Quality-of-care issues exist in all long-term care (LTC) settings, but they are especially pronounced for those with advanced dementia, according to David Grabowski, PhD. The Harvard Medical School professor of health care policy proposed five possible ways to address these issues when he spoke at a Jan. 21 Institute of Medicine (IOM) meeting titled “Policy Issues in Improving Care for People with Advanced Dementia.”
Three barriers to high-quality care for those with advanced dementia include inadequate payment, the limited existence of quality information and fragmentation of care in LTC and healthcare services, Grabowski said.
1. Payment for services. When payment is based on expected use of resources, as it is now, rather than on outcomes or care quality, he said, then the system makes no distinction between providers of quality care and providers of poor care.
Right now, public sources (mainly Medicaid but also Medicare for home healthcare) base payment on a resource utilization group system that pays less for the two categories into which those with advanced dementia typically fall, Grabowski said. “You either get paid based on the individual having impaired cognition…or you get paid based on [him or her] having reduced physical functioning,” he added. “There’s no interaction between the two. I’m a health economist. That doesn’t make sense to me. …It seems like there should be some interaction where if I have impaired cognition and reduced physical functioning, I should require more resources. …That seems intuitive…but there’s no mechanism for that.”
2. Regulation of service providers. The difficulty in measuring quality across various providers makes it tricky to identify good versus poor providers, Grabowski said, adding that such measurement is even more complicated as pertains to advanced dementia.
“The obvious reason: high levels of cognitive impairment,” he said, “but I also think there’s a real lack of availability of family and financial resources in some instances. And…just the urgency of some of those care decisions and how quickly things change.”
Research Grabowski conducted with Susan Mitchell, MD, MPH, found a U-shaped relationship between family oversight and the quality of care provided to nursing home residents with advanced dementia. “When you move from no oversight to having a moderate level of oversight, we actually saw an improvement in quality of care,” he explained. “So as the family began to visit the individual with advanced dementia in the nursing home, quality of care improved.”
When family visits increased and involved a high level of oversight, however, Grabowski said, quality of care decreased. The reason remains elusive, he added, but perhaps families were interfering with care, or maybe family visits increased to a high level because a nursing home had more quality-of-care issues.
3. Fragmentation. Separation in the system of care is magnified for those with advanced dementia, Grabowski said, because they tend to use many more healthcare and LTC services and are transferred from site to site.
“I would argue that part of the reason they’re bouncing around from site to site is that we’re not paying any of the providers in that system to manage their care,” he said. “We’re really paying everybody on a silo basis.”
When Medicaid only pays providers to care for patients/residents in their direct care, Grabowski said, providers are not incentivized to reduce hospitalizations, and Medicaid is not able to realize savings that would come with those reduced hospitalizations. “So ultimately we see advanced dementia patients bouncing around,” he said. “That then flows down to the delivery level. Providers aren’t going to invest in the infrastructure and the expertise to treat individuals in that setting, because they can’t enjoy any of the savings if they prevent a hospitalization, for example.”
System fragmentation also stymies the implementation of innovative programs, Grabowski said. “It’s a payment failure,” he added. Nursing homes “are not incentivized to have those programs. If we pay providers to implement these kinds of programs—reward them for these kind of delivery-level innovations, we’ll see greater sustainability.”
Potential answers to the challenges exist, Grabowski said. Some have shown more promise than others.
1. Increased payment. Improving payment for the care of people with dementia has been shown to influence the quality of care, Grabowski said. Iowa and New York, for instance, have implemented rate add-ons, and some states pay higher rates for dementia special care units. “That’s going to, obviously, encourage that model and also provide potentially higher quality if that’s indeed the case—that special care units are of higher quality,” he said.