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Rehab as a Key to Quality Measurement
Home » News » Rehab as a Key to Quality Measurement |
This is an interview with Barbara Paul, MD, Senior Vice President and Chief Medical Officer for Beverly Enterprises and former director of the Quality Measurement and Health Assessment Group at the Centers for Medicare and Medicaid Services (CMS), which was responsible for launching the Nursing Home Quality Measures.
Q: Just to make it clear from the beginning, what is the difference between quality indicators and quality measures?
Dr. Paul: Both are derived from MDS data. Quality indicators (QIs) are measures created by the Center for Health Systems Research and Analysis (CHSRA) at the University of Wisconsin–Madison to be used by facilities to track quality and by state surveyors to monitor for areas needing further investigation during the survey. Quality measures (QMs), created by CMS, are posted on the Medicare Web site (www.medicare.gov) to help inform consumers as they choose a nursing home. QIs and QMs are similar and in some cases are exactly the same.
Q: Why did CMS create QMs for nursing home residents?
Dr. Paul: When CMS put together its QMs, it was trying to find a way to share useful information with Medicare beneficiaries about the quality of care in nursing homes. Unlike the CHSRA indicators, the CMS measures include short-stay residents and have some risk adjustment. Many of these short-stay residents are receiving rehab services, so QMs are particularly important to the rehab community.
Q: Why is Medicare publicly reporting these measures?
Dr. Paul: From our perspective at CMS, we believed that measurement in and of itself helps to improve quality—it shines a light. Using standardized measures helps to improve quality because you are comparing yourself in a standardized way to your colleagues. We believed that this transparency itself is a driver of higher quality.
Q: How does rehab fit into the quality picture?
Dr. Paul: Excellence in rehab is absolutely integral to excellence in QIs and QMs. The nursing home should have an active and thoughtfully developed quality assurance structure that includes therapy. Therapists should be fully engaged in discussions about such issues as falls and about patients who are bedfast, who have worsening mood, or who have a decline in ADLs. The rehab team should be thinking of new ways to provide care so that patients can achieve the highest level of functioning possible.
One of the system changes a nursing home can make to improve clinical quality is to provide higher quality rehab services—for example, partnering with a company or using a program that measures and shares outcomes. In simply hiring such a team, the nursing home will help ensure delivery of higher-quality care and improved performance on a number of QMs, as well as indicate that the nursing home cares about quality.
Q: Which specific rehab-oriented quality measures or indicators should providers/rehab focus upon, and how can nursing and rehab partner on a quality-improvement project?
Dr. Paul: CMS posts 14 QMs on its Web site. While facilities should look at all measures, there’s a tremendous opportunity to partner with a rehab provider to make improvements in those measures specific to falls, weight loss, mobility, and pressure ulcers. For example, rehab can help identify some of the causes of weight loss, such as problems with swallowing or positioning. A strengthening program can help decrease falls. Rehab can also help a facility identify those residents at risk for falls and create appropriate interventions. Also, the partnering of nursing and rehab staff in dementia management can really make a difference in success with QMs.
Q: From your new industry standpoint, what should CMS do to adjust or further refine these QMs?
Dr. Paul: I think they are quite good. Several have a risk adjustment so facilities that accept a sicker patient population are not penalized. However, I think it would be beneficial if some of the measures were framed in the positive rather than the negative. For example, for the hospital and home health settings, CMS reports quality to the public as measures of success rather than of failure. I believe that providers will reach higher to achieve superior quality if they are chasing ever-higher measures of success.
Q: What future plans does CMS have to ensure quality?
Dr. Paul: While I was at CMS, the long-term view was that there would be standardized quality measures of care across the entire spectrum—every site and every major subset of healthcare, including rehab. Results would be shared publicly, and those providing superior care would receive extra recognition from the Medicare program.
Right now, in the hospital setting, Medicare is testing some models of providing bonus financial payments for superior quality care. I think that is a reasonable possibility. I would also advocate for some relief in the oversight process as another “reward.” For example, perhaps providers of measurably superior care could get some regulatory relief by streamlining some aspect of the survey process.
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