Transcript Document 7249208

Development of Home Care
Quality Indicators Based on
the MDS-HC
Brant E. Fries, Ph.D.
University of Michigan
May 7, 2002
Brant E. Fries
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1
Agenda
RAI-HC as the basis for Quality Indicators
 Home Care Quality Indicators (HCQIs)

Development
• Summarizing HCQIs
•

Use of HCQIs in evaluating the MI Choice
Programs
Brant E. Fries
Please do not cite without permission
2
Agenda
RAI-HC as the basis for Quality Indicators
 Home Care Quality Indicators (HCQIs)

Development
• Summarizing HCQIs
•

Use of HCQIs in evaluating the MI Choice
Programs
Brant E. Fries
Please do not cite without permission
3
RAI-Home Care Assessment System
Developed by interRAI, a multi-nation
group of clinicians, researchers and
policymakers
 Community analogue to the RAI,
mandated in U.S. nursing homes

Brant E. Fries
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Improvements in the RAI

Primary purpose:
•
Improve care plans through improved
assessment
Brant E. Fries
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Improvements in the RAI
Three parts of the RAI-HC
 Minimum Data Set (MDS-HC)
 Triggers
 Client Assessment Protocols (CAPs)
(Care planning guidelines)
Brant E. Fries
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Improving Assessment Process

Items clearly defined, including:
full definitions
• examples and exclusions
• time delimiters
•

Cover all relevant domains
individuals’ strengths and weaknesses
• tradeoff of breadth/depth and length
•
Brant E. Fries
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Improving Assessment Process

Use all possible sources of information
individual, formal/informal caregivers, MD,
medical record, etc.
• self-reporting may be inaccurate
• assessor decides when sources are
inconsistent
•
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Improving Assessment Process
Careful testing of psychometric
properties
 Training manual
 Ongoing refinement - RAI-HC Version 2

Brant E. Fries
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Applications of MDS-HC Data
Care Plan (CAP)
Case-Mix Algorithm
(RUG-III/HC)
ASSESSMENT
Eligibility Systems
(MI Choice)
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Quality Measures
(HCQI)
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RAI Family of Instruments







Chronic care/nursing homes
Home Care
Mental Health
Acute Care
Post-Acute Care-Rehabilitation
Assisted Living
Palliative Care
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RAI 2.0
RAI-HC 2.0
RAI-MH
RAI-AC
RAI-PAC
RAI-AL
RAI-PC
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Common Basis
All interRAI instruments have common
basis of care planning
 Major items in common
 Possible to link across time and setting
 Start of a “language” to describe longterm care users

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Implementation of RAI-HC
InterRAI grants royalty-free license to
governments
 Adopted by 10 states, Department of
Veterans Affairs
 International adoptions
 Used in fee-for-service and managed
care programs

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Agenda
RAI-HC as the basis for Quality Indicators
 Home Care Quality Indicators (HCQIs)

Development
• Summarizing HCQIs
•

Use of HCQIs in evaluating the MI Choice
Programs
Brant E. Fries
Please do not cite without permission
15
Uses of MDS-HC Data for
Quality Measurement

User Profiles
•

Performance Benchmarks
•

Are we serving the “right” people?
Outcome Measures
•

Whom are we serving?
What happens to the people we serve?
Quality Indicators
•
How do care strategies affect the people
we serve?
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Why HCQIs Are Important
HCQI= Home Care Quality Indicators
 Citizens, legislators, administrators want
“proof” that programs work

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Uses of HCQIs

Regulation
•

Management
•

Where should I get care?
Best practices
•

How well am I doing? Compared with last year?
Consumers
•

Who is doing a substandard job?
Who is doing an outstanding job?
Benchmarking
•
How do I compare with others?
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HCQI Authors
John P. Hirdes Ph.D.
Brant E. Fries Ph.D.
John N. Morris Ph.D.
David Zimmerman Ph.D.
Naoki Ikegami M.D., Ph.D.
Dawn Dalby M.Sc.
Suzanne Hammer M.Sc.
Pablo Aliaga M.Sc.
Rich Jones, Ph.D.
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Considerations in Developing
HCQIs
Reliability and validity of data items
 Points of comparison

•
Prevalence, incidence
Validity of indicators
 Application – when agency is responsible

•
•
Prevalence: follow-up data only
Incidence: intake to follow-up
Brant E. Fries
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HCQI Research in a Nutshell
Two year effort in Canada, USA, Japan
 Involved many stakeholders
 Started with QIs from other sectors
 Workgroups in Canada and Michigan
 Identification of exclusions
 Analysis with data from Canada, US, Italy
 HCQIs with reasonable prevalence
 Adjustments

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Prevalence HC Quality Indicators
 Nutrition
• Inadequate Meals
• Weight Loss
• Dehydration

Pain
•
•
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
•
•
•
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Disruptive/Intense Pain
Unmanaged Pain
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•
No Assistive Device for
Clients with Difficulty in
Locomotion
ADL/Rehabilitation Potential
and No Therapies
•
•
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Falls
Any injuries
Neglect/Abuse
Other
•
•
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No medication review
Safety/Environment
•

Social Isolation with
Distress
Delirium
Negative mood
Medication
•
Physical function
•
Psychosocial function
No Influenza Vaccination
Hospitalization
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Incidence HC Quality Indicators

Incontinence
•
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•
Failure to improve/
incidence of skin ulcers
Physical function
•
•
Psychosocial function
•
Ulcers
•
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Failure to improve/
incidence of bladder
continence

Failure to improve/ incidence
of cognitive decline
Failure to improve/ incidence
of difficulty in communication
Other
•
Increased health instability
Failure to improve/
incidence of decline in ADL
Failure to improve/
incidence of impaired
locomotion in the home
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Adjusting HCQIs

Risk adjustment
•
•
•
Should we adjust?
Team identified candidate risk adjusters
Analyze Ontario, Michigan and Italian data:
–Adjustment in same direction/ magnitude
in 2 out of 3 countries
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Example: Two Nutrition HCQIs
TITLE
DESCRIPTION
W7. Prevalence
of inadequate
meals
Numerator:
-Aged 65 years or older
Clients who ate 1 or fewer -End-stage disease
meals in 2 of the last 3
days
W24.
Prevalence of
weight loss
Denominator:
All clients
Numerator:
Clients with unintended
weight loss
RISK ADJUSTERS
-ADL impairment (ADL
hierarchy score)
-Diagnosis of cancer
Denominator:
All clients, excluding
clients with end-stage
disease on initial
assessment
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Adjusting HCQIs

Selection/Ascertainment adjustment
Should we adjust?
Use intake rates to derive agency-level
measure of bias
• Analysis of Ontario and Michigan data
•
•
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Risk/Ascertainment Adjustments
for Mood, 8 Michigan Agencies
60%
50%
40%
30%
20%
10%
0%
Unadjusted
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Adjusted: Risk
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Adjusted: Risk+Ascert.
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Two HCQIs, by Agency
60%
40%
20%
0%
Michigan
Ontario
Disruptive/intense daily pain
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Michigan
Ontario
Delirium
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All HCQI – Agency “A”
a_wmeal
a_whosp 2
a_wloss
a_inj
a_deh
a_wabus
a_phy
a_painhp
a_wdecb
a_paina
a_wisul
1
a_pain
a_wloco
a_com
a_wther
0
a_dep
a_wmeal
a_delir
a_wloss
a_wcogd
a_wisol
a_fallhp
a_lochp
a_wdfnd
a_deh
a_phy
a_wdecb
a_wisul
a_wloco
a_wther
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All HCQI – Agency “B”
a_wmeal
a_whosp 2
a_wloss
a_inj
a_deh
a_wabus
a_phy
a_painhp
a_wdecb
a_paina
a_wisul
1
a_pain
a_wloco
a_com
a_wther
0
a_dep
a_wmeal
a_delir
a_wloss
a_wcogd
a_wisol
a_fallhp
a_lochp
a_wdfnd
a_deh
a_phy
a_wdecb
a_wisul
a_wloco
a_wther
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People want simple quality
measures
Good Housekeeping Seal
 Consumer Report Circles
 Olympic Medals
 Michelin Stars

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Average Relative QIHC, by
Michigan Agency
1.4
1.2
1
0.8
0.6
0.4
0.2
0
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Single Measure of Home Care Quality

People want simple, but…
We lose critical information
• May not be feasible
•

When we present multiple measures…
Difficult to interpret
• Still seeking good “views”
•
Brant E. Fries
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33
Agenda
RAI-HC as the basis for Quality Indicators
 Home Care Quality Indicators (HCQIs)

Development
• Summarizing HCQIs
•

Use of HCQIs in evaluating the MI Choice
Programs
Brant E. Fries
Please do not cite without permission
34
Are you just pissing and moaning, or can you verify what you’re
saying with data?
Methods
Used adjusted HCQIs
 23 agencies
 Over 8 quarters, from Jan 99 to Dec 01

•
Training and computerization in 2nd quarter
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Change in Agency Average HCQI
Score, by Period
Meal
160%
Wtloss
Ratio to Period 1 HCQI
Dehyd
MedsRev
140%
Worse
Contin
SkinUlc
AssistDev
120%
Therapy
ADLdecl
Locomot
100%
Falls
SocIsol
80%
CogDecl
Delirium
Mood
60%
Communic
Pain
DisruptPain
40%
Quarter
IntensePain
1
2
3
4
5
6
7
8
Abuse
Injuries
Hospitaliz
Results
Over 8 periods (2 years) – (p<.005)
 16 HCQIs improved (e.g., mood, falls,
hospitalizations, weight loss, social
isolation, decubiti)
 4 HCQIs remained the same (e.g., pain,
disruptive pain, injuries, no assistive
dev.)
 2 HCQIs worsened (intense pain, rehab
potential without therapies)

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Defining Good /Poor Quality
GOOD
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POOR
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Average “Good”/ “Bad” HCQIs,
by Quarter
Number of HCQIs
5
Bad
4
Good
3
2
1
0
1
2
RAI
Training
3
4
5
Quarter
6
7
8
Distribution of a HCQI
GOOD
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BAD
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Next Steps
Further validation of HCQIs
 Develop archives for benchmarking
 Applicability to subpopulations
 Quality of Life?

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Conclusions
RAI-HC has potential to improve care
directly, through improved care planning
 MDS-HC has multiple uses, including
measuring quality of care
 HCQIs can be used to monitor care

Directly computed from MDS-HC
• Useful for comparisons, benchmarking
•
Brant E. Fries
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43