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The quality-improvement intervention INTERACT II (Interventions to Reduce Acute Care Transfers) can reduce hospitalization rates among nursing home residents, according to a report published in the Journal of the American Geriatrics Society.

The study found that nursing homes that diligently employed INTERACT tools reduced the hospitalization rates of their residents by 24 percent.

Hospitalization can be emotionally and psychologically traumatic for nursing home residents, and stressful for their family members. A “substantial proportion” of such hospitalizations may be avoidable, the researchers write.

Hospitalizations are also costly. The researchers estimated that, in a 100-bed nursing home, a 24 percent reduction in hospitalizations can save Medicare approximately $125,000 a year.

Role for CNAs

The INTERACT II intervention tools comprise “clinical and educational tools and strategies” that can be used daily in long-term care facilities, according to the INTERACT website.

Among the tools used in the INTERACT II program is “Stop and Watch” (pdf), a checklist that allows certified nursing assistants (CNAs) to easily alert nurses to changes in residents’ behavior — changes which could lead to hospitalization if left unchecked.

The INTERACT program was developed initially by the Georgia Medical Care Foundation with funding from the Centers for Medicare and Medicaid Services (CMS). INTERACT II is the second, more refined, iteration of the intervention, which was developed by the authors of the study with input from direct-care providers.

Study Shows Reductions in Hospitalization

The researchers evaluated the effectiveness of INTERACT II in 25 nursing homes spread across three states — New York, Massachusetts, and Florida — over a six-month period.

Of the 25 facilities, 17 were judged to be “moderately or highly engaged” in the INTERACT II program. Those facilities saw a 24 percent reduction in their hospitalization rate.

The other eight facilities were characterized as “minimally” engaged in INTERACT II. They reduced their hospitalization rate by six percent.

The researchers concluded that these results “strongly suggest” that INTERACT II is effective in helping nursing home residents stay out of the hospital.

The study was funded by the Commonwealth Fund.

– by Matthew Ozga

The newest additions to PHI’s National Clearinghouse on the Direct Care Workforce:

Economic Contribution of Nursing Facilities — This February 2011 brief from the Alliance for Quality Nursing Home Care explains the economic significance of nursing facilities in the U.S. For example, the brief notes that $138 billion was spent on nursing facility care in 2008 alone. The brief also explains the negative impact that the economic recession has had on nursing facilities. Specifically, nursing facilities have had to grapple with a tightened credit market as well as cuts to or freezes on Medicaid payment rates.

Generations, Winter 2010-11 issue — This issue of Generations contains multiple articles that are pertinent to the direct-care workforce, including articles authored or co-authored by PHI experts.

In “Caregivers on the Front Line: Building a Better Direct-Care Workforce,” PHI National Policy Research Director Dorie Seavey gives a general overview of the workforce. Meanwhile, in “Federal and State Policy Strategies for Developing a Quality Eldercare Workforce,” members and staff of the Eldercare Workforce Alliance — including PHI President Steven Dawson — explain how the Affordable Care Act will benefit the eldercare workforce.

Other articles from the issue include:

• The Changing Face of Long-Term Care and How a New Immigrant Workforce Will Shape Its Future — This article explains the important role that immigrants and ethnic and racial minorities play in the direct-care workforce. The author examines several pressing issues facing the long-term services sector as the U.S. minority population expands over the next several decades, including the potential exploitation of immigrant direct-care workers.
• A Vision for the Future: New Care Delivery Models Can Play a Vital Role in Building Tomorrow’s Eldercare Workforce — This article details the increasingly important role that direct-care workers will play in the nation’s long-term care services and supports sector following the implementation of health reform provisions such as the CLASS Act. The article also provides a brief overview of the direct-care workforce. The authors are deputy assistant secretaries at the Department of Health and Human Services (HHS).
• Reinventing Management Practices in Long-Term Care: How Cultural Evolution Can Affect Workforce Recruitment and Retention — This article analyzes the extent to which the Better Jobs Better Care initiative succeeded in introducing elements of culture change into the management practices of long-term care providers. The authors write that incremental culture change — making gradual, visible changes to a long-term care facility — can be better at fostering sustainable culture change than a more radical, wholesale approach. As a result of these visible changes, workers feel more valued, and are more likely to stay.

PHI’s National Clearinghouse on the Direct Care Workforce is a national online library for people in search of solutions to the direct-care staffing crisis in long-term care. It houses over 1,000 articles, reports, issue briefs, and fact sheets on the direct-care workforce.

– by Matthew Ozga

The Centers for Medicare and Medicaid Services‘ (CMS) final rule on Medicare and Medicaid Programs, Civil Money Penalties (CMP) for Nursing Homes was published in the Federal Register on March 18.

These regulations, implementing provisions of the Affordable Care Act, establish new ways to spend CMPs collected by CMS. According to the Federal Register notice (pdf), there is some flexibility on how the money can be spent, but some of the CMP funds must be applied directly to promote quality care in nursing homes and the well-being of nursing home residents.

As of March 23, CMS is responsible for authorizing how all CMP funds garnered from nursing home penalties imposed by CMS and states can be used.

Funds Must Benefit Nursing Home Residents

The final rule states that 90 percent of the collected CMP funds that are required “to be placed in escrow, and that remain after all administrative appeals have been exhausted and where the facility is unsuccessful in its appeals,” are to be used for activities that benefit nursing home residents. The remaining 10 percent will be returned to the U.S. Department of the Treasury.

Rather than issue an “exhaustive list” of appropriate uses for the CMP funds, CMS plans to have workgroups develop and publish guidance in the State Operations Manual. It is expected that CMS will identify certain categories for which CMP funds can be used. The federal agency will require pre-approval on a case-by-case basis for proposed uses that are not on the list.

The Affordable Care Act offers examples of activities that would be acceptable uses for CMP funds, such as projects that support resident and family councils and other consumer involvement in assuring quality care in facilities, and facility improvement initiatives approved by CMS such as joint training of facility staff and surveyors.

Supporting the Direct-Care Workforce

The final rule also noted that “several commenters suggested using civil money penalty funds to support the frontline direct-care workforce enhancement projects such as facilitating the education and credentials, tracking of the State’s direct-care workforce, creating a direct-care worker registry, and providing improvements in the competency, education, and training standards for direct-care workers, as these front line workers are responsible for the care of our elders.”

CMS responded that it “concurs with the importance of the frontline direct-care workforce, such as certified nurse assistants, in the care of our vulnerable beneficiaries and the value that workforce enhancements could contribute in improving care of the nursing home residents.” A decision on whether the CMP funds can be used for this purpose is expected to be in the CMS State Operations Manual.

Iowa’s CMP Experience

“In 1999/2000, the Iowa Legislature approved the use of civil monetary penalty funds to support one year of the Iowa CareGivers Association‘s (ICA) three-year direct-care worker recruitment and retention pilot project, and the request still had to receive final approval from CMS,” said Di Findley, the association’s executive director.

“The ICA was the first to tap the funds to support direct-care worker initiatives. This year, rules (pdf) were finally established on how the funds can be used through a new Quality Improvement Initiative grant program,” Findley said.

– by Deane Beebe

Nursing Home Compare's star rankings

The National Quality Forum (NQF) has endorsed a slate of 21 measures designed to assess the quality of nursing home care.

Three of the measures are based on survey data gathered from current and former residents as well as residents’ family members.

Most of the other measures are quantifiable resident health outcomes that are known to correlate with care quality, including the incidence of pressure ulcers, moderate-to-severe pain, and urinary tract infections among residents.

The 21 measures will be integrated into Nursing Home Compare, a searchable online database of more than 17,000 U.S. nursing homes. Nursing Home Compare is operated by the Centers for Medicare and Medicaid Services (CMS).

Survey Assesses Person-Centered Care

One of the three survey-based measures uses responses from people who have resided in a nursing home for at least 30 days.

That survey asks respondents to rank, on a scale of 1 to 10, the comfort of their surroundings and the professionalism of the staff.

It also asks residents whether their facilities are person-centered by asking questions such as, “Can you choose what time you go to bed?” and “Can you choose what activities you do here?”

“These sorts of questions demonstrate that the concept of person-centered care has positively impacted nursing home care throughout the country,” said PHI Director of Training and Organizational Development Services Susan Misiorski. “We applaud NQF and CMS for advancing person-centered practices through their nursing home assessments.”

A second survey asks relatives of nursing home residents to give their impression of the care their loved ones are receiving. A third survey is designed to be answered by recently discharged residents and is administered by mail only.

The surveys used in the NQF-endorsed measures were created by the Consumer Assessment of Health Providers and Systems (CAHPS).

Long-term care stakeholders who are dissatisfied with any of the 21 measures should notify NQF, via its website, by April 1.

NQF is a nonprofit organization that establishes and disseminates voluntary standards designed to improve the quality of U.S. health care.

– by Matthew Ozga

A March 2011 report released by the Office of the Inspector General (OIG) at the Department of Health and Human Services (HHS) shows that 92 percent of nursing homes had at least one employee with one or more criminal convictions on staff.

Other findings reported in Nursing Facilities’ Employment of Individuals with Criminal Convictions (pdf) are:

• Nearly half of the nursing homes sampled were found to employ five or more employees with criminal convictions.
• Overall, 5 percent of nursing home employees had at least one conviction in FBI-maintained criminal history records.
• Of the employees with convictions, 84 percent had their most recent conviction prior to their start date of employment.
• “Crimes against property,” such as burglary, shoplifting, and writing bad checks, was the most common conviction, with 44 percent of employees with criminal convictions having committed such a crime.

The OIG surveyed a sample of 260 nursing homes and requested information on all employees for the study.

The study also found that 43 states require a criminal background check for prospective employees, despite the fact that there are no federal regulations or laws that require nursing homes to conduct such checks. Some states require FBI interstate background checks, while others only require a statewide check.

Under the Patient Protection and Affordable Care Act, the HHS Secretary is required to develop a nationwide program for states to conduct national and statewide criminal background checks on “direct patient access employees” working at nursing facilities and other providers. States will have the option of participating in the National Background Check Program.

OIG Recommendations and CMS Response

The OIG made the final recommendations to the Centers for Medicare and Medicaid Services (CMS) regarding criminal background check procedures:

• CMS should clearly define the employee classifications that qualify as direct patient access employees.
• CMS should work with participating states to develop a list of state and local convictions that disqualify an individual from nursing home employment under the federal regulation, and the time periods for which each conviction bars the individual from employment.

Federal regulation prohibits Medicare and Medicaid nursing homes from hiring people whom a court has found guilty of abusing, neglecting, or mistreating residents. Also prohibited is employing someone who is listed in a state nurse aide registry with a finding concerning abuse, neglect, or mistreatment of a resident or misappropriation of their property.

CMS agreed with the OIG recommendations and defined “direct patient access employees” as “anyone who routinely comes into contact or has the potential to come into contact with residents or clients.” It deemed all nursing home staff to be direct patient access employees.

CMS also stated that it will work with the states to help them develop “lists of convictions that disqualify individuals from employment, as well as defining whether any of those conviction types can be assumed to be mitigated because of the passage of time and which convictions should never be considered mitigated or rehabilitated.”

– by Deane Beebe

Tens of thousands of public employees and their supporters have been demonstrating at the state capitol in Madison, Wisconsin since February 15 to protest a bill that would require public employees to pay more for their health care coverage and pensions — and eliminate just about all of their collective bargaining rights.

According to the SEIU, “9,000 nurses and nursing home staff, along with about 5,000 home care workers” would be affected if Governor Scott Walker‘s (R) “budget-repair bill” passed, in addition to Wisconsin’s schoolteachers, firefighters, police officers, and other state and local public workers.

Also slated for elimination under the bill is the Wisconsin Quality Home Care Authority (pdf).

Agreed to Monetary Increases but Collective Bargaining Rights Untouchable

State and local public employees, including the county nursing home workers, reportedly agreed to pay more toward their health care and pensions, which amounts to a 7 percent cut in take-home pay. These workers would be required to contribute 5.8 percent of their pay toward their pensions, and, for most, double the contribution to their health care premiums from 6 percent to 12.6 percent, according to The New York Times.

The public employees have refused to accept, however, limiting their collective bargaining rights to negotiating wages only, as proposed by Walker.

“If you can only bargain for wages, you are basically unable to do much of anything,” said Bonnie Strauss, staff director, SEIU Healthcare Wisconsin. “The bulk of contracts are about what is most important — the working conditions: scheduling; staffing; holiday, vacations, and sick days; and input into safety issues.”

Under the bill, the collective bargaining rights for the 5,000 independent home care providers would be eliminated entirely.

“These rights are especially important to low-wage workers, because if you don’t have a sick day and get sick, it’s a major loss,” Strauss said.

Wisconsin was the first state in the nation to have collective bargaining rights, which were passed in the late 1950s, an NPR interview on states’ efforts to scale back collective bargaining rights explains.

Eliminate Matching and Registry Services

Less known is that the budget bill also contains a provision that would eliminate the Wisconsin Quality Home Care Authority, which provides matching and registry services, “like it never happened, erasing it from the map,” said Patti Becker, the Authority’s executive director.

The Authority helps consumers who want to direct their own care locate and employ compatible independent home care providers, as well as providing other services to support consumer-directed care.

“It would no longer be lawful for the Wisconsin Department of Health and Human Services to contract with the Authority to provide matching and registry services,” Becker said.

The independent home care workers just reached a tentative agreement on their first contract with the Wisconsin Department of Health and Human Services in December 2010; it was voted down the same month by the Wisconsin Senate along with other state contracts.

The Authority, which was enacted into law in 2009 and launched in late 2010, had plans to roll out its services to the entire state by July 1, but those plans are now in limbo.

Vote Delayed

Walker’s “budget-repair bill” has the full support of Republican legislators, who are the majority in the state legislature. They are one senator short to hold a vote, however, because the Democratic lawmakers have reportedly left the state to delay a vote on the bill.

Wisconsin has a budget shortfall of $137 million and faces a $3.6 billion gap in the coming two-year budget.

– by Deane Beebe