.
∗Wisconsin has abbreviated survey for consistently good
performers (based on outcomes reported to the state)
∗Many state agencies continue dealing with limited
resources, personnel changes.
38

Life Safety – a Major Breakthrough

∗ Four-year effort led by NCAL’s life safety engineer
succeeded in updating and harmonizing two major
life safety standards for assisted living:
∗ The National Fire Protection Association adopted the
changes in 2012 edition of Life Safety Code for existing
buildings.
∗ Key committees of the International Code Committee
recently adopted similar standards for new construction
in 2012.
39

Life Safety Standards
∗ The new standards address major issues:
∗ As residents become less able to evacuate without assistance,
the standards allow AL facilities to remain in residential
classification while ensuring high level of safety.
∗ Results in major cost savings for many providers and improved
quality of life for residents who won’t have to move to
institutional settings.

∗ Over time most states adopt these two bodies’ standards.
NCAL generally recommends adoption of 2012 edition of Life
Safety Code.
40

Health Coverage Expansion under
the Affordable Care Act (ACA)
Major Components take effect Jan. 1, 2014.
∗Individual responsibility to maintain coverage.
∗Employer coverage requirements but the Administration has
delayed penalties for not offering coverage until Jan. 1, 2015.
∗Health plan reforms.
∗Insurance exchanges offering subsidized coverage
(enrollment begins in October 2013).
∗Major expansion of the Medicaid program in about ½ the
states that opted to expand.
41

Implications for LTC Providers
∗ The new requirements for employers to offer specified
levels of coverage or pay penalties may increase costs for
many long term care providers in 2015.
∗ Working with employee benefit specialists and insurance
brokers and carriers, providers have begun the process of
analyzing their options for providing affordable coverage
or potentially paying penalties.
∗ However, until more key policy decisions are made, it is
impossible for employers to precisely gauge the extent of
the financial impact of the new requirements.
42

Employer Pay-or-Play Mandates:
LTC Providers Most at Risk
LTC providers most at risk for financial impact
include:
Those with high percentage of low-wage workers.
Small firms not able to self-insure.
Those offering limited health benefits or not offering
coverage to some full-time workers.
Those with low margins.
Those reliant on government reimbursement (they cannot
unilaterally raise prices if their labor costs suddenly go up).
43

Evaluate Your Options
for Compliance with ACA

www.ncalbenefits.com
&
Learn more about the ACA at:
www.ncal.org
www.ahca.org
44

Federal Agencies with Initiatives Impacting
Assisted Living
• CDC-- Infection Control + Hepatitis B Outbreaks
• National Labor Relations Board (NLRB)
• AHRQ– LTSS Public Reporting
• DOL Wage and Hour Enforcement
• DEA –Disposal of Controlled Substances

• EPA Disposal of Medications
• FDA Disposal of Narcotics and Fentanyl patches

• CPSC Ban on Portable Bedrails in Assisted Living
• CMS Definition of HCB Setting
• EPA Energy Star Program
• CFPB Efforts on Senior Fraud and Scams

Fair Labor Standards Act Enforcement
Continues in LTC Settings including AL
∗ Working before and after shifts
∗ Working during an employee’s scheduled meal break
including interruptions of short duration
∗ Employees not being paid for staff meetings and
compensable training session
Why the violations?
∗
∗
∗
∗

Lack of understanding of the FLSA
“We did it that way the last place I worked”
Caring employees
LTC culture and environment

LTC Specific Fact Sheets are Available at:
www.dol.gov/whd
∗ #31 Nursing Care Under the FLSA (Guidance
applicable to all provider types)
∗ #52 Youth Employment
∗ #53 Hours Worked
∗ #54 Calculating Overtime

Eligible for ENERGY STAR score
Senior Care Communities

Hospital

Medical Office Building

Office Building

Retail

Warehouse

Hotel

Bank/Financial

Dormitory

Waste Water
Treatment Plant

Supermarket

Court
House

School

Benefits of Energy Conservation
•

Senior Care Providers
– Margin maximization strategy
– Performance management

•

Residents
– Enhanced affordability
– Quality enhancement program

•

Environmental Leadership
– Lead on addressing climate change

Health Information Technology will Transform
Assisted Living and All Health Care
• EHR: electronic health record – across health care
organizations
• EMR: electronic medical record – within a health organization
• eMAR: technology that automatically documents the
administration of medication into certified EHR technology
using radio frequency ID or bar coding
• HIE: health information exchange across providers,
purchasers, regulators
• HIE –HIX: health insurance exchange
• m-Health: health care through mobile devices

What Does Interoperability Mean?
∗ Basic interoperability: ability to electronically communicate
health data
∗ Semantic interoperability: enable the receiving computer to
display the text or data received AND accurately interpret the
meaning of the data
∗ Levels of Interoperability:
• Non-electronic data (paper)
• Machine transportable data (fax/e-mail)
• Machine-organizable data (structured messages,
unstructured content –documents and images)
• Machine-interpretable data (structured messages, and
standardized content) – Ultimate Goal!

Liability: CNA Analysis of Allegations
at Assisted Living Facilities
Allegations at AL Facilities
Highest Frequency Closed Claims:
∗Resident fall
46.2%
∗Abuse
9.5%
∗Pressure ulcer
7.7%
∗Elopement
7.1%
∗Improper care
7.1%
Death occurred in 37.2% of the closed claims associated with falls.
Source: “Aging Services 2012: Data Analysis Supporting the Need for Industry Change,”
CNA.
53

Liability: CNA Analysis of Allegations
at Assisted Living Facilities (2)
Allegations at AL Facilities
Highest Average Total Paid for Closed Claims:
∗Gross improper care
$541,908
∗Elopement
$378,312
∗Failure to follow physician’s order
$360,939
∗Delay in seeking medical treatment $256,309
∗Pressure ulcer
$251,370
CNA.
54

Liability: CNA Analysis of Injuries at
Assisted Living Facilities
Injuries at AL Facilities
Highest Frequency Closed Claims:
∗Death
37.3%
∗Fracture(s)
32.5%
∗Pain and suffering
6.5%
∗Emotional distress
4.1%
∗Contusion/bruise
4.1%
CNA.
55

Liability: CNA Analysis of Injuries at
Assisted Living Facilities (2)
Injuries at AL Facilities
Highest Average Total Paid for Closed Claims:
∗Death
$291,060
∗Emotional distress
$230, 926
∗Contusion/bruise
$215,590
∗Loss of limb/amputation
$188,080
∗Fracture(s)
$174,469
CNA.
56

HealthCap Resolved Claims
2001 – 2011
Fractures/Head Injuries

47%

Minor/No Injury

31%

Sudden/Unexpected Death

6%

Pain/Suffering

3%

Burns

2%

Sexual Assault

2%

Pressure Ulcer

1%

Average Paid for Closed Claims
Choking

$214,168

Burns

$203,580

Unexpected Death

$145,470

Pressure Ulcer

$133,503

Pain & Suffering

$ 92,050

Sexual Assault

$ 63,769

Fractures/Head Inj.

$ 49,416

*HealthCap (2001 to 2011 Data)

What Led to the Litigation?
Source: “HealthCap Data based on resolved claims from 20012011 for residential care/assisted living/independent living

Common causes:
∗ Fractures and head injuries primarily due to falls
∗ Sudden/unexpected deaths due to unnoticed change
of conditions, elopements, bedrails and medication
errors.
∗ Burns due to cigarette smoking and inappropriate
use of hot packs

AHCA Quality Initiative Goals
Safely reduce 30-day hospital readmissions by 15% by
2015
Maintain nursing staff turnover below 30% until 2015

Maintain customer satisfaction above 90% by 2015
Safely reduce the off-label use of antipsychotics by
15% by March 2015

Safely Reduce Hospital
Readmissions
Target: By March 2015, individual communities will safely reduce hospital
readmissions by 15 percent (this includes any admitting diagnosis).
Individual communities that have less than 5 percent of residents with
hospital readmissions will maintain hospital readmissions below 5 percent.

Hospital Readmissions:
Measurement
Calculation:
# of AL residents admitted to a hospital (excluding ER-only visits and
observation stays) from the AL within 30 days of hospital discharge
DIVIDED BY
All AL admissions to this community within 30 days of hospital
discharge

Let’s Practice
Resident
Resident 1
Resident 2
Resident 3
Resident 4
Resident 5
Resident 6
Resident 7
Resident 8
Resident 9
Resident 10

Transfer from
Hospital to AL
January 1
January 3
January 4
January 8
January 10
January 15
January 19
January 25
January 31
January 31

Hospital
Readmission Date
January 31
February 5

February 28

Let’s Practice

# of AL Residents admitted to a hospital from the AL within 30
days of hospital discharge = 3
Divided by
All AL admissions to this community within 30 days of hospital
discharge: 10
3/10 = .30 or (.30 x 100) = 30% hospital readmission rate

Other Ways to Track Your Progress

• Percent of all admissions sent to any hospital within
30, 60, and 90 days of admission to your community
• Percent of all admissions sent to any hospital within
30, 60, and 90 days of admission to your community,
excluding planned readmissions
• Track the number of days since your last readmission

Using Counts: “Time Between Events”
• Simple counts
• # of hospitalizations last week
• Time between events (e.g. OHSA employee injuries)
• # of days since last hospitalization
• Use for any clinical measure
• As you increase the time between events you will
improve on any quality measure risk adjusted or not
• Simple
• Easy to display where all staff can see
• Rapid feedback

Tracking Counts & Time Between
Events

Factors Associated with low
rehospitalizations

Young Y et al. Clinical and Nonclinical Factors Associated with potentially preventable hospitalizations
among nursing home residents in NYS. JAMDA 2011;12:364-371.
1

Strategies to Reduce Hospitalizations
INTERACT Is a comprehensive program that uses these strategies
•Track your rehospitalizations
•Improve Communication
• Externally (e.g. with hospital/ER)
• Internally (e.g. between nursing & physicians)
•Identify small changes in a resident’s status early on
•Change Staffing
• Consistent Assignment
• Reduce staff turnover
• Utilize nurse practitioners
•Advance Care Planning

Hospital Readmissions: The
Business Case
• Decreases hospital acquired infections, resulting in less
opportunity for skin breakdown, injury or harm from
transfers.
• Decreases the exacerbation of symptoms for people with
dementia.
• Means less stress for nurses who must take time for the
readmission and transfer requirements.
• Better outcomes make your facility more attractive as a
preferred provider in integrated care models (such as ACOs)

Why Hospitals Care About You
• CMS has implemented a payment penalty to hospitals with
high 30 day readmission rates for discharges diagnoses
• CHF
• Pneumonia
• Myocardial infarction

• Hospitals participating in ACO or Bundle payment demos can
only achieve savings by reducing rehospitalizations
• Hospitals are partnering with LTC providers
• Referring to low readmission providers

Achieving the Goal
• Adopt the INTERACT program
• Ensure seamless information exchanges between providers
through the use of electronic health records (EHRs)
• Engage providers at all points throughout the spectrum of
care. Expand the use of nurse practitioners
• Use consistent assignment of staff to ensure that staff are
familiar with residents’ normal patterns and characteristics so
that they detect early changes in resident’s conditions before
they lead to a hospitalization
• Utilize the tools on the Quality Initiative for Assisted Living
website

Resources
•
•
•
•
•
•
•

Business Case
Measurement Summary
INTERACT SBAR for Assisted Living Nurses
INTERACT SBAR for Assisted Living Caregivers
INTERACT Stop & Watch
INTERACT Measurement of Hospital Transfer Rates
INTERACT Change in Condition Cards

*All the above resources are available at qualityinitiative.ncal.org

INTERACT for Assisted Living
• NCAL Quality Committee nurses and AALNA Board
worked together to revise INTERACT tools for AL –
approved by developers of INTERACT
• These are posted on NCAL’s website (www.NCAL.org
) and recommended for use until the developers of
INTERACT release INTERACT for AL

Stop & Watch for AL

• Purpose:
• Guide front-line staff
through brief review
of early, often
subtle, indicators of
change in condition
• Improve
communication
between frontline
staff and the nurse in
charge

Tips on Implementing Stop & Watch
• Stop & Watch
•
•
•
•
•

Send staff to learn from another facility using tool
Pilot test 1 team on 1 unit
Let team decide how to use stop & watch
Meet with pilot team daily for feedback
Make changes based on feedback

• Start with CNA – Nurse using
• Gradually expand to other staff, then to families

6 months to successfully roll out
Stop & Watch

Tips on Implementing Stop & Watch

• Need to work with staff to remind them to complete
stop & watch
• Need to work with RN’s to follow-up on submitted
stop & watch
• Look at stop & watch forms (or lack thereof)
• Engage Physicians
• Support notification of MDs/NPs on early signs

6 months to successfully roll out Stop &
Watch

SBAR for Assisted Living Nurses
• Structured format to
assemble key
information
physicians need to
make a decision
• Complete prior to
calling MD
4-6 months to
successfully roll out
SBAR

SBAR for AL Nurses

• Situation
• Background
• Assessment (RN) or Appearance (LPN/LVN)
• Request

Tips on SBAR implementation
• Start with 1 nurse/staff
• Announce to all staff that your using SBAR but piloting with
<insert nurse’s name>
• Review each day nurse’s experience with SBAR
• Modify SBAR protocol based on each day’s feedback

• Engage Physicians
• Seek feedback from attending and covering MDs

• Try pilot testing for 1 condition on 1 unit
• INR calls to physicians
• Elevated blood glucose
• Falls

4-6 months to successfully roll out SBAR

SBAR for AL Caregivers

• Structured format to
assemble key information
physicians need to make
a decision
• Complete prior to calling
MD
4-6 months to successfully
roll out SBAR

SBAR for AL Caregivers

• Situation
• Background
• Appearance
• Ready to call

Increase Staff Stability

Target: Each year, until March 2015, maintain
nursing staff turnover rates below 30
percent.

Staff Stability: Measurement
Calculation:
# of terminations for nursing staff in the calendar year
DIVIDED BY:
Total # of current nursing staff employees at the end of the year
*total includes full-time, part-time, permanent, short-term, seasonal salaried
and hourly RN, LPN/LVN, CNA, CMA, personal caregivers and other similar
front-line staff directly responsible for the daily care of residents. Employees of
temporary agencies and outside contractors are not included. For Minnesota,
include home health aides.

Staff Stability: The Business
Case
• The better staff members know a resident, the easier it is to
deliver person-centered care.
• Staff who are satisfied are more likely to recommend the
community as a place to work. Good caregivers recruit
good caregivers.
• Communities have a positive reputation that spreads in the
community leading to greater opportunity for business
development.
• Training new staff and turnover costs are high.

Staff Stability: Achieving the
Goal
• Focus on staff satisfaction, turnover, and empowerment, as
well as consistent assignment.
• Regularly measure staff satisfaction, including drill-down to
specific factors to inform quality improvement efforts
• Measure and track staff turnover to identify patterns, trends
and potential root causes of high turnover in order to act on
them
• Empower staff at all levels to participate in problem-solving
and quality improvement
website

Staff Stability: Resources

• Staff Turnover Calculator (Excel Spreadsheet)
• Introducing Peer Mentoring in Long-Term Care Settings
• Staff Stability toolkit (available in the AHCA/NCAL Bookstore!)


Recognize deserving staff!
Noble Caregiver in Assisted Living Award
NCAL Assisted Living Nurse of the Year
NCAL Administrator of the Year
National Assisted Living Week Programming Award
Application submission for 2013 is now closed.
Visit www.ncal.org for more information.

Increase Customer Satisfaction

Target: By March 2015, maintain the number of customers
who would recommend the community to others at or
above 90 percent.
Communities with customer satisfaction below 90 percent
should improve to 90 percent by March 2015

Customer Satisfaction:
Measurement

Calculation: Current residents/families who would recommend the
community
# of current residents/families who answer a survey question about
“willingness to recommend” a community positively
DIVIDED BY:
# of current residents/families responding to a survey question on
“willingness to recommend”

Measurement

Calculation: Residents who have moved out of AL who would
recommend community
# of residents who moved out and answer a survey question about
“willingness to recommend” a community positively
DIVIDED BY:
# of residents who moved out and respond to a survey
question on “willingness to recommend”

Customer Satisfaction: The
Business Case
• Increasing customer satisfaction can have a direct impact on
increasing census and generating additional revenue from positive
customer referrals.
• Achieving customer satisfaction is the root of person-centered care.
• High customer satisfaction data can be used to support participation
in preferred provider plans, including Accountable Care Organizations
medical homes and other organizations that provide health care
services in the care continuum.
• High customer satisfaction data can help the community differentiate
themselves from other providers.

Achieving the Goal
• Regularly measuring customer satisfaction, including
identifying key factors that are contributing to overall ratings
• Utilizing satisfaction data to prioritize quality improvement
needs and act on them.
• Using consistent assignment of staff to allow positive and
continuing relationships to develop that allow staff to
successfully provide individualized, person-centered care.
website

Resources
• Better Serving the Lesbian, Gay, Bisexual, and Transgender
Populations in AL
• Preparing Residents to Move Out
• Assisted Living Staff Checklist for Responding to
Complaints
• Making Resident and Family Councils Successful in AL
• Turning Complaints into Compliments
• The Power of Ethical Marketing

Safely Reduce Off-Label Use of
Antipsychotics
Target: By March 2015, safely reduce off-label use of
antipsychotics by 15 percent.
Communities that have less than 5 percent of off-label use
maintain rates at or below 5 percent.
All communities will implement use of at least one tool
aimed at reducing off-label use of antipsychotics by March
2015.

Antipsychotic Medications
•
•
•
•
•
•
•
•
•
•
•

Conventional (Generic)
Haldol (Haloperidol)
Loxitane (Loxapine)
Navane (Thiothixene)
Orap (Pimozide)
Compazine (Prochlorperazine)
Mellaril (Thioridazine)
Moban (Molindone)
Prolixin (Fluphenazine)
Stelazine (Trifluoperazine)
Thorazine (Chlorpromazine)

•
•
•
•
•
•
•
•
•

Atypical (Generic)
Abilify (Aripiprazole)
Saphris (Asenapine)
Clozaril Fazaclo
(Clozapine)
Fanapt (Iloperidon)
Zyprexa (Olanzapine)
Invega (Paliperidone)
Seroquel (Quetiapine)
Risperdal (Risperidone)
Geodon (Ziprasidone)

FDA Approved Diagnoses
• Schizophrenia
• Bi-polar Disorder
• Irritability associated with Autistic Disorder (Aripiprazole
& Risperidone)
• Treatment Resistant Depression (Olanzapine)
• Major Depressive Disorder (Quetiapine)
• Tourettes (Orap)
When prescribed to a patient without an FDA approved
diagnosis; considered off-label use, which is allowed by
FDA and Medical Boards

Common Off-label uses
• Dementia with behavior difficulties
• Agitation
• Aggression
• Wandering

•
•
•
•

Acute Delirium
Depression
Obsessive-compulsive disorder
Psychotic symptoms (e.g. hallucinations, delusions) with
neurological diseases
• Parkinson’s disease
• Stroke

Effectiveness in Dementia
• Antipsychotic effect takes 3-7 days
• Acute response most likely due to sedating properties, not
antipsychotic effect

• In RCTs, recipients do a little bit better than placebo but the
effect beyond 3 months is unclear and:
• Not everyone who receives the meds improves
• A large number of people getting the placebo improve
• The net effect is that 10 to 20 people out of 100 who receive
the medication improve due to the medication

Associated with Adverse Outcomes

• Off-label use of antipsychotics in nursing facility residents is
associated with increase in:
•
•
•
•

Death (heart failure or pneumonia) 1.6 x greater than placebo
Hospitalization (40% increase)
Falls & fractures
Venothrombotic events

• Conventional antipsychotics are worse than atypical
antipsychotics

Effectiveness with Low Doses
• Low dose Risperidone (<1 mg/d): small positive effect but
also increased risk of adverse events
• Low dose Olanzapine (5 mg/d): no positive effect but does
have increase risk of adverse events
• Low dose Aripiprazole and Quetiapine: effectiveness
unknown, but Quetiapine at normal dose has no evidence
of effectiveness

Source: Cochrane Review 2012; Meta-analysis 16 RCTs in dementia

Evidence for Discontinuing Low
Doses
• RCTs for withdrawal of medication show
• No difference in outcomes between placebo and continued
medication
• About 75% remain off the drug after the trial
• Less than 25% need to be restarted on the medication
• Placebo group (drug withdrawal) have fewer adverse events

Antipsychotic Measurement:
Incidence
Calculation:
Incidence: % of residents who have an antipsychotic drug initiated
for an off-label use within the first 90 days at assisted living
community

# of residents with antipsychotic drug use indicated on
medical records over the first 90 days at the assisted living
DIVIDED BY:
# of residents who have been at the assisted living for 90
or less days

Let’s Practice!

# of residents with antipsychotic drug use indicated on
medical records over the first 90 days at the assisted living =
2
DIVIDED BY:
# of residents who have been at the assisted living for 90 or
less days = 10
Incidence: 2/10 = 0.20 or (0.20 x 100) = 20%

Antipsychotic Measurement:
Prevalence
Calculation
Prevalence:
% of resident with off-label use of an antipsychotic drug
# of residents (who have been at the AL over 90 days) with
antipsychotic drug use indicated on medical records at the end of
the target period
DIVIDED BY:
# of residents (who have been at the AL over 90 days) at the end
of the target period

Let’s Practice

# of residents (who have been at the AL over 90 days) with
antipsychotic drug use indicated on medical records at the
end of the target period = 10
DIVIDED BY:
# of residents (who have been at the AL over 90 days) at the
end of the target period = 100
Prevalence: 10/100 = 0.10 or (0.10 x 100) = 10%

Percent Reduction – Let’s Practice!

By December 2013 your community now has 8 residents on antipsychotics
% reduction = ((Initial value – final value) / (Initial value) ) x 100
% reduction = ((10-8) / 10) x 100
% reduction = (2/ 10) x 100
% reduction = .20 x 100
% reduction = 20%

Tracking On a Real-time Basis
• Percent of new admissions without approved psychiatric diagnoses
admitted to your community on antipsychotic drugs that have those
drugs discontinued at 30, 60, 90 days of their stay
• Percent of new admissions without FDA approved diagnoses that are
admitted without antipsychotic prescriptions and started on these.
• Percent of residents in the community for more than 90 days that are
taking antipsychotic drugs without psychiatric diagnoses that are on
antipsychotic drugs
• On an ongoing basis, track the number of days since the last person
was started on an antipsychotic medication in the community.

Antipsychotics: The Business
Case
• Decreases the side effects and adverse drug reactions associated
with these medications.
• Non-pharmacologic interventions help to enhance an individual’s
ability to direct their care, which improves their independence,
dignity, and quality of life.
• Adverse Drug Events (ADEs) may require hospitalization and the
community may experience lost revenue for days the resident is
not in the community.
• A reputation for using innovative, person-centered care
approaches will provide a competitive advantage.

Antipsychotics: Achieving the
Goal
• Focus on non-pharmacologic approaches for preventing the
frustrations that can lead to challenging behavior and for
addressing resident’s behavioral expressions when they do
occur
• Using a positive physical approach, engaging residents in
meaningful activity, and using therapeutic strategies for
catastrophic events can make a real difference for residents
with dementia.
• Environmental changes : reducing noise, improving lighting,
and allowing flexible scheduling.

Antipsychotics: Resources

•
•
•
•
•

Qualityinitiative.ncal.org
CEAL Clearinghouse www.theceal.org
Alzheimer’s Association
IA-ADAPT https://www.healthcare.uiowa.edu/igec/iaadapt/
The National Dementia Initiative White Paper
http://www.ccal.org/national-dementia-initiative/whitepaper.shtml

The assisted living portion of the AHCA/NCAL Quality Initiative
Recognition Program is designed to recognize NCAL members that
demonstrate the attainment and a commitment to one or more of the
four NCAL Quality Initiative goals:
•Safely reduce hospital readmissions by 15%
•Increase staff stability by maintaining nursing staff turnover below 30%
•Increase customer satisfaction to 90%
•Safely reduce the off-label use of antipsychotics by 15%.
All submissions must be received by NCAL no later than 11:59 PM (EDT)
September 30, 2013. Those receiving recognition will be notified in
November.

Get Recognized!
Assisted living communities must submit their staff turnover
data to NCAL through the
Assisted living communities must submit their 2012 customer
satisfaction survey results to NCAL through the online
Customer Satisfaction survey.
Assisted living communities may pledge their intent to join the
PSO by submitting their information through NCAL’s online
survey. Communities will need to sign-up for the PSO by a
specified date once official registration is open

Data Collection in Assisted
Living

“In God we trust, all others bring
data” – Elements of Statistical Learning

Why Representative Data Matters

Quality of Life
Performance Measures
• Identified 10 performance measures related
to:
 Operational performance
 Resident quality of life
• Completed 3 years of surveys (2010-2012)
• Links to survey reports on NCAL Website

Quality of Life
Performance Measures
• Resident & family
satisfaction
• Employee
satisfaction
• Staff retention
• Census/Occupancy rate
• Resident Councils

• Family councils
• Mission and vision
statements
• Safety programs
• Nurse availability
• State criminal
background checks

Vacancy, Retention, and Turnover

• NCAL launched the first national survey for
assisted living in January 2010
• Fourth annual survey launched January
2013
• Supported by Leading Age, ALFA, and
ASHA
• Links to results on NCAL’s Website

Next Step:
Clinical Performance Measures
• Falls
• Pain management
• Pressure ulcers
• Infection control
• End-of-life care
• Demographics

• Medication
management
• Hospitalizations
• Depression
• Elopements
• Advanced care
planning

Patient Safety Organizations

January 2013 – NCAL Board of Directors voted to collaborate
with the New Jersey Hospital Association’s (NJHA) Institute
for Quality and Patient Safety Organization (PSO) to collect
Tier II Clinical Performance Measure

What is a PSO?
• PSOs serve as a group of independent, external experts who
can collect, analyze, and aggregate Patient Safety Work
Products locally, regionally, and nationally to develop insights
into the underlying causes of patient safety events.
• Communications with PSOs are protected from disclosure to
allay fears of increased risk of liability because of collection and
analysis of patient safety events
• PSOs are certified by the Agency for Healthcare Research &
Quality (AHRQ)

Benefits of Partnering with a PSO
• Improve safety and quality leading to better resident outcomes
• Participate in a non-punitive reporting system that is designed to
reduce or minimize harm to members
• Contribute to national safety initiatives
• Move toward a culture of safety and awareness and away from a
culture of blame and shame
• Reduce liability costs and exposures
• Use of de-identified quality data to assist members in quality efforts
• Detect and address emerging quality issues as they arise through
alerts and other communication methods

PSO: Timeline & Cost
Timeline
• August 2013- Contract between
NCAL & NJHA signed and
measures finalized
• September start signing up
pilot communities
• October-December Pilot study
• Nov-Dec – sign-up NCAL
members
• January 1, 2014 data collection
for all NCAL members

Cost
• 25 or less beds: $35 per unit with
a $250 minimum
• 26 or more units: $35 per unit
with a maximum annual
compensation of $3,500
• Multi-community Entities (with
100+ units): $3,500 for the first 2
communities plus $800 for each
additional community
*Note that multi-community entities
with less than 100 units will pay $35
per unit with a maximum annual
compensation of $3,500.

NCAL 2014 Spring Conference
The Future is Now

March 10 -12, 2014
Casers Palace, Las Vegas, NV
Registration opens in November!

Visit www.NCAL.org for more information

Questions?

www.ncal.org
Dave Kyllo – dkyllo@ncal.org

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