State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. 6.2 Formal Assessment of TA Impact Among Study States


Missouri is far ahead of other states in using systematic data to measure the impact of its TA program. Missouri's TA program began in 1999, when a pilot test demonstrated that providing written reports to nursing facilities on their quality improvement status was not enough to motivate changes in processes that would improve resident outcomes. The researchers who performed the pilot test noted that on-site expert TA, particularly when delivered as a series of on-going visits, was most effective in changing resident outcomes.

Since the program's inception, staff have used the MDS-based quality indicators developed by the Center for Health Systems Research and Analysis (CHSRA) to measure the impact of their TA program on resident quality of care and quality of life. Although the quality of MDS data has improved, as familiarity with the tool has increased and data edits have been implemented by individual states and CMS, there is still considerable confusion around the coding of some items. Recognizing the potential for problems in the MDS data early on, Missouri developed standardized training materials for the MDS and mandates that anyone offering MDS training in the state utilize those materials. Their TA nurses also provide monthly support groups for MDS coordinators, as a forum to clarify issues regarding MDS coding.

In addition to analyzing median quality indicator scores, the program staff analyze trends for the 90th and 95th percentile, so that the effectives of the program in improving outcomes for low-quality facilities can be understood. Analysis of data since the implementation of the TA program across all facilities participating in the program demonstrated improvement in 16 quality indicators, declines in only six.31 The following are the indicators that have improved:

  • Behavioral symptoms (for both high and low-risk residents);
  • Prevalence of depression;
  • Prevalence of depression with no treatment;
  • Cognitive impairment;
  • Prevalence of occasional or frequent bladder or bowel incontinence without a toileting plan;
  • Fecal impaction;
  • Dehydration;
  • Prevalence of bedfast residents;
  • Decline in late loss ADLs for low-risk residents;
  • Decline in range of motion, overall and for both high-risk residents;
  • Decline in range of motion for low-risk residents;
  • Antipsychotic/hypnotic use;
  • Hypnotic use more than two times in last week;
  • Prevalence of little or no activity;
  • Pressure ulcers for both low-risk residents; and
  • Pressure ulcers for high-risk residents.

Several quality indicators have gotten worse in Missouri since the implementation of QIPMO, including behavior problems for high-risk residents, patients receiving nine or more medications, range of motion training/practice, and antipsychotics use in the absence of an appropriate diagnosis. Preliminary investigations by QIPMO staff suggest that these declines may reflect MDS coding issues rather than actual decline of care.

Maryland is the only other state that has attempted to formally evaluate the impact of quality on a select number of indicators. According to Maryland Department of Health and Mental Hygiene/Office of Health Care Quality (OHCQ), the eventual evaluation will look at complaint rates, correlations between deficiency citations and areas targeted for facility quality improvement, and facility satisfaction with the Second Survey.

31. Missouri program staff have not compared outcomes for TA participants vs. non-participants because such a comparison would confound programmatic effects vs. selection effects, due to the non-random selection of facilities.

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