Quality Indicators for the Management of Medical Conditions in Nursing Home Residents Debra Saliba, MD, MPH, David Solomon, MD, Laurence Rubenstein, MD, MPH, Roy Young, MD, John Schnelle, PhD, Carol Roth, RN, MPH, and Neil Wenger, MD, MPH Purpose: The purpose of this study was to develop a set of specific care processes associated with better outcomes for general medical conditions identified as quality improvement targets for institutionalized vul- nerable elders. Methods: A national panel of nursing home experts used a modified-Delphi process to rate the validity (process linked to improved outcomes) and feasibility (of implementation and measurement) of candidate measures for depression, diabetes, hearing impair- ment, heart failure, hypertension, ischemic heart dis- ease, osteoarthritis, osteoporosis, pneumonia, stroke, and vision impairment. Each quality indicator was written as an “if” statement, describing persons to whom the quality indicator applied followed by a “then” statement identifying the care process to be provided. A separate clinical committee reviewed the resulting set of indicators. Results: One hundred fourteen quality indicators were identified across the 11 medical conditions. The quality indicators capture a broad range of medical care ad- dressing assessment, management, and follow up. Fifty- five indicators (48%) were identical to quality measures for community-dwelling vulnerable elders. A limited number were rated as questionably feasible to imple- ment or measure (6 and 2, respectively). Thirty-eight (33%) would not be applied to measures of care quality for persons with advanced dementia or poor prognosis. Conclusions: Explicit care processes linked to improved nursing home outcomes for general medical condi- tions can be identified. Most of these care processes can be measured by medical records or interview. Nursing home quality measures for medical conditions must account for exclusions related to poor prognosis and advanced dementia. (J Am Med Dir Assoc 2004; 5: 297–309) Keywords: Nursing home; quality; depression; diabe- tes; hearing; heart failure; hypertension; heart dis- ease; osteoarthritis; osteoporosis; pneumonia; stroke; vision; dementia; terminal disease Each year, almost two million adults are admitted to one of 16,800 nursing homes in the United States. 1 These nursing home (NH) residents have a significant illness burden, mak- ing disease management important but challenging. 2 A set of explicit evidence-based medical care processes, or steps of care, that have been tailored to NH residents could aid providers in the evaluation and management of these com- plex patients. 3,4 Because process-based quality indicators (QIs) explicitly identify steps of care that are associated with better outcomes, they can be used to evaluate the care actu- ally provided to elderly populations and can guide efforts to improve care and outcomes. 5 Despite the potential value of care-focused QIs, providers do not have access to an aggregate set of evidence-based medical care processes that have been specifically targeted to NH populations. Many sets of process-based QIs have been developed for younger populations in hospital and outpatient care settings. Yet, because several factors coalesce to make care processes in NHs different from community-based care, these existing QI sets cannot be imported automatically into measures of NH care. The most obvious factor is the burden of disease in the NH setting. As a group, NH residents are more complex and frail than populations in other settings. Another important differ- ence is the length and content of patient–provider encounters. Community medical care often consists of a series of discrete provider–patient encounters, whereas NH care involves a con- VA HSR&D Center for the Study of Healthcare Provider Behavior, VA Greater Los Angeles (D.S.); Geriatric Research Education and Clinical Center, VA Greater Los Angeles Health Care System (D.S., L.R., J.S.); RAND Corporation (D.S., D.S., L.R., R.Y., C.R., N.W.), Santa Monica, California; UCLA Department of Medicine, Los Angeles, California (D.S., R.Y., J.S., N.W.); UCLA Multicampus Program in Geriatrics (L.R.), Los Angeles, California; and Borun Center for Gerontological Research/Jewish Home for the Aging Health Services (J.S.). Supported by a contract from Pfizer, Inc. to RAND. Dr. Saliba is a recipient of a VA Health Services Research and Development Career Development Award (#RCD 01– 006). Copies of the monographs or original voting sheets are available from the corresponding author. Address correspondence to: Debra Saliba, MD, MPH, RAND, 1700 Main Street, Santa Monica, CA 90401. E-mail: saliba@rand.org Copyright ©2004 American Medical Directors Association DOI: 10.1097/01.JAM.0000136960.25327.61 ORIGINAL STUDY Saliba et al 297