The Development of Person-Centered Care Criteria and Measurement Tools: Process and Content of a Multidisciplinary Enterprise

AHCA Quality SymposiumSan Antonio, TX

February 18, 2011

Michael Lepore, PhDDirector of Quality, Research, &

EvaluationPlanetree

mlepore@planetree.org&

Investigator in Community HealthBrown University

michael_lepore@brown.edu

Collaborators

Planetree•Heidi Gil•Susan Frampton, PhD•Christy Davies•Affiliate sites

Brown University•Susan Miller, PhD•Michael Lepore, PhD

My InnerView•Vivian Tellis-Nayak, PhD•Mary Tellis-Nayak

IDEAS Institute•Maggie Calkins, PhD•Jennifer Brush

Research Support

The Commonwealth Fund

◦Developing Systems to Support Person-

Centered Care: Optimizing Planetree’s

Continuing Care Designation Criteria and

Measurement Strategies

A note on language

For the purpose of this presentation, the

terms person-centered care and person-

centeredness are used, though other terms

also are recognized (patient-centered,

resident-centered, family-centered,

relationship-centered, etc.)

Outline

Person-centered care (PCC) criteria and measures

◦Why develop PCC criteria and measures?

◦How were PCC criteria and measures developed?

◦What are the PCC criteria and measures?

◦How can we use the PCC criteria and measures?

Why develop PCC

criteria and

measures?

Why develop PCC criteria and measures?The Institute of Medicine identified PCC as

a healthcare priority

What is person-centered care?◦“health care that establishes a partnership

among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients wants, needs, and preferences and that patients have the education and support they require to make decisions and participate in their own care.” (IOM, 2001, Envisioning a National Healthcare Quality Agenda)

Why develop PCC criteria and measures?

PCC is a complex concept requiring multiple dimensions of culture change

MJ Koren (2010). Person-Centered Care For Nursing Home Residents: The Culture-Change Movement. Health Affairs, 29: 312-317

PCC

Homelike atmosphere

Close relationships

Staff empowerment

Collaborative decision making

Quality-improvement

processes

Resident direction

Why develop PCC criteria and measures?

Benchmark performance internally / longitudinally

Benchmark performance externally / in comparison to competitors

Understand relationship between PCC and other factors (e.g., financial, regulatory performance)

Why develop PCC criteria and measures?Long-term care executives call for new

measures

◦“I think measurement is key. We have to develop new measurements if we want new outcomes. And people pay attention to what we’re measuring, and many of the current measurements are still good, but we need additional measurements.”

Long-Term Care Improvement Guide (available for free download at www.planetree.org)

How were PCC

criteria and

measures

developed?

How were PCC criteria developed?

Step 1

•Preliminary criteria developed through focus groups and expert committee from Planetree, My InnerView, IHI, Joint Commission, etc

Step 2

•Preliminary criteria crosswalked with PCC measurement tools & literature (evidence base)

•Recommendations made for revision (e.g., drop, add, merge, split)

Step 3

•Criteria revisions reviewed by research team & representatives from affiliated LTC sites

•Consensus on criteria established

Original

A plan for caring touch is developed and implemented as appropriate. (Exceptions include behavioral health patients.) Examples of caring touch include massage, healing touch, therapeutic touch and Reiki.

Related Measurement or Literature

CAHPS Resident Surveys: What number would you use to rate how gentle the nursing home staff were when they helped you?

Revised

…Beyond implementation of formal caring touch programs, patients’/residents’ daily care is provided with gentleness.

Multi-Method Evaluation Protocol

Focus Groups

Satisfaction Survey

Quality Profile (QP)

Self Assessme

nt

How were PCC measures developed?

Step 1

•Preliminary Quality Profile measures suggested based on review of existing satisfaction and PCC measurement tools and literature

Step 2

•Providers interviewed about measurement needs and surveyed about feasibility and importance of preliminary measures

Step 3

•Measures reviewed by research team & representatives from affiliated provider sites

•Consensus reached on Quality Profile measures

Originally Recommended Measure

% of residents who did not die alone (some one was within 10 feet some time during the last hour) during the month

Response from Providers

(Not at all) (Very)1-----------------------------------------------------5

Revised Measure

% of residents who died in place (not transferred to the hospital in the 7 days prior to death)

Importance Feasibility

Nursing home

2.25 3.57

Assisted living

3 1

What are the PCC

criteria and

measures?

What are the PCC criteria?

Component

Criterion 3

Criterion 2 Criterio

n 1

Eleven core Components each with specific criteria

Component I. Structures & Functions Necessary for Implementation, Development & Maintenance of Resident-Centered Concepts & Practices

Component XI. Measurement

Component VI. Healing Environment: Architecture & Design

Component II. Human Interactions / Independence Dignity & ChoiceComponent III. Resident Choice & ResponsibilityComponent IV. Family Involvement

Component V. Nutrition Program

Component X. Healthy Communities / Enhancement of Life's Journey

Component IX. Integrative Therapies / Paths to Well-Being

Component VIII. Spirituality & Diversity

Component VII. Arts Program / Meaningful Activities / Entertainment

Planetree Components of Person-Centered Care

What are the PCC criteria?

I. Structures & Functions

A multi-disciplinary task force oversees resident-centered practices

Resident-centered

care coordinator

is designated

Resident, family & staff focus groups

are conducted

periodically

What are the PCC criteria?

II. Human Interactions

A comprehensive presentation on PCC concepts, practices & initiatives is provided for all new staff & residents as a part of orientation

Staff have the opportunity for personalizing

care in partnership with each resident

Numerous opportunities are provided

for staff celebration,

reward & recognition

What are the PCC criteria?

III. Resident Choice &

Responsibility

Residents are provided with meaningful discharge/ transition instructions

A process is in place for sharing

clinical information, including the

medical record & care plan, with

residents

A process is in place to fully

disclose & apologize for

unanticipated outcomes to

residents

What are the PCC criteria?

IV. Family Involvement

A process aligned with each resident’s preferences is in place to contact family to communicate progress

Partner with

families in all aspects

of residents’

care

Flexible, 24-hour, resident-directed visiting hours

What are the PCC criteria?

V. Nutrition Program

24-hour access to a variety of foods & beverages

Fresh, healthy food at

appropriate temperatures, & a variety of food

choices

Residents have

opportunities to participate

in meal planning

What are the PCC measures?

Quality Profile (QP) includes quantitative metrics for evaluating an organization’s performance with regard to important elements of PCC as identified in the literature and from providers

◦QP to be completed on last Friday of month

What are the PCC measures?

The measures, like the criteria, are designed to teach and to motivate, not merely to avoid lapses in quality

◦They beckon affiliates to rise up to the challenge and to reach for excellence

◦Some measures relate to specific criteria, and some are more global (e.g., relating to org. health)

Criterion

A multi-disciplinary task force is established to oversee and assist with implementation and maintenance of patient-/resident-centered practices, which includes a mix of non-supervisory and management staff, including a combination of clinical and non-clinical staff, and meets regularly (every 4-6 weeks) on an ongoing basis. In continuing care environments, this task force also includes residents and family members.

Measure

Numerator: Cumulative meetings this year Denominator: Data month (1-12)

Criterion

Processes are in place for evaluating, identifying and effectively integrating into the care plan what is important to each resident, based on his/her identity, decision-making ability, and mastery skills, and what is meaningful to that resident in the living environment and in daily activities.

Measure

% of care plans completed in which the resident participated

Criterion

A model of care delivery or work design is adopted that embraces continuity, consistency and accountability-based care, and allows staff the opportunity and responsibility for personalizing care in partnership with each patient/resident.

Measure

% of care plans completed in which a CNA participated

Criterion

A comprehensive formalized approach for partnering with families in all aspects of the patient’s/ resident’s care, and tailored to the needs and abilities of the organization and its facility, is developed. An example is a Care Partner Program.

Measure

% of care plans in which families participated

Criterion

Residents are given an opportunity to participate, as appropriate, in a retreat experience or an equivalent to assist with internalizing resident-centered care concepts and to enhance sensitivity to the needs of the entire community. Resident retreats are conducted at a minimum annually.

Measure

% of residents that have completed the retreat

Criterion

A flexible transportation system is provided that enables residents to satisfy personal wishes, to participate in off-site activities and to volunteer.

Measure

% of residents (who are not unable to leave site due, for instance, to health) participating in off-site activities promoting personal growth, such as volunteering, political or religious activities, arts and leisure, etc

Criterion

Leadership includes approaches that motivate and inspire others, promote positive morale, mentor and enhance performance of others, recognize the knowledge and decision-making authority of others and model organizational values.

Measure% of supervisors that are specifically trained to mentor on the person-centered approach.

Criterion

All staff, including off-shift, part-time, prn, providers and support staff are given an opportunity to participate in a minimum of eight hours of patient-/resident-centered staff retreat experiences or an equivalent, with a minimum concurrent completion rate of 85%.

Measure % of staff that have completed the retreat

Criterion

Continuing education to reinforce and revitalize staff engagement in patient-/resident-centered behaviors and practices and build competence around the community’s evolving needs is offered on an ongoing basis to all staff in meaningful ways determined by the organization.

Measure

Numerator: # of staff who have been participated in advanced training opportunities

Denominator: Total # of staff

Criterion

Residents’ wellness needs are approached holistically. Examples include the provision of wellness programs, such as nutrition counseling and stress management and implementation of (or access to) programs that support residents in chronic disease management. Residents have convenient access to physical and mental fitness opportunities, as well as to podiatry, vision, hearing, and dental services, and psychological and pharmaceutical consultation.

Measure

% of residents that participated in one or more organized wellness activities

Additional PCC measures

Measures broadly related to PCC, but not tied to specific criteria

Concept Measure

Staff Empowerment

% of new employee interviews in which line staff participate (dietary, housekeeping, CNA)

Resident Empowerment

% of CNA hiring decisions made in which a resident participated

Resident Health & Wellness

% of residents that participated in one or more organized wellness activities

Concept Measure

End of Life Care

% of residents with advance care wishes documented

End of Life Care

% of residents who died in place (not transferred to hospital in the 7 days prior to death)

Emotional Support Services

# of events for residents that specifically and primarily address topics of loss (e.g., loss of mobility/driving, vision or hearing; grief management; mental status changes; incontinence)

Concept Measures

Consistent Care

% of nursing shifts (RN, LPN, CNA) covered by agency staff

% of staff consistently assigned to the same residents (Advancing Excellence measure)

Turnover of staff•Voluntary•Involuntary

Absenteeism: %of nursing staff who did not report to work as scheduled

Concept(s) Measure

Organizational Stability Tenure of DON(s)

Organizational Stability Tenure of Administrator(s)

Organizational Stability & Consistent Care

Tenure of nursing staff (average months of service of all nursing staff)

Concept Measure

Organizational Health

Occupancy rate (Census): % of units/apartments that are occupied

Organizational Health # of vacant positions

Organizational Health # of staff injuries

Summary

Person-centered care criteria established through review of literature and provider experiences and views

Multi-method system for evaluating person-centered care established

Quantitative instrument for measuring person-centered care established

Next Steps

Identify sites to formally pilot measures

◦Provide sites data collection measurement guides (e.g., worksheets for measures)

◦Provide sites mentoring in data use

Test measurement instrument

◦Validity, Reliability, Harmonization/Transportability

For guidance in achieving person-centered care, the Long Term Care Improvement Guide is available for free download at

http://www.planetree.org

Questions: mlepore@planetree.org