"Gaming the 5 Star System"

By / Posted on September 3rd, 2014

It was disheartening to read the NY Times story this week about the CMS 5 Star rating system. Such reporting leaves both the providers and the consumers asking, “If a 5 Star nursing home isn’t a 5 Star nursing home … then does that mean that a 1 Star nursing home isn’t a 1 Star nursing home?” “Hip, hip hooray,” say the 1 Star homes. “I told you that those 5 Star homes weren’t better than us. They just game the system.” Wow!

The article asserts that nursing home leaders game the 5 Star system in two ways – 1) By falsely documenting better clinical outcomes via the Quality Measures; and 2) By staffing up during the survey and then reducing staff after the inspectors are gone. I would like to address both.

Regarding the accusation of gaming the Quality Measures (QMs) – consider that the QMs are calculated from each of the residents’ Minimum Data Set (MDS) assessments. The MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. MDS assessments are required on admission and then periodically throughout their stay. The participants in the assessment process are licensed healthcare professionals including RNs, therapists, dieticians and social workers. MDS assessments are legally signed by these professionals and submitted electronically to CMS. So … are these professionals falsifying the coding of the MDS in order to game the QMs? No way!

Regarding the accusation of staffing up – it may be happening. Let’s start collecting payroll data in order to ensure accurate reporting and that nursing homes are consistently, appropriately staffed.

Another solution is for providers to adopt innovative, evidence-based models like The GREEN HOUSE® model. One of the essential elements of the model is higher direct care staffing than traditional nursing homes. Traditional SNFs average about 2.50 C.N.A. hours per resident, per day (HPPD) compared to Green House homes that average 4.00 HPPD. Green House homes are able to provide this consistent, high level of staffing by utilizing a versatile caregiver service approach. And organizations that follow The Green House staffing and organizational model can deliver high quality care at a cost that is no more than a traditional institutional nursing home.

The elders depicted in the article were in need of short-term rehabilitation with a plan to get back home. Green House homes focused on short-term rehabilitation are achieving great results. Elders rehabilitating in Green House homes experience fewer rehospitalizations and typically get back home 10 days sooner than the elders in traditional, post acute SNFs. The Green House model, with its’ unique approach to care and staffing, plays a key role in these outcomes.

The vast majority of Green House model adopters are 4 and 5 Star nursing homes and they deserve the high ratings. But, if the goal of the Five Star rating system is to guide consumers to the best performing homes, perhaps CMS should add a specific mark of excellence designed to identify providers that have adopted innovative, evidence-based models like The Green House model.

CMS currently cautions consumers to be wary of certain nursing homes that have had consistently low performance via a Special Focus Facility designation next to their name on the CMS site. I’m sure consumers appreciate the chance to steer clear of the lowest performers. Let’s find a better way to direct them to the best.


Reflections from the Director: Changing Times / Changing Measures / Changing Behavior

By / Posted on June 11th, 2013

Changing performance metrics can catalyze a dramatic improvement. I recall the story of Walgreens in the book “Good to Great” by Jim Collins. Collins and his research team describe Walgreens as nothing more than a sleepy retail pharmacy chain that limped along for years before a dramatic rise to great results that lasted for over 15 years. The researchers examined what triggered the change and discovered that Walgreens had deviated from the industry norm of measuring their performance. All retail pharmacies, including Walgreens before their rise to greatness, had used one key performance metric to measure their performance – revenue per square foot per store. When Walgreens began measuring their own performance with a new measure – revenue per customer visit – their dramatic acceleration began. Gradually, all other retail pharmacies followed suit and began to use this new performance metric and it changed the retail pharmacy industry forever. The change in this one performance metric led to new systems, improved staffing and re-designed stores. In fact, when Walgreens reset their measure they set a new goal. The goal was $40 per customer visit. My wife consistently exceeds that goal.

In the Skilled Nursing profession, for over 45 years, we have all measured our performance by, generally, a single measure – our annual department of health inspection results. Recently, my Dad shared with me a newspaper article that described 5-Star nursing home closing its’ doors in Massachusetts and the article kind of shook me up. After all, the whole intent of the 5-Star rating system is to drive consumers to the best performing SNFs. So…why do 5-Star homes close and 1-Star homes remain full? Perhaps the 1-star home is actually a better performer than the 5-star home. The answer lies outside of our one key performance measure.

The metrics of SNFs are shifting – and this bodes well for the profession as a whole. Two performance measures are taking hold that will surely help to separate the star performers from the rest of the pack. The two we are speaking of have been hammered away at the nursing home professionals nationwide – reduce or eliminate the off-label use of antipsychotics and reduce the avoidable re-hospitalizations. Just like Walgreens, the improvements in these two measures will require improving the systems of care, enhanced staff composition and competence, and changing the physical environment of SNFs.

Reducing or eliminating the off-label use of anti-psychotics triggers providers to get serious about delivering person-centered care. Organizations will need to reduce their C.N.A. to resident ratios and de-institutionalize their physical environments (and we are not talking about simply new wallpaper). Enhancing the competence of the entire staff through a significant increase in education hours that are focused on caring for those living with dementia will be foundational to their success.

Reducing re-hospitalization rates leads SNF leader’s to raise the bar on increasing clinical competence and adding talented and compassionate RNs to their staff. Also, this new measure forces leaders’ to re-examine their turnover rates and absenteeism because staff instability does not allow for consistent assignment and diminishes communication. Clearly, the health of the relationships among the staff of each SNF is reflected in their re-hospitalization rate. Therefore, better systems of communication and new job descriptions are needed to strengthen staff relationships. Today, many providers can see that their current physical environment – an average of 85 elders living together in tight quarters, shared rooms, shared bathrooms, shared shower rooms – is perfectly designed to spread infections among the elders and staff. Private rooms with private baths and showers for each elder will become the new norm. A smaller and better designed environment is critical to both clinical outcomes and a dignified quality of life.

Of course, a SNF’s performance on their annual department of health inspections is important and always will be. It has to remain a key measure with the other 5-Star metrics. Examined next to a SNF’s performance on these two measures will provide consumers, operators, surveyors and policy makers a way to more clearly identify where elders should flock to for their care.


Visiting Mt. San Antonio Gardens, A Reflection on The First Green House Project in California

By / Posted on March 28th, 2013

Visionary leader Randy Stoll, CEO of Mt. San Antonio Gardens, and his dedicated team have been toiling away for years to navigate California’s complex regulations in order to introduce the very first Green Houses to the state. As we toured the construction site, you could see the home taking shape – the fireplace, the kitchen, plenty of windows and the 10 bright, private bedrooms with private baths and showers. At the end of the tour I thought – the day the elders move in, these two homes will immediately become the top two places to receive skilled care in the state.

I felt a great sense of relief to see Green House homes under construction on the campus of Mt. San Antonio Gardens. After all, I have been a licensed Administrator in the state of California since 1989. We have over 1,150 licensed Skilled Nursing Facilities here – more than any other state. In California, many well-intentioned providers are struggling to deliver high quality care and service to over 100,000 people each day. The typical setting is an old institution with 2, 3 or 4 beds per room with an adjoining single bathroom (one sink and one toilet for 4 – 8 people to share). Speaking from experience – we paint the walls, we buy new beds, we add flat screen TVs, but…at the end of the day, it’s still not the place we would want for our loved ones or ourselves.

 

I am grateful for the leadership team at Mt. San Antonio for making this happen. California needs to see this. When The Green House homes open this spring, California’s providers, regulators and policy makers will see the future of skilled nursing care. It represents a radical change from what we are all used to, because, these Green House homes are the places that we would want for our loved ones or ourselves.


Notes from The Green House Director: Achieving the Triple Aim of Long Term Care: Quality, Health, Affordability

By / Posted on March 22nd, 2013

Recently, I was honored to speak at the Michigan LANE (Local Area Network for Excellence) conference in East Lansing that was attended by close to 300 dedicated leaders of skilled nursing facilities.  It was there that I was reminded of the Centers for Medicare and Medicaid Services (CMS) Triple Aim –

1.) Improve the persons’ experience of care – both quality and satisfaction

2.) Improve the health of people and the community’s health

3.) Reduce the cost and wasteful spending

I feel confident that The Green House Model addresses all three of these goals.  And we have a significant amount of independent research to support this feeling.   Thanks to the support of The Robert Wood Johnson Foundation, The Weinberg Foundation and AARP, model is spreading and Green Houses nationwide have the outcomes that hit these marks and outpace traditional SNF’s.

After the LANE event, I stayed in Michigan and I saw an excellent example of how visionary leaders in Michigan collaborated in order to hit the CMS Triple Aim while helping to revitalize downtown Detroit.  I had the opportunity to tour the new Rivertown Neighborhood, an affordable senior community that will provide over 770 seniors access to desperately needed housing and supportive services.   The grand opening is April 12th.

Presbyterian Villages of Michigan (PVM), in collaboration with Henry Ford Health System and United Methodist Retirement Communities, have creatively adapted an old dilapidated pharmacy plant and expanded The Center for Senior Independence (CSI) program (nationally recognized as PACE).  Two Green Houses serving 20 – 24 elders will be an integral part of the Rivertown Neighborhood.

At the end of the tour, Roger Myers, the President and CEO of PVM, and his incredible team of partners, brought us into bottom floor of a cold, open space of a four-story brick building attached to the beautifully renovated building.   None of the floors were in the building so that you could look up to the ceiling that was 4 stories up.  This is where a huge vat of cough syrup used to brew and this is where the two Green Houses will sit on two floors above a café.

The Rivertown Neighborhood demonstrates how we can tackle complex social factors that effect elders’ heath and their well-being.   Over 200 employees (and Shahbazim) at Rivertown will address the social determinants of health, and the healthcare, of hundreds of the community’s seniors every day.  In so doing, they will give peace-of-mind to thousands of the elders’ family and friends.   Its’ an exciting project and am thrilled the Green House Project is a part of it.

 

 


Empowerment is Foundational to Success: Herzberg and The Green House Model

By / Posted on March 11th, 2013

One of the subjects that have befuddled Long Term Care leaders over the years is worker motivation. One of the foremost researchers in this field is Frederick Herzberg, an industrial psychologist. It is Herzberg’s work on motivation and job enrichment that strikes at the heart of the success of self-direction concepts that are so foundational to The Green House model.

In the 1960’s, Herzberg proposed that a person’s needs break down into two categories: hygiene factors and motivational factors.
Hygiene factors relate to what makes us work and our biological needs, such as providing food, clothing, and shelter. Herzberg says we have a build-in drive to avoid pain relative to these needs, so we do what is necessary, such as work, to provide what we need.

Motivator factors, however, are very different. These factors include those specific items related to what makes us work well such as achievement, and through achievement, the ability to experience psychological growth.
Herzberg used the term job enrichment to describe how the motivator factors can be used to achieve higher levels of satisfaction with a job. The following list was taken from his Harvard Business Review article of 1968 (reprinted in 1987) entitled, One More Time…How Do You Motivate Employees? Take particular note of how closely these factors align with concepts embodied in radical workforce redesign with The Green House model.

Herzberg said that meaningful job enrichment involves the following:
1. Removing controls while retaining accountability.
2. Increasing the accountability of individuals for their work.
3. Giving a person a complete natural unit of work.
4. Granting additional authority to employees in their activity such as job freedom.
5. Making data and reports directly available to the workers themselves rather than just to supervisors.
6. Introducing education programs designed to enrich critical thinking skills.
7. Assigning individuals specific assignments or specialized tasks, enabling them to become experts.

It is surprising to think that Herzberg first discussed these concepts in the 1960’s, but that we are now just beginning to incorporate them through innovative models. In the elder care field, we have a mountain of research that supports the link between frontline caregivers involvement and improved clinical outcomes of care and quality of life. Organizational changes that support self-direction will continue to grow because it makes sense to leaders desperately searching for ways to increase responsibilities of frontline staff as well as the elders’ perception of feeling valued and respected. The Green House model’s systematic approach to workforce redesign and the creation of the Shahbazim, combined with radical environmental redesign, help ensure that the institutional, hierarchical model can’t slip back in.

The empowered Shahbazim that you find within the Green House homes nationwide helps to explain why 83% of Green House projects are ranked as either 4 or 5 Star homes on the CMS Nursing Home Compare website. The Green House model supports the relational coordination among the Shahbaz and the nurses and other staff. The theory of relational coordination states that the effectiveness of care and service is determined by the quality of communication among staff. The quality of staff’s communication depends on their relationships with each other. This theory is highly applicable in healthcare settings where tasks employees perform are closely interrelated. Their interdependence forces the staff to work with one another. But if their relationships and communication are weak, and institutional hierarchies minimize the voice of the elders and their caregivers, then elders’ needs tend to fall through the cracks.

The Green House model develops people’s communication and critical thinking skills so they know what to share and why it’s important. And the redesigned work environment supports good communication creating both a culture of safety and a meaningful life for the elders. Systems and redesigned roles that support relational coordination among staff are the key to the successful outcomes achieved by Green House projects.

Forty-five years ago, Herzberg was spot on. And he still is.