Nursing Facility Performance-Based Incentive Payment Program (PIPP)

Nursing Facility Performance-Based Incentive Payment Program (PIPP)

Request for Proposals Published October 17, 2011

Proposals must be submitted via email attachment by 11:59 p.m. on February 15, 2012

SECTION 1

Facility Name or Organization
Address / 239 Williams Ave NE
Dassel, MN 55325
Primary Contact Name / Chere Rikimoto
Contact Title / Consultant
Contact Phone / 320-760-4677
Contact Email /
Contact Address / 301 8thSt. South
Wheaton, MN 56296
If this is a collaborative proposal, enter all participating facility names, addresses and contact information for each. / Mother of Mercy Campus of Care
Attn: John Hoefs
230 Church Ave.
Albany, MN 56307

Annandale Care Center
Attn: Deb Reitmeier
500 Park Street East
Annandale, MN 55302
320-274-3737

Assumption Home, Inc.
Attn: Jan Luthens
715 First Street North
Cold Spring, MN 56320
320-685-3693

Pioneer Care
Attn: Nathan Johnson
1131 Mabelle Ave. S
Fergus Falls, MN 56537
218-739-7700

Knute Nelson
Attn: Angie Urman
420 12th Ave. East
Alexandria, MN 56308
320-763-6653

Belgrade Nursing Home
Attn: Phil Lord
103 School Street
Belgrade MN 56312
320-254-8215

Cokato Manor
Attn: Nancy Stratman
182 Sunset Ave.
Cokato, MN 55321
320-286-2158

Lakeside Health Care Center of Dassel
Attn: Bill Ward
239 William Ave. East
Dassel, MN 55325
320-275-3308

Glenwood Retirement Village
Attn: Mary Krueger
719 SE Second Street
Glenwood, MN 56334
320-634-5131

Long Prairie Memorial Hospital and Home
Attn: Dan Swenson
20 Ninth Street SE
Long Prairie, MN 56347
320-732-2141

Galeon
Attn: Dave Carlson
410 West Main Street
Osakis, MN 56360
320-859-2142

Talahi Care Center
Attn: Darwin Schwantes
1717 University Drive SE
St. Cloud, MN 56304
320-251-9120

Traverse Care Center
Attn: Chelsy Stattelman
303 7th St. South
Wheaton, MN 56296
320-563-8124

Fair Oaks Lodge
Attn: Roberta Cline
201 Shady Lane Drive
Wadena, MN 56482
218-631-1391

Elders Home
Attn: Cal Anderson
215 Tousley Ave S
PO Box 188
New York Mills, MN 56567
218-385-2005

Frazee Care Center
Attn: Austin Blilie
219 West Maple
Frazee, MN 56544
218-334-4501

SECTION 2

Provide a brief overview of the facility or collaborative.
Care Ventures Cooperative (CVC) was founded by a group of senior service facility leaders in response to the mounting challenges being faced by rural, independent facilities. CVCfacilities, all located in greater Minnesota, are non-profit organizations with the exception of one. The cooperative maintains goals and strategies that were developed with five core values in mind: Cooperation, Mutual Support, Stewardship, Ethical Practice and Innovation. Since its inception in 1999, CVC has worked hard to develop a solid foundation of operational efficiencies for centralized managed care contracting and group purchasing. In the past five years, the cooperative has expanded its focus to include shared educational opportunities, quality initiatives and other collaborative efforts as the need arose.

SECTION 3

Write an introduction to your project and how your project supports one or more of the goals of the PIPP program.

• Improve the quality of care and quality of life of nursing home residents in a measurable way.
• Deliver good quality care more efficiently.
• Rebalance long-term care and make more efficient and effective use of resources.

The Care Ventures Cooperative (CVC) project will not only improve the quality of care and quality of life for our residents, but will also deliver care more efficiently while helping to rebalance long-term care through assuring the more effective use of its resources in several ways. Sixteen CVC facilities will work together in the development and implementation of a program aimed towards the reduction of unnecessary medications and treatments for skilled nursing facility residents..
Older adults have been found to be more susceptible to the adverse side effects of medications and when taking multiple medications, their interaction alone can cause even more unwanted health situations (Froom & Trilling, 2000); thus, reviewing and possibly reducing the number of medications being taken has the potential to improve the overall health and well-being of our residents. Falls, which often lead to serious injury or death for older adults, have been associated with certain medications (Spector, Shaffer, Potter, Correa-de-Araujo, & Limcangco, 2007). An in-depth review of the various medication risk factors relating to those who continue to suffer from frequent falls could ultimately help to further reduce falls and serious injuries for all CVC residents.
The focus on reducing unnecessary medications and treatments for older adults will undoubtedly save money for not only private pay residents but also Medicare and Medicaid recipients. Care Ventures Cooperative gathered information from twelve of its sixteen participating facilities and reviewed the medication costs of residents on a skilled stay for a period of six months ending in December, 2011. This data revealed the average cost per prescription to be $27 with an average per resident cost of $340 per month. With a combined capacity of 1,259 beds among the sixteen facilities that are planning to participate in this project, the medication costs could total $428,060 per month for all residents. With these amounts in mind, it is clear to the cooperative that there is potential to save money.
According to Thomson, Gruneir, Lee, Baril, Field, Gurwitz, et al. (2009) a large proportion of nursing time is spent on administering medications which presents quality of care concerns due to so much time being dedicated to only one task; in addition, it is during those med passes that an interruption occurs 80% of the time which then leads to distribution concerns. The reduction of medications and treatments addresses these concerns by reducing the time spent doing medication passes which in turn, will allow the nurses to have more time to deliver quality care in a significantly more efficient manner.
Finally, CVC feels that this project is a step in the direction of rebalancing long term care and making more efficient and effective use of resources. The CVC culture continues towards a more preventative mindset that focuses on programs to keep older adults healthy and as independent as possible. CVC hopes to be able to contract with a tele-psychiatry service so that behavioral health evaluations will be made available through the use of telemedicine, which uses video and audio technology to allow the resident and specialist to talk to each other, even when in different locations. The reduction of medication and treatment costs, along with decreased staff time administering these, will also help make better use of resources. In making these changes, CVC hopes to improve the health and quality of life for nursing home residents.

SECTION 4

Provide a detailed description of the problem you want to solve or you need to improve.

• What story is your data telling you?
• Why is it a problem?
• What impact is it having on the residents, staff, facility, etc.?
• What are the consequences of not solving this problem?
• What is the difference between the way things are now and the way you want them to be?

Care Ventures' goal for this project is to develop an innovative, systemic process for medication and treatment reduction that can be easily duplicated in other care settings. When addressing the older adult population, regardless of care setting, polypharmacy has become a "disease" that increases the likelihood of nursing home placement, impaired mobility, morbidity, hospitalizations and death (Garfinkel & Mangin, 2010). Most residents within skilled nursing facilities receive at least one psychotropic medication despite these medication types being known to be associated with the deterioration of medical, physical and cognitive status (Gurvich & Cunningham, 2000) not to mention an increased risk of falls and fractures (Spector, Shaffer, Potter, Correa-de-Araujo, & Limcangco, 2007). In addition, use of antipsychotic medications have been correlated to the diminishment of personalities and energy for residents; speeding up condition declines and increasing adverse drug effects that could lead to hospitalization or death (Ecumen, 2011). Besides the potentially negative impact that antipsychotics can have on residents, they are also expensive, creating annual revenues of $14.6 billion (Medicare Advocacy, n.d.). Care Venture Cooperative's (CVC) rural communities wish to reduce the use of multiple medications use in an effort to create a better life for the older adult population that it serves.
To identify this as a problem in our facilities, CVC gathered data related to medication use from fourteen of the sixteen organizations participating in this project and found their residents to be taking an average of 12.55 medications. This number of medications is well above the national average, as a study done by the American Geriatric Society found residents to be taking an average of only 8.8 medications (Simoni-Wastila, Stuart, & Shaffer, 2006). Furthermore, Froom and Trilling (2000) reported research with averages ranging from 7.2 to 9.4 medications. Additional data gathered by CVC facilities showed an astonishing 62% of CVC residents take some form of psychotropic medications with antipsychotics being the most popular. CVC also looked at the cost of medications for just its skilled residents as that data was readily available to us and arrived at an average per medication cost. Upon further analysis, it was determined that when assuming a full census in the sixteen participating facilities, the cost of medications for our residents could potentially amount to an astonishing $5,136,720 a year. If the cooperative was able to reduce just one medication per resident, we could eliminate approximately $407,916 per year in medication costs alone! These results combined with other research on medication use, clearly support that CVC has room for improvement in regards to medications; and that the potential for medications to be reduced or even discontinued clearly exists in our facilities.
In addition to the various issues addressed prior, we also know that medications have side effects. Some medications can cause older adults to feel drowsy, dizzy or light headed which, in turn, has been known to cause a loss of balance, an increased fall risk and ultimately a decreased quality of life. Some medications have also been linked to poor appetite. Residents taking multiple medications or large volumes of fluids at each medication pass can experience a decreased appetite at meal time (Pioneer Network Food & Dining Clinical Standards Task Force, 2011).
CVC plans to work closely with both providers and consultants to help evaluate the rationale of why our residents are taking these medications in relation to their diagnoses. CVC has already been
successful in fall reduction, we are also aware that medications can add to the risk for falls. Because the aftermath of a fall can be detrimental to not only the resident, but also the resident's family and facility staff, the correlation between numerous medications and falls has given CVC a cause for alarm. The overall CVC average is 12.55 medications per resident; however, some residents take more medications than that.
Reducing treatments, when at all possible, will also help to further improve both the efficiency of our nursing staff by reducing the time spent to complete them; but most importantly, the quality of life for our residents by decreasing the need to receive an injection, for example. Greater efficiencies in the use of nursing time can lead to an increase in the quality of direct care and reduced costs. The Pioneer Network Food and Dining Clinical Standards Task Force (2011) stated, "While we agree that people should be given as much freedom as possible in choice of diets and foods, it may be more appropriate in many cases to liberalize the treatment goals or targets (such as hemoglobin A1C or cholesterol) rather than add more medication." They also add that the use of sliding scale insulin injections should be used only when a patient is newly diagnosed to determine insulin dosages (Pioneer Network Food and Dining Clinical Standards Task Force, 2011). They support limiting treatments of sliding scale insulin injections and decreased glucometer finger sticks for residents as they ascertain "for this reason, insulin sliding scale should be used sparingly if at all, and glucose monitoring should be done no more than once daily in stable diabetics, more frequently, albeit temporarily, if actively adjusting the regimen" (August 2011).
We ask you to please consider these facts: the more "unnecessary" medications a person takes now, the more "necessary" medications they will have to take in the future; furthermore, at least 100,000 people die each year simply as the result of taking the recommended dose of a pharmaceutical drug (Six, 2011). CVC feels that if we do not take a stand against this medication epidemic now, the older adult populations of the future will most likely suffer from various negative effects, such as an increased risk of falls, fractures, hospitalizations and possibly even death while living a medication dependent lifestyle. As our society ages, this presents quite the dismal outlook for one's senior years. CVC maintains that if prevention through education is not made a priority, providers in our communities will continue the practice of ordering additional medications to manage symptoms and the cycle of medication reliance will continue, all while health care costs keep skyrocketing.
Currently, CVC facilities are implementing physician's orders for our residents without a systemic method of evaluating and determining the necessity of medications and treatments being ordered. During the course of this project, we plan to develop and implement a systemic process where medications and treatments can be fully evaluated for necessity and reduction whenever possible. CVC is looking forward to working with other area providers in its efforts to accomplish our goals. Through education of providers and consumers alike, our goals will be achieved by focusing on health, well-being and quality of life. Our group will also explore the possibility of being able to implement a tele-psychiatry service available in areas that may not have access to behavioral health experts. CVC wants to lead the way for a culture change in relation to the use of medications within our organizations, in our partnerships with other providers; and ultimately, the way older adults look at and think about medication use. As a result of our efforts, we expect to have more staff time dedicated to direct care and an improved quality of life for our residents all while we are successful in reducing their cost of care.

SECTION 5

Describe the process you are using to discover the root cause(s) of the problem you have identified. What have you discovered so far? Quality improvement is an evolving process and you may make new discoveries as you progress, but you must have some understanding of the causes before you can propose strategies.
During the process of evaluating the root cause of the problem we have previously identified, Care Ventures has determined that the residents in our nursing homes are on more medications overall, including psychotropic medications, than the national average. Reviewing medication use will assist the cooperative with better development of the root causes for issues that our residents expericence that our collaborative effort can then track and evaluate as it relates to falls, overall side effects, poor appetite, etc. in the older adult population. We have determined through the collection of baseline data from each participating organization, that the number of medications for our residents who frequently fall also exceeds the norm. CVC hopes that by having the time and resources to develop methods and systems for medication reduction, we will be able to thoroughly evaluate medication use in all the residents we serve. This will in turn enable us to develop the expertise, knowledge and systems necessary to effectively conduct the same analysis for all residents taking medications in the skilled setting. It is this knowledge that we will utilize in educating residents, families, staff, as well as other medical providers in a joint community effort.

SECTION 6

Write a detailed description of your strategies to address the problem you have identified.

• What do you propose to do?
• What is the precise nature of the intervention?
• What is your plan to implement this project?
• Who is going to do what?

Our project consists of two phases, each phase lasting one year in duration. Year one will focuson educating staff, residents and families on the new initiative in an effort to gain support and enthusiasm for the program. CVC will identify a pilot group to work with the program prior to implementaion in all sixteen facilites. CVC will establish a contract(s) with a consulting pharmacist who will assist us in the project. The consulting pharmacist(s) will help to develop a review process and ongoing education of residents and staff, as well as assist in establishing standards of practice, protocols, processes, policies, procedures and chart audit systems. The consulting pharmacist(s) will consult with staff to evaluate the results and will be available as a resource to residents, staff, families and other providers.
The CVC Board will contract for a CVC project manager and each facility either contract with and/or assign a Licensed Nurse as its facility coordinator to assist with this project. Both the CVC project manager and each individual facility's coordinator will be responsible for developing, implementing and evaluating the medication reduction program in accordance with the established timeline.
Medication reviews for unnecessary medications through chart audits will begin with residents who fall and who trigger a significant change or decline MDS assessment or as directed/suggested by consultant pharmacists. After collecting data pertinent to medication reduction efforts, CVC and consulting teams can then evaluate the root cause of any trends found and then re-evaluate and/or revise systems as needed. CVC team members will develop policies and procedures related to the processes. The team will also begin developing educational materials for the local providers in each community that will explain the purpose and goals of this project. The project manager and/or each facility coordinator will research the availability of tele-psychiatry options for more effective management of psychotropic medications and then move forward with plans to implement at a trial facility if available.
The project will include re-evaluating systems, processes, and findings including any identified trends or root causes from the results from pilot facilities. Systems and/or policies will be revised based on these results.
CVC facilities will begin efforts at reducing psychotropic medications by first training all care giving staff on non-pharmacological ways and best practices in working with residents experiencing behavioral type symptoms and dementia. All facilites will provide additional dementia training to aisst in the management of demtia related behaviors. The facilities will begin evaluating all medications of those residents prescribed psychotropic medications. CVC consultants will further educate residents, staff, families and area providers on the project effort and findings. The facility coordinator will ensure that facility systems are implemented and will collect data, evaluate and report findings. The CVC project manager will research availability of and use of (if applicable) tele-psychiatry for further assistance with psychotropic medication reductions and implement the use of it in additional facilities.
CVC teams will consult with each facility's Medical Director for assistance with the development of the next step of the project. This involves developing pathways for medication reduction, including evaluating the need for crushed medications, sliding scale insulin use, glucometer checks and other labs that pertain to medication use. Each facility will implement full chart reviews on all residents as it relates to their medication regimen according to a developed schedule. The CVC team will begin a more focused effort on developing and providing educational materials for area providers on project findings and efforts at medication reduction.

SECTION 7