Quality Improvement Efforts in VA Community Living Centers Following Public Reporting of Performance

For two decades, the U.S. government has publicly reported performance measures for most nursing homes, spurring some improvements in quality. Public reporting is new, however, to Department of Veterans Affairs nursing homes (Community Living Centers [CLCs]). As part of a large, public integrated healthcare system, CLCs operate with unique financial and market incentives. Thus, their responses to public reporting may differ from private sector nursing homes. In three CLCs with varied public ratings, we used an exploratory, qualitative case study approach involving semi-structured interviews to compare how CLC leaders (n = 12) perceived public reporting and its influence on quality improvement. Across CLCs, respondents said public reporting was helpful for transparency and to provide an "outside perspective" on CLC performance. Respondents described employing similar strategies to improve their public ratings: using data, engaging staff, and clearly defining staff roles vis-à-vis quality improvement, although more effort was required to implement change in lower performing CLCs. Our findings augment those from prior studies and offer new insights into the potential for public reporting to spur quality improvement in public nursing homes and those that are part of integrated healthcare systems.

First Year of Skilled Nursing Facility Value-based Purchasing Program Penalizes Facilities With Poorer Financial Performance

BACKGROUND

The Skilled Nursing Facility Value-based Purchasing Program (SNF-VBP) incentivizes facilities to coordinate care, improve quality, and lower hospital readmissions. However, SNF-VBP may unintentionally punish facilities with lower profit margins struggling to invest resources to lower readmissions.

OBJECTIVE

The objective of this study was to estimate the SNF-VBP penalty amounts by skilled nursing facility (SNF) profit margin quintiles and examine whether facilities with lower profit margins are more likely to be penalized by SNF-VBP.

RESEARCH DESIGN

We combined the first round of SNF-VBP performance data with SNF profit margins and characteristics data. Our outcome variables included estimated penalty amount and a binary measure for whether facilities were penalized by the SNF-VBP. We categorized SNFs into 5 profit margin quintiles and examined the relationship between profit margins and SNF-VBP performance using descriptive and regression analysis.

RESULTS

The average profit margins for SNFs in the lowest profit margin quintile was -14.4% compared with the average profit margin of 11.1% for SNFs in the highest profit margin quintile. In adjusted regressions, SNFs in the lowest profit margin quintile had 17% higher odds of being penalized under SNF-VBP compared with facilities in the highest profit margin quintile. The average penalty for SNFs in the lowest profit margin quintile was $22,312.

CONCLUSIONS

SNFs in the lowest profit margins are more likely to be penalized by the SNF-VBP, and these losses can exacerbate quality problems in SNFs with lower quality. Alternative approaches to measuring and rewarding SNFs under SNF-VBP or programs to assist struggling SNFs is warranted, particularly considering the coronavirus disease 2019 pandemic, which requires resources for prevention and management.

Potential, challenges and pitfalls of pay-for-performance schemes: a narrative review evaluating the merits for the Australian home care sector

PURPOSE

This qualitative narrative review aims to identify and evaluate the potential, challenges and pitfalls of pay-for-performance (P4P) schemes for the home care of adults with a disability. Due to a limited experimentation with P4P schemes in the context of the home and disability care sectors, the authors conducted a narrative review focusing on related areas of care, primarily nursing home care, to better understand the effectiveness of P4P schemes as a care intervention and evaluate the challenges associated with the introduction of these schemes.

DESIGN/METHODOLOGY/APPROACH

The authors employed a narrative review approach to examine the effectiveness of P4P schemes as a care intervention. The approach included a manual content analysis of the relevant academic and grey literature, focusing on the potential, challenges and pitfalls of P4P for care funders and providers.

FINDINGS

There is some, albeit limited, evidence from other related areas of care to support the effectiveness of P4P to improve the quality of care or the efficiency of its delivery for the home care sector. The results of prior studies are, however, often mixed and inconclusive, due to flaws with the design of schemes, including the nature of the incentives. Limited duration and poor-quality evaluations have further hampered the ability of studies to demonstrate the effectiveness of P4P schemes, which diminishes the credibility of these care interventions. When undertaken systematically, there seems to be some evidence that P4P can work; however, it requires careful design, implementation, measurement and evaluation.

PRACTICAL IMPLICATIONS

Based on the challenges associated with the successful implementation of P4P schemes, the authors identified lessons for the design, implementation, measurement and evaluation of P4P schemes for care funders and policymakers.

ORIGINALITY/VALUE

This study critically evaluates the potential of P4P as a care intervention for the home care and disability sectors. By evaluating the potential, challenges and pitfalls associated with P4P in related areas of care, the study provides guidance to home care funders, providers and policymakers in care settings.

Lessons Learned From Ohio's Statewide Implementation of the Preferences for Everyday Living Inventory as a Pay for Performance Initiative to Enhance Person-Centered Care

Person-centered care (PCC) in nursing homes is an elusive organizational goal that has attracted the attention of pay-for-performance (P4P) programs. P4P programs are used to incentivize providers to improve the quality of care delivered. However, P4P programs have both overarching policy initiatives (big "P") that must incorporate an implementation framework that is adaptable in practice (little "p"). The purpose of this paper is to apply six key factors that are central to P4P design in long-term care settings: financial incentives, measurement, stakeholder involvement and alignment, feasibility, education and awareness, and reporting and transparency as a framework for a case study of a P4P initiative conducted in Ohio between 2015 and 2019. Notably, the case study is focused on PCC and how the Ohio Department of Medicaid selected the Preferences for Everyday Living Inventory (PELI) for nursing home providers to use with all of their residents. Although inclusion of the PELI met some of the key factors, such as measurement, its implementation did not meet other key factors, such as reporting and transparency. Based on lessons learned from the Ohio P4P, recommendations are presented for use of the PELI as both a process and outcome measure in future P4P initiatives.

The CoreQ: Development and Testing of a Nursing Facility Resident Satisfaction Survey

The development and testing of a nursing facility resident satisfaction survey (i.e., CoreQ) that could be used for public reporting purposes is presented here. This is important as very little satisfaction with care information is publicly available for nursing facility consumers. Validity testing is reported detailing the development of the CoreQ: Short Stay Discharge questionnaire and a measure that was calculated from the items in the questionnaire. This questionnaire resulted in four items whose combined score gives a measure representing participants' overall satisfaction with the nursing facility. The measure parsimoniously reports this satisfaction as a score (ranging from 0 to 100) and was recently endorsed by the National Quality Forum (NQF). The measure may have significance for report cards and payment metrics, as it incorporates the consumers' opinion.

Nurse Aide Retention in Nursing Homes

Background and Objectives

The association of nurse aide retention with three quality indicators is examined. Retention is defined as the proportion of staff continuously employed in the same facility for a defined period of time.

Research Design and Methods

Data used in this investigation came from survey responses from 3,550 nursing facilities, Certification and Survey Provider Enhanced Reporting data, and the Area Resource File. Staffing characteristics, quality indicators, facility, and market information from these data sources were all measured in 2016. Nurse aide retention was measured at 1, 2, and 3 years of employment. The quality indicators examined were a count of all deficiency citations, quality of care deficiency citations, and J, K, L deficiency citations. Negative binomial regression analyses were used to study the associations between the three different retention measures and these three quality indicators.

Results

The 1-, 2-, and 3-year nurse aide retention measures were 53.2%, 41.4%, and 36.1%, respectively. The regression analyses show low levels of retention to be generally associated with poor performance on the three deficiency citation quality indicators examined.

Discussion and Implications

The research presented starts to provide information on nurse aide retention as an important workforce challenge and its potential impact on quality. Retention may be an additional staffing characteristic of nursing facilities with substantial policy and practice relevance.

Person-Centered Care as Facilitated by Kansas' PEAK 2.0 Medicaid Pay-for-Performance Program and Nursing Home Resident Clinical Outcomes

Purpose of the Study

Person-centered care (PCC) is intended to improve nursing home residents’ quality of life, but the closer bonds it engenders between residents and staff may also facilitate improvements to residents’ clinical health. Findings on whether adoption ameliorates resident clinical outcomes are conflicting, with some evidence of harm as well as benefit. To provide clearer evidence, the present study made use of Kansas’ PEAK 2.0 Medicaid pay-for-performance (P4P) program, which incents the adoption of PCC. The program is distinctive in training facilities’ staff on adopting PCC through a series of well-defined stages and providing regular feedback about their progress.

Design and Methods

A retrospective cohort study was performed with 349 Kansas facilities spread across several well-defined PCC adoption stages, ranging from nonadoption to comprehensive adoption. The outcomes were thirteen 2014–2016 Nursing Home Compare long-stay resident clinical measures and a composite measure incorporating only nonimputed data for those 13 outcomes. Observed facility demographic differences were controlled for with propensity score adjustment. Treatment effect analyses were run with each outcome, with the predictor variable of program stage.

Results

Seven of the 13 clinical measures plus the composite measure indicated better health for residents in homes at higher program stages, relative to those in nonparticipating homes, including a 49% lower prevalence of major depressive symptoms in strongly adopting facilities.

Implications

The findings suggest that greater PCC adoption through PEAK participation is associated with better quality of care. Policymakers in other states may want to consider implementing a program modeled on PEAK 2.0.

Does Nursing Home Compare Reflect Patient Safety In Nursing Homes?

The past several decades have seen significant policy efforts to improve the quality of care in nursing homes, but the patient safety movement has largely ignored this setting. In this study we compared nursing homes' performance on several composite quality measures from Nursing Home Compare, the most prominent recent example of a national policy aimed at improving the quality of nursing home care, to their performance on measures of patient safety in nursing homes such as pressure sores, infections, falls, and medication errors. Although Nursing Home Compare captures some aspects of patient safety, we found the relationship to be weak and somewhat inconsistent, leaving consumers who care about patient safety with little guidance. We recommend that Nursing Home Compare be refined to provide a clearer picture of patient safety and quality of life, allowing consumers to weight these domains according to their preferences and priorities.

Nursing home Facebook reviews: who has them, and how do they relate to other measures of quality and experience?

BACKGROUND

The growing use of social media creates opportunities for patients and families to provide feedback and rate individual healthcare providers. Whereas previous studies have examined this emerging trend in hospital and physician settings, little is known about user ratings of nursing homes (NHs) and how these ratings relate to other measures of quality.

OBJECTIVE

To examine the relationship between Facebook user-generated NH ratings and other measures of NH satisfaction/experience and quality.

METHODS

This study compared Facebook user ratings of NHs in Maryland (n=225) and Minnesota (n=335) to resident/family satisfaction/experience survey ratings and the Centers for Medicare and Medicaid (CMS) 5-star NH report card ratings.

RESULTS

Overall, 55 NHs in Maryland had an official Facebook page, of which 35 provided the opportunity for users to rate care in the facility. In Minnesota, 126 NHs had a Facebook page, of which 78 allowed for user ratings. NHs with higher aid staffing levels, not affiliated with a chain and located in higher income counties were more likely to have a Facebook page. Facebook ratings were not significantly correlated with the CMS 5-star rating or survey-based resident/family satisfaction ratings.

CONCLUSIONS

Given the disconnect between Facebook ratings and other, more scientifically grounded measures of quality, concerns about the validity and use of social media ratings are warranted. However, it is likely consumers will increasingly turn to social media ratings of NHs, given the lack of consumer perspective on most state and federal report card sites. Thus, social media ratings may present a unique opportunity for healthcare report cards to capture real-time consumer voice.

Satisfaction of Discharged Nursing Home Residents

The psychometric properties of The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Nursing Home survey: Discharged Resident Instrument (NHCAHPS-D) are examined. A random sample of 550 nursing homes was selected from across the United States and 365 agreed to participate (participation rate = 66%). From 7,020 surveys sent to discharged residents, 4,926 were returned (response rate = 70%). The psychometric properties of the resident responses and the survey items were robust. Confirmatory factor analyses model fit statistics met the criterion for good conformance. Five of the initial NHCAHPS-D instrument domains were identified (environment, care, communication and respect, autonomy, and activities), along with a sixth (transitions) added by the authors. The standardization and reliability that NHCAHPS-D provides could facilitate the same benefits we have seen in other industries for the CAHPS family of instruments (i.e., quality improvement, reimbursement, public reporting, and benchmarking) and also become an industry standard.

Pay-for-performance policy and data-driven decision making within nursing homes: a qualitative study

INTRODUCTION

Health systems globally and within the USA have introduced nursing home pay-for-performance (P4P) programmes in response to the need for improved nursing home quality. Central to the challenge of administering effective P4P is the availability of accurate, timely and clinically appropriate data for decision making. We aimed to explore ways in which data were collected, thought about and used as a result of participation in a P4P programme.

METHODS

Semistructured interviews were conducted with 232 nursing home employees from within 70 nursing homes that participated in P4P-sponsored quality improvement (QI) projects. Interview data were analysed to identify themes surrounding collecting, thinking about and using data for QI decision making.

RESULTS

The term 'data' appeared 247 times in the interviews, and over 92% of these instances (228/247) were spontaneous references by nursing home staff. Overall, 34% of respondents (79/232) referred directly to 'data' in their interviews. Nursing home leadership more frequently discussed data use than direct care staff. Emergent themes included using data to identify a QI problem, gathering data in new ways at the local level, and measuring outcomes in response to P4P participation. Alterations in data use as a result of policy change were theoretically consistent with the revised version of the Promoting Action on Research Implementation in Health Services framework, which posits that successful implementation is a function of evidence, context and facilitation.

CONCLUSIONS

Providing a reimbursement context that facilitates the collection and use of reliable local evidence may be an important consideration to others contemplating the adaptation of P4P policies.

Minnesota's provider-initiated approach yields care quality gains at participating nursing homes

Minnesota's Performance-Based Incentive Payment Program uses a collaborative, provider-initiated approach to nursing home quality improvement: up-front funding of evidence-based projects selected and designed by participating facilities, with accountable performance targets. During the first 4 rounds of funding (2007-10), 66 projects were launched at 174 facilities. Using a composite quality measure representing multiple dimensions of clinical care, we found that facilities participating during this period exhibited significantly greater gains than did nonparticipating facilities, in both targeted areas and overall quality, and maintained their quality advantage after project completion. Participating and nonparticipating facilities were similar at baseline with respect to quality scores and improvement trends, as well as acuity-adjusted payment, operating costs, and nurse staffing. Although self-selection precludes firm conclusions regarding the program's impacts, early findings indicate that the program shows promise for incentivizing nursing home quality improvement, both in facility-identified areas of concern and overall.

Do Medicaid incentive payments boost quality? Florida's direct care staffing adjustment program

Beginning in April 2000 and continuing for 21 months, Florida's legislature allocated $31.6 million (annualized) to nursing homes through a Medicaid direct care staffing adjustment. Florida's legislature paid the highest incentives to nursing homes with the lowest staffing levels and the greatest percentage of Medicaid residents--the bottom tier of quality. Using Donabedian's structure-process-outcomes framework, this study tracks changes in staffing, wages, process of care, and outcomes. The incentive payments increased staffing and wages in nursing home processes (decreased restraint use and feeding tubes) for the facilities receiving the largest amount of money but had no change on pressure sores or decline in activities of daily living. The group receiving the lowest incentives payment (those highest staffed at baseline) saw significant improvement in two quality measures: pressure sores and decline in activities of daily living. All providers receiving more resources improved on deficiency scores, suggesting more Medicaid spending improves quality of care regardless of total incentive payments.

State "technical assistance programs" for nursing home quality improvement: variations and potential implications

To improve nursing home quality, many states have developed "technical assistance programs" that provide on-site consultation and training for nursing facility staff. We conducted a national survey on these state programs to collect data on program design, operations, financing, and perceived effectiveness. As of 2010, 17 states had developed such programs. Compared to existing state nursing home quality regulations, these programs represent a collaborative, rather than enforcement-oriented, approach to quality. However, existing programs vary substantially in key structural features such as staffing patterns, funding levels, and relationship with state survey and certification agencies. Perceived effectiveness by program officials on quality was high, although few states have performed formal evaluations. Perceived barriers to program effectiveness included lack of appropriate staff and funding, among others. In conclusion, state technical assistance programs for nursing homes vary in program design and perceived effectiveness. Future comparative evaluations are needed to inform evidence-based quality initiatives.

Examining the lived experience of nursing home quality improvement: the case of a multifacility falls reduction project

We conducted a case study based on interviews with nursing home employees (staff and management) participating in a falls reduction project to better understand the lived experience of nursing home quality improvement. Our case study was part of an evaluation of an innovative pay-for-performance policy in the state of Minnesota. In-depth semi-structured interviews were conducted with 37 nursing home employees from within each of the 13 facilities participating in the successful falls reduction project. Our analysis focused on respondent perceptions of the quality improvement implementation process. Interview respondents noted the importance of organizational flexibility and adaptation to change; communication and connections between residents, family members, and staff; and the importance of input from diverse roles. Importantly, interview respondents noted changes that extended well beyond the domain of falls. Knowledge from this study highlights the experiences of care providers enacting change and potentially informs the development of management and program policies that encourage and reward quality nursing home care.

Nursing home quality and financial performance: does the racial composition of residents matter?

OBJECTIVE

To examine the effects of the racial composition of residents on nursing homes' financial and quality performance. The study examined Medicare and Medicaid-certified nursing homes across the United States that submitted Medicare cost reports between the years 1999 and 2004 (11,472 average per year).

DATA SOURCE

Data were obtained from the Minimum Data Set, the On-Line Survey Certification and Reporting, Medicare Cost Reports, and the Area Resource File.

STUDY DESIGN

Panel data regression with random intercepts and negative binomial regression were conducted with state and year fixed effects.

PRINCIPAL FINDINGS

Financial and quality performance differed between nursing homes with high proportions of black residents and nursing homes with no or medium proportions of black residents. Nursing homes with no black residents had higher revenues and higher operating margins and total profit margins and they exhibited better processes and outcomes than nursing homes with high proportions of black residents.

CONCLUSION

Nursing homes' financial viability and quality of care are influenced by the racial composition of residents. Policy makers should consider initiatives to improve both the financial and quality performance of nursing homes serving predominantly black residents.

Culture change practice in U.S. Nursing homes: prevalence and variation by state medicaid reimbursement policies

PURPOSE OF THE STUDY

To estimate the prevalence of culture change practice in U.S. nursing homes (NHs) and examine how state Medicaid policies may be associated with this prevalence.

DESIGN AND METHODS

In 2009/2010, we conducted a survey of a stratified proportionate random sample of NH directors of nursing (DONs) and administrators (NHAs) at 4,149 U.S. NHs; contact was achieved with 3,695. Cooperation rates were 62.6% for NHAs and 61.5% for DONs. Questions focused on NH (physical) environment, resident-centered care, and staff empowerment domains. Domain scores were created and validated, in part, using qualitative interviews from 64 NHAs. Other NH covariate data were from Medicare/Medicaid surveys (Online Survey, Certification and Reporting), aggregated resident assessments (Minimum Data Set), and Medicare claims. Medicaid policies studied were a state's average NH reimbursement rate and pay-for-performance (P4P) reimbursement (including and not including culture change performance measures). Multivariate generalized ordered logit regressions were used.

RESULTS

Eighty-five percent of DONs reported some culture change implementation. Controlling for NH attributes, a $10 higher Medicaid rate was associated with higher NH environment scores. Compared with NHs in non-P4P states, NHs in states with P4P including culture change performance measures had twice the likelihood of superior culture change scores across all domains, and NHs in other P4P states had superior physical environment and staff empowerment scores. Qualitative interviews supported the validity of survey results.

IMPLICATIONS

Changes in Medicaid reimbursement policies may be a promising strategy for increasing culture change practice implementation. Future research examining NH culture change practice implementation pre-post P4P policy changes is recommended.

Performing well on nursing home report cards: does it pay off?

OBJECTIVE

To examine whether high performance or improvement on quality measures leads to economic rewards for nursing homes in the presence of public reporting.

DATA SOURCES

Data from 6,286 freestanding Medicare-certified nursing homes between 1999 and 2005 were identified in Medicare Cost Reports, Minimum Data Set, and Online Survey and Certification Reporting System.

STUDY DESIGN

Using a facility-level fixed-effects model, the effect of public reporting on financial performance was measured by comparing each of four financial outcomes (revenues, expenses, operating, and total profit margins) before (1999-2002) to after (2003-2005) public reporting was initiated. The effects were estimated separately by level of performance and improvement over time.

PRINCIPAL FINDINGS

Facilities that improved on publicly reported performance had increased revenues and higher profit margins after public reporting, mainly through increased Medicare admissions. High-scoring facilities showed similar patterns, though differences were not statistically significant.

CONCLUSIONS

Providers that improve their performance under public reporting may receive a return on their investment in quality improvement. This supports the business case for public reporting.

What is nursing home quality and how is it measured?

PURPOSE

In this commentary, we examine nursing home quality and indicators that have been used to measure nursing home quality.

DESIGN AND METHODS

A brief review of the history of nursing home quality is presented that provides some context and insight into currently used quality indicators. Donabedian's structure, process, and outcome (SPO) model is used to frame the discussion. Current quality indicators and quality initiatives are discussed, including those included in the Facility Quality Indicator Profile Report, Nursing Home Compare, deficiency citations included as part of Medicare/Medicaid certification, and the Advancing Excellence Campaign.

RESULTS

Current quality indicators are presented as a mix of structural, process, and outcome measures, each of which has noted advantages and disadvantages. We speculate on steps that need to be taken in the future to address and potentially improve the quality of care provided by nursing homes, including report cards, pay for performance, market-based incentives, and policy developments in the certification process. Areas for future research are identified throughout the review.

IMPLICATIONS

We conclude that improvements in nursing home quality have likely occurred, but improvements are still needed.

Pressure ulcer prevalence among black and white nursing home residents in New York state: evidence of racial disparity?

OBJECTIVE

The occurrence of pressure ulcers (PUs) in nursing homes is a marker for poor quality of care. We examine whether differences in PU prevalence between black and white residents are due to within- or across-facility disparities.

METHODS

Minimum Data Sets (2006-2007) are linked with the Online Survey Certification and Reporting database. Long-term care residents with high risk for PUs are identified. The dependent variable is dichotomous, indicating PU presence/absence. Individual race and facility race-mix are the main variables of interests.The sample includes 59,740 long-term care high-risk residents (17.4% black and 82.6% white) in 619 nursing homes. We fit 3 risk-adjusted logit models: base, conditional fixed-effects, and random-effects.

RESULTS

Unadjusted PU prevalence is 14.5% (18.2% for blacks and 13.8% for whites). Overall, blacks are more likely to have PUs than whites, controlling for individual risk factors. We find no such effect within facilities after additional accounting for facility fixed effects. The effect of race is significantly different between the base and the conditional fixed-effects logit model. The random-effects and conditional fixed-effects logit models show similar results, demonstrating that higher PU presence among blacks is associated with greater facility-specific concentration of black residents.

CONCLUSION

Greater PU occurrence among blacks may not result from differential within-facility treatment of blacks versus whites. Rather, blacks are more likely to reside in facilities with poorer care quality. To improve PU care for blacks, efforts should focus on improving the overall quality of care for facilities with high proportion of black residents.

State Adoption of Nursing Home Pay-for-Performance

Whereas numerous policies have been adopted to improve quality of care in nursing homes over the past several decades—with varying degrees of success—health care payment has been a largely untapped but potentially powerful policy tool to improve quality of care. Recently, however, payers have invested significant resources in the development and implementation of pay-for-performance (P4P) programs for nursing homes. The authors present results from a survey of state Medicaid agencies documenting the use and structure of P4P in nursing homes. Although the number of states that are implementing nursing home P4P is growing, the structure of these incentives varies across states, and little evidence exists to guide the planning or implementation of these initiatives.

Minnesota's Nursing Facility Performance-Based Incentive Payment Program: an innovative model for promoting care quality

PURPOSE

Minnesota's Nursing Facility Performance-Based Incentive Payment Program (PIPP) supports provider-initiated projects aimed at improving care quality and efficiency. PIPP moves beyond conventional pay for performance. It seeks to promote implementation of evidence-based practices, encourage innovation and risk taking, foster collaboration and shared learning, and establish a solid case for investing in better quality from the perspective of the state, providers, and consumers. We explain PIPP rationale and design, describe projects and participating facilities, and present findings from interviews with project leaders.

DESIGN AND METHODS

Provider-initiated projects lasting from 1 to 3 years are selected through a competitive process and are funded for up to 5% of the daily operating per diem rate. Providers are at risk of losing up to 20% of their project funding if they fail to achieve targets on state nursing facility performance measures.

RESULTS

Minnesota has made a major investment in the PIPP by supporting 45 individual or collaborative projects, representing approximately 160 facilities and annual funding of approximately $18 million. Projects involve a wide range of interventions, such as fall reduction, wound prevention, exercise, improved continence, pain management, resident-centered care and culture change, and transitions to the community.

IMPLICATIONS

The PIPP can serve as a model for other states seeking to promote nursing facility quality either in combination or in place of conventional pay-for-performance efforts.