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Quality Improvement in the Nursing Home Setting Assoc Prof Samuel Scherer Quality Improvement in the Nursing Home Setting Assoc Prof Samuel Scherer

EXAMPLES OF CURRENT QI PROCESSES AMONG PROVIDER ORGANISATIONS IN SINGAPORE • Quality Department and EXAMPLES OF CURRENT QI PROCESSES AMONG PROVIDER ORGANISATIONS IN SINGAPORE • Quality Department and Quality Manager – ISO 9001: 2008 framework • Structured Induction and Orientation programme for new staff • Quality Objectives focused on: – Clinical Governance (MAB; M&M meetings) – Clinical measures (eg aim for ZERO NH acquired Pressure Ulcers) – Internal and External Quality Audits (Quantitative) – Quality Service Performance Monitoring (Qualitative) • PFG Meetings; Written & verbal feedback • Service quality (Customer satisfaction); • Training Programs Very similar frameworks and initiatives • Develop and involve staff in QI in Australia – Communication; mutual trust; manage and communicate adverse events – Quality Circles; Staff Suggestion Scheme; Quality Improvement Workgroups • Nursing Quality Assurance Activities; Quarterly Meetings; Quality Projects

OUTLINE Quality Improvement in the Nursing Home Setting 1. 2. 3. 4. A framework OUTLINE Quality Improvement in the Nursing Home Setting 1. 2. 3. 4. A framework for QI The NH in the 21 st Century QI for the NH of the 21 st Century Putting it together

DOMAINS OF QUALITY AND SAFETY http: //www. health. vic. gov. au/clinrisk/publications/clinical_gov_policy. htm 1. 2. DOMAINS OF QUALITY AND SAFETY http: //www. health. vic. gov. au/clinrisk/publications/clinical_gov_policy. htm 1. 2. 3. 4. Consumer participation Clinical effectiveness An effective workforce Risk management These Domains provide a conceptual framework for strategies to enhance the delivery of care in all settings Within each Domain there a number of quality and safety management functions that require attention Under these Domains all of the required principles of clinical governance and QI should be addressed

VALUES CONSCIOUSNESS SCIENCE SYSTEMS http: //www. health. vic. gov. au/clinrisk/publications/clinical_gov_policy. htm VALUES CONSCIOUSNESS SCIENCE SYSTEMS http: //www. health. vic. gov. au/clinrisk/publications/clinical_gov_policy. htm

SCIENCE The US Institute of Medicine has defined quality health care as: • SCIENCE The US Institute of Medicine has defined quality health care as: • "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. ”

INTERRAI MDS ASSESSMENT SYSTEM Assessment Outcome Measurement Scales Care planning Protocols (RAP, CAP) Minimum INTERRAI MDS ASSESSMENT SYSTEM Assessment Outcome Measurement Scales Care planning Protocols (RAP, CAP) Minimum Data Set Eligibility & Placement Screening Resource Use RUG Quality Indicators (Carpenter 2003)

CLINICAL PRACTICE GUIDELINES Medical capacity to deliver & role of nurse practitioners CLINICAL PRACTICE GUIDELINES Medical capacity to deliver & role of nurse practitioners

Risk-adjusted indicators of quality of care : intervention vs control residential care facilities over Risk-adjusted indicators of quality of care : intervention vs control residential care facilities over six-months (Boorsma 2011) Indicator (My selections) Intervention Facilities (% of Res) Control Facilities (% of Res) Adjusted OR* (95% CI) Behavioural problem 8. 7 26. 5 0. 27 (0. 10– 0. 74) High Risk 15. 4 45. 5 0. 24 (0. 07– 0. 89) Low risk 2. 0 8. 6 0. 20 (0. 03– 1. 34) 33. 3 46. 2 0. 78 (0. 66– 0. 91) High Risk 62. 5 71. 1 0. 79 (0. 28– 2. 28) Low Risk 19. 4 34. 1 0. 52 (0. 40– 0. 67) Worsening of pain 12. 9 40. 9 0. 20 (0. 07– 0. 52) Pressure ulcers 4. 9 7. 5 0. 63 (0. 21– 1. 91) High Risk 16. 0 19. 0 0. 80 (0. 18– 3. 44) Low Risk 1. 3 2. 1 0. 51 (0. 06– 4. 04) Antipsychotic agents 3. 8 11. 0 0. 25 (0. 08– 0. 78) High Risk 25. 0 0. 89 (0. 03– 36. 1) Low Risk 2. 1 10. 7 0. 15 (0. 03– 0. 66) Bladder or bowel incontinence

 • QI’s traditionally conceptualized as interventions (discrete changes) separated from their surroundings in • QI’s traditionally conceptualized as interventions (discrete changes) separated from their surroundings in order to assess whether they cause changes –eg patient outcomes. If the change is an improvement, the assumption is they can be repeated elsewhere to achieve the same outcome • However in QI nothing ever happens for one reason or cause. It would be convenient to package changes as a QI which could work anywhere, like an effective drug. But to change social systems, a number of factors influence implementation and success • Some useful knowledge can be generated using medical treatment research designs like RCT’s but we also require non-experimental naturalistic methods that are more often used in the social sciences (Øvretveit J, BMJ Qual Saf 2011) • “The Quality Improvement field is still emerging, still relies a great deal on trial and error, and lacks a strong theory and empirical base. ” (Leviton L, BMJ Qual Saf 2011)

EVIDENCE TO PRACTICE TRANSLATIONAL IN LTC A randomised controlled trial of staff education to EVIDENCE TO PRACTICE TRANSLATIONAL IN LTC A randomised controlled trial of staff education to improve the quality of life of people with dementia living in residential care facilities: the Dementia In Residential care: Education intervention Trial (DIRECT) study. Christopher Beer 1, 2*, Barbara Horner 3, Leon Flicker 1, 2, Samuel Scherer 5, Nicola T Lautenschlager 1, 4, 6, Nick Bretland 7, Penelope Flett 8, Frank Schaper 9, Osvaldo P Almeida 1, 4

SYSTEMS: HUMAN RESOURCES • Create positive working conditions for nursing home practitioners with attractive SYSTEMS: HUMAN RESOURCES • Create positive working conditions for nursing home practitioners with attractive career development opportunities, recognition, and similar rewards enjoyed by health care workers in comparable roles within the acute care services • Effective leadership structures include an expert physician (medical director), an expert registered nurse (nursing director), and skilled administrator

SYSTEMS: HUMAN RESOURCES AT ALL LEVELS TEAMS Caregiver Care Team Facility Organisation Quality Agency SYSTEMS: HUMAN RESOURCES AT ALL LEVELS TEAMS Caregiver Care Team Facility Organisation Quality Agency Professional – Academic Bodies Bureaucracy Government Consumer Expectations International Best Practice

Caregiver LEVELS WITHIN QI HIERARCHY Care Team Facility THE CARE TEAM Organisation Quality Agency Caregiver LEVELS WITHIN QI HIERARCHY Care Team Facility THE CARE TEAM Organisation Quality Agency Professional – Academic Bodies Patient Centered Multidisciplinary Bureaucracy Government Nurse Doctor Consumer Expectations International Best Practice Patient Resident Care Staff Therapists

HEALTH CARE QI IN LTC - AUSTRALIAN “SYSTEM” INITIATIVES Report Of Ministerial Reference Group HEALTH CARE QI IN LTC - AUSTRALIAN “SYSTEM” INITIATIVES Report Of Ministerial Reference Group (2002) “GP's & hospitals are reluctant to be involved with aged care services and as a result the provision of basic medical services to people in residential care is poor” Response strategies: – Sponsored innovation program s (eg “EBPAC”) and guidelines – New programs and funding incentives for GP’s – “Telehealth” – Hospital-based “Inreach” and Substitution Programs – Decrease reliance on doctors alone/increase support for doctors • Nursing and Nurse Practitioner initiatives – education, career structure, funding • Allied health funding and career streams • eg Royal Freemasons - Chief Nurse, Geriatrician, AH Coordinator – (External, Internal or Regional Models for Medical Service? )

ALLIED HEALTH RESOURCES FOR LTC? ALLIED HEALTH RESOURCES FOR LTC?

VALUES The US Institute of Medicine has defined quality health care as: • VALUES The US Institute of Medicine has defined quality health care as: • "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. ” The Department of Health and Human Services in the US says: • “quality health care means doing the right thing at the right time, in the right way for the right person and getting the best possible results. ” Ethical Principles – Autonomy – Beneficence – Distributive Justice

Projected success of alternative model of health care versus the current model Braithwaite MJA Projected success of alternative model of health care versus the current model Braithwaite MJA 2011

Braithwaite. MJA 2011 Braithwaite. MJA 2011

A CONSENSUS ON MINIMUM GERIATRICS COMPETENCIES FOR GRADUATING MEDICAL STUDENTS. (Academic Medicine, Vol. 84, A CONSENSUS ON MINIMUM GERIATRICS COMPETENCIES FOR GRADUATING MEDICAL STUDENTS. (Academic Medicine, Vol. 84, No. 5 2009) Include Inter Alia, to be able to: • Define and differentiate among types of code status, health care proxies, and advance directives • Accurately identify clinical situations where life expectancy, functional status, patient preference, or goals of care should override standard recommendations for screening tests in older adults • Accurately identify clinical situations where life expectancy, functional status, patient preference, or goals of care should override standard recommendations for treatment in older adults

CONSCIOUSNESS • • • • Knowhow Intention Attention Empathy Confidence Integrity Compassion Application Professional CONSCIOUSNESS • • • • Knowhow Intention Attention Empathy Confidence Integrity Compassion Application Professional Identity Personal Identity Experience Courage Sense of reward Privilege Gratefulness Caregiver Care Team Facility Organisation Quality Agency Professional – Academic Bodies Bureaucracy Government Consumer Expectations International Best Practice “Whether ye be the taker or giver of care, Is naught but a trick of time”

OUTLINE Quality Improvement in the Nursing Home Setting 1. 2. 3. 4. A framework OUTLINE Quality Improvement in the Nursing Home Setting 1. 2. 3. 4. A framework for QI The NH in the 21 st Century QI for the NH of the 21 st Century Putting it together

WHY DO WE NEED NURSING HOMES? Disability Ageing Overlapping Concepts Frailty Disease WHY DO WE NEED NURSING HOMES? Disability Ageing Overlapping Concepts Frailty Disease

AGEING, FRAILTY, DISEASE AND DISABILITY Ferruci 2001 AGEING, FRAILTY, DISEASE AND DISABILITY Ferruci 2001

PREVALENCE OF SYSTEMIC DISEASES WITH AGE Prevalence rate 2. 5 2 1. 5 1 PREVALENCE OF SYSTEMIC DISEASES WITH AGE Prevalence rate 2. 5 2 1. 5 1 0. 5 0 75 78 81 84 Age (N=522. Age trends: * p < 0. 05) Sydney Older Persons Study Creasey 2001; Broe 2004 87 90 93 Other Systemic Peripheral Vascular Disease Chronic Lung Disease* Stroke Obesity Heart Disease Arthritis

PREVALENCE OF NEURODEGENERATIVE DISEASES WITH AGE 3. 5 3 Prevalence Rate 2. 5 2 PREVALENCE OF NEURODEGENERATIVE DISEASES WITH AGE 3. 5 3 Prevalence Rate 2. 5 2 1. 5 1 0. 5 0 75 78 81 84 Age (N=522. Age Trends: * P < 0. 05; ** P< 0. 01) Sydney Older Persons Study Creasey 2001; Broe 2004 87 90 93 Parkinsonism** Dementia** Gait Slowing (Excl. Park)** Cognitive Impairment ** Vision** Ataxia**

MEDICAL CHARACTERISTICS OF LTC POPULATIONS Condition Prevalence % Dementia (NH) 60 Cognitive Impairment (NH) MEDICAL CHARACTERISTICS OF LTC POPULATIONS Condition Prevalence % Dementia (NH) 60 Cognitive Impairment (NH) 90 Dementia (Hostel) 28 Cognitive Impairment (Hostel) 54 Pain Sensory Loss (Vision/hearing) Depression Sleep Disturbance 15 -83% 80+ Reference Rosewarne 1997 Teno 2001 Worrall 1993 30 -40 Mann 2000 67 Ersser 1999 (Scherer 2001)

THE NURSING HOME OF THE 21 st CENTURY THE NURSING HOME OF THE 21 st CENTURY

LENGTH OF STAY IN NURSING HOMES AT THE END OF LIFE (Kelly et al LENGTH OF STAY IN NURSING HOMES AT THE END OF LIFE (Kelly et al JAGS 2010) • Median LOS to death 5 months • Men 3 months • Women 8 months • Average LOS 14 months • Shorter LOS if married • Shorter LOS if wealthy • 65% died within 1 year • 53% died within 6 months • Australian data: ~ 35% of total high plus low care population die within 6 months • ~ 50% HC die within 6 months • 19% stay 5 y+

COMMON TRAJECTORIES OF DECLINE AND DEATH #1. SHORT DECLINE • Primarily Somatic. • Not COMMON TRAJECTORIES OF DECLINE AND DEATH #1. SHORT DECLINE • Primarily Somatic. • Not typically, but sometimes in NH’s High Function Mostly cancer PALLIATIVE GROUP Trajectory #1 Possible hospice enrollment Death Low Onset of incurable cancer Time Often a few years Decline usually few months (Murray 2005)

TRAJECTORY #2: LONG TERM LIMITATIONS WITH INTERMITTENT SEVERE EPISODIC DECLINE Function High Mostly heart TRAJECTORY #2: LONG TERM LIMITATIONS WITH INTERMITTENT SEVERE EPISODIC DECLINE Function High Mostly heart & lung disease PALLIATIVE GROUP Trajectory #2 • Primarily Somatic. • Typically admitted to NH late in course of illness when functional decline is severe. • “End stage” in terms of response to therapy Emergency hospitalisations Low Death Hospital use Time ~ 2 -5 years, death may be “sudden” Profound decline in weeks or months (Murray 2005)

TRAJECTORY #3: PROLONGED DWINDLING FRAILTY GROUP Trajectory #3 b) Mostly Dementia & Frailty High TRAJECTORY #3: PROLONGED DWINDLING FRAILTY GROUP Trajectory #3 b) Mostly Dementia & Frailty High DEMENTIA GROUP Trajectory #3 a) Function #3 a) Dementia Group: Often admitted to NH earlier in course of (physical) functional decline #3 b) Frailty Group: • Primarily Somatic (or mixed) • Admitted to NH later in course of functional decline Likely NH admission Low Death Onset Time Variable ++: ~ 6 -8 + years (from dementia onset) (Murray 2005 modified)

TRAJECTORY #4: STABLE +/- RESTORATIVE POTENTIAL Eg: Stroke; Musculoskeletal; Psychosocial; ABI; Ageing ID High TRAJECTORY #4: STABLE +/- RESTORATIVE POTENTIAL Eg: Stroke; Musculoskeletal; Psychosocial; ABI; Ageing ID High STABLE GROUP Trajectory #4 Function Stable/Restorative Group(s): • Somatic or Cognitive • Longer life expectancy • Death from new event or illness Likely NH admission Low Death Onset Time Life Expectancy Variable ++

OUTLINE Quality Improvement in the Nursing Home Setting 1. 2. 3. 4. A framework OUTLINE Quality Improvement in the Nursing Home Setting 1. 2. 3. 4. A framework for QI The NH in the 21 st Century QI for the NH of the 21 st Century Putting it together

WORKING DEFINITION OF QUALITY IMPROVEMENT: “The totality, at any point in time, of an WORKING DEFINITION OF QUALITY IMPROVEMENT: “The totality, at any point in time, of an interaction of multiple dynamic (evolving) concepts, structures and processes” Caregiver Care Team Facility Organisation Need To Align: Quality Agency 1. Patient Focused Goals – Enhance outcomes for a particular patient – – Life expectancy Function QOL Symptom control 2. System Focused Goals • Match the level and type of resources provided to particular goals • • • Effectively Efficiently Economically Professional – Academic Bodies Bureaucracy Government Consumer Expectations International Best Practice

“SPECIALISATION” Somatic vs Dementia – NH’s (Clustering) – Units/Wings ( “ ” ) – “SPECIALISATION” Somatic vs Dementia – NH’s (Clustering) – Units/Wings ( “ ” ) – Programs/Teams/ “Champions” (only) Restorative vs Maintenance vs Palliative Programs – NH’s , Units/Wings, Programs/Teams STABLE GROUP Trajectory #4 FRAILTY GROUP Trajectory #3 b) DEMENTIA GROUP Trajectory #3 a) – (If programs – define on admission) Method for transition to Palliative Status PALLIATIVE GROUP Trajectories #1, 2

Fig. 1 THE TRANSITION FROM ROUTINE CARE TO END-OF-LIFE CARE IN A NURSING HOME Fig. 1 THE TRANSITION FROM ROUTINE CARE TO END-OF-LIFE CARE IN A NURSING HOME DEMENTIA GROUP Trajectory #3 a) FRAILTY GROUP Trajectory #3 b) STABLE GROUP Trajectory #4 Source: Deborah P. Waldrop, LMSW, Ph. D and Kathy Nyquist, GCS, NHA JAMDA 2011; 12: 114 -120 (DOI: 10. 1016/j. jamda. 2010. 04. 002 )

INTEGRATION OF PALLIATIVE CARE AND AGED CARE • • • A palliative approach Dignity INTEGRATION OF PALLIATIVE CARE AND AGED CARE • • • A palliative approach Dignity and quality of life Advance care planning Advanced dementia Physical symptom assessment and management Psychological support Family and social support, intimacy and sexuality Cultural and spiritual issues, including Aboriginal issues Volunteer, staff support End of life care Bereavement Developing a team http: //www. nhmrc. gov. au/_files_nhmrc/publications/attachments/pc 29. pdf 40

HOW CAN THESE GUIDELINES BE INTRODUCED? Professional – Academic Bodies Bureaucracy Government • Ethical HOW CAN THESE GUIDELINES BE INTRODUCED? Professional – Academic Bodies Bureaucracy Government • Ethical issues: Consumer Expectations Internation al Best Practice – capacity to care, philosophy • • Introducing to Boards of Management Liaising with palliative care services Preventing unnecessary hospitalisation Encouraging GP participation Caregiver Care Team Facility Organisation Quality Agency

AN ETHICAL FRAMEWORK FOR INTEGRATING PALLIATIVE CARE PRINCIPLES INTO THE MANAGEMENT OF ADVANCED CHRONIC AN ETHICAL FRAMEWORK FOR INTEGRATING PALLIATIVE CARE PRINCIPLES INTO THE MANAGEMENT OF ADVANCED CHRONIC OR TERMINAL CONDITIONS CLINICAL INTEGRITY REQUIRES: http: // www. nhmrc. gov. au 1. Best available continuing and integrated treatment and care as health care needs change 2. Responsible health professionals undertake a specific review of a person’s treatment, care options and wishes 3. People are referred in timely and transparent ways to the most appropriate health professionals 4. Health professionals communicate and collaborate with each other in a timely and regular way 5. Review by multidisciplinary health teams is available when needed

HOW CAN THESE GUIDELINES BE INTRODUCED? MACRO LEVEL INITIATIVES PROVIDE EDUCATION & TRAINING DEVELOP HOW CAN THESE GUIDELINES BE INTRODUCED? MACRO LEVEL INITIATIVES PROVIDE EDUCATION & TRAINING DEVELOP POLICIES & PROCEDURES MANAGEMENT RESPONSIBILITIES WITHIN THE LEGISLATIVE FRAMEWORK PROMOTE COMMUNICATION CONSULTATION & NETWORKING PROVIDE STAFF SUPPORT

Professional – Academic Bodies Bureaucracy Government Consumer Expectations International Best Practice 75% of respondents Professional – Academic Bodies Bureaucracy Government Consumer Expectations International Best Practice 75% of respondents said loved ones had not discussed care preferences with them

HOW CAN THESE GUIDELINES BE INTRODUCED? - MICRO LEVEL INITIATIVES Caregiver Care Team Facility HOW CAN THESE GUIDELINES BE INTRODUCED? - MICRO LEVEL INITIATIVES Caregiver Care Team Facility Organisation Quality Agency • Implementing a palliative approach in NH’s can reduce the potential distress to residents and their families caused by a transfer to an acute setting • A palliative approach can be provided in the resident’s familiar surroundings if adequately skilled care is available • Providing information about a palliative approach may help residents and their families to consider a palliative approach as active care rather than withdrawal of treatment

IMPLEMENTING A PALLIATIVE APPROACH • A multidisciplinary team that promotes goal setting in collaboration IMPLEMENTING A PALLIATIVE APPROACH • A multidisciplinary team that promotes goal setting in collaboration with the family is critical to the success of a palliative approach • This approach decreases discomfort for residents, saves valuable resources and improves satisfaction levels for the family when they recall the care provided Self Directed Learning Package http: //agedcare. palliativecare. org. au/Default. aspx? tabid=1765

Self Directed Learning Packages for Staff and Doctors http: //agedcare. palliativecare. org. au/Default. aspx? Self Directed Learning Packages for Staff and Doctors http: //agedcare. palliativecare. org. au/Default. aspx? tabid=1765 http: //www. palliativecare. org. au/Portals/46/Factsheet%20 -%20 online%20 education%20 -%20 palliative%20 care%20 in%20 aged%20 care%20 homes. pdf

PROCESS OF END OF LIFE DECISION MAKING PROCESS OF END OF LIFE DECISION MAKING

(C Stirling; S Andrews; F Mc. Inerney; C Toye; M Ashby; A Robinson 2011) (C Stirling; S Andrews; F Mc. Inerney; C Toye; M Ashby; A Robinson 2011)

OUTLINE Quality Improvement in the Nursing Home Setting 1. 2. 3. 4. A framework OUTLINE Quality Improvement in the Nursing Home Setting 1. 2. 3. 4. A framework for QI The NH in the 21 st Century QI for the NH of the 21 st Century Putting it together

CONSCIOUSNESS DEVELOP EACH DOMAIN FOR EACH GROUP PREPARE FOR AND MANAGE PALLIATIVE TRANSITIONS STABLE CONSCIOUSNESS DEVELOP EACH DOMAIN FOR EACH GROUP PREPARE FOR AND MANAGE PALLIATIVE TRANSITIONS STABLE GROUP Trajectory #4 DEMENTIA GROUP Trajectory #3 a) FRAILTY GROUP Trajectory #3 b) PALLIATIVE GROUP Trajectories #1, 2 VALUES SCIENCE INTEGRATE THE FOUR DOMAINS FOR EACH GROUP SYSTEMS Thank you