Celebrating Progress: Improving Quality Measures in Qsource Nursing Homes

When it comes to Composite Scores, the lower the better. Scores are comprised of 13 long-stay quality measures. The Centers for Medicare & Medicaid Services (CMS) has set a national goal for nursing homes to achieve a 6.00 or less.

From 2015 through 2017, the average Composite Score among participating nursing homes in Qsource states – Alabama, Indiana, Kentucky, Mississippi and Tennessee – improved from 8.43 to 7.97. Almost 40 percent of those homes (465 of 1172) have achieved the CMS goal of 6.00 or lower.

Quality improvement advisors identified three top priorities for improvement:

  1. Reducing unnecessary use of antipsychotic medications
  2. Reducing incontinence
  3. Reducing assistance with activities of daily living (ADLs)

Here are some examples of tactics atom quality improvement advisors are using in the field to help nursing homes meet their goals:

  • In Alabama, quality improvement advisors sent monthly reminders to nursing home administrators for them to complete their Quality Assurance and Performance Improvement (QAPI) Self-Assessment (either initial or follow-up). This helped the facilities stay on track with their improvement efforts and make quality improvement a top priority.
  • In Indiana, quality improvement advisors partnered with the state health department in nine regional nursing home collaboratives to work on Quality Assurance and Performance Improvement (QAPI) projects. Advisors provided targeted data and best practices to improve the nursing homes’ measures and lower their composite scores.
  • In Kentucky, quality improvement advisors identified nursing facilities with composite scores between 6.10 and 7.00 to focus on their immunization (flu and pneumonia) quality measures. It helped nursing homes reach their improvement goals to ensure that more of their residents received both immunizations and that shots were documented accurately.
  • In Mississippi, quality improvement advisors attended stakeholders’ regional meetings to maximize face-to-face opportunities with nursing home administrators. This fostered trust and allowed the advisors to offer targeted resources for individual nursing homes to improve critical measures.
  • In Tennessee, quality improvement advisors hosted one-on-one virtual meetings with nursing home administrators and providers. Advisors coached them how to drill down into their data to determine which measure to target for a specific performance improvement project (PIP) that would lower their composite score.

Our work across the five states has resulted in these successes:


To learn more about the work we do with nursing homes, visit www.atomalliance.org/initiatives/reducing-healthcare-acquired-conditions/.

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