FY 2019 Annual Performance Plan and Report - Goal 3 Objective 4

Fiscal Year 2019
Released April, 2018

Goal 3. Objective 4:  Maximize the independence, well-being, and health of older adults, people with disabilities, and their families and caregivers

Older adults and people with disabilities face a complex set of difficulties. About one in every seven, or 14.9 percent, of the population is an older American.  Approximately 12 percent of working-age adults in the United States have some type of disability.  Of these adults, 51 percent had a mobility disability, and 38.3 percent had a cognitive disability.

To support older adults, people with disabilities, and the system of friends, family, and community members that support them, the Department collaborates across the Federal Government, with States, Tribes, and territories, and with faith-based and community organizations.  Aging and Disability Resource Centers provide a gateway to a broad range of services and supports for older adults and people with disabilities.  Centers for Independent Living are community-based centers that offer services to empower and enable people with disabilities to stay in their communities. Every State and territory has an Assistive Technology Act program that can help people find, try, and obtain assistive technology devices and services. Assistive technology includes resources ranging from “low tech” helping tools—like utensils with big handles—to higher-tech solutions like talking computers.

The Department also supports caregivers of older Americans and Americans living with disabilities. At least 90 percent of older adults receiving help with daily activities receive some form of unpaid care, and about two-thirds receive only unpaid care. In 2011, an estimated 18 million unpaid caregivers provided 1.3 billion hours of care on a monthly basis to Medicare beneficiaries age 65 and over.

The Office of the Secretary leads this objective.  The following divisions are responsible for implementing programs under this strategic objective: ACF, ACL, CDC, CMS, HRSA, IHS, OASH, and SAMHSA.

Objective 3.4 Table of Related Performance Measures

Demonstrate improvement in health care quality of participating Medicare and Medicaid one-star nursing homes (Lead Agency - CMS; Measure ID - QIO7.2)
Measure FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Target N/A N/A N/A N/A Set Baseline N/A 6.0 5.0
Result N/A N/A N/A N/A 8.0% Oct 31, 2018 Oct 31, 2019 Oct 31, 2020
Status N/A N/A N/A N/A Baseline Historic Actual Pending Pending

More than 3 million Americans rely on services provided by nursing homes each year. There are 1.4 million Americans who reside in the nation’s 15,600 nursing homes on any given day.  Those individuals, and an even larger number of their family members, friends, and relatives, must be able to count on nursing homes to provide reliable, high-quality care.  Current law requires CMS to develop a strategy that will guide local, state and national efforts to improve the quality of care in nursing homes.  The most effective approach to ensure quality is one that mobilizes and integrates all available tools and resources – aligning them in a comprehensive, actionable strategy.

In December 2008, CMS added a star rating system to the Nursing Home Compare website.  This rating system serves three purposes: 1) to provide residents and their families with an assessment of nursing home quality, 2) to make a distinction between high and low performing nursing homes, and 3) to provide incentives for nursing homes to improve their performance.  The one-star rating is the lowest rating and the five star rating is the highest.  CMS tracks nursing home care quality using this rating system.

The Quality Innovation Network-Quality Improvement Organization (QIN-QIO), via recruitment of nursing homes and other activities, shall support the creation of a National Nursing Home Quality Care Collaborative (NNHQCC).  The purpose of the NNHQCC is to ensure, along with its partners, that every nursing home resident receives the highest quality of care.  Specifically, the QIN-QIO shall support the Collaborative’ s objective to “instill quality and performance improvement practices, eliminate health care acquired conditions, and improve resident satisfaction.”  Although the QIN-QIO recruited nursing homes with an existing star status, all nursing homes or facilities providing long-term care services to Medicare beneficiaries are eligible and encouraged to participate in the Collaborative.

One-star nursing homes face specific challenges, including lack of understanding of quality improvement processes; lack of resources to implement the processes; poor understanding of the data for use in improvement; lack of consistent leadership; and perhaps lower resident and family engagement.  Participation in the NNHQCC entails peer-to-peer learning activities in an “all \teach/all learn” environment involving virtual, face-to-face meetings, and quality improvement activities which help guide the nursing home to engage in the use of facility- specific data for rapid-cycle quality improvement activities, such as Plan-Do-Study Act (PDSA) cycles, to instill systems-level improvement in the individual nursing home.  There are two collaborative time periods, and recruitment goals are measured at the start of each collaborative.  Continued engagement in collaborative activities is monitored throughout the life of each collaborative via the facilities’ individual quality and outcome measures, such as the decreased use of antipsychotic medication in residents with dementia.

The one-star recruitment measure will assess the ability of the QIN-QIO to gain participation in peer-to-peer quality improvement activities, measured by the percentage increase of one-star nursing homes participating in the NNHQCCs through 2018.  Participation would therefore ensure safer care received by Medicare beneficiaries residing in the lowest performing nursing homes.  While CMS plans to begin with measuring participation in the early years of the project, the goal is to move toward measuring improvement utilizing the Quality domain of the Five Star Rating system of each participating nursing home as the project matures.

The QIN-QIOs exceeded the recruitment goal of 50 percent by recruiting 72 percent of the total One-Star Category Target Number (SCTN) in the Collaborative I time period.  With the re-balancing of the Medicare.gov 5-Star Rating system effective February 20, 2015, one-star homes continued to be recruited by QIN-QIOs as part of Collaborative II in the NNHQCC.  For both Collaborative I and II combined, the QIN-QIOs recruited more than 100 percent of the SCTN for the 11th Statement of Work (SOW).

The measure “quality improvement in one star nursing homes” (C.7.2) tracks the change in the percentage of nursing homes with a one-star quality rating over time.  CMS monitors quality improvement progress generated at the national, QIN-QIO, and nursing home levels using the quality domain of the Five Star Rating system.  The total quality score is one of three domains within CMS’ Five Star Rating system, which also rates facilities based on inspections and staffing ratios.  As of January 2017, the total quality score is based on data for 13 quality measures for short and long-stay residents derived from the Minimum Data Set and 3 claims based measures for short-stay residents, Nursing Home Compare Five-Star Quality Rating System: Technical User's Guide.  The QIO program is focusing on the quality domain because of its capacity to influence this specific domain most effectively.

Nursing homes participating in the NNHQCC focus on processes that improve their systems and measure individual tests of change.  Specifically, nursing homes look at their PDSA improvement cycle results, clinical outcomes measures such as falls with major trauma, and measures of quality improvement.  Nursing homes participating in the NNHQCC are encouraged to improve quality as a whole rather than focus on anyone measure.  Therefore, the 16 measure total quality score appropriately reflects general quality improvement.  A reduction in the percentage of homes that receive the lowest quality score would indicate progress in the hardest to reach nursing homes.

Decrease the percentage of long-stay nursing home residents receiving an antipsychotic medication (Lead Agency - CMS; Measure ID - MSC5)
Measure FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Target N/A 20.3% 19.1% 17.9% 16.7% 16% 16% 15.5%
Result 19.8% 20.3% 19.1% 17.1% 16.7% Mar 31, 2018 Feb 28, 2019 Feb 28, 2020
Status Historic Actual Target Met Target Met Target Exceeded Target Met Pending Pending Pending

The purpose of including this measure as a CMS performance measure is to decrease the use of antipsychotic medications in nursing homes with emphasis on improving dementia care.  These medications have common and dangerous side effects when used for the behavioral and psychological symptoms of dementia.

In 2012, CMS began a nationwide initiative - the Partnership to Improve Dementia Care in Nursing Homes – to improve dementia care and reduce the use of antipsychotic medications.  CMS staff have been working with partners, including state coalitions, provider associations, nursing home resident advocates, and stakeholders to decrease the use of these drugs.  Some of this work includes developing and conducting trainings for nursing home providers, surveyors, and consumers; conducting research; raising public awareness; using regulatory oversight; improving surveyor guidance; conducting focused dementia care surveys in selected states; and by public reporting to increase transparency.  CMS hopes to enhance person-centered care for all nursing home residents, particularly those with dementia-related behaviors.

A number of evidence-based non-pharmacological interventions and approaches have been reviewed by national scientists and thought leaders through the National Partnership to Improve Dementia Care.  These have been incorporated into clinical practice guidelines and various tools and resources and are now posted on the Advancing Excellence website (in the public domain) at www.nhqualitycampaign.org.  State Coalitions are reaching out to providers in every state and encouraging the use of these resources, as well as Hand in Hand, the training for nursing home staff developed by CMS.  A number of meta-analyses have reviewed the use of non-pharmacological approaches to behaviors in people with dementia.  Studies have shown that these interventions may be effective in reducing behaviors associated with dementia that may be distressing to residents or families.22

Person-centered care is an approach to care that focuses on residents as individuals and supports caregivers working most closely with them.  It involves a continual process of listening, testing new approaches, and changing routines and organizational approaches in an effort to individualize and de-institutionalize the care environment.  Person-centered care is the central theme of the Hand in Hand training.

In July 2012, CMS began posting on the Nursing Home Compare website quality measures of antipsychotic use in long-stay and short-stay nursing home residents, excluding residents with schizophrenia, Tourette’s syndrome, or Huntington’s disease.  In 2015, CMS added the quality measures to the Five-Star Quality Rating System on the website.

CMS reports the prevalence of antipsychotic use in the last three months of the fiscal year.  The numerator consists of long-stay residents receiving an antipsychotic medication on the most recent assessment.  The denominator is all long-stay nursing home residents, excluding residents with schizophrenia, Tourette’s syndrome, or Huntington’s disease.  Residents are considered to be long-stay residents if they have resided in the nursing home for 101 or more days.  The baseline number reflects the prevalence of use in the last quarter of CY 2011.  It was selected because it was the last quarter in the pre‑intervention period.

The CY 2012-2013 goal represented approximately a 15 percent reduction in prevalence from the baseline.  The goals for succeeding years represent an additional 5 percent reduction each year.  The resulting CY 2016 goal represents a 30 percent reduction from the baseline, for a prevalence rate of 16.7 percent or lower by the end of the CY.  Prior to the CMS and National Partnership intervention in CY 2012, the prevalence rates had consistently risen each quarter. In January 2015 the Government Accountability Office affirmed that CMS had made clear progress in reducing antipsychotic use in nursing homes, and recommended that HHS undertake similar efforts in settings beyond nursing homes (such as assisted living and home and community-based environments). CMS met its CY 2016 goal.

CMS continues to have quarterly national calls with the public on aspects of good dementia care and the use of non-pharmacological approaches.  CMS is conducting focused dementia care surveys on those facilities that continue to have high rates of antipsychotic use, and has modified the regulations limiting the use of antipsychotic medications on an as needed basis.

Improve dementia capability of long-term support systems to create dementia-friendly, livable communities (Lead Agency ACL; Measure ID – ALZ.3)
Measure FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Target N/A N/A N/A N/A N/A Baseline N/A TBD
Result N/A N/A N/A N/A N/A January 1, 2019 January 1, 2020 January 1, 2021
Status N/A N/A N/A N/A N/A Pending Pending Pending

The effects of Alzheimer’s Disease and Related Dementias (ADRD) are devastating for individuals living with the disease and their family caregivers.  Serving people with ADRD typically requires significant levels of health care as well as the provision of person-centered, dementia-capable home and community-based services (HCBS).  Of the community dwelling individuals with ADRD, approximately one-third live alone, exposing them to numerous risks, including unmet needs, malnutrition and injury and various forms of neglect and exploitation.23 As the number of people with ADRD is projected to grow by almost 300% by 205024 from an estimated 5.3 million individuals, it is important to develop effective and coordinated service delivery and health care systems that are responsive to these individuals and their caregivers.

Establishing enhanced dementia capable HCBS systems designed to meet the needs of formal and informal caregivers of individuals with ADRD is critical to helping caregivers to continue to provide care and improving the care that individuals with ADRD receive. ACL’s Alzheimer’s Disease Program provides funding for the development and implementation of these person-centered systems of services and supports partnerships with public and private entities to identify and address the unique needs of persons with ADRD and their caregivers.

ACL has developed a new indicator to measure the Program’s success at improving the dementia capability of long term services and support systems.  Baseline data collected in FY 2017 will be used to set targets and develop a performance plan for improving results.

As a result of the Protection and Advocacy Program’s individual or systemic advocacy, the percentage of individuals with developmental disabilities whose right to be safe, receive an appropriate education, live in the community, be economically self-sufficient and/or participate in their communities is enforced, retained, restored or expanded (Lead Agency ACL; Measure ID – 8F)
Measure FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Target N/A N/A N/A N/A N/A Baseline N/A TBD
Result N/A N/A N/A N/A N/A January 1, 2019 January 1, 2020 January 1, 2021
Status N/A N/A N/A N/A N/A Pending Pending Pending

People with developmental disabilities are significantly more likely to experience abuse or neglect than their peers without disabilities.  Specifically, with regard to abuse, research indicates that they are four to ten times more likely to be abused than their peers without disabilities.  ACL’s Developmental Disabilities Protection and Advocacy (P&As) programs provide a range of legal services to traditionally unserved or underserved individuals with developmental disabilities to ensure they are protected from abuse and neglect and are able to exercise their rights to make choices, contribute to society, and live independently.  The purpose of this new measure is to increase the success of P&As to promote the rights of individuals with developmental disabilities through individual or systemic advocacy. ACL will use baseline data collected in FY 2017 to set targets and develop its performance plan.

22 Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic Management of Behavioral Symptoms in Dementia. JAMA, November 21, 2012; 308(19): 2020-2029.

23 Gould, E., Maslow, K., Yuen, P., Wiener, J. Providing Services for People with Dementia Who Live Alone: Issue Brief. Accessed April 14, 2014 at http://www.adrc-tae.acl.gov/tiki-index.php?page=adsspkey&filter=key .

24 Alzheimer’s Association. 2017 Alzheimer’s Disease Facts and Figures. Accessed May 9th, 2017 at http://www.alz.org/alzheimers_disease_facts_and_figures.asp .


Content created by Office of Budget (OB)
Content last reviewed