Indiana Healthcare Leadership Conference: Improving Nutrition.

Indiana Healthcare Leadership Conference: Improving Nutrition

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Review of Quality of Care Initiatives

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Nursing HomeQuality Status: 2007

High number of immediate jeopardy violations (5th highest)

High number of deficiencies per standard survey (7.6 compared with national average of 6.9)

Above average number of deficiency free surveys (11.7% compared with national rate of 8.3%)

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Quality Improvement Efforts: Studies

Medical error reporting system (2005)

Staffing study (2009)

Bladder scanner study (2009)

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Quality Improvement Efforts: Education Programs

Alzheimer’s and dementia care training programs (2005)

Leadership Conference (2007)

Consultant program (2004)

Healthcare Quality Resource Center (2009)

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Quality Improvement Efforts: Communications

ISDH LTC Newsletter (2008)

Monthly meetings of provider associations and ISDH (2008)

Regular meetings with consumer organizations to discuss quality of care concerns (2005)

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Quality Improvement Efforts: Survey Process

Implemented MDS 3.0 (2010)

Implemented CMS Special Focus Facility Program (2008)

CMS and ISDH consistency workgroups (2008)

Review of immediate jeopardy surveys with provider associations (2008)

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Quality Improvement Efforts: Collaborative Initiatives

Indiana Pressure Ulcer Initiative (2008 – 2010)

Indiana Healthcare Associated Infection Initiative (2009 – 2011)

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Quality Improvement Efforts: Regional Projects

Health Care Excel (QIO) statewide support of CMS GPRA goals (2004)

Health Care Excel pilot of CMS care coordination project in Evansville (2009)

CMS Critical Need Nursing Home Project Pilot in northwest Indiana (2010) coordinated by Health Care Excel

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Quality Improvement Efforts: New in 2011

Community Foundation of St. Joseph County Regional Nursing Home Collaborative (2011)

ISDH Survey Report System (2011)

ISDH Posting of Surveys (2011)

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OUTCOMES TO QUALITY IMPROVEMENT EFFORTS

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Indiana Pressure Ulcer Initiative

CMS GPRA Initiative – 2005 – 2007

Indiana Healthcare Leadership Conference on Preventing Pressure Ulcers – October 2008

Indiana Pressure Ulcer Initiative – August 2008 – November 2010

Quality Improvement Organization ongoing projects with providers

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Indiana Pressure Ulcer Initiative: Outcomes

Source: CMS GPRA data from PDQ

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Indiana Restraint Reduction Initiative

CMS GPRA Initiative: 2005 –2007

Indiana Healthcare Leadership Conference on Restraints and Behavior Management: March 2008

Quality Improvement Organization ongoing projects with providers

Focus by provider associations

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Indiana Restraint Reduction Initiative: Outcomes

Source: CMS GPRA data from PDQ

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Indiana Healthcare Associated Infection Initiative

Overview– Collaborative initiative – Two-year initiative from Sept 2009 – Dec 2011– 130 participating facilities (80 nursing homes)

Priorities – Catheter associated urinary tract infections

(CAUTI) – Clostridium difficile (CDI)

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Indiana Nursing Homes: Deficiency Free Surveys

2006: 33 facilities - 7.0% 2007: 47 facilities - 9.6% 2008: 55 facilities - 11.0% 2009: 56 facilities – 10.7% 2010: 51 facilities - 10.3%

Source: ISDH QAMIS

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Outcomes: Average Number of Deficiencies per Standard Survey

Indiana National Region V (fewest is 1st)

Fed FY 2007 7.6 6.9 4th Fed FY 2008 8.0 6.9 5th Fed FY 2009 7.2 6.8 4th Fed FY 2010 7.1 6.3 4th

Source: CMS data from CASPER 11/8/2010

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Outcomes: Percent of LTC with a “J” or Higher on Standard Surveys

Indiana National Region V (lowest is 1st)

Fed FY 2007 5.0 2.1 4th Fed FY 2008 4.6 2.9 5th Fed FY 2009 1.8 2.7 2nd Fed FY 2010 2.9 2.5 2nd

Source: CMS data from CASPER 11/8/2010

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Outcomes: Number of Immediate Jeopardy Findings on all LTC Surveys

Indiana Region V (lowest is 1st)

Fed FY 2007 68 5th Fed FY 2008 50 5th Fed FY 2009 35 3rd Fed FY 2010 33 3rd

Source: CMS data from CASPER 11/8/2010

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Outcomes: Average Number of Onsite Survey Hours on Standard Surveys

Indiana National Region V (lowest is 1st)

Fed FY 2010 83.7 105.6 1st

Source: CMS data from CASPER 11/8/2010

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COMING QUALITY IMPROVEMENT PROJECTS

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Coming Initiatives for 2011

Healthcare Associated Infections

Three online learning modules designed for staff and consumers

Consumer brochure

In-service programs

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Coming Initiatives for 2011

Education programs for wound care and infection prevention leading to increased staff certification

Updated aide curriculum

Long Term Care Bed Tracking System

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Coming Initiatives for 2011

Leadership Conference on care coordination and transition

Complete 50% of training for Quality Indicator Survey (QIS) Process

Develop a care coordination and transition initiative for 2012 implementation

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Improving Nutrition

Conference Checklist

Provide an in-service on information and resources provided at today’s conference

Develop a plan for improving nutrition

Identify and implement 3 activities for improving nutrition