Disseminating a Dashboard for VA Purchased Community Nursing Homes

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 DESCRIPTION (provided by applicant): Background: The VA Office of Geriatrics and Extended Care (GEC) is responsible for the oversight and planning of purchased Community-based Nursing Home (CNH) care for eligible Veterans at an annual cost of $810 Million. The selection, contracting, and quality oversight of CNH facilities is performed at the local VAMC. Markers of CNH quality for a VAMC or VISN are not readily available to GEC leadership. The GEC Data and Analyses Center (GEC DAC) has developed a dashboard for purchased CNH quality. The CNH Dashboard compares the ratio of the Centers for Medicare and Medicaid Services (CMS) 5-star rankings for CNH facilities where the VAMC purchases care (observed) to the non-contracted CNH facilities in the surrounding community (expected). Preliminary analyses of this observed to expected ratio (O/E) measure demonstrate that VA purchased CNH care generally performs lower on CMS's 5-star ranking than non- contracted CNH facilities (mean O/E 0.86 ±0.17) and there is substantial variability across VAMC facilities (O/E range 0.32 to 1.31). The O/E summarizes the CMS 5-star rankings for all CNH residents, not just Veterans. From the VA perspective, the ultimate measure of quality in CNH is to determine, on a Veteran specific level, the quality of care. Thus, there is significant opportunity for understanding and improving the quality in CNH process. Objectives: The overarching goal of this proposal is to improve the quality of care Veterans receive in purchased CNH facilities. To achieve this goal, this proposal has three objectives: Objective 1) to understand the role of quality measurement by examining the purchased CNH selection process, Objective 2) to evaluate the impact of the CNH Dashboard implementation on the quality of VA Purchased CNH care relative to other CNH facilities, and Objective 3) to evaluate the quality of Veteran-specific care in purchased CNH facilities by transition and safety outcome measures derived from Veteran-specific CMS data. Methods: We will map the process of CNH selection, contracting, and monitoring by conducting semi- structured interviews with contract officials and GEC leaders. We will evaluate the effect of the CNH Dashboard release in a randomized, stepped-wedge dissemination. This dissemination design allows us to determine the impact of the CNH Dashboard on the quality of purchased CNH facility more systematically than a single phase roll-out. In each of the 4 steps, we will release the CNH Dashboard to a randomly selected set of VISNs. An educational program designed to address the process gaps of CNH selection will accompany the CNH Dashboard release. Finally, we will evaluate the quality of care of Veterans in VA- purchased CNH by capturing detailed quality and outcomes CMS data on Veterans in CNH. Findings: Currently, the VA is purchasing CNH care that is of lower quality on the CMS 5-star ranking system than other CNH facilities in the VAMC market. The CNH Dashboard has actionable information to leaders in GEC at the local, regional, and national levels that will improve the quality of CNH care. Status: This two year program is led by Dr. James Rudolph, a VA Boston geriatrician, who has successfully implemented innovative quality projects. The Office of GEC is the partnered sponsor for this project and the implementation involves substantial support from the GEC DAC, led by Dr. Orna Intrator. The GEC DAC Steering committee will provide oversight for the progress of this program. Impact: When completed, this program will improve the quality of care Veterans receive in VA purchased CNH programs as demonstrated by improved selection of CNH facilities and Veteran-specific measures.