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Key Issues in Long-Term Services and Supports Quality

Issue Brief
  1. Omnibus Budget Reconciliation Act of 1987 (OBRA, 1987).  Public Law 100-203. Subtitle C: nursing home reform; Institute of Medicine [IOM], Committee to Study Nursing Home Regulation. (1986). Improving the quality of care in nursing homes.  Washington, DC:  National Academies Press.

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  2. While assisted living is a common licensure term, states use a wide range of terms describing similar facilities such as residential care, board and care homes, adult care homes, domiciliary care homes, and personal care homes.  Carder, P., O’Keeffe, J., & O’Keeffe, C. (2015).  Compendium of Residential Care and Assisted Living Regulations and Policy:  2015 Edition.  Research Triangle Park:  RTI International.  https://aspe.hhs.gov/sites/default/files/pdf/110391/15alcom.pdf.

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  3. Nelson, D., Rohde, D., Lesser, B. and McNeill, R.  (2016). How hospitals, nursing homes keep lethal ‘superbug’ outbreaks secret.  Reuters Investigates.  December 22, 2016.  http://www.reuters.com/investigates/special-report/usa-uncounted-outbreaks/; Gutierrez, M. (2014).  Care-home reforms lose momentum. San Francisco Chronicle.  September 4; Thomas, K.  (2014). Medicare star ratings allow nursing homes to game the system.  New York Times.  August 24. http://www.nytimes.com/2014/08/25/business/medicare-star-ratings-allow-nursing-homes-to-game-the-system.html?emc=edit_th_20140825&nl=todaysheadlines&nlid=41627184; PBS News Hour Frontline, Thompson, A.C., Propublica and Jones, J.  (2013). Investigation finds patterns of problems for elder care in assisted living.  July 30.   Life and death in assisted living.  October 29.  http://www.pbs.org/wgbh/pages/frontline/social-issues/life-and-death-in-assisted-living/elderly-at-risk-and-haphazardly-protected/; Hakim, D. and Buettner, R. (2011).  In state care, 1,200 deaths and few answers, New York Times, 5 November, http://www.nytimes.com/2011/11/06/nyregion/at-state-homes-simple-tasks-andfatal-results.html?pagewanted=all&_r=0; Duhigg, C. (2007).  At many homes, more profit and less nursing.  New York Times, (September, 23). http://www.nytimes.com/2007/09/23/business/23nursing.html?mcubz=0

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  4. U.S. Office of the Inspector General (US OIG). (2017). Early alert: The Centers for Medicare & Medicaid Services has inadequate procedures to ensure that incidents of potential abuse or neglect at skilled nursing facilities are identified and reports in accordance with applicable requirements. A-01-17-00504, August. https://oig.hhs.gov/oas/reports/region1/11700504.asp; U.S. Office of the Inspector General (US OIG). (2014).  Adverse events in skilled nursing facilities:  National incidence among Medicare beneficiaries.  OEI-06-11-00370.  February. https://oig.hhs.gov/oei/reports/oei-06-11-00370.asp; U.S. Office of the Inspector General (US OIG).  (2013). Medicare nursing home resident hospitalization rates merit additional monitoring.  OEI-06-11-00040. November. https://oig.hhs.gov/oei/reports/oei-06-11-00040.pdf; U.S. Office of the Inspector General (US OIG).  (2014). Nursing facilities’ compliance with federal regulations for reporting allegations of abuse or neglect. OEI-07-13-00010t August. https://oig.hhs.gov/oei/reports/oei-07-13-00010.pdf; Hawes, C., and Phillips, C.D. (2000).  A national study of assisted living for the frail elderly:  A final summary report:  Washington, DC: US Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/daltcp/reports/finales.htm.

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  5. California Advocates for Nursing Home Reform (2013).  Residential care in California: Unsafe, unregulated & unaccountable.  San Francisco, CA: CANHR. http://www.canhr.org/reports/Residential_Care_in_California.pdf; Wiener, J.M., Freiman, M.P. and Brown, D. (2007).  Nursing home quality: Twenty years after the Omnibus Budget Reconciliation Act of 1987.  Report Prepared by RTI International.  Washington, DC: The Henry J. Kaiser Family Foundation.

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  6. Centers for Medicare & Medicaid Services (CMS). (2016). Minimum data set 3.0 RAI manual.  http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Saliba, D., Jones, M., Streim, J., Ouslander, J., Berlowitz, D. and Buchanan, J.  (2012).  Overview of significant changes in the minimum data set for nursing homes Version 3.0.  J. American Medical Directors Association, 13 (7):595-601.

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  7. Centers for Medicare & Medicaid Services. (2017). Medicare nursing home compare. http://www.medicare.gov/NursingHomeCompare/search.aspx?bhcp=1

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  8. Centers for Medicare & Medicaid Services (CMS). (2017). Design for nursing home compare:  five-star quality rating system: users guide.  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/usersguide.pdf.

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  9. Mukamel, D.B., Weimer, D.L., Harrington, C., Spector, W.D., Ladd, H., and Li, Y. (2012). The effect of state regulatory stringency on nursing home quality. Health Services Research, 47(5):1791-813.

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  10. Centers for Medicare & Medicaid Services (CMS). (2017) Hospice Compare website. https://www.medicare.gov/hospicecompare/

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  11. Ibid.

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  12. Centers for Medicare & Medicaid Services. (2017). Medicare home health compare. http://www.medicare.gov/homehealthcompare/search.html;  https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/OASIS-Data-Sets.html

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  13. Administration for Community Living (2017).  Long-Term Care Ombudsman Program. https://www.acl.gov/programs/protecting-rights-and-preventing-abuse/long-term-care-ombudsman-program; Consumer Voice (2017). History of the ombudsman program.  http://ltcombudsman.org/about/about-ombudsman/program-history

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  14. Han, X., Yaraghi, N., and Gopal, R. (2016). Five-star ratings for sub-par service: evidence of inflation in nursing home ratings. Governance Studies. Washington, DC: Brookings, December. https://www.brookings.edu/wp-content/uploads/2016/12/gs_20161213_nursing-homes.pdf

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  15. Centers for Medicare & Medicaid Services (CMS). (2016). New quality measures on Nursing Home Compare.  April 27, 2016. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-27.html

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  16. Harrington, C., Carrillo, H., and Garfield, R. (2017).  Nursing facilities, staffing, residents and facility deficiencies, 2010 through 2015.  The Kaiser Commission on Medicaid and the Uninsured. August. http://files.kff.org/attachment/REPORT-Nursing-Facilities-Staffing-Residents-and-Facility-Deficiencies-2009-2015

     

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  17. Ibid.; Harrington, C., Carrillo, H., Dowdell, M. Tang, P.P. and Blank, B.W. (2011).  Nursing facilities, staffing, residents and facility deficiencies, 2005 Through 2010. San Francisco, CA: University of California, Department of Social and Behavioral Sciences. http://theconsumervoice.org/uploads/files/issues/OSCAR-2011-final.pdf

     

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  18.  U.S. Office of the Inspector General (US OIG).  (2014). Adverse events in skilled nursing facilities:  National incidence among Medicare beneficiaries.  OEI-06-11-00370.  February.  Washington, DC: OIG; https://oig.hhs.gov/oei/reports/oei-06-11-00370.asp

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  19.   U.S. Office of the Inspector General (US OIG).  (2013).  Medicare nursing home resident hospitalization rates merit additional monitoring.  OEI-06-11-00040. November. https://oig.hhs.gov/oei/reports/oei-06-11-00040.pdf; Walsh, E. G., Wiener, J. M., Haber, S., Bragg, A., Freiman, M., & Ouslander, J. G. (2012). Potentially avoidable hospitalizations of dually eligible Medicare/Medicaid beneficiaries from nursing facility and home and community-based services waiver programs. Journal of the American Geriatric Society, 60(5), 821–829

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  20. Harrington, C., Carrillo, H., and Garfield, R. (2017).  Nursing facilities, staffing, residents and facility deficiencies, 2010 through 2015.  The Kaiser Commission on Medicaid and the Uninsured. Augusthttp://files.kff.org/attachment/REPORT-Nursing-Facilities-Staffing-Residents-and-Facility-Deficiencies-2009-2015.

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  21. Centers for Medicare & Medicaid Services (CMS). (2016). Nursing home data compendium 2015 edition.  Baltimore, MD: CMS. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareMedicaidStatSupp/index.html.

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  22. Centers for Medicare & Medicaid Services (CMS). (2016). Nursing home penalty data 2014-2016.  Baltimore, MD: CMS. https://data.medicare.gov/Nursing-Home-Compare/Penalty-Counts/t8q7-k6ku Accessed December 23.

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  23. Mor, V., Zinn, J, Angelelli, J., Teno, J.M., and Miller, S.C. (2004).  Driven to tiers: socio-economic and racial disparities in the quality of nursing home care.  Milbank Quarterly. 82 (2): 227-56.

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  24. Ibid.

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  25. Li, Y., Harrington, C., Temkin-Greener, H., Cen, X., Cai, X., and Mukamel, D.B. (2015). Deficiencies in care at nursing homes and in racial/ethnic disparities across home fell, 2006-11.  Health Affairs. 34(7): 1139-46; Li, Y., Harrington, C., Mukamel, D.B., Cen, X., Cai, X., and Temkin-Greener, H. (2015). Nurse staffing hours at nursing homes with high concentrations of minority residents, 2001-11.  Health Affairs. 34(12): 2129-2137; Smith, D.B., Feng, Z., Fennell, M.L., Zinn, J.S., Mor, V. (2007). Separate and unequal: Racial segregation and disparities in quality across U.S. nursing homes.  Health Affairs (Millwood). 26 (5): 1448-58.

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  26. Comondore, V.R., P.J. Devereaux, Q. Zhou, S.B. Stone, et al., (2009).  Quality of care in for-profit and not-for-profit nursing homes: Systematic review and meta-analysis. British Medical Journal, 339:b 2732; Hillmer, M.P., Wodchis, W.P., Gill, S.S., Anderson, G.M. and Rochon, P.A. (2005).  Nursing home profit status and quality of care: Is there any evidence of an association? Medical Care Research and Review. 62 (2):139-166.

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  27. Harrington, C., Olney, B, Carrillo, H., and Kang, T. 2012. Nurse staffing and deficiencies in the largest for-profit chains and chains owned by private equity companies. Health Services Research, 47 (1), Part I: 106-128; U.S. Government Accountability Office (US GAO). (2011).   Private investment homes sometimes differed from others in deficiencies, staffing, and financial performance. GAO-11-571. http://www.gao.gov/products/GAO-11-571; U.S. Government Accountability Office (US GAO). (2009). CMS’s special focus facility methodology should better target the most poorly performing homes, which tended to be chain affiliated and for-profit.  GAO-09-689.

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  28. Grabowski, D.C., Feng, Z., Hirth, R., Rahman, M., and Mor, V. (2013). Effect of nursing home ownership on the quality of post-acute care: An instrumental variables approach. J. of Health Economics, 14; 32(1):12-21.

     

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  29. Harrington, C., Carrillo, H., and Garfield, R. (2017).  Nursing facilities, staffing, residents and facility deficiencies, 2010 through 2015.  The Kaiser Commission on Medicaid and the Uninsured. August http://files.kff.org/attachment/REPORT-Nursing-Facilities-Staffing-Residents-and-Facility-Deficiencies-2009-2015; Harrington, C., Carrillo, H., Wellin, V., and Shemirani, B.B. (2002).  Nursing facilities, staffing, residents and facility deficiencies, 1996 Through 2001. San Francisco, CA: University of California, Department of Social and Behavioral Sciences.

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  30. Harrington, C., Schnelle, J.F., McGregor, M., and Simmons, S.F. (2016).  The need for higher minimum staffing standards in U.S. nursing homes. Health Services Insights. 9: 13-19; Centers for Medicare & Medicaid Services (CMS).  (2001). Appropriateness of minimum nurse staffing ratios in nursing homes. Report to Congress: Phase II Final. Volumes I to III. Baltimore: CMS (prepared by Abt Associates).

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  31. Dellefield, M.E., Castle, N. G., McGilton, K.S., & Spilsbury, K. (2015). The relationship between registered nurses and nursing home quality: An integrative review (2008-2014). Nursing Economics, 33 (2):95-108 and 116; Castle, N. (2008). Nursing home caregiver staffing levels and quality of care: A literature review.  Journal of Applied Gerontology, 27: 375-405; Bostick, J.E., Rantz, M.J., Flesner, M.K. and Riggs, C.J. (2006). Systematic review of studies of staffing and quality in nursing homes. J. American Medical Director Association, 7:366-376; Institute of Medicine (IOM), Committee on the Work Environment for Nurses and Patient Safety.  (Page, A. [Ed.]). (2003). Keeping patients safe. Washington, DC: National Academies Press.

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  32. Bowblis, J.R. (2011). Staffing ratios and quality: An analysis of minimum direct care staffing requirements for nursing homes. Health Services Research, 46(5): 1495-516; Harrington, C., Swan, J.H., and Carrillo, H. (2007).  Nurse staffing levels and Medicaid reimbursement rates in nursing facilities.  Health Services Research, 42: 1105-1129; Mueller, C., Arling, G., Kane, R., Bershadsky, J., Holland, D., & Joy, A.  (2006).  Nursing home staffing standards:  Their relationship to nurse staffing levels.  The Gerontologist, 46 (1):74-80; Park, J., & Stearns, S.C. (2009).  Effects of state minimum staffing standards on nursing home staffing and quality of care. Health Services Research, 44(1), 56–78; Tong, P.K. (2011).  The effects of California minimum nurse staffing laws on nurse labor and patient mortality in skilled nursing facilities.  Health Economics, 20:802-816.

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  33. Bostick, J.E., Rantz, M.J., Flesner, M.K. and Riggs, C.J. (2006). Systematic review of studies of staffing and quality in nursing homes.  J. American Medical Director Association, 7:366-376; Castle, N.  (2008). Nursing home caregiver staffing levels and quality of care: A literature review. Journal of Applied Gerontology, 27: 375-405; Dellefield, M.E., Castle, N.G., McGilton, K.S., & Spilsbury, K. (2015).  The relationship between registered nurses and nursing home quality: An integrative review (2008-2014).  Nursing Economics, 33 (2):95-108 and 116; Schnelle, J. F., Simmons, S. F., Harrington, C., Cadogan, M., Garcia, E. & Bates-Jensen, B. (2004).  Relationship of nursing home staffing to quality of care? Health Services Research, 39(2), 225-250.

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  34. Institute of Medicine (IOM), Committee on the Work Environment for Nurses and Patient Safety. (Page, A. [Ed.]).  (2003).  Keeping patients safeWashington, DC: National Academies Press; Castle, N., & Engberg, J.  (2008).  Further examination of the influence of caregiver staffing levels on nursing home quality.  Gerontologist, 48: 464-76.

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  35. Omnibus Budget Reconciliation Act of 1987 (OBRA, 1987).  Public Law 100-203. Subtitle C: nursing home reform, Washington, D.C., December 22, 1987.

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  36. Harrington, C., Kovner, C., Kayser-Jones, J., Berger, S., Mohler, M., Burke R. et al. (2000). Experts recommend minimum nurse staffing standards for nursing facilities in the United States.  The Gerontologist, 40 (1):1-12; Institute of Medicine [IOM], Committee on the Work Environment for Nurses and Patient Safety. (Page, A. [Ed.]). (2003). Keeping patients safe. Washington, DC: National Academies Press; American Nurses’ Association (2014). Nursing staffing requirements to meet the demands of today’s long term care consumer recommendations from the Coalition of Geriatric Nursing Organizations (CGNO).  Position Statement 11/12/14. www.nursingworld.org; Coalition of Geriatric Nursing Organizations (CGNO). (2013). Nursing staffing requirements to meet the demands of today's long-term care consumer recommendations. https://hign.org/sites/hartford/files/policy/partnerships/cgno/CGNO%20Nurse%20Staffing%20seven%20orgs_2014.pdf.

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  37. Centers for Medicare & Medicaid Services (CMS).  (2001). Appropriateness of minimum nurse staffing ratios in nursing homes. Report to Congress: Phase II Final. Volumes I to III. Baltimore: CMS (prepared by Abt Associates) http://theconsumervoice.org/uploads/files/issues/CMS-Staffing-Study-Phase-II.pdf;

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  38. Schnelle, J. F., Simmons, S. F., Harrington, C., Cadogan, M., Garcia, E. & Bates-Jensen, B. (2004).  Relationship of nursing home staffing to quality of care? Health Services Research, 39(2), 225-250

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  39. Abt Associates Inc.  (2011). Nursing home staffing study TEP presentation.  Prepared for the CMS Medicare Nursing Home Compare 5-Star TEP Panel.  Durham, North Carolina: October 11.

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  40. Schnelle, J.F., Schroyer, L.D., Saraf, A.A., and Simmons, S.F. (2016).  Determining nurse aide staffing requirements to provide care based on resident workload: A discrete event simulation model.  J. American Medical Directors Association.  17:970-977.

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  41. Centers for Medicare & Medicaid Services (CMS).  (2001). Appropriateness of minimum nurse staffing ratios in nursing homes. Report to Congress: Phase II Final. Volumes I to III. Baltimore: CMS (prepared by Abt Associates). http://theconsumervoice.org/uploads/files/issues/CMS-Staffing-Study-Phase-II.pdf

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  42. Wells, J., & Harrington, C. (2013).  Implementation of Affordable Care Act provisions to improve nursing home transparency and quality.  Kaiser Commission on Medicaid and the Uninsured: Washington, DC.  https://www.kff.org/medicare/upload/8406.pdf

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  43. Centers for Medicare & Medicaid Services. (2017). Staffing Data Submission PBJ.  Baltimore, MD:  CMS.  https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html.

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  44. Centers for Medicare & Medicaid Services. (2016). SNF quality reporting program (IMPACT Act 2014). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-IMPACT-Act-2014.html.

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  45. Centers for Medicare and Medicaid Services (CMS). (2017) Hospice Compare website. https://www.medicare.gov/hospicecompare/

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  46. Ibid.

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  47. Broyles, I, Li, Q., Zheng, T., Frank, J., Sherif, N., Rokoske, F. (2016). The Emerging Picture of Quality of Care in Hospice. RTI International. Issue Brief, June. https://www.rti.org/sites/default/files/rti_issue_brief_hospice_quality_care.pdf;  Medicare program; 2017 hospice wage index and payment rate update and hospice quality reporting.   https://www.federalregister.gov/documents/2016/08/05/2016-18221/medicare-program-fy-2017-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting; See also CMS Hospice certification regulations. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_m_hospice.pdf.

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  48. Ibid.; Teno, J.M., Plotzke, M., Gozalo, P., and Mor, V. (2014). A national study of live discharges from hospice. Palliative Medicine. 17(10):1121-27.

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  49. RTI International. (2016).  Hospice quality reporting program:  HIS-based quality measures annual testing executive summary.  Prepared for CMS. Baltimore, DC: October 2016. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Downloads/HQRP-HIS-Based-QMs-Annual-Testing-Executive-Summary-October-2016.pdf;  Price, R.A., Parast, L., Haas, A., Teno, J.M., and Elliott, M.N. (2017).  Black and Hispanic patients receive hospice care similar to that of white patients when in the same hospice.  Health Affairs. 36(7):1283-1290.

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  50. Centers for Medicare and Medicaid Services (CMS). (2017) Home Health Compare website. https://data.medicare.gov/data/home-health-compare

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  51. Ibid.

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  52. Centers for Medicare and Medicaid Services (CMS). (2017) Home Health Compare website. http://www.medicare.gov/homehealthcompare/search.html

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  53. Ibid.

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  54. Ibid.

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  55. Cabin, W., Himmelstein, D.U., Siman, M.L., and Woolhandler.  (2014). For-profit Medicare home health agencies’ costs appear higher and quality appears lower compared to nonprofit agencies.  Health Affairs.  33(8):1460-1465.

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  56. Ibid.

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  57. Grabowski, D.C., Stevenson, D.G., and Keating, N.L. (2009).  Ownership status and home health care performance.  J. of Aging & Social Policy.  21:130-143.

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  58. Carder, P., O’Keeffe, J, and O’Keeffe, C., RTI International (2015). Compendium of residential care and assisted living regulations and policy: 2015 edition.  US Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation.  https://aspe.hhs.gov/basic-report/compendium-residenial-care-and-assisted-living-regulations-and-policy-2015-edition;   Hawes, C., and Phillips, C.D. (2000).  A national study of assisted living for the frail elderly:  A final summary report:  Washington, DC: US Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/daltcp/reports/finaleshtm

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  59. A Place for Mom (2017). State guide to assisted living records and reports.  http://www.aplaceformom.com/assisted-living-state-licensing

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  60. Khatutsky G, Ormond C, Wiener JM, Greene AM, Johnson R, Jessup EA, Vreeland E, Sengupta M, Caffrey C, Harris-Kojetin L. (2016). Residential care communities and their residents in 2010: A national portrait. DHHS Publication No. 2016-1041. Hyattsville, MD: National Center for Health Statistics. Available at:  https://www.cdc.gov/nchs/data/nsrcf/nsrcf_chartbook.pdf.

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  61. Ibid.

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  62. Khatutsky, G., Wiener, J.M., Greene, A.M., Johnson, R., and O’Keefe, J. (2013).  Do services and staffing in resident care facilities vary with residential needs?  Washington, DC: Assistant Secretary for Planning and Evaluation. July 22.  http://aspe.hhs.gov/daltcp/reports/2013/resneed.shtml;

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  63. Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, US Department of Health and Human Services (2016).  Long-term care providers and services users in the United States: Data from the national study of long-term care providers, 2013-2014. Vital and Health Statistics. 3 (38). Hyattsville, MD. https://www.cdc.gov/nchs/data/series/sr_03/sr03_038.pdf

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  64. Khatutsky G, Ormond C, Wiener JM, Greene AM, Johnson R, Jessup EA, Vreeland E, Sengupta M, Caffrey C, Harris-Kojetin L. (2016). Residential care communities and their residents in 2010: A national portrait. DHHS Publication No. 2016-1041. Hyattsville, MD; National Center for Health Statistics. Available at:  https://www.cdc.gov/nchs/data/nsrcf/nsrcf_chartbook.pdf.  Khatutsky, G., Wiener, J.M., Greene, A.M., Johnson, R., and O’Keefe, J. (2013).  Do services and staffing in resident care facilities vary with residential needs?  Washington, DC: Assistant Secretary for Planning and Evaluation. July 22.  http://aspe.hhs.gov/daltcp/reports/2013/resneed.shtml.

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  65. Brown, R., Carlson, B.L., Dale, S., Foster, L., Phillips, B. and Schore, J.  (2007). Cash and counseling: Improving the lives of Medicaid beneficiaries who need personal care or home and community-based services.  Princeton, NJ:  Mathematica Policy Research. http://www.rwjf.org/en/library/research/2007/08/cash---counseling.html;  Newcomer, R.J., Kang, T. and Doty, P. (2012).  Allowing spouses to be paid personal care providers: spouse availability and effects on Medicaid-funded service use and expenditures.  Gerontologist, 52(4):517-30; Doty, P., Mahoney, K.J., and Sciegaj, M. (2010). New state strategies to meet long-term care needs.  Health Affairs. (Millwood), 29(1):49-56.

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  66. Centers for Medicare & Medicaid Services, Department of Health and Human Services. (2014).  Medicaid program: State plan home and community-based services, provider payment reassignment, and home and community-based setting requirements for community first choice and home and community-based services (HCBS) waivers. 42 CFR Parts 430, 435, 436, 440, 441 and 447.  Federal Register.  2014-00487. January 10.  https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-01-10-2.html

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  67. Ibid.

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  68. Ibid.

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  69. National Quality Forum (2016).  Quality in home and community-based services to support community living:  addressing gaps in performance measurement.  Final Report.  Washington, DC:  September.  http://www.qualityforum.org/Publications/2016/09/Quality_in_Home_and_Community-Based_Services_to_Support_Community_Living__Addressing_Gaps_in_Performance_Measurement.aspx

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  70. National Association of States United for Aging and Disabilities (2017).  NCI-AD national core indicators aging and disabilities: 2015-2016 national results. Washington, DC.  http://www.nasuad.org/initiatives/national-core-indicators-aging-and-disabilities.

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  71. Kane, R.A. and Cutler, L.J. (2015).  Re-imagining long-term services and supports: towards livable environments, service capacity, and enhanced community integration, choice, and quality of life for seniors.  The Gerontologist. 55(2):286-95.

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  72. Kaiser Family Foundation, Rebalancing in Capitated Managed Long-Term Services and Supports Programs:  Key Issues from a Roundtable Discussion on Measuring Performance (Feb. 2015), http://kff.org/report-section/rebalancing-in-capitated-medicaid-managed-long-term-services-and-supports-programs-issue-brief/.

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  73. Ibid.

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  74. Harrington, C, Ross, L. and Kang, T. (2015).  Hidden ownership, hidden profits, and poor quality of nursing home care: A case study.  International Journal of Health Services.  45 (4): 779-800; Stevenson, D., Bramson, J.S. and Grabowski, D.C.  (2013). Nursing home ownership trends and their impacts on quality of care: A study using detailed ownership data from Texas.  J. of Aging & Social Policy, 25:30-47; U.S. Government Accountability Office. (2010). Nursing Homes: Complexity of Private Investment Purchases Demonstrates Need for CMS to Improve the Usability and Completeness of Ownership Data. GAO-10-710. Washington, D.C. http://www.gao.gov/products/GAO-10-710

     

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  75. Centers for Medicare & Medicaid Services. (2017). Medicare nursing home compare. http://www.medicare.gov/NursingHomeCompare/search.aspx?bhcp=1  See website data on www.Medicare.data.gov

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  76.  Centers for Medicare & Medicaid Services (CMS). (2017) Home Health Compare website. https://data.medicare.gov/data/home-health-compare

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  77. Kaye, H.S. (2015). Measuring quality in home and community-based services.  San Francisco, CA:  Community Living Policy Center, University of California San Francisco. http://clpc.ucsf.edu/sites/clpc.ucsf.edu/files/reports/Selected%20item%20inventory%20by%20NQF%20domains%20March%2016.pdf; National Association of States United for Aging and Disabilities (2017).  NCI-AD national core indicators aging and disabilities: 2015-2016 national results. Washington, DC.  http://www.nasuad.org/initiatives/national-core-indicators-aging-and-disabilities.

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  78. Ibid.; Kaye, H.S. (2014). Toward a model long-term care services and supports system: State policy elements.  The Gerontologist.   54(5):754-61.

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  79. National Quality Forum (2016).  Quality in home and community-based services to support community living:  addressing gaps in performance measurement.  Final Report.  Washington, DC:  September.

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  80. Chepaitis, A., Greene, A.M., Hoover, S., Khatutsky, G., Lyda-McDonald, B., Ormond, C., Walsh, E.G., Zheng, N.T., Booth, M., Fralich, J., Justice, D., Weiss, A.M. (2015). Report on Early Implementation of the Demonstrations under the Financial Alignment Initiative. Waltham, MA:  RTI International  https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/MultistateIssueBriefFAI.pdf.

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  81. Centers for Medicare & Medicaid Services. (2016). Medicare-Medicaid Coordination Office Fiscal Year 2016 Report to Congress. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_2016_RTC.pdf  

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  82. Gold M., Jacobson G., and Garfield R. (2012).  There is little experience and limited data to support policy making on integrated care for dual eligibles. Health Affairs, 31(6):1176-85.

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  83. Paradise, J., and Musumeci, M. (2016). CMS’s Final Rule on Medicaid Managed Care: Summary of Major Provisions. Washington, D.C.: Kaiser Family Foundation. http://kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/

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  84. U.S. Government Accountability Office (US GAO).  (2007).  Nursing home reform: Continued attention is needed to improve quality of care in small but significant share of homes. GAO-07-794T, Washington, DC: May 2, 2007 http://www.gao.gov/products/GAO-07-794T;  U.S. Government Accountability Office (US GAO). (2008).  Nursing homes: Federal monitoring surveys demonstrate continued understatement of serious care problems and CMS oversight weakness. GAO-08-517, Washington, DC: May 9, 2008 http://www.gao.gov/products/GAO-08-517; U.S. Government Accountability Office (US GAO). (2009).  Medicare and Medicaid participating facilities: CMS needs to reexamine state oversight of health care facilities. GAO-09-64, Washington, DC: February 13, 2009 http://www.gao.gov/products/GAO-09-64; U.S. Government Accountability Office (US GAO). (2009). Nursing homes: Addressing the factors underlying understatement of serious care problems requires sustained CMS and state commitment. GAO-10-70. Washington, D.C. http://www.gao.gov/products/GAO-10-70.

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  85. U.S. Office of the Inspector General (US OIG). (2014).  Adverse events in skilled nursing facilities:  National incidence among Medicare beneficiaries.  OEI-06-11-00370.  February. https://oig.hhs.gov/oei/reports/oei-06-11-00370.asp; U.S. Office of the Inspector General (US OIG).  (2013). Medicare nursing home resident hospitalization rates merit additional monitoring.  OEI-06-11-00040. November. https://oig.hhs.gov/oei/reports/oei-06-11-00040.pdf.

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  86. Edelman, T. (2014). Quality assessment and performance improvement (QAPI) in nursing homes: Diverting CMS attention from enforcement.  Washington, DC: Center for Medicare Advocacy, June 12. http://www.medicareadvocacy.org/quality-assessment-and-performance-improvement-qapi-in-nursing-homes-diverting-cms-attention-from-enforcement/

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  87. U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2016). Medicare and Medicaid programs:  Reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483,485, 488, and 489.  Final Rule.  Federal Register, 81 (192). October 4. 68688-68872. https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities

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  88. Khatutsky G, Ormond C, Wiener JM, Greene AM, Johnson R, Jessup EA, Vreeland E, Sengupta M, Caffrey C, Harris-Kojetin L. (2016). Residential care communities and their residents in 2010: A national portrait. DHHS Publication No. 2016-1041. Hyattsville, MD: National Center for Health Statistics. Available at:  https://www.cdc.gov/nchs/data/nsrcf/nsrcf_chartbook.pdf.  Khatutsky, G., Wiener, J.M., Greene, A.M., Johnson, R., and O’Keefe, J. (2013).  Do services and staffing in resident care facilities vary with residential needs?  Washington, DC: Assistant Secretary for Planning and Evaluation. July 22.  http://aspe.hhs.gov/daltcp/reports/2013/resneed.shtml; California Advocates for Nursing Home Reform (2013).  Residential care in California: Unsafe, unregulated & unaccountable.  San Francisco, CA: CANHR. http://www.canhr.org/reports/Residential_Care_in_California.pdf;

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  89. U.S. Office of the Inspector General (US OIG). (2017). Early alert: The Centers for Medicare & Medicaid Services has inadequate procedures to ensure that incidents of potential abuse or neglect at skilled nursing facilities are identified and reports in accordance with applicable requirements. A-01-17-00504, August https://oig.hhs.gov/oas/reports/region1/11700504.asp;

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  90. Ibid.

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  91. U.S. Government Accountability Office (US GAO). (2011). Nursing homes:  More reliable data and consistent guidance would improve CMS oversight of state complaints investigations. GAO-11-280. Washington, D.C http://www.gao.gov/assets/320/317514.pdf ; U.S. Office of the Inspector General (US OIG). (2011). Unidentified and unreported federal deficiencies in California’s complaint surveys of nursing homes participating in the Medicare and Medicaid Programs. A-09-09-00114. https://oig.hhs.gov/oas/reports/region9/90900114.pdf

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  92. U.S. Government Accountability Office (US GAO). (2009).  Medicare and Medicaid participating facilities: CMS needs to reexamine state oversight of health care facilities. GAO-09-64, Washington, DC: GAO, February 13, 2009 http://www.gao.gov/products/GAO-09-64; U.S. Government Accountability Office (US GAO). (2009). Nursing homes: Addressing the factors underlying understatement of serious care problems requires sustained CMS and state commitment. GAO-10-70. Washington, D.C. http://www.gao.gov/products/GAO-10-70; US Office of Inspector General (2005). Nursing home enforcement: The use of civil money penalties. April.  https://oig.hhs.gov/oei/reports/oei-06-02-00720.pdf; Harrington, C., Stockton, J. and Hooper, S. (2014).  The effects of regulation and litigation on a large for-profit nursing home chain.  J. of Health Politics, Policy and Law, 39 (4):781-809.

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  93. Edelman, T. (2014). Staffing deficiencies in nursing facilities: rarely cited, seldom sanctioned.  Washington, CD:  Center for Medicare Advocacy.  http://www.medicareadvocacy.org/staffing-deficiencies-in-nursing-facilities-rarely-cited-seldom-sanctioned/.

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  94. Li, Y., Harrington, C., Spector, W.D., and Mukamel, D.B. (2010). State Regulatory Enforcement and Nursing Home Termination from the Medicare and Medicaid Programs.  Health Services Research.  45 (6):1796-1814.

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  95. Centers for Medicare & Medicaid Services (CMS). (2017). Revision of Civil Money Penalty (CMP) Policies and CMP Analytic Tool. S&C 17-37-NH. July.  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-37.pdf;   Inside Health Policy (2017). Beneficiary groups concerned CMS’ nursing home guidance could lower penalties.  https://insidehealthpolicy.com/daily-news/beneficiary-groups-concerned-cms-nursing-home-guidance-could-lower-penalties. Ihs://insidehealthpolicy.com/daily-news/beneficiary-groups-cncerned-s-nursing-home-guidance-could-lower-penaltiesn

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  96. U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2016). Medicare and Medicaid programs:  Reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483,485, 488, and 489.  Final Rule.  Federal Register, 81 (192). October 4. 68688-68872. https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities.

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  97. [xcvii] Parkinson, M., American Health Care Association and National Center for Assisted Living (2017).  Letter to Secretary Thomas Price, Health and Human Services Agency, March 9, Washington, DC; Centers for Medicare & Medicaid Services (CMS). (2017).  CMS Issues Proposed Revision Requirements for Long-Term Care Facilities’ Arbitration Agreements. June. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-06-05.html;   Pear, R. (2017). Trump moves to impede consumer lawsuits against nursing homes. New York Times. August 18. https://www.nytimes.com/2017/08/18/us/politics/trump-impedes-consumer-lawsuits-against-nursing-homes-deregulation.html?mcubz=0

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  98. Werner, RM, Konetzka, RT, and Polsky, D. Changes in consumer demand following public reporting of summary quality ratings: An evaluation in nursing homes.  Health Serv Res. 2016; 51 Supple 2:1291-309.

     

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  99. Mukamel, DB, Amin, A, Weimer, DL, et al. Personalizing nursing home compare and the discharge from hospitals to nursing homes.  Health Services Research.  2016; 1(6):2076-2094.

     

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  100. Tyler, D.A., Gadbois, E.A., McHugh, J.P., Shield, R.R., Winblad, U. and Mor, V. (2017). Patients are not given quality-of-care data about skilled nursing facilities when discharged from hospitals.  Health Affairs. 36(8):1385-1391.

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  101. Abt Associates. (2013). Nursing home compare 5-Star quality rating system: Year three report. Report Prepared for the Centers for Medicare and Medicaid Services. June 7th. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/FSQRS-Report.pdf

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  102. Centers for Medicare & Medicaid Services (CMS). (2015). MDS / Staffing Focused Surveys Update. S&C 15-25-NH.. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-06.pdf

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  103. Harrington, C, Ross, L. and Kang, T. (2014).  Hidden ownership, hidden profits, and poor quality of nursing home care: A case study.  International Journal of Health Services.  45 (4): 779-800; Stevenson, D., Bramson, J.S. and Grabowski, D.C.  (2013).  Nursing home ownership trends and their impacts on quality of care: A study using detailed ownership data from Texas.  J. of Aging & Social Policy, 25:30-47.

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  104. U.S. Government Accountability Office (US GAO). (2016).  Skilled nursing facilities: CMS should improve accessibility and reliability of expenditure data. GAO-16-700. Washington, D.C.: GAO, September.

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  105. Harrington C, Ross L, Mukamel D, Rosenau P. (2013). Improving the financial accountability of nursing facilities. Washington, DC: Kaiser Commission on Medicaid and the Uninsured. June.  http://kff.org/medicaid/report/improving-the-financial-accountability-of-nursing-facilities/.

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