The long-term care delivery system was designed to mirror the medical model of care, which has “institutionalized” nursing home care, resulting in the warehousing of our most frail and vulnerable citizens.
The Kansas Department on Aging (KDOA) implemented the Promoting Excellent Alternatives in Kansas (PEAK) Nursing Homes initiative in 2002 to promote “culture change” in nursing homes through recognition and education. The term “culture change,” as it applies to long-term care, is “a transformation anchored in values and beliefs that return control to elders and those who work closest with them. Its ultimate vision is to create a culture of aging that is life-affirming, satisfying, humane and meaningful.” (Pioneer Network)
Secretary Pamela Johnson-Betts states:
"At the Kansas Department on Aging we created the PEAK Nursing Homes program to encourage continued progressive improvements and to recognize the many ways in which Kansas nursing homes are transforming the ways they provide care to our seniors. The goal of every change, however, is always to improve the quality of the lives of the people who live and work in our nursing homes."
The PEAK initiative uses a two-prong approach, recognizing nursing home providers which have made innovative changes in the way long-term care is delivered and educating those who are desirous of creating change. Innovations in the domains of resident control, staff empowerment, home environment, and community involvement are recognized annually by KDOA. Education is provided through a contract with Kansas State University’s (KSU) Galichia Center on Aging to develop and produce culture change resources for nursing homes.
The Nursing Facility Quality and Efficiency Outcome Incentive Factor is a component of the Kansas Medicaid nursing home rate setting methodology. The quality and efficiency factor was implemented on July 1, 2005 to provide a monetary incentive for favorable outcomes in the following areas: direct care staffing; operating costs; direct care staff turnover; staff retention; total occupancy; Medicaid occupancy; and, Medicaid certification survey results. Thirty-eight percent of the nursing home providers received a quality incentive factor of $1.00, $2.00 or $3.00 in their Medicaid per diem rate.
The purpose of the case study is to compare PEAK nursing home winners from 2002-2005 to non-PEAK nursing homes using the Nursing Facility Quality and Efficiency Outcome Incentive Factor as the measurement.
The case mix adjusted direct care staffing ratio was based on the hours reported for registered nurses, licensed practical nurses, licensed mental health technicians, medication aides nursing aides, restorative and rehabilitation aides and contract nursing in the 2004, or most recently filed, Nursing Facility Financial and Statistical Report (Medicaid Cost Report).
The hours were adjusted based on the case mix indices of the nursing homes to determine the median staffing hours. The Resource Utilization Groups-III (RUG-III) Version 5.12b, 34 group, index maximizer model is used as the resident classification system to determine all case mix indices, using data from the Minimum Data Set (MDS) submitted by each nursing home. Standard Version 5.12b case mix indices developed by the Health Care Financing Administration, now the Centers for Medicare and Medicaid Services, are the basis for calculating the facility average case mix indices used to adjust the direct care staffing hours.
Homes received two points if they were at or above 120% of the resident day-weighted median; one point if they were at or above 110% but less than 120% of the resident day-weighted median, and no points if they were below 110% of the resident day-weighted median. The following are the hour thresholds:
The following are the results of the comparisons:
Nursing homes at or above 120% of the day-weighted mean staffing ratio:
Nursing homes at or above 110% but less than 120% of the day-weighted mean staffing ratio:
A higher percentage of PEAK homes (67% versus 31%) had direct care staffing ratios at or above 110% of the median.
The Operating Cost Center in the 2004 or most recently filed Medicaid Cost Report was used for this criterion. The Operating Cost Center consists of administrative and plant operating expenses. The resident day-weighted median cost was $20.23. Homes received a point if they were at or below the median.
The following are the results of the comparison of nursing homes with operating costs at or below the median:
A slightly lower percentage of PEAK homes (46% versus 50%) had operating expenses below the median.
The staff turnover criterion consisted of the following employee classifications in the 2003 Medicaid Cost Report Turnover/Retention Analysis: director of nursing, registered nurse, licensed practical nurse, licensed mental health technician, and aides. The resident day-weighted median turnover for the above classifications was 70%.
Contract labor was an excluding factor from the turnover criterion. Homes received a point if turnover was at or below the median of 70% and were not excluded for using excessive contract labor, defined as an amount greater than 10% of the direct care salaries in contract labor expense.
The following are the results of the comparison of nursing homes with turnover at or below the median:
A higher percentage of PEAK homes (58% versus 42%) had turnover at or below the median.
The staff retention criterion consisted of all employee classifications in the 2003 Medicaid Cost Report Turnover/Retention Analysis. The resident day-weighted median retention was 64%. A home received a point if they were at or above the median.
The following are the results of the comparison of nursing homes with retention at or above the median:
A higher percentage of PEAK homes (67% versus 53%) had staff retention at or above the median.
The statewide average occupancy rate, based on the 2004 or most recently filed Medicaid Cost Reports, is 85%. The occupancy criterion for the Quality and Efficiency Outcomes Incentive Factor was set at or above 90%. Homes received a point if they were at or above 90% occupancy.
The following are the results of the comparison of nursing homes with total occupancy at or above 90%:
A higher percentage of PEAK homes (50% versus 35%) had an occupancy rate at or above 90%.
The statewide average Medicaid occupancy rate, based on the 2004 or most recently filed Medicaid Cost Reports, is 56%. The Medicaid occupancy criterion for the Quality and Efficiency Outcomes Incentive Factor was set at or above 60%. Homes received a point if they were at or above 60% Medicaid occupancy.
The following are the results of the comparison of nursing homes with Medicaid occupancy at or above 60%:
A lower percentage of PEAK homes (25% versus 38%) had a Medicaid occupancy rate at or above 60%.
There were two criteria for survey outcomes. Homes received two points if they had a deficiency free survey and remaining homes that had no more than five deficiencies, none of which greater than a scope and severity of E, received one point. The survey history was for the 15 month period ended December 31, 2004.
The following are the results of the comparisons:
Deficiency free surveys:
Five or less deficiencies and none greater than an “E”:
Overall, a higher percentage of PEAK homes (38% versus 29%) had five or less deficiencies and none above an “E”, thereby earning one or two points.
The per diem factor was based on the number of points each home scored. Homes scoring three or fewer points did not receive a per diem add-on; homes scoring four points received a $1.00 per diem add-on; homes scoring five or six points received a $2.00 per diem add-on; and, homes scoring seven to nine points received a $3.00 per diem add-on.
The following are the results of the comparisons:
$1.00 incentive factor:
$2.00 incentive factor:
$3.00 incentive factor:
A higher percentage of PEAK homes (63% versus 36%) received a quality and efficiency outcomes incentive factor.
In summary, the PEAK homes benefited more than the non-PEAK homes with the new Quality and Efficiency Outcomes Incentive Factor. The PEAK homes did not do as well with the Medicaid Occupancy criterion and were slightly lower with the Operating Expense criterion. The PEAK homes consistently scored higher in the other criteria. To the extent the incentive factor measures quality and efficiency, the PEAK homes overall performed better.
Primary focus of the PEAK Nursing Home initiative will be to continue performing outcome-based research. Additional variables, such as quality indicators and quality measures, will be used to validate the outcomes of nursing homes that have started the journey of culture change, moving from the medical or institutional model to resident-directed care.
Winners of the Kansas PEAK Nursing Home award state they are on the journey. They are constantly looking at changing the way they do business to better serve their residents, staff and community. It will be exciting to track the changes longitudinally.
To learn more about the Kansas PEAK Nursing Home initiative, visit the KDOA website at www.agingkansas.org/CultureChange/PEAK/peak.htm. To learn more about the PEAK-Education component, visit the KSU website at www.ksu.edu/peak.