Analysis: Provider-initiated solutions improve quality of care in nursing homes

September 10, 2013

A new study from the Regenstrief Institute and the Indiana University Center for Aging Research has found that nursing home care improves in critical areas—including falls, quality of life and rehospitalizations—when state government and nursing homes collaborate in a performance-based incentive program that promotes local solutions to local problems.

The researchers analyzed the impact that Minnesota's Performance-based Incentive Payment Program had on care quality in participating . With state funding, PIPP puts emphasis on nursing homes, individually or in collaboration with other nursing homes, taking initiative to identify their specific problems, employ evidence-based solutions and evaluate outcomes; it is the only program of this type in the nation.

Their findings appear in "The Care Span: Minnesota's Provider-Initiated Approach Yields Care Quality Gains at Participating Nursing Homes" published in the September issue of the journal Health Affairs.

"Traditionally the federal government and the states have addressed nursing home quality through regulations and where nursing homes delivering poor care are fined or even forced to close," said Regenstrief Institute investigator Greg Arling, Ph.D., IU Center for Aging Research scientist and associate professor of medicine at the IU School of Medicine, who led the analysis. "Recently, states have taken another approach to care quality by introducing pay-for-performance models that base Medicaid payment on performance measures handed down from the state. Aside from mandated performance measures and the possibility of increased reimbursement, nursing homes are left to fend for themselves in improving their care. Neither of these approaches has shown to be effective in actually increasing quality. Minnesota's PIPP approach, with its focus on provider initiated and evidence based practices, resulted in collaboration, high buy-in and significant quality improvement in a wide range of areas."

The researchers examined trends in a broad set of clinical quality measures for Minnesota nursing homes before and after introduction of PIPP. They found that facilities participating in PIPP exhibited significantly greater gains than did nonparticipating facilities within the state in both the areas they targeted in their projects and in overall quality. Moreover, they maintained their quality advantage after project completion.

With $6.7 million in state share of Medicaid funding, an equal amount in federal Medicaid match and private-pay resources, PIPP projects receive $18 million in funding annually, which is only a small fraction of the hundreds of millions spent on nursing home care in the state each year. With PIPP, state funding is provided as the project is being carried out so facilities can make investments up front in their quality improvement projects. A percentage of money must be returned to the state if the project is unsuccessful. By contrast, under typical pay-for-performance programs, the nursing homes receive a funding increase only after a quality threshold is met.

"When we looked closely at PIPP projects and interviewed nursing home staff, we discovered fundamental changes in the way facilities approached quality improvement," said Dr. Arling, a health services researcher. "Organizational impacts extended beyond the PIPP projects themselves. Facilities gave greater attention to evidence-based care practice, staff had more effective teamwork and communication, and better relationships emerged among nursing home management, staff, residents and family members."

The PIPP program has garnered widespread nursing home participation in Minnesota. Since 2007, PIPP has supported 102 projects involving 225 facilities. PIPP did not simply attract the better-performing facilities or those with more financial resources. PIPP facilities did not significantly differ from non-PIPP facilities in operating costs or total nursing staff hours per resident day. Most important, PIPP facilities were not significantly different at the start of the program in their measures of care quality or history of regulatory deficiencies, the authors of the Health Affairs paper report.

None of the PIPP facilities experienced a decline in overall quality, evidence that PIPP projects did not divert attention to areas of care quality that were the focus of projects at the expense of areas that were not.

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