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Long-term Care

Performance Budget Submission for Congressional Justification

This statement summarizes budget information submitted to Congress by the Agency for Healthcare Research and Quality (AHRQ).


Long-term Care

Long-term Goal: Improve quality and safety in all long-term care settings and during transitions across settings.


Improve quality and safety in all long-term care settings and curing transitions across settings.


2008Develop annual nursing home (NH) final injurious falls measure in partnership with the Centers for Medicare & Medicaid Services (CMS); quantify baseline final measure.Dec-08
2007Develop annual nursing home injurious falls draft measure in partnership with CMS; quantify baseline draft measure.Dec-07
2007Develop partnerships, and access needs and barriers to the adoption of a 2nd generation injurious falls program in nursing homes.Dec-07
2007Initiate dissemination activities for adoption of 2nd generation pressure ulcer intervention.Dec-07
2007Implement and evaluate, in at least 30 nursing homes and in partnership with the State's Quality Improvement Organizations (QIOs), 2nd generation nursing home pressure ulcer intervention.Dec-07
2006Synthesize recent research findings on what aspects of nursing home care prevents inappropriate hospitalizations.Completed: Final Report Sep-06
2006Distribute report on implementation of evidence-based protocols for pressure ulcers prevention in nursing homes.Jun-07
2006Disseminate findings from Agency for Healthcare Research and Quality (AHRQ) nursing home fall prevention program (FPP).Completed:
   -Journal publication
   -FPP Manual available in QIO website
   -QIO received FPP training
2005Partner with a second NH chain that is embarking on fall prevention program.Complete
2004Develop multi-faceted falls prevention program focused on high risk fallers based on evidence-based research and pilot in NH chain.Complete

Improve coordination of formal long-term care with hospital care, primary care, and informal caregivers to facilitate clinical decision making and assure timely transfer of clinical data.


2008Award 2nd generation transition project.Dec-08
2007Draft contractual award materials for 2008 multiple provider implementation of 2nd generation e-communication tool in diverse geographic settings.Dec-07
2007Complete initial identification of user needs and barriers associated with 2nd generation e-communication tool use.Dec-07
2007Disseminate e-communication user aids and expand network of provider partnerships to jumpstart use of e-communication tools by multiple provider organizations.Dec-07
2006Initiate dissemination of e-communication tool (i.e., a Eeb-based tool to improve coordination between hospital, primary care and home care clinicians and patients and their informal care providers to improve care planning and self-care).Completed:
   -Initiated discussion with CMS.
   -Presentation at professional meetings and with potential adopters.

Improve community-based care to maximize function and community participation, and prevent inappropriate institutionalizations and hospitalizations.


2008In partnership with CMS, develop final annual measure of re-hospitalization from long-term care settings of persons receiving formal home health care; quantify final baseline measure.Dec-08
2007In partnership with CMS, develop annual draft measure of re-hospitalization from long-term care settings of persons receiving formal home health care; quantify baseline draft measure.Dec-07
2006New Freedom Initiative: Initiate evaluation plan to assess findings from youth in transition (from pediatric to adult services) projects.Resource Manual Draftb
Synthesize recent research findings on what aspects of community-based services and care in assisted living can prevent inappropriate institutionalizations and hospitalizations.Completed: Final Report on Hospitalizations

Improve information about services and quality so that consumers can make informed choices about the care they receive.


2008Continue cognitive testing on 1st priority measures and initiate cognitive testing on 2nd priority measures for assisted living/residential care consumer tools and resources.Dec-08
2007Initiate cognitive testing on 1st generation of assisted living/residential care consumer tools and resources (1st priority measures).Dec-07
2006Produce report on the state-of-the-art instruments and tools available to profile assisted living/residential care.Report completed
2006Publish report on how states monitor assisted living/residential care facilities and how states report to consumers.Report posted:
2006Determine final sampling methodology and plan of implementation to enhance measurement on the long-term care population.Sample design memo completed in June 2006 as a contract deliverable.

Data Source:  National Health Care Quality Report based on CMS's Minimum Data Set and Outcome and Assessment Information Set (OASIS) data.
Data Validation:  AHRQ products under go extensive peer review for merit and relevance.
Cross Reference:  SG-1/5/6; HP2010-1; 500-Day Plan—Transform the Healthcare System.

a. New measure—FY 2004.
b. Limited AHRQ funding produced a draft manual. No current funding/ongoing activities are associated with this initiative.
c. New measure—FY 2006.

An Institute of Medicine (IOM) report entitled Improving the Quality of Long-term Care (2001) states that concerns about problems in the quality of long-term care persist despite some improvements in recent years, and are reflected in, and spurred by, recent government reports, congressional hearings, newspaper stories, and criminal and civil court cases. "Examples of high priority quality and safety concerns are the high prevalence of pressure ulcers, the large number of residents having serious falls, medical and drug errors, preventable hospitalizations caused by inadequate care management at transitions from hospital to long term care, and the difficulty consumers of assisted living and residential care have evaluating the quality and services provided in those settings."

The purpose of AHRQ's Long-term Care Portfolio is to develop processes and tools supported by evidence-based research and to foster the integration of those processes and tools into the practice of long term care so that providers can improve quality and safety while reducing costs and consumers of long term care have tools available to make informed decisions.

To meet these goals the Long-term Care Portfolio funds research to develop evidence to support tool development and test the impact on quality of integrating evidence-based tools into every day practice. It partners with stakeholders to disseminate evidence-based tools, and evaluates approaches to implementing these practices into the day-to-day practice of care received by longterm care users. The portfolio is currently focusing on preventing pressure ulcers and injurious falls in nursing homes, improving care management of person discharged from hospital to home health, and improving tools to help consumers of assisted living make informed choices.

In 2006, the Portfolio expanded its pressure ulcer prevention projects to help train Medicare Quality Improvement Organizations (QIOs) in decision support approaches to pressure ulcer prevention care. It also began efforts to disseminate the falls prevention program. In 2006 projects that assess the state of the art of assisted living consumer tools were completed. The 2007 projects build on early small studies of pressure ulcer and falls prevention in nursing homes that have been shown to improve quality and it is part of the Portfolio's strategy to bring these interventions to scale.

In 2008, as in 2007, AHRQ continues to develop tools to help consumers make informed choices about their use of home and community-based and institutional-based long-term care services. In 2008 the Portfolio continues to expand its development, implementation, and dissemination activities for these four priority areas.

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Pharmaceutical Outcomes

Long-term Goal: By 2014 antibiotic inappropriate use in children between the ages of one and fourteen should be such that use is reduced from 0.56 prescriptions per year to 0.42 per child (25%).


By 2014 antibiotic inappropriate use in children between the ages of one and fourteen should be such that use is reduced from 0.56 prescriptions per year to 0.42 per child (25%)


20081.8% dropDec-08
20071.8% dropDec-07
20061.8% drop0.60
20051.8% drop0.59
2004Establish baseline rates0.56


Long-term Goal: Reduce congestive heart failure hospital readmission rates in those between 65 and 85 years of age.


Reduce hospitalization for upper gastrointestinal bleeding due to the adverse effects of medication or inappropriate treatment of peptic ulcer disease, in those between 65 and 85 year of age from 55 per 10,000 population to 45 per 10,000.


20081.8% dropDec-08
20072.0% dropDec-07
20062.0% drop54.38/10,000
20052.0% drop55/10,000 (no change from baseline)
2004Establish baseline rates(55 per 10,000)

The decreased number of admissions for upper gastrointestinal (GI) bleeding will generate a per year drop in per capita charges for GI bleeding.

(FY 2001 Baseline $93.36) Efficiency Outcome

20074.0% dropDec-07
20063.0% drop$93.46 per capita
(3.2% drop)
20052.0% drop$93.20 per capita
(3.4% drop)
2004Establish baseline$93.36 per capita

Data Source:  The data source for trends in children's use of antibiotics is the Medical Expenditure Panel Survey (MEPS). MEPS is one of the core national sentinel data resources for tracking trends in health care use and expenditures. MEPS is widely used by researchers in academia, government, and other research institutions and is recognized as a premier source of nationally representative data on medical use and expenditures. The data source for trends in congestive heart failure readmission rates and reduced hospitalization for upper gastrointestinal bleeding is the Healthcare Cost and Utilization Project (HCUP) database. HCUP is a family of health care databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ). HCUP databases bring together the data collection efforts of 37 State data organizations, hospital associations, private data organizations, and the Federal government to create a national information resource of patient-level health care data. HCUP includes the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information beginning in 1988.
Data Validation:  The MEPS family of surveys includes a Medical Provider Survey and a Pharmacy Verification Survey to allow data validation studies in addition to serving as the primary source of medical expenditure data for the survey. The MEPS survey has been cleared and meets standards for adequate response rates, and timely release of public use data files. The validity of the HCUP data is verified several times a year by 37 state data organizations and then at the federal level by AHRQ.
Cross Reference:  SG-1/5; HP2010-14/17; 500-Day Plan—Transform the Healthcare System.

d. New measure beginning FY 2004 for PARTed program.

Reduction in antibiotic use should be associated reduction of adverse reactions to medication and the cost of medical care. It may also be associated with improvement in the rates of resistant organisms. A two-fold approach to this reduction is needed, through both the clinician and the caretaker. This goal includes children, a priority population for AHRQ. Antibiotic resistance is an important public health problem. During this past year, this target was not achieved. Concerns have been raised as to our inability to separate inappropriate use from appropriate use. During the upcoming year, we will discuss narrowing the target to diagnoses that more appropriately identify inappropriate usage (e.g., antibiotic usage for viral illness).

In FY 2006, efforts have continued to reduce congestive heart failure hospital readmission rates in those between 65 and 85 years of age. A recent study of patients undergoing home health care highlighted some issues related to hospitalization. A recent AHRQ-funded grantee publication from the Centers for Education and Research on Therapeutics (CERTs) showed improvement in patient-based education on discharge when improvements were made through usage of an IT intervention. Lack of education during this transition of care may well be one of the major causes of re-hospitalizations.

The third major long-term goal of the portfolio is to reduce hospitalizations for upper gastrointestinal bleeding in those between 65 and 85 year of age. During FY2006, a number of studies and projects have been underway within the portfolio that relate to appropriate use of products that can cause bleeding.

A recent CERTs-funded study showed that. Doctors ordered 15 percent fewer prescriptions for drugs that can interact with the blood thinner warfarin by using a computerized system that produced a safety alert whenever the interacting drug's name was keyed in. Whenever a doctor in one of the 15 primary care clinics, involved in the study, prescribed any drug that would interact with warfarin to cause abnormal bleeding, an alert on the computer screen would tell the doctor the potential adverse outcome and suggest an alternative medication. AHRQ's Office of Communications and Knowledge Transfer developed a dissemination plan for this study finding. Although the incidence of hospitalizations did not drop this past year, the cost for these hospitalizations did drop.

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Long-term Goal: To translate evidence-based knowledge into current recommendations for clinical preventive services that are implemented as part of routine clinical practice to improve the health of all Americans.


Increase the quality and quantity of preventive services that are delivered in the clinical setting especially focusing on priority populations.


2008Percentage of men & women (50+) report they ever had a flexible sigmoidoscopy/colonoscopy.Dec-08
Percentage of men & women (50+) who report they had a fecal occult blood test (FOBT) within the past 2 years.Dec-08
2007Develop tools to facilitate the implementation of clinical preventive services among multiple users.Dec-07
2006Establish baseline for reach of evidence-based preventive services though use of products and tools.Completed:
  1. Views and downloads of electronic content:
    • United States Preventive Services Task Force (USPSTF) recommendations: 4,242,074e
    • General Preventive services: 1,621,848.e
    • Preventive Services Selector tool: 26,291.e
    • National Guideline Clearinghouse™ related to USPSTF recommendations: 359,634.e
  2. Dissemination of published products:
    • 2005 Clinical Guide: 18,969.
    • Consumer products: 276,531.
    • Adult Preventive Care Timeline: Release in August 2006.
    • Journal publications: Pediatrics, 2 publications, circulation 63,000.
    • Annals of Internal Medicine, 1 publication, circulation 92,756.
2005Establish baseline quality and quantity of preventive services delivered.


  • Percentage of women (18+) who report having had a Pap smear within the past 3 years: 81.3%
  • Percentage of men and women (50+) report they ever had a flexible sigmoidoscopy/colonoscopy: 38.9%
  • Percentage of men and women (50+) who report they had a fecal occult blood test (FOBT) within the past 2 years: 33%
  • Percentage of people (18+) who have had blood pressure measured within preceding 2 years and can state whether their blood pressure is normal or high: 90.1%
  • Percentage of adults (18+) receiving cholesterol measurement within 5 years: 67.0%
  • Percentage of smokers receiving advice to quit smoking: 60.9%
2004Benchmark best practices for delivering clinical preventive services.Completed: Expert opinions regarding best practices for delivering clinical preventive services obtained through stakeholder meetings and focus groups.
Increase Continuing Medical Education (CME) activities by developing a Train the Trainer program for implementing a system to increase delivery of clinical preventive services.Completed: Developed Train the Trainer program.

Improve the timeliness and responsiveness of the USPSTF to emerging needs in clinical prevention.



Biennial topic submission/nomination through the Federal Register.

Track improvements in timeliness.

2007Decrease by 10% the number of USPSTF recommendations that are five years or older.Dec-07
2006Decrease the median time from topic assignment to recommendation release.Four topics released to date in FY 2006, time from assignment to release ranged from 14 to 30 months, median time 25 months.
2005Establish baseline measures for timeliness and responsiveness.Completed:
  • 9 recommendations released.
  • 78% current within National Guideline Clearinghouse™ standards (reviewed within 5 years).
  • 100% of recommendations related to IOM priority areas for preventive care current within National Guideline Clearinghouse™ standards.
  • Developed new topic criteria, submission, review, and prioritization processes with new USPSTF topic prioritization workgroup.

Increase the number of partnerships that will adopt and promote evidence-based clinical prevention.


2008Sustain and further develop targeted partnerships related to the elderly, colorectal cancer screening and healthy behaviors.Dec-08
2007Three new partners will adopt and/or promote USPSTF-based tools.Dec-07
2006Increase the number of partnerships promoting evidence-based clinical prevention by 5%.Completed:

AHRQ has an IAA with the Centers for Disease Control and Prevention (CDC) to support Steps to a Healthier US through technical assistance to Steps grantee communities to facilitate linkages between clinical prevention and public health efforts focused on healthy behaviors.

National Business Group on Health partnerships include development of Purchaser's Guide to Clinical Preventive Services (including coverage for colorectal cancer [CRC] screening), and an assessment of the integration of employer supported prevention efforts.

In partnership with Administration on Aging, CDC, and National Council on Aging, support a project to assist community dwelling older adults maintain independent living through evidence-based disease and disability prevention and early detection. AHRQ is supporting linkages between clinical providers and aging social services and public health programs.

2005Establish baseline partnerships within the Prevention Portfolio promoting clinical prevention.Federal partners—10
Non-Federal partners:
  • 10 Primary Care Organizations.
  • 2 Health Care Insurance Industry.
  • 2 Consumer Organizations.
  • 3 Employer Organizations.
  • 6 other organizations.
2004Produce fact sheets for adolescents, seniors, and children. Partner with appropriate professional societies and advocacy groups.Completed:
  • Pocket Guide to Staying Healthy at 50+—revised Nov. 2003 (English and Spanish).
  • AARP Partnership Adult Health Timeline (for clinicians/patients)—revised Jan. 2004.
  • Women: Stay Healthy at Any Age—printed Jan. 2004 (English and Spanish).
  • Men: Stay Healthy at Any Age—printed Feb. 2004 (English and Spanish).
  • Pocket Guide to Good Health for Children—revised May 2004 (English and Spanish).

Data Source:  National Health Quality Report; National Healthcare Disparities Report; AHRQ—USPSTF/Preventive Services website; AHRQ product distribution process; AHRQ Preventive services databases (internal); Web trends; AHRQ Publications Clearinghouse; National Guideline Clearinghouse™; Preventive Services Selector Tool; Evidence Based Practice Center task order documents
Data Validation:  Because the Prevention Portfolio cannot collect primary quantitative data regarding healthcare service delivery or quality, it relies on federal partners and federal public release data sources for these measures, which include the National Health Quality Report and National Healthcare Disparities Report. As legislated by Congress, AHRQ produces these reports annually. Data comprising the reports are drawn from multiple databases (e.g., MEPS, HCUP, CAHPS® [Consumer Assessment of Healthcare Providers and Systems]) supported by AHRQ, in addition to other databases (such as the National Health Interview Survey [NHIS], supported by CDC). These reports and the databases from which they are drawn are considered definitive sources of healthcare quality measures. Other data sources (qualitative): Stakeholder meetings, expert panel meetings, and focus groups. Qualitative data were gathered primarily by outside contractors. The information obtained was analyzed, synthesized and reported using established methodology. Because of the limitations of qualitative data with respect to validity, the results obtained from these sources were used to identify successful case studies, themes, and areas for future opportunity. Other data sources (internal): Database established to monitor the timeliness of current recommendations. Database established in 2006 to track partnership development and collaborative activities with public and private organizations.
Cross Reference:  SG-1/5; HP2010-13/14/15/16/18/19/21/22/24/25/27; 500-Day Plan: Transform the Healthcare System; prevention; improving the clinical research network.

e. Data are for 7/1/05-6/30/06.
f. New measure developed FY 2004.
g. New measure developed FY 2005.

The prevention portfolio focuses on increasing the quality and quantity of preventive services with the goal of improving health and health care quality. Each of the measures supports the improved delivery of clinical preventive services in the primary care setting. In FY 2005, the portfolio successfully completed the targets for each of the performance goals. In FY 2006, the portfolio continues it work by:

  • Developing targeted products for clinicians, consumers and employers by improving and increasing the distribution of Prevention Portfolio products and tools is a critical means of expanding the 'reach' of evidence-based clinical preventive services. To reach as many clinicians, consumers, and employers as possible, a mix of products and tools has been developed and is currently being tracked. These products and tools include electronic media (AHRQ Preventive Services Web site, PDA clinical services selector tool, AHRQ Prevention Listserv), print publications for clinicians (2005/2006 Guide to Clinical Preventive Services), print publications/products for consumers (e.g., Adult Preventive Services timeline/wall chart), a guide to preventive services developed for health care purchasers, and web and print publications oriented toward academic audiences (e.g., peer-review journal articles for clinicians and researchers). Insurance coverage for clinical preventive services removes an economic barrier to access. AHRQ provided technical assistance to National Business Group on Health and CDC in development of a Purchaser's Guide for clinical preventive services to provide employers and benefit managers and consultants with evidence-based guidelines for Summary Benefit Plans that are based on the US Preventive Services Task Force recommendations.
  • Enacting processes for topic submission/nomination developed in FY 2005 and track number of topics nominated by producing recommendations that are responsive to the needs of practicing clinicians which is critical to getting the recommendations implemented into routine clinical practice and improving health. The process for submitting (nominating) topics that was developed by the new USPSTF topic prioritization workgroup in FY 2005 has been implemented, with the result that 32 topics were nominated by federal agencies and professional organizations to be considered for review by the USPSTF in response to the Federal Register notice. Consideration of these topics by the USPSTF topic prioritization work group has been completed and recommendations have been made to the full Task Force regarding their review. As a result two new topics have been added to the queue for review by Evidence-Based Practice Centers (EPCs).
  • Track improvements in timeliness by producing evidence-based recommendations in a timely way is essential to the translation of research on clinical preventive services into high quality, effective, and safe health care that improves the health and well-being of Americans. In FY 2005, the USPSTF and AHRQ staff established and implemented processes to identify, select, and prioritize topics for review and updating. Keeping recommendations updated within the National Guideline Clearinghouse™ standards involves constant consideration of new evidence and careful allocation of Task Force resources because a variable number of topics need to be considered for updating each year. The Prevention Portfolio is on track to maintain the high level of performance achieved in FY 2005 in keeping topics up to date. FY 2006 data by December 2006.
  • Develop targeted partnerships related to the elderly, colorectal cancer screening and healthy behaviors as indicated by data from FY 2005. Strong partnerships have been established with many federal and non-federal partners to strategically leverage and expand the work of the Prevention Portfolio. This strong foundation of effective partnerships provides a springboard for multiple activities of differing intensity, duration, scope, and reach that targets different audiences. For FY 2006, these activities include a focus on employers and purchasers of benefit plans (development of the National Business Group on Health [NBGH] Purchasers Guide to evidence-based clinical preventive services including colorectal screening and healthy behavior counseling); facilitating linkages between clinical providers of preventive services and public health programs and community based social service organizations (CDC partnership with Steps to a Healthier US—prevention of chronic disease through healthy behaviors; Administration on Aging/CDC partnership supporting evidence based prevention programs for older adults); support to clinical providers through their health professional societies (partnership with Partnership for Prevention Health Professional Roundtable).

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Page last reviewed February 2007
Internet Citation: Long-term Care: Performance Budget Submission for Congressional Justification. February 2007. Agency for Healthcare Research and Quality, Rockville, MD.


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