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SEPTEMBER / OCTOBER 2014 :: 75(5)
Long-Term Care in North Carolina

As North Carolina’s population ages, an increasing number of elderly individuals will need long-term care. Fortunately, a variety of options are available for older adults, including nursing homes, assisted living, and home- and community-based resources. This issue of the NCMJ also covers topics such as fall prevention, advance care planning, caregiver support, adaptive leadership and person-directed care, and behavioral interventions for dementia.


Providing High-Quality Care in North Carolina Nursing Homes

Polly Godwin Welsh, Eric Kivisto

N C Med J. 2014;75(5):336-340.PDF | TABLE OF CONTENTS

Quality in North Carolina’s nursing facilities is intertwined in multiple dimensions of person-centered care, evidence-based practice, innovation, pursuit of continued excellence, meaningful relationships, and recognition of choice and autonomy. By striving to excel in their role of providing skilled nursing care for medically related acuity, North Carolina’s nursing facilities have been a contributor to the growth of the long-term care continuum, enabling North Carolina to have an extensive and well-developed system of skilled care and home- and community-based service models.

North Carolina has 421 nursing facilities [1], in which approximately 37,000 North Carolinians reside on either a short-term or long-term basis [2]. A short-term stay is an episode of care in which the patient spends no more than 100 cumulative days in the facility during the target period (the quality measure reporting period, such as a calendar quarter), and a long-term stay is one in which the patient spends at least 101 cumulative days in the facility during the target period [3]. Nearly all (95%) of the state’s nursing facilities are certified by the Centers for Medicare & Medicaid Services (CMS) to participate in both Medicare and Medicaid [1], and 90% of these facilities are members of the North Carolina Health Care Facilities Association (NCHCFA) [4].

Residents’ Perceptions of the Quality of Nursing Home Care
The residents of nursing facilities are diverse, not only in terms of demographic characteristics but also in their individual characteristics. Although psychosocial, cultural, environmental, and genetic factors are among the many determinants of health, these factors also determine an individual’s conception of what constitutes high-quality care. Other factors shaping perceptions of quality in nursing facilities are the congregate living environment; anticipated length of stay; and patient-specific goals, such as short- or long-term rehabilitation or palliation. Quality measures often focus on the receipt of care and on the effectiveness and outcomes of that care. In the field of long-term care, interpersonal relationships and the provision of person-centered care are equally important, if not the most important dimensions of quality.

Quality of Care in North Carolina Nursing Homes
According to data for the second quarter of 2014 [5], residents of North Carolina nursing homes needed more total assistance, on average, with activities of daily living (ADLs)—such as bathing, eating, and toileting—than did residents of nursing homes in other states. North Carolina currently ranks fifth in the nation on this measure [5]. Higher rates of stroke, hypertension, and diabetes, which have been observed throughout the Southeast [6-8], may partly explain North Carolina nursing home residents’ higher requirement for assistance with ADLs, but such trends are only one aspect of health. The circumstances and events precipitating admission to a nursing facility are highly individualized, ranging from an injury requiring hospitalization and rehabilitation to comorbid acute and chronic medical conditions. Also, measures of ADL dependence are only minimally reflective of patient acuity levels (ie, requirements for nursing care), and acuity levels have increased over the recent past in North Carolina nursing facilities.

Two years ago, CMS replaced the Online Survey and Certification and Reporting (OSCAR) system with the Certification and Survey Provider Enhanced Reports (CASPER) system and the Health Care Quality Improvement and Evaluation System (QIES). CASPER/QIES is a component of a large relational database within CMS, which serves as a resource for many quality initiatives. The primary use of these data is to support the quality measures of the Nursing Home Quality Initiative. The intended purposes of the initiative’s quality measures are to provide information about quality of care to nursing facility residents, their family members, and others who are choosing a nursing facility; to facilitate discussions with nursing facility staff members regarding the quality of care; and to help the nursing staff develop quality improvement programs. These nursing home quality measures come from data about residents that CMS requires facilities to collect and report at specified intervals [9]. Categorized as short-stay or long-stay quality measures, these relate to things such as pressure ulcers, need for indwelling urinary catheters, depressive symptoms, and seasonal influenza and pneumococcal vaccination [9]. [Editor’s note: A detailed list of these measures can be found in the sidebar by DePorter on pages 338–339.] CMS generates quarterly reports showing how nursing homes perform on these measures.

CMS contracts with federally designated quality improvement organizations (QIOs) in each state, the District of Columbia, Puerto Rico, and the US Virgin Islands. These QIOs, which champion health care quality improvement and patient safety, are private, mostly not-for-profit organizations staffed by health care quality improvement professionals, including physicians and nurses. QIOs work at the local level with providers and other stakeholders across the health care spectrum, including professional associations and patient advocacy groups, to address health care quality and safety topics that are important to the Medicare population.

During their most recent 3-year work cycle, the QIOs’ efforts included initiatives to reduce the incidence of pressure ulcers and the use of physical restraints. The Carolinas Center for Medical Excellence (CCME), which is the QIO in North Carolina, partnered with 45 North Carolina nursing homes to work on these goals. For pressure ulcers, the aggregate percentage of patients with pressure ulcers at participating nursing facilities during the baseline period (the fourth quarter of 2010 and the first quarter of 2011) was compared with the aggregate percentage during the evaluation period (the first and second quarters of 2013); this comparison revealed a relative improvement rate of 40.35%. For use of physical restraints, the relative improvement rate was 75.28%.

Quality Assurance and Performance Improvement (QAPI)
The Patient Protection and Affordable Care Act of 2010 requires nursing facilities to submit an acceptable QAPI plan within 1 year of the promulgation of a QAPI regulation by CMS [10]. QAPI is the merger of 2 complementary approaches to quality: quality assurance (QA) and performance improvement (PI). QA and PI both involve seeking and using information, but they differ in key ways. QA is a process of meeting quality standards and assuring that care reaches an acceptable level. Nursing facilities typically set QA thresholds to comply with regulations, but they may also create standards that go beyond regulations. PI is the proactive and continuous study of processes with the intention of preventing or decreasing the likelihood of problems by identifying areas of opportunity and testing new approaches that fix underlying causes of persistent or systemic problems.

In August 2011, CMS issued a memorandum regarding initiatives that the agency would be undertaking to implement the mandates of section 6102(c) of the Affordable Care Act [10] relating to QA and PI. CMS issued a guide to implementing QAPI in December 2012, and the agency made this set of introductory materials available online in June 2013 [11]. Many nursing facilities are already demonstrating leadership in developing and implementing effective QAPI plans while they await the issuance of a CMS regulation.

In the meantime, CMS has a longstanding regulation (mandated by the Omnibus Budget Reconciliation Act of 1987) that requires nursing facilities to perform quality assessment and assurance. Specifically, every facility must maintain a quality assessment and assurance committee that meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; the committee must also develop and implement appropriate plans to correct identified quality deficiencies [12]. This requirement will remain in place until promulgation of the new QAPI regulation.

Current Initiatives of the NCHCFA
Early in 2011, CMS launched the National Partnership to Improve Dementia Care in Nursing Homes, a national effort to reduce the use of antipsychotic medications among persons with dementia. North Carolina nursing homes were charged with effecting a reduction in the use of antipsychotic medication and quickly emerged as a national leader in this effort. North Carolina began the initiative in the second quarter of 2011 with a relatively low antipsychotic medication usage rate of 21.1%, which was lower than both the average rate for the Southeast and the national average. By the fourth quarter of 2013, the prevalence of antipsychotic medication use among long-stay residents of nursing homes in the state had dropped to 15.6%, for a decrease of 27.1%. The use of antipsychotic medications nationwide decreased from 23.6% to 20.2% over this period, with North Carolina remaining the national leader. Every CMS region showed at least some improvement [13].

Another focus of the NCHCFA efforts is to reduce the risk of falls, which are an ever-present risk for those with impaired mobility. Falls are often a precipitating event for entry into a nursing facility, not only for the provision of acute care (when a fracture or other serious injury occurs) but also for the initiation of long-term residence if safety concerns merit the need for rehabilitation therapy or a more supervised environment. Although there is no way to guarantee a “fall-free” environment, nursing facilities have for decades searched for effective ways of addressing this concern. Well-intended use of restraints was once a widely accepted practice for preventing falls in acute and long-term care facilities, but use of restraints is now strictly limited. In 1996 the NCHCFA embarked on a very successful statewide collaborative effort to change the philosophy and practice of using physical restraints and to educate and empower nursing home residents, families, providers, regulatory personnel, and advocacy groups. As a result of these efforts, restraint use in North Carolina declined markedly in the late 1990s [14]. The current rate of medically necessary use of restraints in North Carolina is 1.56% [5].

Nursing facilities continue to seek new evidence-based practices that reduce the incidence of falls. Empira, a Minnesota consortium of service providers for older adults, received funding from the Minnesota Department of Human Services in 2008 to target the prevention and reduction of resident falls in 16 skilled nursing facilities. The fall prevention program that Empira developed, which is a combination of nationally recognized evidence-based practices and practical applications of the most recent research findings, challenged many of the standards of practice for reducing falls. At the completion of the 3-year program, participating facilities collectively achieved a considerable reduction in the prevalence of resident falls. There were also decreases in the number of recurrent falls and the number of falls with injuries [15].

NCHCFA has engaged Empira’s director of education, Sue Ann Guildermann, to lead a quality initiative intended to help North Carolina nursing facilities make several changes: eliminating the use of alarms, restraints, and floor mats; using beds whose height has been corrected rather than traditional low beds; and advocating use of gripper socks. This is not a “nursing only” program. Rather, it is a comprehensive fall prevention program focusing on post-fall analysis (looking for the root cause of the fall), which advances the skills, knowledge, participation, and commitment needed to implement and sustain successful outcomes. In the spring and fall of 2013, NCHCFA hosted statewide educational sessions about fall prevention. Approximately 400 clinical and administrative personnel from nursing facilities participated. In addition, a large number of survey staff and managers from the North Carolina Department of Health Service Regulation participated, as did members of CCME. In the spring of 2014, NCHCFA again hosted educational sessions on the relation of quality of sleep to falls and to overall quality of life. Nursing facility personnel, surveyors, representatives of Area Agencies on Aging, and state ombudsmen attended this program.

NCHCFA is an affiliate of the American Health Care Association (AHCA) and thus participates in national quality programs as well. Together with the National Center for Assisted Living (NCAL), the AHCA conducts a National Quality Award Program that is based on the core values and criteria of the Baldrige Performance Excellence Program. The AHCA/NCAL award program provides a pathway for providers of long-term care services to work towards performance excellence. Of 381 NCHCFA member facilities, 1 has won a gold award in the program (only 18 gold awards have been given out nationwide), and 153 North Carolina facilities have earned a bronze or silver award. The AHCA quality initiative program assists facilities in setting measurable targets in 4 core areas: safely reduce hospital readmissions, increase staff stability, safely reduce the off-label use of antipsychotics in long-stay residents, and increase customer satisfaction.

Using Resident Satisfaction to Guide Improvement
Resident satisfaction is one of the most valuable indicators in the ongoing attempt to measure quality in nursing facilities, as the personal insights of residents can help to guide the improvement processes. Going beyond regulations, many facilities—either individually or as part of a multifacility effort—conduct their own satisfaction surveys and convene groups of residents to help guide facility management. In addition, much work has been done in North Carolina to deinstitutionalize the living environments of nursing homes by moving away from a medical model.

The quality of a process is measured by outcomes, but quality of life is measured by individual perception. Although many physical changes take place as people age, each individual remains the same person. Person-centeredness is challenging to measure but is the ultimate driver of quality in long-term care.

The data on the incidence of pressure ulcers and use of physical restraints among North Carolina nursing facilities was prepared by The Carolinas Center for Medical Excellence under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health & Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-NC-ALL-14-2.

Potential conflicts of interest. All authors have no relevant conflicts of interest.

1. American Health Care Association (AHCA). Nursing Facility Operational Characteristics Report. AHCA Web site. Accessed August 18, 2014.

2. Centers for Medicare & Medicaid Services (CMS). Nursing Home Data Compendium. Washington, DC: CMS; 2013:174. Accessed July 10, 2014.

3. Centers for Medicare & Medicaid Services (CMS). MDS [Long-Term Care Minimum Data Set] 3.0 Quality Measures: User’s Manual, version 5. CMS Web site. March 1, 2012. Accessed July 11, 2014.

4. North Carolina Health Care Facilities Association Web site. Accessed July 11, 2014.

5. American Health Care Association (AHCA). Nursing Facility Patient Characteristics Report. AHCA Web site. Accessed August 18, 2014.

6. Centers for Disease Control and Prevention (CDC). Prevalence of stroke—United States, 2006–2011. MMWR Morb Mortal Wkly Rep. 2012;61(20):379-382.

7. Casper ML, Barnett E, Williams GI Jr, Halverson JA, Braham VE, Greenlund KJ. Atlas of Stroke Mortality: Racial, Ethnic, and Geographic Disparities in the United States. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention; 2003. Accessed July 11, 2014.

8. Barker LE, Kirtland KA, Gregg EW, Geiss LS, Thompson TJ. Geographic distribution of diagnosed diabetes in the United States: a diabetes belt. Am J Prev Med. 2011;40(4):434-439.

9. Centers for Medicare & Medicaid Services (CMS). Quality measures. CMS Web site. Page last modified March 28, 2014. Accessed July 11, 2014.

10. Pub L No. 111-148, 124 Stat 704.

11. Centers for Medicare & Medicaid Services (CMS). QAPI at a Glance: A Step by Step Guide to Implementing Quality Assurance and Performance Improvement (QAPI) in Your Nursing Home. CMS Web site. Accessed July 12, 2014.

12. Requirements for, and assuring quality of care in, skilled nursing facilities. 42 USC 1395i-3 (1987). Accessed July 13, 2014.

13. Tritz K, Langman M, Bonner A. Report on the CMS National Partnership to Improve Dementia Care in Nursing Homes: Q4 2011 Q1 2014. Washington, DC: Centers for Medicare & Medicaid Services; 2014. Pub No. 10SOW-GA-IIPC-12-230. Accessed July 11, 2014.

14. Center for Medicaid and State Operations/Survey and Certification Group. Release of Report: “Freedom from Unnecessary Physical Restraints: Two Decades of National Progress in Nursing Home Care” [memo from the director of the Survey and Certification group to state survey agency directors]. November 7, 2008. Accessed August 18, 2014.

15. Guildermann SA. Effective fall prevention strategies without physical restraints or personal alarms. Webinar presentation, April 24, 2012. Slides available at Accessed August 22, 2014.

Polly Godwin Welsh, RN-BC executive vice president, North Carolina Health Care Facilities Association, Raleigh, North Carolina.
Eric Kivisto, MSW executive director, FutureCare of North Carolina, Raleigh, North Carolina.

Address correspondence to Ms. Polly Godwin Welsh, North Carolina Health Care Facilities Association, 5109 Bur Oak Cir, Raleigh, NC 27612 (