A Long-Term Care Q&A with Carmen Winston

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Carmen Winston, CMS
Carmen Winston, CMS

Carmen Winston, MHSA, BSN, BA, currently serves as Government Task Leader for the QIO Program’s Nursing Home Task at the Centers for Medicare & Medicaid Services (CMS). In that capacity, she is responsible for overseeing Quality Innovation Network-Quality Improvement Organizations’ (QIN-QIOs’) quality improvement activities with long-term care facilities. Prior to joining CMS, Ms. Winston served as Executive Director of the Delmarva Foundation of the District of Columbia, formerly the District of Columbia QIO, and Vice President for the former Maryland QIO Program of the Delmarva Foundation for Medical Care. At Delmarva, Ms. Winston worked in the areas of hospital quality improvement and collaborative initiatives, cultural competency/​health disparities, physician adoption of health information technology, and the Medicare Part-D pharmacy initiative. Ms. Winston has more than 25 years of health care experience in quality improvement and quality assurance, ambulatory health care, physician group-practice management, home health care and long-term care, including serving as Director, Survey Management, at the National Committee for Quality Assurance in Washington, D.C. Ms. Winston holds a Masters in Health Services Administration from The George Washington University, Washington, D.C.; a Bachelor of Science in Nursing from Cornell University-New York Hospital School of Nursing; and a Bachelor of Arts from Clarion State University in Pennsylvania. Ms. Winston’s graduate work was in the field of long-term care, and she earned licensure as a Nursing Home Administrator in the State of Virginia.

Q. The CMS/QIN-QIO National Nursing Home Quality Care Collaborative is conducted to improve care for the millions of nursing home residents across the country. What were some of the successes achieved from the collaborative that was active from August 2011 through July 2014?

A. Our inaugural National Nursing Home Quality Care Collaborative (NNHQCC) was intended to bring together nursing homes for large-scale peer-to-peer learning. QIOs successfully recruited more than 5,000 nursing homes to participate in the 18-month collaborative, and homes continued to join right up until its conclusion. Our collaboratives are different; we are aware that not all nursing homes can attend in person, and homes wishing to participate are not excluded based on when they decide they are able to join the effort and commit to actively participating. Bringing together nursing home representatives to identify areas they wanted to work on helped foster deep involvement and desire to stick with the collaborative. Between 2011 and 2014, QIOs also contributed to the prevention or healing of 3,374 pressure ulcers in 787 nursing homes; helped 6,250 residents at 981 nursing homes become restraint free; and contributed with other partners to a 17.1 percent national reduction in antipsychotic medication usage rates at nursing homes.

Q. The new National Nursing Home Quality Care Collaborative I that kicked off on April 1, 2015 is the first of two collaboratives that are an integral component of the 14 QIN-QIOs’ quality improvement activities through July 2019. Collaborative II will begin on April 1, 2017. How do these activities differ or expand upon the inaugural collaborative’s work from 2011-2014?

A. Because QIN-QIOs now have five years instead of three years to complete their work, they can better implement quality improvement activities and see the results of their efforts. QIN-QIOs recruited more than 5,000 nursing homes in the initial collaborative. By the time of Collaborative II, our goal is to recruit 75 percent of all Medicare-certified nursing homes in the nation, approximately 11,000 nursing homes. We will continue the work of engaging in peer-to-peer learning. Homes will continue to work on learning quality improvement practices, looking at their internal operational systems and improving the care and environment for their residents.

Another new development is that QIN-QIOs are recruiting high-performing nursing home staff, beneficiaries and family members to serve as peer coaches who will support and enhance resident-centered care at other nursing homes. These individuals are currently undergoing training. We are very excited about this aspect of the program.

"By the time of Collaborative II, our goal is to recruit 75 percent of all Medicare-certified nursing homes in the nation, approximately 11,000 nursing homes." 

Q. Between 2012 and 2014, the QIO Program identified successful practices for reducing the use of antipsychotic medications in nursing home residents. What factors contributed to this success?

A. The QIO Program’s alignment of efforts with the National Partnership to Improve Dementia Care in Nursing Homes, the Advancing Excellence in America’s Nursing Homes Campaign and other professional organizations helped contribute to the 17.1 percent national reduction in antipsychotic medication usage that was announced in July 2014. Based on this success, we are continuing to align with these partners as we pursue even more aggressive reduction rates. At individual nursing homes, reducing the use of antipsychotic medications requires more than just changing how they dispense medication. It is a question of changing the nursing home culture and educating staff that a resident’s agitation might be symptomatic of something other than a condition requiring medication. Nursing homes are learning to consider the resident’s past life and occupation as a means of instituting behavioral alternatives to the administration of medication.

Nursing homes that succeeded at bringing down antipsychotic usage rates showed a coordinated effort, a high level of education and a willingness on the part of their staff to look behind the need for medication. Often patients come to nursing homes after having had medications initiated during a hospital stay; nursing home staff are now evaluating whether these medications really need to be continued in the nursing home setting. 

Q. How does the QIO Program relate to resident-centered care? What are some of the best examples of resident-centered care that you have seen or heard about?

A. The principles of resident-centered care are embraced by our Collaborative Aim statement, which helps focus our work. Our Aim is to ensure that every resident receives the highest quality of care by instilling quality and performance improvement practices in nursing homes, so we can eliminate health care-acquired conditions and enhance resident satisfaction by improving their quality of life. To provide one example – at the end of our last collaborative, a QIO showed everyone a video about a resident at an Oklahoma nursing home who greatly benefited from stopping use of antipsychotic medications that were no longer medically necessary. Since stopping the medication, the resident has become more awake and alert, and is playing musical instruments again. This is an example of the positive change that can happen when we work with a facility to reassess its internal operations and when the nursing home staff becomes empowered to change how things occur.

Q. What are nursing homes doing to improve their star rating on Nursing Home Compare?

A. With the recent rebalancing of Nursing Home Compare’s 5-star system, it is important for nursing homes to have a sound foundational system and a culture of continuous quality improvement supported by a well-trained staff. Quality improvement is a long-term, continuous process revolving around internal operations, so nursing homes may need to change their operational structure in order to create an environment that supports measurable improvement in clinical outcomes. It is conceivable that by doing this and engaging with QIN-QIOs in quality improvement projects, a nursing home could improve its star status over time.

Q. Anything else you would like QIO News readers to know?

A. We are incredibly proud of QIN-QIOs’ recruitment efforts and the commitment of nursing homes nationwide to improve the quality of their care. Our original goal was to recruit approximately 4,000 nursing homes for the collaborative that kicked off in April, but based on our most recent tabulations, we have recruited more than 5,600 homes. Since nursing homes can continue to join the collaborative at any time through September 30, 2016, we anticipate participation by more than 6,000 homes. Any nursing home that is interested in learning more about the collaborative or joining it may contact their regional QIN-QIO.