Improving Quality of Care for Nursing Home Residents with Dementia

描述(由申请人提供)：痴呆症是一个关键的卫生保健和卫生政策问题，随着人口老龄化，它有望变得更加重要和昂贵。我们在这项研究中的总体目标是通过批判性地检查并改进一项主要政策倡议-公开报告高质量信息-对疗养院痴呆症患者护理过程和结果的影响，来提高疗养院居民的护理质量。养老院是痴呆症患者的主要护理场所，但养老院部门几十年来一直受到质量问题的困扰。在多年的日益严格的监管未能将质量提高到可接受的水平后，医疗保险和医疗补助服务中心于2002年推出了疗养院比较(NHC)，这是一项公共报告倡议，根据选定的护理方面对美国所有获得联邦医疗保险和医疗补助认证的疗养院进行评级。新出现的证据表明，由于NHC，报告的临床质量发生了轻微但积极的变化，美国政府继续为这一努力投入资源。然而，照顾痴呆症居民与照顾非痴呆症居民本质上是不同的。如果成绩单没有反映对患有痴呆症的疗养院居民最重要的质量方面，或者强调不适合他们的结果，他们可能无法从质量改进中受益，痴呆症护理的质量可能会下降。这取决于这些设施是通过只针对所报告的措施的重点努力，还是通过目前尚不为人所知的广泛的结构性改革，以求提高质量，以回应公众报告。尽管养老院是照顾患有痴呆症的老年人的主要提供者，但这一重大政策举措对照顾痴呆症患者的影响尚未得到评估。我们在这个项目中的第一个目标是根据痴呆症状态来定量检查NHC对居民水平结果的影响，考虑到每个报告的痴呆症居民测量方法的适当性或潜在的不适当性。我们还考虑了几个未报告的质量衡量标准。我们的第二个目标是通过对管理人员和工作人员的半结构化访谈，定性地检查疗养院提供者如何看待患有痴呆症的居民的质量，疗养院针对公共报告采取的战略，以及这些战略--有意和无意的--对照顾患有痴呆症的居民的影响。这些战略可能包括改变编码、避免高危居民以及提高质量的不同方法。我们的最终目标是评估改善公共报告能力以提高痴呆症患者护理质量的几种可能性，包括对现有措施进行额外的风险调整，以及可能将痴呆症纳入NHC-适合但目前未报告的措施。 公共卫生相关性：我们在这项研究中的总体目标是通过批判性地检查并改进一项主要政策倡议-公开报告高质量信息-来提高养老院痴呆症患者的护理质量，这是关于对养老院痴呆症患者护理质量的有意和无意影响。痴呆症是一个关键的卫生保健和卫生政策问题，随着人口老龄化，这一问题有望变得更加重要，代价也将更加高昂。

DESCRIPTION (provided by applicant): Dementia is a critical health care and health policy issue which promises to become even more important and costly as the population ages. Our overall goal in this study is to improve the quality of care for nursing home residents with dementia by critically examining and developing improvements to a major policy initiative -public reporting of quality information- in terms of the effects on processes and outcomes of care for nursing home residents with dementia. Nursing homes are a major site of care for persons with dementia, but the nursing home sector has been plagued with quality problems for several decades. After years of increasingly stringent regulation failed to raise quality to acceptable levels, the Centers for Medicare and Medicaid Services in 2002 launched Nursing Home Compare (NHC), a public reporting initiative that rates all Medicare- and Medicaid- certified nursing homes in the United States on selected aspects of care. Emerging evidence documents modest but positive changes in reported clinical quality as a result of NHC, and the US government continues to pour resources into this effort. However, care of demented residents is inherently different from care of non- demented residents. If report cards do not reflect aspects of quality most important to nursing home residents with dementia or emphasize outcomes that are not appropriate for them, they may not benefit from quality improvements and quality of dementia care may decline. This depends on whether facilities pursue quality improvement in response to public reporting through focused efforts directed only at the reported measures or through broad, structural changes, which is currently unknown. Despite the fact that nursing homes are a major provider of care to elderly individuals with dementia, the effects of this major policy initiative on care of persons with dementia have not been evaluated. Our first aim in this project is to examine quantitatively the effect of NHC on resident-level outcomes by dementia status, considering the appropriateness or potential inappropriateness of each reported measure for demented residents. We also consider several unreported measures of quality. Our second aim is to examine qualitatively, using semi-structured interviews with administrators and staff, how nursing home providers think of quality for their residents with dementia, the strategies that nursing homes pursue in response to public reporting, and the implications of these strategies- intended and unintended--for care of residents with dementia. These strategies may include coding changes and avoidance of high-risk residents as well as varied approaches to quality improvement. Our final aim is to evaluate several possibilities for improving the ability of public reporting to raise quality of care for residents with dementia, including additional risk-adjustment of existing measures and potential inclusion in NHC of dementia-appropriate but currently unreported measures. PUBLIC HEALTH RELEVANCE: Our overall goal in this study is to improve the quality of care for nursing home residents with dementia by critically examining and developing improvements to a major policy initiative -public reporting of quality information- in terms of the intended and unintended effects on quality of care for nursing home residents with dementia. Dementia is a critical health care and health policy issue which promises to become even more important and costly as the population ages.