Government's report card on nursing homes shows improvement.

Leaders of the Quality First initiative and the government-led effort to improve the level of care in nursing homes announced improvements at the nation's 6,400 nursing homes, which care for approximately 1.6 million residents. But the results, released by the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid (CMS) were tempered with the knowledge that there is still much more to accomplish.

Announced by outgoing HHS Secretary Tommy Thompson, the report on the two-year-old Nursing Home Quality Initiative (NHQI) included a call to expand its efforts through further funding of Quality Improvement Organizations (QIOs).

"Nursing home residents have better care and are better off than when we began the program," Thomspon said.

To bolster his point, Thompson related the report's findings on use of restraints and pain management. The reduction in use of restraints, which should only be used when ordered by a physician, and reports of chronic pain were the two primary highlights of the report.

In the two years of the program, use of restraints went from 9.7 percent of nursing home residents on any day in 2002 down to 7.5 percent in 2004. Nursing homes working closely with their QIO improved by 33 percent on average.

Chronic pain among both long term and short term nursing home patients dropped as well. Thompson said the prevalence of chronic pain was down in all 50 states during the past two years, with problems of long term pain decreased 30 percent.

The quality measurement of chronic pain improved every quarter of the two years studied, according to the report.

Those homes that worked intensively with their QIO improved on average by almost 50 percent. For short-stay pain management, the decrease was 11 percent, according to the report. Again, those facilities working with their QIO improved more (18 percent).

Improvements in reports of pressure ulcers still have a ways to go, according to the report, which showed a 2 percent increase. But CMS director Mark McClellan said that among facilities that specifically focused on addressing them, there was an 8 percent decrease.

McClellan noted that the department's popular Nursing Home Compare Web site (www.medicare.gov/NHCompare) will have several improvements made this winter and spring, including following up on previous studies and implementing back-end edits to subject information for confirmation and correction. The site includes data on facilities' care records for both regular and complaint surveys, staffing levels, number and type of residents, ownership information, and Quality Measure scores in comparison to state and national averages.

A pilot program will begin in seven states (Alaska, Idaho, Michigan, Nevada, New Mexico, South Carolina and Wisconsin) to conduct a more thorough background check of direct care workers. Also, even more attention will be given to reduce pressure ulcers, restraints and depression.

Hal Daub, president and chief executive officer of American Health Care Association in Washington, D.C., was pleased with the positive findings, but added, "anything less than progress was unacceptable.... These early results are promising but our members are involved for the long haul."

Later, in a teleconference with members of the press, Daub said the initiative has been the impetus for cultural change in the skilled nursing environment. "At every level of skilled nursing care, people are talking about the initiative," he said. "I hope we can continue to count on the support of the federal government as we move forward."

To John Rother, AARP's director of policy and strategy, the results proved three things in particular worked: that it's important to measure quality; that making such measurements public is valuable; and that the QIO program makes a difference. "We're showing we're learning what we have to do," he said. "It's time we think more about not just regulating the industry but rewarding ... a culture of excellence."

Rother called the public aspect of the quality improvement effort crucial to its success, now and in the future. "When we made these measurements public, then people paid attention."

Katie Sloan, chief operating officer of the American Association for Homes and Services for the Aging (AAHSA), added that staff deserved the most credit for improving the care and lives of elderly residents, and more can be done. "We must constantly refine our quality measures to make sure they best reflect what resident and family members need to know," she said.

Steve Guillard, chair of the Alliance for Quality Nursing Home Care and CEO of Harborside Healthcare in Boston, said he was impressed by the results of the effort and hoped the initiative would stand as a model more facilities follow to "provide true benefit to the frail and elderly ... populations we serve."

The quality improvement program is voluntary, and while officials called for all facilities to address these quality issues, it remains a hope.

Alice Hedt, executive director of the National Citizens Coalition for Nursing Home Reform, based in Washington, D.C., called for more focus on facilities known to be poor performers. "The facilities that have volunteered tend to be the facilities that are eager to improve," she said.

"The nursing home experience in this country for many people is not necessarily a positive one.... We hope this is a start and that the (initiative) will go further."

David Schulke, executive vice president of American Health Quality Association praised the government's effort, "(which) backed the statements it made with money" by hiring the QIOs that assessed the facilities and taught them new ways to work more effectively.

Yet, while the progress "did not succeed beyond all imagination" citing pressure ulcers as an area that needs further improvement, "this was an initiative that should be taken seriously, and nursing homes should give it a try."