About the Reports
1. What is in this report?
NuHealth is displaying our extended care facility specific performance data on prevalence of falls, skin care, restraints, mental health, bowel/bladder management, physical activity, vaccination and pain management.
Data Quality Indicators:
NuHealth looks at two types of indicators. Process indicators which measure the completion of steps in the process for example; flu and pneumonia vaccinations. Outcome indicators measure the result of the process such as preventing pressure ulcers. Clinical outcomes are numbers calculated to represent our performance for a quality indicator.
Ratings
We rate our performance for a quality indicator as a percentage. Our performance is compared to either a national or state average and then color coded as follows: green indicates at or better than the national or state average, yellow near the national or state average and red indicates room for improvement.
Additional Information
Throughout the report additional information is available by clicking on the link highlighted in blue.
2. Where did these quality indicators come from?
Quality Indicators are developed from the recommendations of professional societies and research studies.
Extended Care Facilities are required to collect and submit data to the Center for Medicare & Medicaid Services (CMS).
These findings are publically reported by the US Department of Health and Human Services on Nursing Home Compare http://www.medicare.gov/default.asp
3. How did we determine a value for each color-code?
If our extended care facility performed at or above the national or state average we color-code our performance as green. Performance 10% or less below the national or state benchmark is color-coded yellow. Red indicates performance greater than 10% below the national or state average.
4. If the performance for an indicator is red, does that mean the hospital provided bad care?
Unfortunately, this question cannot be answered with a simple yes or no. Many components go into this and there are a variety of reasons why an indicator may be red and a hospital may still be providing good care. Some of those reasons are:
The extended care facility may do a better job of detecting and reporting complications and/or infections than other extended care facilities - this would make it seem that the extended care facility's outcomes are worse, when, in reality, that extended care facility is just doing a better job of reporting than other extended care facilities.
The indicator may do a poor job of capturing what it is trying to measure.
The indicator's risk adjustment statistical model may not take into account all of the factors that it should. This could result in the extended care facility not getting full credit for the complexity of its cases.
NuHealth encourages you to discuss any issues you have regarding our outcomes with your healthcare provider.
5. How often will the data in this report be updated?
Reports will be updated on a quarterly basis and will represent an average of the most current 12 months of available data.
6. How can I contact NuHealth if I have any questions regarding the Quality Reports?
You can contact us at qualityanswers@numc.edu. All questions will be promptly answered by a member of NuHealth’s Quality Management team.
Bowel or Bladder
Loss of bowel or bladder control is not a normal sign of aging and can often be successfully treated. Some causes are reaction to a medication, diet and fluid intake, limited ability to walk and physical problems.
A catheter is a thin soft tube attached to a bag that is inserted into the bladder and collects the urine.
A urinary tract infection (UTI) is an infection of the urethra. If the area where waste (urine and bowel movements) leaves your body is not kept clean, bacteria from your colon may multiply and enter the urethra causing a UTI.
These findings are publically reported by the US Department of Health and Human Services on Nursing Home Compare. http://www.medicare.gov/default.asp
Key
| At or better than N.Y. State average | |
| Near the N.Y. State average | |
| Room for Improvement |
 |
Ribbon = best possible value |
Additional information is available by clicking the links hightlighted in blue.
A. Holly Patterson Extended Care Facility: : January 2010 – September 2010 |
|||
| Quality Measures | A. Holly |
N.Y. State Average |
|
Bladder and Bladder: |
|||
Percent of low risk long-stay residents who lose control of their bowels or bladder:Residents have a “low risk” for losing bowel and bladder control, if they do not have severe dementia or if they do not have a very limited ability to move on their own. Finding the cause and treating a problem with bowel or bladder control can help prevent infections and pressure ulcers, restore dignity and social interaction. |
Residents who lose control of their bowels or bladder | 56 |
|
Percent of long-stay residents who have /had a catheter inserted and left in their bladder:A catheter is used only when medically necessary as it may result in complications such as infections, skin problems and bladder stones. |
Residents who have a catheter inserted and left in their bladder | 4 |
|
Percent of long-stay residents who had a urinary tract infection:Most urinary tract infections can be prevented by keeping the area clean, emptying the bladder regularly and drinking enough fluid. It is important to find whether a physical problem is present so proper treatment can be given. |
Residents who had a urinary tract infection | 9 |
|
Fall Prevention
Falls can happen to anyone, at any time and almost any place. They can have bad effects on your health. Falls can be accidental or may result from a physical condition caused by illness, medications and/or risk factors. The best way nursing homes can prevent falls from happening is to always be aware that they can happen and to take appropriate prevention measures.
These findings are publically reported by the US Department of Health and Human Services on Nursing Home Compare. http://www.medicare.gov/default.asp
Key
| At or better than N.Y. State average | |
| Near the N.Y. State average | |
| Room for Improvement |
|
Ribbon = best possible value |
Additional information is available by clicking the links hightlighted in blue.
A. Holly Patterson Extended Care facility 08/01/10 – 1/31/11 |
|||
| Quality Measures | A. Holly |
N.Y. State Average |
|
Fall Prevention Measures of Care: |
|||
Prevalence of FallsCertain factors increase your risk of falling
|
Prevalence of Falls | 10.5 |
|
Mental Status
Depression is a medical problem that effects how you think, feel and behave. Signs of depression may include a loss of interest or pleasure, disturbed sleep or appetite, low energy, and poor concentration.
Anxiety is constant worry or obsession about small or large concerns. Signs of anxiety can include restlessness, difficulty concentrating, irritability and trouble sleeping.
These problems can become chronic or recurrent and interfere with a resident's ability to take care of their everyday responsibilities.
Delirium is severe confusion and rapid change in brain function, usually caused by a treatable physical or mental illness. Causes may be a stroke, dehydration, reaction to surgery, anesthesia or medication, disease or uncorrected vision or hearing problems.
These findings are publically reported by the US Department of Health and Human Services on Nursing Home Compare. http://www.medicare.gov/default.asp
Key
| At or better than N.Y. State average | |
| Near the N.Y. State average | |
| Room for Improvement |
|
Ribbon = best possible value |
Additional information is available by clicking the links hightlighted in blue.
A. Holly Patterson Extended Care Facility |
|||
| Quality Measures | A. Holly |
N.Y. State Average |
|
Report Period: January 2010 – September 2010 |
|||
Percent of long-stay residents who are more depressed or anxious:Nursing home residents are at high risk for developing depression or anxiety for many reasons such as loss of a spouse, family members or friends, chronic pain and illness, difficulty adjusting to the nursing home and frustration with memory loss. Proper treatment may include medication, therapy or an increase in social support. |
Long-stay residents who were more depressed or anxious | 15 |
|
Report Period: October 2009 – September 2010 |
|||
Percent of short stay residents who have delirium:Symptoms may include
|
Short-stay residents who have delirium | |
1 |
Pain Management
Pain can be defined as “an unpleasant sensory and/or emotional experience”. Nursing homes use pain scales to assess personal pain. Pain relief is an important part of treatment. If pain is not treated, a resident may not be able to perform daily routines, may become depressed, or have an overall poor quality of life. The goal of pain management is to reduce pain and suffering whenever that is possible. Residents may recover faster when their pain is managed.
These findings are publically reported by the US Department of Health and Human Services on Nursing Home Compare. http://www.medicare.gov/default.asp
Key
| At or better than N.Y. State average | |
| Near the N.Y. State average | |
| Room for Improvement |
|
Ribbon = best possible value |
Additional information is available by clicking the links hightlighted in blue.
A. Holly Patterson Extended Care facility |
|||
| Quality Measures | A. Holly |
N.Y. State Average |
|
Long-Stay Pain Management January 2010 – September 2010 |
|||
Long-stay residents who have moderate to severe painNursing home staff should check long-stay residents regularly to see if they are having pain. Residents (or someone on their behalf) should let staff know if they are in pain so efforts can be made to find the cause and make the resident more comfortable. This percentage may include some residents who are getting or have been prescribed treatment for their pain, but who refuse pain medicines or choose to take less. Some residents may choose to accept a certain level of pain so they can stay more alert. |
Long-stay residents who have moderate to severe pain. | |
2 |
Short-Stay Pain Management October 2009 – September 2010 |
|||
Short-stay residents who have moderate to severe painNursing home staff should check short-stay residents regularly to see if they are having pain. Residents (or someone on their behalf) should let staff know if they are in pain so efforts can be made to find the cause and make the resident more comfortable. This percentage may include some residents who are getting or have been prescribed treatment for their pain, but who refuse pain medicines or choose to take less. Some residents may choose to accept a certain level of pain so they can stay more alert |
Short-stay residents who have moderate to severe pain. | |
17 |
Physical Activity
A decline in physical activity may come with age due to muscle loss, joint stiffness, and fear of injury, worsening illness or depression. Nursing home staff can help residents be more active through physical therapy, planned activities and regular walks. Staying in a bed or chair has side effects such as muscle weakness, increased risk for pressure ulcers, heart disease, stroke diabetes and blood clots.
Residents sometimes need help with basic daily tasks such as feeding oneself, moving from one chair to another, changing positions while in bed and going to the bathroom. While some loss of function may be expected with the normal aging process, a sudden or rapid loss could signal a resident’s need for medical attention. Residents are therefore routinely assessed to see how they function doing these daily tasks.
These findings are publically reported by the US Department of Health and Human Services on Nursing Home Compare. http://www.medicare.gov/default.asp
Key
| At or better than N.Y. State average | |
| Near the N.Y. State average | |
| Room for Improvement |
|
Ribbon = best possible value |
Additional information is available by clicking the links hightlighted in blue.
A. Holly Patterson Extended Care Facility: January 2010 – September 2010 |
|||
| Quality Measures | A. Holly |
N.Y. State Average |
|
Physical Activity |
|||
Percent of long-stay residents who spend most of their time in bed or in a chair:Residents who spend too much time in bed or a chair may lose the ability to perform activities of daily living like eating, dressing or getting to the bathroom. |
Residents who spend most of their time in bed or in a chair | |
2 |
Percent of long-stay patients whose ability to move about in and around their room got worse:Nursing home staffs encourage residents to do as much as they can for themselves and stay as active as physically possible. |
Residents whose ability to move about in and around their room got worse. | 13 |
|
Percent of long-stay residents whose need for help with daily activities has increased:A lower percentage is better. A resident’s ability to perform daily functions is important in maintaining their current health status and quality of life. Residents who do these tasks often feel better about themselves and stay more active. |
Percent of long-stay residents whose need for help with daily activities has increased. | 14 |
|
Physical Restraints
A physical restraint is any device that restricts the resident from moving freely or prevents normal access to their body. Some examples of physical restraints include special types of vests, chairs with lap trays, lap belts and enclosed walkers.
These findings are publically reported by the US Department of Health and Human Services on Nursing Home Compare. http://www.medicare.gov/default.asp
Key
| At or better than N.Y. State average | |
| Near the N.Y. State average | |
| Room for Improvement |
|
Ribbon = best possible value |
Additional information is available by clicking the links hightlighted in blue.
A. Holly Patterson Extended Care Facility: January 2010 – September 2010 |
|||
| Quality Measures | A. Holly |
N.Y. State Average |
|
Physical Restraints |
|||
Percent of long-stay residents who were physically restrained:Restraints require an order by a physician and should only be used when they are necessary as part of the treatment of a resident’s medical condition. |
Residents who were physically restrained | |
3 |
Skin Care
A pressure ulcer is a skin wound that usually develops on the lower back, hip, ankle, back of the head, heel or elbow. They are usually caused when soft tissue is compressed between a bony area and an external surface for a extended period of time. Pressure ulcers are sometimes called bedsores. A pressure ulcer is an area of skin that breaks down when you stay in one position for too long without shifting your weight. This often happens if you use a wheelchair or you are bedridden, even for a short period of time. The constant pressure against the skin reduces the blood supply to that area, and the affected tissue dies. There are several things that nursing homes can do that may help to prevent or treat pressure ulcers, such as frequently changing the resident’s position, proper nutrition, controlling moisture and using soft padding to reduce pressure on the skin.
These findings are publically reported by the US Department of Health and Human Services on Nursing Home Compare. http://www.medicare.gov/default.asp
Key
| At or better than N.Y. State average | |
| Near the N.Y. State average | |
| Room for Improvement |
|
Ribbon = best possible value |
Additional information is available by clicking the links hightlighted in blue.
A. Holly Patterson Extended Care facility |
|||
| Quality Measures | A. Holly |
N.Y. State Average |
|
Pressure Ulcer Prevention Measures of Care: January 2010 – September 2010 |
|||
High-Risk Long-Stay Residents With Pressure UlcersYou have a "high risk" for getting a pressure ulcers if you are in a coma, if you don’t get the nutrients you need (like water, vitamins and minerals), or if you can’t move or change position on your own. |
High-Risk Long-Stay Residents With Pressure Ulcers | 11 |
|
Low Risk Long-Stay Residents With Pressure UlcersYou are a “low risk” for getting a pressure ulcer if you are ambulatory, have good nutritional intake and keep your skin dry. |
Low Risk Long-Stay Residents With Pressure Ulcers | |
2 |
Pressure Ulcer Prevention Measures of Care: October 2009 – September 2010 |
|||
Short-Stay Residents With Pressure UlcersShort-stay residents who have developed pressure sore or who had pressure sores that did not get better between their 5 day and 15 day assessments in the nursing home. |
Short-Stay Residents With Pressure Ulcers | 14 |
|
Vaccination
Influenza is a very contagious respiratory infection. The influenza vaccine (flu shot) can prevent residents from getting the flu or reduce your risk of becoming seriously ill from the flu.
The pneumococcal vaccination may help residents prevent or lower the risk of becoming seriously ill from pneumonia caused by bacteria.
These findings are publically reported by the US Department of Health and Human Services on Nursing Home Compare. http://www.medicare.gov/default.asp
Key
| At or better than N.Y. State average | |
| Near the N.Y. State average | |
| Room for Improvement |
|
Ribbon = best possible value |
Additional information is available by clicking the links hightlighted in blue.
A. Holly Patterson Extended Care Facility |
|||
| Quality Measures | A. Holly |
N.Y. State Average |
|
Influenza Vaccinations: October 2008 – March 2010 |
|||
Percent of long-stay residents given the influenza vaccination during the flu season:People 65 and older are at high risk for developing serious life-threatening medical complications from the flu. Residents should be given a flu shot during the flu season. (October through March) |
Long-stay residents who were given influenza vaccination during the flu season. | |
91 |
Percent of short-stay residents given the influenza vaccination during the flu season:People 65 and older are at high risk for developing serious life-threatening medical complications from the flu. Residents should be given a flu shot during the flu season. (October through March) |
Short-stay residents who were given influenza vaccination during the flu season. | 87 |
|
Pneumococcal Vaccinations: October 2009 – September 2010 |
|||
Percent of long-stay residents who were assessed and given Pneumococcal vaccination:The Center for Disease Control and Prevention recommends that all persons should get a pneumococcal vaccination after age 65. |
Long-stay residents who were assessed and given pneumococcal vaccination. | |
93 |
Percent of short-stay residents who were assessed and given Pneumococcal vaccination:The Center for Disease Control and Prevention recommends that all persons should get a pneumococcal vaccination after age 65. |
Short-stay residents who were assessed and given pneumococcal vaccination. | 88 |
|
Weight Loss
A loss of 5% or more of body weight in one month is usually considered unhealthy. It is important that the resident’s diet is balanced and nutritious and that staff spend enough time feeding people who can’t feed themselves.
These findings are publically reported by the US Department of Health and Human Services on Nursing Home Compare. http://www.medicare.gov/default.asp
Key
| At or better than N.Y. State average | |
| Near the N.Y. State average | |
| Room for Improvement |
|
Ribbon = best possible value |
Additional information is available by clicking the links hightlighted in blue.
A. Holly Patterson Extended Care Facility: January 2010 – September 2010 |
|||
| Quality Measures | A. Holly |
N.Y. State Average |
|
Weight Loss |
|||
Percent of long-stay residents who lose too much weight:Too much weight loss can make a person weak, change how medicine works in the body or cause the skin to break down which can lead to pressure ulcers. |
Residents who lose too much weight. | 7 |
|
