Developing clinical indicators for needed skilled nursing facility care : a feasibility assessment : final report, January 2001

298 Pages·2001·19 MB·English

by  Schmitz, Robert

Developing
Clinical Indicators
Needed
for
Nursing
Skilled
Facility Care:
A
Feasibility
Assessment
Mathematica Policy Research, Inc.
P.O. Box 2393
Princeton, NJ 08543
MedPAC A study conducted by
1730 K Street, NW Mathematica Policy Research, Inc. for the
Medicare Payment Advisory Commission
Suite 800
Washington, DC 20006
[phone]
Fax: [phone]
www.medpac.gov
The views expressed in this report
are those ofthe authors.
No endorsement by MedPAC
is intended or should be inferred.
For additional copies of this report,
please contact MedPAC. March 2001 • No.01-1

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MedPAC MAIHEMATICA
„
MPR Reference No.: 8702-150
Policy Research, Inc.
Developing Clinical
Indicators for Needed
Skilled Nursing Facility
A
Care: Feasibility
Assessment
Final Report
January 2001
Robert Schmitz
Arnold Chen
Nancy Archibald
Submitted to: Submitted by:
Medicare Payment Advisory Commission Mathematica Policy Research, Inc.
1730 K Street NW, Suite 800 P.O. Box 2393
Washington DC 20006 Princeton, NJ 08543-2393
[phone]
Project Officer: Project Director:
Raymond Wedgeworth Robert J Schmitz

23
CONTENTS
Chapter Page
EXECUTIVE SUMMARY xi
INTRODUCTION
I 1
BACKGROUND
A. 2
Medicare-Covered SNF Care 2
1 .
2. Clinically Based Indicators 3
3. Access to Needed SNF Care 4
4. Implementing Clinically Based Indicators in Administrative Data 5
ACCESS AND MEASURES OF ACCESS
B. 5
STRUCTURE OF THE REPORT
C.
1
ADMINISTRATIVE DATA FOR MEASURING ACCESS TO CARE
II 1
SOURCES OF ADMINISTRATIVE DATA
A. 13
Medicare Enrollment Database (EDB) 14
1 .
2. Medicare Claims and Utilization Data 14
3. Minimum Data Set (MDS) 16
B. MATCHING MDS ASSESSMENT DATA TO SNF CLAIMS DATA 19
C. STUDIES USING ADMINISTRATIVE DATA 20
Studies of SNF Placement 21
1.
2. Studies of Care Within the SNF 23
D. OTHER PROJECTS POTENTIALLY RELEVANT TO THIS STUDY 23
CHSRA
1. Indicators 23
2. Quality Outcomes in Subacute and Home Care Programs 24
3. The "Mega QI" Project 24
4. SNF PPS Quality Medical Review Project 24
SUMMARY
E. 26
iii
CONTENTS
(continued)
Chapter Page
I
HI STANDARDS FOR SKILLED NURSING FACILITY CARE 27
A. STANDARDS FOR ADMISSION TO SKILLED NURSING FACILLTIES 27
Postacute Care Setting 27
1 .
2. Guidelines for Referral to Skilled Nursing Care 29
3. Predictors of Nursing Home Admission 32
4. Measuring Access to SNF Admission 35
B. STANDARDS FOR PATIENT CARE WITHIN SNFs 36
Hip Fracture 37
1 .
2. Stroke 41
3. Congestive Heart Failure 45
4. Pneumonia 47
5. Diabetes 48
6. Urinary Incontinence 48
7. Pressure Ulcers 50
Depression 52
8.
9. Pain 53
RECOMMENDATIONS FOR NEEDED CARE
C. 56
IV EXPERT OPINIONS ON DEVELOPMENT OF INDICATORS 65
METHODS
A. 65
1. Recruiting Expert Respondents 65
2. Interview Goals and Content 69
HOSPITAL DISCHARGE PLANNING AND NECESSARY SNF
B.
ADMISSION
72
1. Basic Patient-Level Factors That Influence the Decision to Discharge
to a SNF 72
2. Patients for Whom SNF Admission Is Necessary 74
3. Using Administrative Data 81
C. Necessary Care For Patients In SNFs 93
Indicators Based on Processes of Care 94
1 .
2. Adverse Outcomes of Care 96
iv
7
CONTENTS
(continued)
Page
Chapter
IV
(continued)
INTERVIEWEES COMMENTS ABOUT SNF PPS AND THE SNF
D.
'
INDUSTRY 97
1. Observations About the Hospital-SNF Interface 100
2. PPS and Care for Patients Admitted to SNFs 104
3. Other External Forces Not Directly Related to SNF PPS 110
4. Other Issues: Rural Versus Urban Location, Integrated Health Systems,
and For-Profit Versus Nonprofit Status 1 12
V A CONCEPTUAL FRAMEWORK 115
DESCRIPTION OF THE FRAMEWORK
A. 1 1
B. BARRIERS TO IMPLEMENTING THE FRAMEWORK 124
SUMMARY
C. 126
VI CONCLUSIONS 129
REFERENCES
133
APPENDIX
A: A.l
APPENDIX B: B.l
APPENDIX
C: C.l
APPENDIX D: D.l
APPENDIX
E: E.l
APPENDIX
F: F.l
v