Nursing Homes: Federal Actions Needed to Improve Targeting and Evaluation of Assistance by Quality Improvement Organizations

Highlights

In 2002, CMS contracted with Quality Improvement Organizations (QIO) to help nursing homes address quality problems such as pressure ulcers, a deficiency frequently identified during routine inspections conducted by state survey agencies. CMS awarded $117 million over a 3-year period to the QIOs to assist all homes and to work intensively with a subset of homes in each state. Homes' participation was voluntary. To evaluate QIO performance, CMS relied largely on changes in homes' quality measures (QM), data based on resident assessments routinely conducted by homes. GAO assessed QIO activities during the 3-year contract starting in 2002, focusing on (1) characteristics of homes assisted intensively, (2) types of assistance provided, and (3) effect of assistance on the quality of nursing home care. GAO conducted a Web-based survey of all 51 QIOs, visited QIOs and homes in five states, and interviewed experts on using QMs to evaluate QIOs.

Recommendations

Recommendations for Executive Action

Agency Affected	Recommendation	Status
Centers for Medicare & Medicaid Services	To ensure that available resources are better targeted to the nursing homes and quality-of-care areas most in need of improvement, the Administrator of CMS should further increase the number of low-performing homes that QIOs assist intensively.	Closed – Implemented CMS agreed with our recommendation and increased the number of low-performing nursing homes QIOs must assist intensively. At the time we did our work, during the 3-year QIO contract that began in 2005, CMS directed a small share of QIO resources to low-performing homes, requiring each QIO to provide intensive assistance to one to three "persistently poor-performing homes" identified in consultation with the state survey agency. The number each QIO was expected to assist was based on the number of nursing homes in the state. (QIOs in 11 states were required to assist three poor performing homes, while the others were required to serve just one or two.) Partly in response to our recommendation, for the subsequent contract that began in 2008, the agency required each QIO to provide special technical assistance to at least three nursing homes in the state that were identified by CMS as in need of assistance with quality improvement efforts. Some of these facilities may be special focus facilities; a CMS official told us that our report helped prompt consideration of ways QIOs might work with such facilities. In addition, under the contract that began in 2008, CMS required QIOs to select at least 85 percent of the other homes they assist intensively from among those whose scores on two quality measures (pressure ulcers and physical restraints) were a specified percentage away from the goals for these measures. Under the prior contract we reviewed for our report, CMS set no such requirements and instead contracted with a QIO that developed guidelines encouraging QIOs to select committed homes and exclude those with many survey deficiencies.
Centers for Medicare & Medicaid Services	To ensure that available resources are better targeted to the nursing homes and quality-of-care areas most in need of improvement, the Administrator of CMS should direct QIOs to focus intensive assistance on those quality-of-care areas on which homes most need improvement.	Closed – Implemented CMS addressed this recommendation by requiring QIOs to select most of the homes they assist intensively from among those who scored poorly in the quality of care areas on which the QIOs were mandated to focus. Under the QIO contract that began in 2008, CMS required QIOs to select at least 85 percent of the homes they assist intensively from among those whose scores on two quality measures (pressure ulcers and physical restraints) were a specified percentage away from the goals for these measures. In this way, CMS focused QIO resources on the quality of care areas in which the homes assisted most need improvement. Under the prior contract we reviewed for our report, CMS set no such requirements and instead contracted with a QIO that developed guidelines encouraging QIOs to select committed homes and exclude those with many survey deficiencies.
Centers for Medicare & Medicaid Services	To improve monitoring of QIO assistance to nursing homes and to overcome limitations of the QMs as an evaluation tool, the Administrator of CMS should revise the QIO program regulations to require QIOs to provide to CMS the identities of the nursing homes they are assisting in order to facilitate evaluation.	Closed – Implemented In 2011, CMS updated its QIO privacy and confidentiality regulation to provide the agency greater access to QIO information. In particular, CMS revised the regulations governing QIOs' disclosure of quality review study information to require QIOs to disclose this information, including the identities of the providers involved in the quality review studies, to CMS when the agency deems it necessary for the purposes of overseeing and planning QIO program activities.
Centers for Medicare & Medicaid Services	To improve monitoring of QIO assistance to nursing homes and to overcome limitations of the QMs as an evaluation tool, the Administrator of CMS should collect more complete and detailed data on the interventions QIOs are using to assist homes.	Closed – Not Implemented At the time our report was issued CMS agreed with the recommendation to improve the monitoring of QIO activities and over the years reported taking some actions but they have not fully addressed the recommendation. As of 2015 CMS has not provided any further updates and the matter is considered closed.
Centers for Medicare & Medicaid Services	To improve monitoring of QIO assistance to nursing homes and to overcome limitations of the QMs as an evaluation tool, the Administrator of CMS should identify a broader spectrum of measures than QMs to evaluate changes in nursing home quality.	Closed – Implemented Consistent with our recommendation, CMS will use additional measures to evaluate the QIOs' work with nursing homes during the contract period from 2011 through 2014. The new measures include the number of nursing homes using evidence-based practice for the prevention and treatment of pressure ulcers, the rate of consistent assignment of certified nurse aides in the nursing home, and the rate of improvement in staff turnover from the prior year.