1. W HAT ARE THE STARS FOR A NURSING HOME C AROL S IEM, MSN, RN, GNP-BC, RAC-CT C LINICAL E DUCATOR, QIPMO

2. B ACKGROUND December 18, 2008 - Five Star Quality Rating System was added to the Nursing Home Compare website – Onsite inspections – Quality Measures – Staffing Levels

3. O NSITE I NSPECTIONS Nursing homes (NH) were compared to each other Higher star rating if they improve relative to other NHs

4. Q UALITY M EASURES Fixed numeric thresholds as boundaries between star categories – 10% will be a 5 STAR – 70% will be evenly divided between 4, 3, and 2 STARs – 20% will be a 1 STAR Providers can increase their star rating regardless of where other nursing homes improve Old data

5. S TAFFING L EVELS Two Measures – RNs per resident day – Total staffing hours for RNs, LPNs and CNAs per resident day

6. J ULY 12, 2012 N EW I NFORMATION Quality Measures based on 3.0 MDS Detailed Enforcement History Detailed Inspection Reports (Form CMS 2567) Ownership information Information on Physical Therapist Staffing Hours

7. N URSING H OME C OMPARE “3.0” F IVE S TAR Q UALITY R ATING S YSTEM 2015 E XPANDED AND S TRENGTHENED

8. F EBRUARY 20, 2015 I MPROVEMENTS Star for QM calculation now includes the antipsychotic medication measures for those who do not have Schizophrenia, Huntington’s or Tourette’s – Short-stay resident started med after admission – Long-stay resident continues med without diagnosis

9. F EBRUARY 20, 2015 I MPROVEMENTS Raise Performance Expectations – Raised the threshold for nursing homes to achieve a high rating on all measures

10. S TAR I MPACT Many homes saw a decline in their QM rating – Addition of the antipsychotic data – Rebasing of the QM star boundary lines Higher expectations

11. F EBRUARY 20, 2015 I MPROVEMENTS Adjust Staffing Algorithms – Must earn 4 Stars on either the individual RN only or the staffing caregivers to receive overall 4 stars on the Overall Staffing rating – Can have no less than a 3 star rating on any of those dimensions

12. F EBRUARY 20, 2015 I MPROVEMENTS Expand Targeted Surveys Assess adequacy and accuracy of information on the MDS

13. J ULY 30,2015 F INAL R ULE : Q UALITY R EPORTING P ROGRAM Improving Medicare Post Acute Care Transformation (IMPACT): Standardized data reporting across 4 post acute care settings including: home health agencies, inpatient rehabilitation faculties, skilled nursing facilities and long term care hospitals – Beginning FY 2018: No report to CMS means market basket percentage updates reduced 2 percentage points – 3 Quality Domains identified Skin integrity and change in skin integrity Incidence of major falls Functional status, cognitive function and changes in both areas

14. M ARCH 3, 2016 F URTHER I MPROVEMENTS April 2016, 6 new quality measures – Percentage of short stay residents who were successfully discharged to the community (claims based) – Percentage of short stay residents who have had an outpatient emergency department visit (claims based) – Percentage of short stay residents who were re- hospitalized after a nursing home admission (claims based)

15. M ARCH 3, 2016 F URTHER I MPROVEMENTS ( CONT.) April 2016, 6 new quality measures – Percentage of short stay residents who made improvements in function (MDS based) – Percentage of long stay residents who ability to move independently worsened (MDS based) – Percentage of long stay residents who received an antianxiety or hypnotic medication (MDS based)

16. O VERVIEW Beginning in July 2016, five of the measures will be used in the calculation of Five Star Quality Rating QM ratings. The five will be phased in over 9 months. – Antianxiety/hypnotic medication measure will not be used in Five Star due to concerns about its specificity and appropriate thresholds for star ratings.

17. O VERVIEW Key Benefits – Increase the number of short stay measures – Covers important domains not covered by other measures – Claims based measures may be more accurate than MDS based measures.

18. O VERVIEW OF C LAIMS BASED M EASURES Measures use Medicare claims, with MDS data for some risk adjustment and building stays Traditional Medicare beneficiaries Short stay measures following an inpatient hospitalization Risk adjusted: from claims, the enrollment database and the MDS

19. % OF S HORT S TAY R ESIDENTS WHO WERE R E - HOSPITALIZED AFTER A NURSING HOME ADMISSION Development of readmission measures is a high priority for CMS Includes both those who were previously in a nursing home and those who are new admits Includes hospitalizations that occur after nursing home discharges but within 30 days of stay start date – Includes observation stay – Excludes planed readmissions and hospice patients

20. % OF S HORT S TAY R ESIDENTS WHO WERE S UCCESSFULLY D ISCHARGED TO THE C OMMUNITY For many this is the most import outcome MDS assessment for community discharge and claims to determine if successful – Discharged with 100 days of admission – Successful discharge: within 30 days not hospitalized, readmitted to nursing home, did not die in the 30 days after

21. % OF S HORT S TAY RESIDENTS WHO HAVE HAD AN OUTPATIENT EMERGENCY DEPARTMENT VISIT Better preventative care and access to physicians and nurse practitioners to reduce ER visits 30 day time frame and considers all outpatient ED visits except those that lead to an inpatient stay (will then be captured by the re-hospitalization measure

22. MDS M EASURES

23. % OF SHORT STAY RESIDENTS WHO MADE IMPROVEMENTS IN FUNCTION Measures the percentage of short stay residents who made functional improvements during their complete episode of care – Based on self performance in 3 mid loss activities in ADL’s: transfer, locomotion on unit, walk in corridor – Calculated the % short stay residents with mid loss ADL functioning from the 5 day assessment to Discharge – Based on discharge return not anticipated – Excludes residents receiving hospice care / less than 6 months to live.

24. P ERCENTAGE OF L ONG S TAY R ESIDENTS WHOSE ABILITY TO MOVE INDEPENDENTLY WORSENED Percentage of long stay residents who experienced a decline in their ability to move around their room & in adjacent corridors over time

25. P ERCENTAGE OF L ONG S TAY R ESIDENTS WHOSE ABILITY TO MOVE INDEPENDENTLY WORSENED Percentage of long stay residents who experienced a decline in their ability to move around their room & in adjacent corridors over time – Risk adjustment based on ADLs from prior assessment Decline is measured by an increase of one or more points between the target assessment and prior assessment

26. P ERCENTAGE OF LONG STAY RESIDENTS WHO RECEIVED AN ANTIANXIETY OR HYPNOTIC MEDICATION Measures the percentage of long stay residents in a nursing facility who receive antianxiety or hypnotic medications. – Look at prescribing patterns – No risk adjustment Excludes hospice care residents or life expectancy of less than 6 months

27. P REVIEW R EPORTS Facilities may now view their 5 STAR report within the password protected CASPER System The new measures are included in this preview

28. SNF V ALUE -B ASED P ROGRAM To be established beginning with FY 2019 Testing has already begun on how this would work – VB incentive payments – Based on performance on an adopted hospital readmission measure – Estimates the risk standardized rate of all cause, unplanned hospital readmission for SNF Medicare beneficiaries within 30 days of their prior proximal short stay acute hospital discharge – CMS to replace the above measure with an all condition, risk adjusted potentially preventable hospital readmission rate

29. S URVEY STAR

30. H EALTH I NSPECTION D OMAIN Based on the most recent 3 standard surveys Results from any complaint investigation during the most recent 3 year period Any repeat revisits needed to verify that required corrections have brought the facility back into compliance

31. H EALTH I NSPECTION RESULTS Points assigned to deficiencies according to scope and severity More points for more serous, widespread deficiencies Fewer points for less serious, isolated deficiencies Substandard quality of care means additional points assigned Life safety surveys are not included Federal Monitoring surveys are not reported on Nursing Home Compare or included in Five Star calculations

32. R EPEAT R EVISITS No points assigned for first revisit Points assigned only for 2 nd, 3 rd, and 4 th revisits – More revisits are associated with more serious quality problems

34. T OTAL S CORE Weighted deficiency score + number of repeat revisits needed Lower survey score corresponds to fewer deficiencies and revisits

35. T OTAL D OMAIN S CORE Most recent survey has 1/2 of the weight of the score Previous survey (13-24 months ago) has a weight factor of 1/3 Second prior survey has a weight factor of 1/6

36. S TATE V ARIATIONS Survey management: skill sets of surveyors and supervision of surveyors State licensure: different expectations for nursing homes Medicaid policy: varies from state

37. S TATE V ARIATIONS Top 10% will receive a 5 Star rating Middle 70% will receive a 2, 3, or 4 Star rating(23.33 %) Bottom 20% will receive a 1 Star rating

38. C UT P OINTS Recalculated each month Individual facility STAR is held constant until there is a change in the facility survey

39. S TAR M AY C HANGE W HEN … New health inspection survey Complaint investigation A 2 nd, 3 rd, 4 th revisit Resolution of IDR or IIDR The “aging” of complaint deficiencies

40. S TAFFING D OMAIN

41. B ASIS OF M EASURE Relationship between nurse staffing ratios and nursing home quality of care Information from the CMS form CMS- 671 Based on case mix adjusted measures – Total nursing hours per resident day (RN + LPN + nurse aide hours) – RN hours per resident day

42. C ALCULATION RN hours: RNs, RN director of nursing and nurses with administrative duties - this includes MDS coordinator even if LPN but does not perform direct care functions LPN hours: include LPN Nurse aide hours: certified nurse aides, aides in training, and medication aides/ technicians Not included are private duty, hospice staff and feeding assistants

43. Q UALITY M EASURES

44. Q UALITY M EASURES I NTENT FOR P UBLIC R EPORTING Intended to provide consumes an additional data source to use when selecting a nursing facility – www.medicare.gov www.medicare.gov Assist facilities to more effectively focus on quality improvement to ensure that systems are in place for consistent quality care for residents – MDS Quality Improvement Evaluation System (QIES)

45. I NTENT OF QM R EPORTS Quality measures reports are designed as “feedback” reports to facilities – Quality improvement efforts – Guide survey These reports are NOT publicly accessible Available to facilities via the “secured intranet”

46. QM S ( CONTINUED ) QMs are process and outcome – Processes are goal directed interrelated series of actions, events, or steps (care delivery) I.e. Catheters, restraints, help with ADLs increased – Outcomes are what happens as a result of care delivery I.e. Falls, urinary tract infection

47. S AMPLE S ELECTION Two samples are selected If multi-episodes, only the last one is used – All residents whose latest episode ends during the target period or is ongoing – Compute the cumulative days – If the CDIF is less than or equal to 100 days, it is a short-stay – If the CDIF is greater than or equal to 101 days, it is a long-stay

48. L OOK -B ACK S CAN Scans all assessments within the current episode that have target dates no more than 275 days prior to the target assessment – Short-stay residents which it indicates one or more new or worsening Stage II-IV pressure ulcers – Long-stay residents with one or more look- back scan assessment(s) that indicate(s) one or more falls that resulted in major injury

49. R ISK A DJUSTMENT Percent of residents with pressure ulcers that are new or worsened (short- stay) Percent of residents who self-report moderate to severe pain (long-stay) Percent of residents who have/had a catheter inserted and left in their bladder (long-stay)

50. R ISK A DJUSTMENT T WO STEPS 1. Exclude residents whose outcomes are not under nursing home control or outcome is unavoidable 2. Logistic regression (See MDS 3.0 Quality Measures Users Manual Appendix A Section 2) – A detailed approach that is 13 steps long

51. M INIMUM D ATA S ET

52. R ESIDENT A SSESSMENT I NSTRUMENT (RAI) Involves the following process (3 steps) – Minimum Data Set (MDS) - initial assessment – Care Area Assessment (CAAs) - in-depth assessment and problem identification – Plan of care - development of problems (risks/actual problems), goals setting and establishing interventions/approaches Used to identify resident specific – Problems – Potential problems (risks) – Strengths – Preferences

53. S UPPORTING D OCUMENTATION The chart must support the MDS coding decision Good clinical practice is an expectation of CMS If staff interviews are done must be documented during the look back period

54. M ANUAL The CMS Long-Term Care Facility Resident Assessment Instrument User’s Manual is the primary source of information for completing an MDS assessment Residents should be the primary source of information for resident assessment items; should the resident not be able to participate in the assessment, the resident’s family, significant other, and guardian or legally authorized representative should be consulted Manual is over 1,200 pages

55. C URRENT D ATA D ATES Short Stay: 10/1/2014 – 9/30/2015 Long Stay: 01/01/15 – 9/30/2015

56. R ESOURCES RAI Manual: https://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/MDS30RAIManua l.htmlhttps://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/MDS30RAIManua l.html Quality Measures: http://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment- Instruments/NursingHomeQualityInits/Downloads/MDS- 30-QM-User’s-Manual-V80.pdf http://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment- Instruments/NursingHomeQualityInits/Downloads/MDS- 30-QM-User’s-Manual-V80.pdf 5 STAR: http://www.cms.gov/Medicare/Provider- Enrollment-and- Certification/CertificationandComplianc/Downloads/user sguide.pdfhttp://www.cms.gov/Medicare/Provider- Enrollment-and- Certification/CertificationandComplianc/Downloads/user sguide.pdf