Q&A with Dr. Dana B. Mukamel: Grading the system, players

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Dr. Dana B. Mukamel, who serves as a watchdog over PACE by studying 28 of the 30 programs for frail seniors staying in their communities, is now tackling nursing home report cards. Armed with a grant from the National Institute on Aging, she's investigating and interviewing to uncover whether the scores indeed improve quality – and what administrators can do better.

Q What can you tell us about your study of nursing home quality report cards?

A We have recently received $1.36 million from the National Institute on Aging to examine the strategies that nursing homes have adopted following the publication of the nursing home quality indicators on the Medicare Compare Web site. This is a five-year study that will investigate both short- and long-term responses of nursing homes, to determine if the report card is effective in improving quality of nursing home care.
   At this time, we are fielding a survey of nursing home administrators for a nationally representative sample, asking for their views of the quality indicators and what strategies they adopted. We will also use the MDS data and other sources to help us answer some of the study questions. The study is conducted in collaboration with William Spector, Ph.D., from the Agency for Healthcare Research & Quality, and Jacqueline Zinn, Ph.D., from Temple University.

Q What sort of pre-study hunches or hypotheses do you have concerning this research?

A We expect to find that nursing homes will have adopted a diverse set of strategies. Some of those will be very positive and will contribute to improved quality of nursing home care. For example, some facilities may have increased staffing if the quality indicators suggest that the care they provide is not as good as the care at other facilities in their area. Facilities may restructure job assignment or develop special interventions to improve in areas in which their performance is below par. We are looking forward to learning from facilities about how they view the Medicare reports, where they see their strengths and weaknesses, and what actions have been prompted by the publication.

Q What could your findings and their implications lead to? What do you think is most important for providers in this regard?

A Our findings will offer insights to all those who are seeking to improve nursing home care in this country. They will indicate how useful the Medicare quality indicators are to consumers and to providers.

Q Before we get too far into this, why do you feel report cards are important? What could or will their impact be?

A The hope is that report cards will inform consumers, thus making the demand for nursing home care much more sensitive to quality. This in turn will provide positive market incentives to nursing homes to offer high quality care. Additionally, report cards give nursing homes a way to compare their own performance to other facilities – to "benchmark." Such benchmarks can help facilities focus their quality improvement efforts by highlighting areas where they could be doing better.

Q Can you tell us about the goals and hopes of your PACE project?

A PACE is a very unique program that offers alternatives to frail individuals who are nursing home-certifiable but wish to remain in the community. There are now over 30 such programs around the country and despite their many similarities, we are finding that each PACE program has its own character and practice styles.
In our study (in collaboration with Helena Temkin-Greener from the University of Rochester), we are trying to identify factors that lead to the best health outcomes for program participants. It is basically a study to understand what contributes to excellence. For example, we identify the programs in which participants have relatively slower rates of decline in functional status and we ask 'What is different about these programs?'

Q What is the scope of the study and how do you think it will affect traditional long-term care providers?

A The study includes 28 PACE programs around the country. We have visited all these programs, interviewed the administrators and the clinical management and have collected a lot of clinical information about ea