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Management Challenge 6: Ensuring Quality in Nursing Home, Hospice, and Home- and Community-Based Care

Why This Is a Challenge

A nurse taking a man's blood pressure in his home

As Americans continue to live longer and with more chronic medical conditions, the Department must ensure that beneficiaries receive high-quality nursing home, hospice, and home- and community-based services (HCBS), including personal care services (PCS). Nursing home and HCBS programs provide ongoing assistance with daily living, as well as care for those who need temporary help recuperating from hospital stays or other acute care. Hospice care provides comfort for terminally ill beneficiaries and supports family and other caregivers.

Nursing Home and Hospice Care. Problems with nursing home and hospice care continue to be identified. Concerns raised include the frequency and severity of preventable adverse events because of substandard nursing home care, limited compliance with federal regulations for reporting abuse and neglect, lack of monitoring of nursing homes' resident hospitalization rates, failure to correct deficiencies identified during the survey process, and employment of caregivers who do not meet relevant licensure requirements. Additional concerns regarding hospice care include inadequate oversight of certification surveys and hospice-worker licensure requirements and fraudulent hospice enrollments undertaken without beneficiary consent.

Home- and Community-Based Services. HCBS programs serve several targeted populations, including people with mental illness, or physical, cognitive, or developmental disabilities. HCBS programs help beneficiaries avoid costly and disruptive facility-based care. These programs help promote beneficiary choice and preferences, but persistent payment, compliance, and quality vulnerabilities continue. Medicaid is the primary payer for PCS, a critical component of HCBS. Without effective PCS, the HCBS goals of keeping beneficiaries out of institutions cannot be achieved. Of significant note are vulnerabilities specific to PCS, such as delivery in private settings in which care may be harder to observe and oversee.

Progress in Addressing the Challenge

The Department continues efforts to improve the quality of nursing home, hospice, and HCBS programs, including PCS. CMS developed the CMS Adverse Drug Event Trigger Tool for use by nursing homes and state surveyors to improve medication safety and reduce medication-related adverse events. In July 2015, the Department published a proposed rule on Reform of Requirements for Long-Term Care Facilities. Along with other quality improvement initiatives, the proposed rule would implement section 6102 of the Affordable Care Act, which requires each nursing facility to have an operational compliance and ethics program that effectively promotes quality of care.

CMS made the following improvements to the Five Star Quality Rating System posted on the Nursing Home Compare Web site to improve beneficiaries' and consumers' ability to determine meaningful differences between nursing homes, incentivize increased quality, and ensure the accuracy of the information posted: added two Quality Measures (QM) for antipsychotic medication use; raised the threshold for nursing homes to achieve a high rating on all measures in the QM dimension of the Five Star System; and expanded focused surveys nationwide to assess coding practices and its relationship to resident care in nursing homes to improve the accuracy of the QMs.

In August 2015, CMS finalized a rule for the PPS and Consolidated Billing for SNFs for FY 2016. This rule implemented section 6106 of the Affordable Care Act, which allows for greater oversight and increased accuracy for reporting of nursing home staffing on the Nursing Home Compare website and in the Five Star Quality Rating System. Also, this rule specified a SNF all-cause all-condition hospital readmission measure and adopts that measure for a new SNF Value-Based Purchasing (VBP) Program. Additionally, the rule will implement a new quality reporting program (QRP) for SNFs that authorizes CMS to reduce payments to nursing homes that do not report certain resident assessment items and establishes the plan to standardize certain elements of assessment tools and quality measures across post-acute care settings.

In July 2015, CMS published a proposed rule to improve the quality of nursing home care that updates Medicare requirements for long-term-care facilities. This proposed rule also would implement provisions of the Affordable Care Act, including requirements for facilities to implement a Quality Assurance and Performance Improvement (QAPI) program that would ensure that facilities continuously identify and correct quality deficiencies and promote and sustain performance improvement. Additional provisions would implement requirements for a Compliance and Ethics program, requirements for dementia and abuse prevention training, and requirements for reporting suspected crimes.

The Department continues efforts to improve access to hospice care. Traditionally, to qualify for hospice services, Medicare required beneficiaries to forego curative services. CMS, through the Medicare Care Choices model, is now testing allowing beneficiaries to receive hospice care to manage discomfort and receive end-of-life counseling while still allowing Medicare payment for treatments aimed at curing the underlying terminal illness. CMS has also taken steps to encourage patients and their physicians to discuss end-of-life issues to improve patients' quality of life and increase the likelihood that the end-of-life care the patients ultimately receive conforms to their informed wishes. As access improves, the Department must continue efforts to ensure that the quality of hospice care delivered to beneficiaries who select hospice meets quality standards.

Federal agencies, including OIG, DOJ, and CMS, continue to pursue enforcement actions against nursing homes, hospices, and HCBS providers, including PCS providers that render substandard care. In the past year, OIG launched an initiative to combat hospice fraud in regions identified as areas of particular concern. In the summer of 2015, OIG completed a national health care fraud takedown that included arrests of several Medicaid providers accused of committing HCBS fraud. CMS and OIG work closely with law enforcement partners at DOJ and through the federal Elder Justice Interagency Working Group to promote better care for older adults and to prosecute providers accused of abuse or neglect. State Medicaid Fraud Control Units (MFCU) devote substantial resources to the investigation and prosecution of abuse and neglect.

In addition to the Department's efforts to improve quality of care, OIG invests substantial efforts in helping providers improve. OIG has developed an innovative quality-oriented corporate integrity agreement process to work with nursing home providers so they may better serve beneficiaries. OIG has placed nearly 40 nursing home companies (covering more than 900 facilities) under corporate integrity agreements that include quality-monitoring provisions designed to ensure that beneficiaries receive the care they deserve.

Ensuring high-quality home- and community-based services and enabling beneficiaries to avoid institutionalization, relies heavily on appropriate personal care services. CMS is in the second year of a four-year cycle of grants to nine qualified states to test quality measurement tools and demonstrate the use of electronic tools in Medicaid community-based long-term services and supports. These tools are designed to establish standardized interoperable data sets for HCBS plans and assessment items, measure the experience of care for beneficiaries and test the use of personal health records. An experience-of-care tool has been designed, tested and is in the final stages of certification. The Department entered into a contract last year with the National Quality Forum and began work on the development of a national quality measure set for home- and community-based services. Domains of measures have been made and an environmental scan started to identify key measures as well as gaps in measures for domains that might not have been developed to date.

What Needs To Be Done

The Department should continue to prioritize quality of care in nursing homes and hospices as well as the care rendered as HCBS, with particular focus on PCS. The Department should monitor how often nursing home residents are hospitalized and develop resources that can be used to help nursing home staff reduce the incidence of adverse events in nursing homes. In addition, the Department should improve internal controls and offer better guidance and training for surveyors to ensure that nursing homes with recorded quality and safety issues correct their deficiencies. CMS should improve coordination with state agencies to ensure that care providers meet relevant licensure requirements. The Department should seek to link payments for services to meeting quality-of-care requirements and work with OIG to hold accountable the providers that have rendered substandard care, thereby preventing additional harm to vulnerable beneficiaries.

Lastly, the Department should ensure the integrity of Medicaid-funded PCS by establishing minimum federal qualification standards for providers based on needs of the individual being served; improving CMS's and states' ability to monitor billing and care quality; and issuing operational guidance for claims documentation, beneficiary assessments, person-centered plans of care, and supervision of personal care attendants when hired by an agency. For self-directed programs in which a beneficiary directs his/her own PCS, CMS and the states should improve oversight of controls to ensure individual health and welfare and financial integrity. The Department should also issue guidance to states regarding adequate prepayment controls and help states access data necessary to identify overpayments.

Key OIG Resources

Management Challenge 7: Implementing, Operating, and Overseeing the Health Insurance Marketplaces

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