Program Goals

The Picker/Commonwealth Fund Program on Long-Term Care Quality Improvement, part of the foundation’s efforts to improve the health care delivery system and spur innovation, aims to 1) raise the quality of postacute and long-term care services and supports, and 2) improve care transitions for patients by integrating these services with the other care that they receive.

Specifically, the program seeks to:

• identify, test, and spread measures, practices, models, and tools that will lead to person-centered, high-performing long-term care services;
• build strong networks among stakeholders to create a sense of common purpose and shared interest in improving performance and
  coordinating care;
• assess, track, and compare the performance of long-term services and supports at the state and national levels; and
• ensure that long-term services are part of an integrated system of patient care and are a component of provider payment, health
  information, and care delivery reforms.

A focus of the program is the development of coordinated care systems for the especially vulnerable group of individuals enrolled in both the Medicare and Medicaid programs.

The Issues

As our population ages, an increasing number of people live with multiple chronic conditions, compromised physical function, and sometimes dementia. These problems not only can complicate our ability to manage our health care needs, but they can also jeopardize our ability to remain independent. Access to high-quality postacute care and long-term services and supports is therefore critical for patients trying to get well, stay well, and remain functional—especially older adults living alone.

Patients and their families know this, often from personal experience. Policymakers, on the other hand, generally have been slow to recognize the importance of long-term care to health system redesign, in terms of reducing overall costs and creating a seamless care system for patients.

As implementation of the Affordable Care Act proceeds, The Commonwealth Fund’s Program on Long-Term Care Quality Improvement is supporting efforts to help nursing homes and other providers improve their performance and ensure successful transitions for patients as they move from one level of care to the next.

Recent Projects

Advancing Excellence in America's Nursing Homes
Advancing Excellence in America’s Nursing Homes is a national, voluntary quality improvement campaign to help nursing homes become good places to live, work, and visit. Launched in 2006 with support from The Commonwealth Fund and the Centers for Medicare and Medicaid Services (CMS), Advancing Excellence was recently incorporated as a not-for-profit educational organization, led by a board representing all those with a major stake in high-quality nursing home care.

The campaign is unique in encouraging the participation of not only nursing home providers but also the individuals who staff facilities and the consumers they serve. To join, nursing homes must agree to work on at least three of eight quality-related issues, such as reducing staff turnover—a problem endemic within the industry—or improving the care planning process to address patients’ goals for care. Nursing homes taking part must also set performance targets and measure change. The campaign works with state stakeholder coalitions called Local Area Networks for Excellence, or LANEs, which help keep nursing homes engaged and moving forward.

Advancing Excellence has achieved great success in attracting nursing homes—now more than 7,400, representing over 47 percent of all U.S. nursing facilities—and in making measurable progress toward quality goals Through the campaign’s Web site, www.nhqualitycampaign.org, nursing homes can access tools for tracking improvement and comparing facilities’ performance, learn about evidence-based practices, and participate in free training webinars. Consumers, meanwhile, can find information that will help them get good care.

Preserving "Critical-Access" Nursing Homes

The Commonwealth Fund’s abiding interest in reducing disparities in health care for vulnerable populations has led to heightened attention on safety-net health care providers. The recent trend of nursing home closures in inner-city neighborhoods, a phenomenon identified by Brown University’s Vincent Mor, Ph.D., and others, points to the importance of nursing homes to the overall health care safety net. Although many of these facilities are of poor quality, they are often the only sources of postacute and long-term care services easily accessible to residents.

With support from the Fund and CMS, a pilot project led by Carol Benner, Sc.M., national director of the Advancing Excellence campaign, is attempting to stabilize "critical access" nursing homes to forestall closure, and then improve them sufficiently to warrant their continued participation in the Medicare and Medicaid programs. The LANE members in Georgia, Illinois, Indiana, and Ohio worked with the management and frontline staff of 18 nursing homes on organizational development aimed at stabilizing staff and improving performance. Over the 10-month pilot, many of the homes reported decreases in staff turnover and improvements in morale.

The Pioneer Network

Since 1997, the Pioneer Network has worked with a broad coalition of long-term care stakeholders to promote person-centered care in America’s nursing homes. Pioneer staff, with Commonwealth Fund support, have provided nursing homes that are pursuing culture change with training, practical tools, and access to a community of peers. In the past year, for example, staff compiled "Just in Time" toolkits to help homes implement person-centered improvements to resident dining, physical environment, and staffing, and comply with federal regulations in those areas.

The Pioneer Network also plays an important policy role, helping federal officials dismantle barriers to culture change and promote improvement. Recently, Pioneer’s leadership, working closely with CMS officials, informed the development of revised regulations issued to guide states on the use of civil monetary penalty (CMP) funds collected from nursing homes in violation of quality standards. The final rule, which will take effect in 2012, stipulates that 90 percent of Medicare’s portion of penalty funds held in escrow during the appeals process may be used for activities that improve care for nursing home residents; formerly these funds were conveyed to the U.S. Treasury. In addition, Pioneer has begun collaborating with the Office for the Assistant Secretary for Planning and Evaluation on ways to advance culture change as a quality improvement strategy and evaluate its impact on nursing home residents. This work will support CMS in its effort to design the culture change demonstration projects called for in the Affordable Care Act.

Expanding Nursing Homes' Capacity to Improve Care

Surprisingly, researchers in the past have been unable to find a clear association between staffing levels in nursing homes and quality of care. A recent study by the University of Pittsburgh’s Nicholas Castle, Ph.D., investigated this issue and identified several staffing characteristics, such as turnover, use of agency staff, and mix of professional staff, that together with staffing levels, do in fact influence quality. To help senior-level managers in nursing homes see how changes to one or more of these characteristics can affect quality, Castle developed a Web-based staffing and quality simulation tool called Staff Assist, which he has introduced to nursing home associations around the country.

A number of studies have shown that a sizable number of hospital admissions of nursing home residents could be avoided if nursing home staff were given the skills and tools necessary to provide safe care to residents. Recent Commonwealth Fund support enabled a team led by Joseph Ouslander, M.D., at Florida Atlantic University to refine and test INTERACT-II, a set of clinical tools he helped develop that assist nursing home staff in the early identification, assessment, communication, and documentation of acute changes in residents’ health status. Of the 25 facilities across Florida, Massachusetts, and New York that took part in the six-month trial, there was a 17 percent overall reduction in hospitalizations, as reported in an April 2011 article in the Journal of the American Geriatrics Society. And while the average implementation cost per nursing home was $7,700, the savings to Medicare for a typical 100-bed home are estimated at approximately $125,000 per year. (The INTERACT-II tools can be found at http://interact2.net.)

Long-Term Care Scorecard
The Affordable Care Act will greatly expand the availability of Medicaid-funded community-based long-term services and provide states with financial incentives intended to forge a better balance between nursing home care and services delivered in the home or by community-based providers. As states embark on this new era in long-term care, they will need the means to assess progress in expanding access to a range of affordable, high-quality long-term care services.

Following on the success of the Fund’s national and state health system scorecards, Susan Reinhard, R.N., Ph.D., and her team from AARP collaborated with The Commonwealth Fund and the SCAN Foundation to develop the first-ever state performance scorecard focused on long-term care. The report, Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers, examines four key dimensions of performance—affordability and access, choice of setting and provider, quality of life and quality of care, and support for family caregivers—and assesses each state’s performance overall as well as on 25 individual indicators. It finds that all states need to improve; even the top three states (Minnesota, Washington, and Oregon) have a long way to go to create a highperforming system of long-term services and supports. According to the authors, areas for improvement include home care, assisted living, nursing home care, and supports for family caregivers.

Future Directions

In addition to continuing its support for person-centered care and quality improvement in nursing homes, the Commonwealth Fund’s Program on Long-Term Care Quality Improvement is supporting a number of projects aimed at improving care transitions for patients. Barriers separating long-term care from the rest of the health care system fragment what should be a seamless continuum of care for the 10 million Americans with chronic illnesses or disabilities who rely on these services. This lack of integration harmsquality of care and drives up costs. With Fund support, the Long-Term Quality Alliance, a broad-based coalition of leaders in health and long-term care, aging, policy, and consumer advocacy, will identify opportunities in the Affordable Care Act for achieving better care coordination and transitional care, develop options to overcome challenges to incorporating long-term care into state and national reform activities, and harvest examples of innovative person-centered transitional care practices. The Alliance is also developing the Innovative Communities Learning Program to promote community-level coordination across all service providers—health care, social services, transportation, and housing—with the goal of improving transitions between care settings and reducing rehospitalizations.

Under another Commonwealth Fund grant, a team led by Penny Hollander Feldman, Ph.D., of the Visiting Nurse Service of New York will determine whether home health care agencies can effectively use the Care Transitions Measure, a three-item patient questionnaire developed previously by Eric Coleman, M.D., with Fund support, to assess how well patients are prepared to manage their care prior to being sent home from the hospital. The study will test whether home health agencies are able to use the tool to assess how well a hospital prepares patients for home care, predict the level of resources new patients will require, tailor services to patients' individual needs, and provide hospitals with feedback on discharge planning activities.

Additionally, Harvard Medical School researchers, led by David Grabowski, Ph.D., are working closely with a telemedicine vendor and 11 nursing homes in Massachusetts to provide physician consultation and treatment recommendations to on-site staff during evenings and weekends. It is hoped that this intervention will be shown to provide a safe, cost-effective way to reduce hospitalizations, and rehospitalizations, of nursing home residents.