Select a healthcare condition

For this assignment, you are to address either “Question A” or “Question B”. Select one or the other – do not compose a response to both.Submit your response as per the guidelines stated in the syllabus. Please submit your document as a “.doc” or “.docx” file using the “Assignments” tab of the web course. Do not submit your response in the “Discussions” section of the course.

Question A:

Select a healthcare condition that has recently been noted to be associated with increasing hospitalization rates within a healthcare organization (hospital) of your choice.

Determine the impact of these hospitalization rates on the community served by the hospital you have selected.
If you were the CEO of this hospital, how would you address the problem in your strategic planning process?
________________________________________________________________________

Question B:

Review the various patient safety indicators presented in the PowerPoint presentation for Module 4 and select an indicator of particular interest to you (excluding hospital-acquired infections). Address the following questions in a response of sufficient length to demonstrate a thorough understanding of the concepts discussed in this chapter.

What specific patient subpopulation, in terms of gender and age, appears to be at greatest risk for the hospital safety event that you selected?
What factors might predispose your subpopulation to the safety event that you selected?
As a healthcare manager, what strategy (or strategies) would you recommend an an organizational approach to reducing the incidence of the safety event you selected.
PLEASE SEE THE LINKS BELOW, THEY PROVIDE INFORMATION FOR THE DISCUSSION

ATTACHED ARE THE POWERPOINTS AND AN ARTICLE THAT SUPPORT THE DISCUSSION AS WELL

http://www.ahrq.gov./ -Agency of Healthcare Resrearch and Quality

http://www.dartmouthatlas.org/ -Dartmouth Atlas of Health

http://www.pbs.org/video/2316010769/ -Hospital Readmissions

Discussion Question Guidelines

• Your response to the discussion question must be of sufficient length to permit the instructor to assess your understanding of the subject matter. I would suggest a discussion posting of no less than 500 words. This assignment should include cited works as indicated with a list of references at the conclusion of the document.
• Please single-space your discussion.
• Do not attach a cover sheet/title page with your posting.
• Please make sure your response relates to the relevant concepts explored in the question and that all components of the discussion question are addressed.
Quality Improvement in Neurology: Dementia Management Quality Measures

GermaineOdenheimer,MD,a SooBorson,MD,bAmyE. Sanders,MD,MS,c Rebecca J. Swain-Eng,MS,d

HelenH.Kyomen,MD,MS,e SamanthaTierney,MPH,f LauraGitlin, PhD,g,h

MaryAnn Forciea,MD,i JohnAbsher,MD,j Joseph Shega,MD,k and Jerry Johnson,MDi

Professional and advocacy organizations have long urged that dementia should be recognized and properly diag- nosed.1,2 With the passage of the National Alzheimer’s Project Act3 in 2011, an Advisory Council for Alzheimer’s Research, Care, and Services was convened to advise the Department of Health and Human Services. In May 2012, the Council produced the first National Plan to address Alzheimer’s disease, and prominent in its recommendations is a call for quality measures suitable for evaluating and tracking dementia care in clinical settings.4 Although other efforts have been made to set dementia care quality stan- dards, such as those pioneered by RAND in its series Assessing Care of Vulnerable Elders (ACOVE),5 practition- ers, healthcare systems, and insurers have not widely embraced implementation. This executive summary (full manuscript available at www.neurology.org) reports on a new measurement set for dementia management developed by an interdisciplinary Dementia Measures Work Group (DWG) representing the major national organizations and advocacy organizations concerned with the care of individ- uals with dementia. The American Academy of Neurology (AAN), the American Geriatrics Society, the American Medical Directors Association, the American Psychiatric

Association, and the American Medical Association– convened Physician Consortium for Performance Improve- ment led this effort. The ACOVE measures and the measurement set described here apply to individuals whose dementia has already been identified and properly diag- nosed. Although similar in concept to ACOVE, the DWG measurement set differs in several important ways; it includes all stages of dementia in a single measure set, calls for the use of functional staging in planning care, prompts the use of validated instruments in patient and caregiver assessment and intervention, highlights the relevance of using palliative care concepts to guide care before the advanced stages of illness, and provides evidence-based support for its recommendations and guidance on the selection of instruments useful in tracking patient-centered outcomes. It also specifies annual reassessment and updat- ing of interventions and care plans for dementia-related problems that affect families and other caregivers as well as individuals with dementia. Here, a brief synopsis of why major reforms in healthcare design and delivery are needed to achieve substantive improvements in the quality of care is first provided, and then the final measures approved for publication, dissemination, and implementa- tion are listed. J Am Geriatr Soc 62:558–561, 2013.

Key words: dementia; dementia management; quality measures

OPPORTUNITIES FOR IMPROVEMENT

Health Care for Persons with Dementia Is Inconsistent, Often Suboptimal, and Largely Unplanned

Peer-reviewed studies of dementia care document incon-sistency in outpatient care,6,7 high rates of potentially preventable episodes of acute care,8,9 and large numbers of locus-of-care transitions.10 These findings suggest that much of health care for individuals with dementia is

From the aDepartment of Geriatric Medicine, College of Medicine, University of Oklahoma, Oklahoma City Veterans Affairs Medical Center, Oklahoma City, Oklahoma; bDepartment of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, Washington; cDepartment of Neurology, Albert Einstein College of Medicine, Bronx, New York; dAmerican Academy of Neurology, Minneapolis, Minnesota; eDepartment of Psychiatry, McLean Hospital and Harvard Medical School, Boston, Massachusetts; fAmerican Medical Association, Chicago, Illinois; gCommunity Public Health, Center for Innovative Care in Aging, Johns Hopkins University, hDivision of Geriatrics and Gerontology, School of Nursing and Department of Psychiatry, School of Medicine, Johns Hopkins University, Baltimore, Maryland; iDivision of Geriatric Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; jAbsher Neurology, Greenville, South Carolina; and kDepartment of Geriatrics and Palliative Medicine, University of Chicago, Chicago, Illinois.

Address correspondence to Rebecca J. Swain-Eng, American Academy of Neurology, 201 Chicago Avenue, Minneapolis, MN 55415. E-mail: acegelka@americangeriatrics.org

DOI: 10.1111/jgs.12630

JAGS 62:558–561, 2013

reactive and unsystematic. Chronic conditions, for which prevention, early recognition, and timely treatment can be delayed in the setting of dementia, leading to exacerba- tions of other chronic conditions, largely drive ambulatory care. Proactive outpatient care and care coordination could reduce avoidable emergency department visits and hospital admissions and potentially avert negative effects on indi- viduals with dementia and caregivers that arise from pre- ventable health crises.

Ethnic and Socioeconomic Disparities Are Important Influences on the Quality of Dementia Care

Ethnic and socioeconomic disparities influence the rate and quality of dementia diagnoses, the stage of decline at which diagnosis occurs, the use of antidementia medica- tions, the quality and type of end-of-life care, and the use of community-based supportive services.11 Although beliefs about dementia’s origins and significance may contribute to some of these healthcare disparities, many quality prob- lems affect minority and mainstream populations alike: a lack of knowledge of what constitutes good dementia care, inadequate resources, insufficient insurance coverage, lack of access to knowledgeable professionals, and institutional barriers. All contribute to the need for improvements in healthcare design.

Partnership with Caregivers Is Integral to Improving Care

Several different models of integrated care for dementia have been described and have been shown to improve use of community-based services, reduce the use of central ner- vous system–active medications that may worsen cogni- tion, increase family caregivers’ competence and reduce their stress, and enhance the capacity of practice environ- ments to provide dementia-specific care.6,10,12–16 Focus is increasingly turning toward nonpharmacological modes of management for mood and behavioral problems because of the newly questioned value of antidepressant medica- tions for depression in dementia,17–19 the modest efficacy of antipsychotic medications for behavioral problems20

and the risks of cardiovascular events and mortality associ- ated with their use, the cognitive toxicity of anticholinergic medications,21 and recognition of the risks of falls and other adverse outcomes associated with use of benzodiaze- pines in elderly adults.22 Caregivers are essential partners in healthcare management, as well as implementation of nonpharmacological interventions that complement health care; their knowledge, well-being, and sustained engage- ment with healthcare providers are critical to the success of medical and psychosocial components of care.

The Well-Being of Their Caregivers Strongly Influences the Well-Being and Behavioral Stability of Individuals with Dementia

Caregivers for individuals with dementia require individu- alized attention and assistance to function their best. Unmanaged caregiving stress adversely affects health,22–24

increases caregiver mortality risk,25 and promotes behav- ioral decompensation in individuals with dementia, but

models for providing integrated care for caregivers and individuals with dementia together have not gained trac- tion outside specialized settings. Interventions targeted at helping caregivers address dementia-related behaviors and functional deficits can be effective,12,26–29 but these inter- ventions are not typically covered under Medicare and other insurance plans, and when such interventions are locally available and caregivers use them, their effects may not be apparent to medical providers, integrated into the overall care plan, or tracked as components of quality of care.

Comprehensive, Integrated Care and Quality Improvement Initiatives Must Be Explicit and Practical

Despite the quality promise of comprehensive dementia management, provider productivity standards and current billing and reimbursement systems discourage its adoption and undermine its consistency. Although much dementia care is done through work with caregivers, the individual with dementia must be present for most physician services to be reimbursed under Medicare, regardless of whether the individual is able to participate actively in his or her own care. Moreover, there may be different handling of neurological and psychiatric codes for the same dementing condition; International Classification of Diseases, Ninth Revision, code 331.0 identifies Alzheimer’s disease and is reimbursed as a medical code, whereas code 294.1 denotes senile dementia and is a psychiatric code reimbursed by some plans under a mental health benefit, for which cover- age may be more limited. Measuring dementia care activi- ties of providers and health systems will create a solid data resource for redesigning payment and coding struc- tures so that they reflect the work providers need to, and actually, do to provide high quality of care for persons with dementia.

DEMENTIA MANAGEMENT QUALITY MEASURES

In dementia care, desired outcomes include preserving, to the maximum possible extent, cognitive and functional abilities; reducing the frequency, severity, and adverse effect of neuropsychiatric and behavioral symptoms; sus- taining the best achievable general health; reducing risks to health and safety; and enhancing caregiver well-being, skill, and comfort with managing the individual with dementia in partnership with healthcare providers. Clinical performance measures would ideally include patient-level outcomes as well as processes of care, although the pro- gressive nature of most dementing diseases, the heterogene- ity of comorbid conditions and the medical and other management requirements, and the multiplicity of factors that influence outcomes in dementia make development of reliable self-reported outcome measures impracticable. In their place, assessing the quality of dementia care must rely on measuring care processes that have been associated with positive outcomes in a rapidly evolving evidence base. The DWG measurement set consists of 10 separate, audit- able quality measures. These measures are inclusive of the multiple stages of illness and can be viewed in five catego- ries relevant to therapeutic decision making: assessment of

JAGS MARCH 2014–VOL. 62, NO. 3 QUALITY IMPROVEMENT IN NEUROLOGY 559

the person with dementia after diagnosis (measures 1–4 and 6), management of neuropsychiatric symptoms (mea- sure 5), patient safety (measures 7 and 8), palliative care and end of life concerns (measure 9), and caregiver con- cerns (measure 10)). For most measures, the proportion of eligible individuals whose documented care meets the iden- tified goal indicate care quality. Situations in which the use of a particular quality measure may not be appropriate for a particular individual (e.g., counseling regarding risks of driving for an individual who does not drive) are speci- fied with an exception to the measure. A brief summary of each measure is found in Table 1. For the full measure specifications, visit the Physician Consortium for Perfor- mance Improvement Web site (www.physicianconsortium. org). Readers interested in examples of how to meet indi- vidual measures are referred to this Web site.

CONCLUSION

The DWG measures have the potential to dramatically affect practice and improve the quality of care provided to individuals with dementia. All of these measures except measure 9 were selected for the 2012 and 2013 Physician Quality Reporting System measures list,30 which provides an incentive payment to eligible professionals who demon- strate provision of high-quality care for specified condi- tions and can accelerate adoption of dementia care quality

standards across all types of practice organizations and all clinical disciplines providing health care for affected indi- viduals. In addition, measure 2, Cognitive Assessment, is included in the clinical quality measure list for Meaningful Use 2, a Centers for Medicare and Medicaid Services Elec- tronic Health Record incentive program designed to offer financial incentives for the “meaningful use” of certified electronic health record technology to improve patient care.31

The emphasis on dementia management in this mea- surement set recognizes the enormous challenge dementia presents to individuals with dementia and their caregivers, healthcare providers, public health agencies, and govern- ment and private insurers. Although individuals with dementia, caregivers, and health professionals await more- effective disease-modifying treatments for individuals with dementia, adherence to the measures outlined here will improve the quality of life for individuals with dementia and their caregivers.

ACKNOWLEDGMENTS

The AAN Board of Directors approved the dementia mea- surement set on October 31, 2011, and the full membership of the American Medical Association–convened Physician Consortium for Performance Improvement approved it on October 31, 2011.

Table 1. Final 10 Dementia Measures

Measure Description

1. Staging of dementia Patients, regardless of age, with a diagnosis of dementia whose severity of dementia was classified as mild, moderate, or severe at least once within a 12-month period

2. Cognitive assessment Patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results are reviewed at least once within a 12-month period

3. Functional status assessment Patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results are reviewed at least once within a 12-month period

4. Neuropsychiatric symptom assessment

Patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and the results reviewed at least once in a 12-month period

5. Management of neuropsychiatric symptoms

Patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12-month period

6. Screening for depressive symptoms Patients, regardless of age, with a diagnosis of dementia who were screened for depressive symptoms within a 12-month period

7. Counseling regarding safety concerns

Patients, regardless of age, with a diagnosis of dementia, or their caregiver(s), who were counseled or referred for counseling regarding safety concerns within in a 12-month period

8. Counseling regarding risks of driving Patients, regardless of age, with a diagnosis of dementia, or their caregiver(s), who were counseled regarding the risks of driving and the alternatives to driving at least once within a 12-month period

9. Palliative care counseling and advance care planning

Patients, regardless of age, with a diagnosis of dementia, or their caregiver(s), who received comprehensive counseling regarding ongoing palliation and symptom management and end of life decisions AND have an advance care plan or surrogate decision-maker in the medical record or documentation in the medical record that the patient did not wish or was not able to name a surrogate decision-maker or provide an advance care plan within 2 years of initial diagnosis or assumption of care

10. Caregiver education and support

Patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support within a 12 month period

Full specifications are available on the Physician Consortium for Performance Improvement Web site at www.physicianconsortium.org. Readers interested

in examples of how to meet the measurement requirements are referred to this document. Readers are also referred to the full version for this article at

www.neurology.org in appendix e-1.

560 ODENHEIMER ET AL. MARCH 2014–VOL. 62, NO. 3 JAGS

Conflict of Interest: Dr. Sanders receives salary and research support from the Einstein Clinical and Transla- tional Science Awards Grant UL1 RR025750 and Grants KL2 RR025749 and TL1 RR025748 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH road- map for Medical Research; loan repayment support from the National Institute on Aging (NIA) Loan Repayment Program; has received pilot funds from the Resnick Gerontology Center; has reviewed for the NIH/NIA, the Centers for Medicare and Medicaid Innovation (CMMI), the Patient-Centered Outcomes Research Institute (PCORI), and the Alzheimer’s Association; has received honoraria for serving on peer-review panels from the CMMI and PCORI; and is a member of Medicare Evidence Development and Coverage Advisory Committee. The contents of this manu- script are solely the responsibility of the authors and do not necessarily represent the official view of the NCRR, NIA, or NIH. Dr. Absher serves on the South Carolina Alzheimer’s disease Board of Directors.

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