1. A Training Program for LTSS Providers Part One: Quality Improvement in Long-Term Services and Supports (QuILTSS) Bridge Payment Submission

2. What is QuILTSS? A TennCare initiative to promote the delivery of high quality LTSS for TennCare members (NF as well as HCBS) Identify performance measures that are most important to people who receive LTSS and their families Creation of a new payment system (aligning payment with quality) for NFs and certain HCBS based on performance on those measures Part One: QuILTSS Overview

3. A Definition of Quality in LTSS: Providing the right care in the right place at the right time— with the best possible outcome that helps people live the lives they want to live Part One: QuILTSS Overview

4. The QuILTSS Journey Technical Assistance Report –Click here to access full reporthere –Stakeholder input –Literature review –Key informant interviews –Recommendations Quality Framework Stakeholder Meetings –Convened twice a month for three months Part One: QuILTSS Overview

5. Framework Contributors Tennessee Health Care Association LeadingAge Tennessee National HealthCare Corporation Signature HealthCARE Tennessee Association for Home Care AARP Alzheimer’s Tennessee, Inc. Tennessee Council on Developmental Disabilities Tennessee Disability Coalition The Arc Tennessee Qsource Tennessee Department of Health Tennessee Commission on Aging and Disability Area Agencies on Aging and Disability Alexian Brothers Community Services (PACE) Lipscomb University School of TransformAging Part One: QuILTSS Overview

6. Part Two: The QuILTSS Nursing Facility Value-Based Purchasing Quality Framework Framework sent to Medicaid NF Providers on August 5, 2014 by Patti Killingsworth Click to access memo and frameworkmemoframework Part Two: Quality Framework

7. Value-Based Purchasing Threshold Measures –Must be met by the facility in order to be eligible for the quality payment portion of their reimbursement rate Quality Measures –Used to determine the amount of quality payment that a facility would receive Part Two: Quality Framework

8. Value-Based Purchasing Model Part Two: Quality Framework Threhold Measures Must be achieved in order to receive any portion of quality payment Quality Measures Satisfaction35 points Resident Satisfaction15 points Family Satisfaction10 points Staff Satisfaction10 points Culture Change/Quality of Life30 points Respectful Treatment10 points Resident Choice10 points Member/Resident & Family Input5 points Meaningful Activities5 points Staffing/Staff Competency25 points RN Hours Per Day5 points CNA Hours Per Day5 points Staff Retention5 points Consistent Staff Assignment5 points Staff Training (On-boarding & Continuing)5 points Clinical Performance10 points Antipsychotic Medication5 points Urinary Tract Infection5 points Total Possible Points100 points

9. Flexibility for Adjustments to Model’s Design Anticipate adjustments will be made over time Based on experience, system-wide performance, stakeholder feedback, and priorities Expect to see changes to threshold and quality measures, categories, elements, definitions, benchmarks and point values Part Two: Quality Framework

10. Calculating Payment for Quality Portion of Rate Total number of points earned on all quality measures Divided by the total possible number of points Equals percentage of quality payment eligibility Part Two: Quality Framework

11. Implementation: Two Phase Process Transition/Bridge Model PaymentDate Range Q1July 1, 2013-June 30, 2014 Q2July 1, 2014-Sept 30, 2014 Q3Oct. 1 – Dec. 31, 2014 Q4Jan. 1 – Mar. 31, 2015 Value-Based Purchasing Model Full implementation of acuity- and quality- adjusted reimbursement rates is expected to begin during FY 2016 Part Two: Quality Framework

12. Bridge Model Periodic interim payments to NFs to adjust the existing cost-based NF rates based on two acuity-based case-mix approaches and a 20% quality component, using an abbreviated version of the quality framework Transitional - recognize efforts toward quality improvement and quality performance Part Two: Quality Framework

13. Bridge Model Aligned as closely to value based purchasing model as possible No threshold measures –Encourage participation –Increase quality improvement initiatives Quality measures will be explained in greater detail in Parts 4-8 of training materials Part Two: Quality Framework

14. Part Three: Brief Overview of the Submission Process Beginning the training with the end in mind. Part Three: Submission Process

15. Organizing Your Submission Part Three: Submission Process 18 Possible Attachments

16. What You Need Reliable Internet Access Form is available online at https://tenncare.wufoo.com/forms/quiltss- bridge-payment-for-nursing-facilitiesq1/ –Write this link down for future reference Click here for submission formhere –Print a copy of the submission form –Review it frequently to become familiar Part Three: Submission Process

17. Possible Attachments Click here to access the “Survey Tool List of Attachments”here –Print this list and follow it closely Potential for 18 attachments –When preparing your submission, determine how many attachments you will submit. –If you want to submit multiple documents for a particular response, you must combine them into a single attachment. Attachments must be titled correctly –For example, [facility name]2.pdf Part Three: Submission Process

18. Creating a PDF document With one exception, attachments must be in.pdf format –If you have Adobe Acrobat on your computer, you should be able convert word or excel documents to pdf using the “save as” a pdf function. –Otherwise, you should consider downloading a pdf creator, pdf writer, or pdf printer software, that can allow you to create a pdf. –Many free software programs available online. Part Three: Submission Process

19. A Few Cautions to Keep in Mind 1.You must complete the submission form in one sitting, as you can not save and exit the form. 2.Important to attach the correct document during the submission process. 3.All submissions must be completed by the stated deadline so start preparing your submission immediately. Part Three: Submission Process

20. Deadlines All submissions must be received before 4:30 p.m. central time on 9/15/14 –Late submissions will not be allowed. –Only one submission is allowed. –No modifications will be allowed to submissions, even if the modification could be made by the deadline. Part Three: Submission Process

21. Part Four: Documenting Quality Measures - Satisfaction

22. Satisfaction Most important aspect of quality from the consumers’ perspective Highest point value at 35 points Comprised of three different perspectives on satisfaction: –Member/Resident –Family –Staff Part Four: Documenting Quality Measures - Satisfaction

23. What is a Member/Resident Satisfaction Survey? Instrument designed to determine level of satisfaction with the services and supports provided by NF Must have gathered information from member/resident’s perspective –Respondent could be the resident himself/herself, or their proxy –A member/resident satisfaction survey answered by a family member on behalf of the resident counts as a member/resident survey and not a family satisfaction survey Part Four: Documenting Quality Measures - Satisfaction

24. Member/Resident Satisfaction Did the facility conduct a member/resident satisfaction survey between July 1, 2013 and June 30, 2014? Part Four: Documenting Quality Measures - Satisfaction ASK If Yes, If No, Conduct a member/resident satisfaction survey during a subsequent quarter and receive points for the following quarters of the bridge year for this measure. Submit documentation and receive five points for the current quarter and every subsequent quarter of the bridge year for this measure.

25. Required Documentation Member/Resident Satisfaction Survey Create a pdf of a blank copy of the member/resident satisfaction survey –Title the document “[facility name]1.pdf” Create a pdf of the survey results report –Title the document “[facility name]2.pdf” You will also need: –Description of methodology for conducting survey –Sample size and number of respondents –How responses were gathered –Dates –Results of data analysis Part Four: Documenting Quality Measures - Satisfaction

26. If You Conducted a Survey… Did the facility utilize the results of the survey to pursue improved member/resident satisfaction? Part Four: Documenting Quality Measures - Satisfaction ASK If Yes, If No, Submit copy of documentation and receive ten points for current quarter. Each subsequent quarter will require documentation of improvement efforts occurring during that time period. NFs do not have to pursue different and distinct areas of improvement each quarter. Conduct a member/resident satisfaction survey and utilize the results to pursue improvement during the remaining subsequent quarters where documentation of new improvement efforts can be provided.

27. Required Documentation Member/Resident Satisfaction Improvement Document showing NF pursued improvement in at least ONE area identified in the member/resident satisfaction survey as needing improvement –Example: Member/Resident Survey showed “staff teamwork” was a significant issue. NF launched a monthly training program on teamwork. –Must be during applicable time period Create a pdf of a document –Title the document “[facility name]3.pdf” Part Four: Documenting Quality Measures - Satisfaction

28. Family Satisfaction Did the facility conduct a family satisfaction survey between July 1, 2013 and June 30, 2014? Part Four: Documenting Quality Measures - Satisfaction ASK If Yes, If No, Submit a copy of documentation and receive five points for every quarter of the bridge year for this measure. Conduct a family satisfaction survey during a subsequent quarter and receive points for the following quarters of the bridge year for this measure. Submit a copy of documentation and receive five points for the current quarter and every subsequent quarter of the bridge year for this measure.

29. What Counts as Family Satisfaction Survey? Must be completed from the family member’s perspective Specific to family’s experience and involvement –EX: Satisfaction with opportunities to participate in plan of care development, the facility’s communication with the family, the facility’s responsiveness to family complaints or concerns NOT a member/resident satisfaction survey completed by a family member on behalf of the resident. Part Four: Documenting Quality Measures - Satisfaction

30. Required Documentation Family Satisfaction Survey Create a pdf of a blank copy of the family satisfaction survey –Title the document “[facility name]4.pdf” Create a pdf of the survey results report –Title the document “[facility name]5.pdf” You will also need: –Description of methodology for conducting survey –Sample size and number of respondents –How responses were gathered –Dates –Results of data analysis Part Four: Documenting Quality Measures - Satisfaction

31. If You Conducted a Survey… Did the facility utilize the results of the survey to pursue improved family satisfaction? Part Four: Documenting Quality Measures - Satisfaction ASK If Yes, If No, Submit copy of documentation and receive five points for current quarter. Each subsequent quarter will require documentation of improvement efforts occurring during that time period. NFs do not have to pursue different and distinct areas of improvement each quarter. Conduct a family satisfaction survey and utilize the results to pursue improvement during the remaining subsequent quarters where documentation of new improvement efforts can be provided.

32. Required Documentation Family Satisfaction Improvement Document showing NF pursued improvement in at least ONE area identified in the family satisfaction survey as needing improvement –Example: Family Survey showed “communication between staff and family members ” was a significant issue. NF implemented new communication policies and procedures and trained staff on better methods of communication. –Must be during applicable time period Create a pdf of a document –Title the document “[facility name]6.pdf” Part Four: Documenting Quality Measures - Satisfaction

33. Staff Satisfaction Did the facility conduct a staff satisfaction survey between July 1, 2013 and June 30, 2014? Part Four: Documenting Quality Measures - Satisfaction ASK If Yes, If No, Submit a copy of documentation and receive five points for every quarter of the bridge year for this measure. Conduct a staff satisfaction survey during a subsequent quarter and receive points for the following quarters of the bridge year for this measure. Submit a copy of documentation and receive five points for the current quarter and every subsequent quarter of the bridge year for this measure.

34. Required Documentation Staff Satisfaction Survey Create a pdf of a blank copy of the staff satisfaction survey –Title the document “[facility name]7.pdf” Create a pdf of the survey results report –Title the document “[facility name]8.pdf” You will also need: –Description of methodology for conducting survey –Sample size and number of respondents –How responses were gathered –Dates –Results of data analysis Part Four: Documenting Quality Measures - Satisfaction

35. If You Conducted a Survey… Did the facility utilize the results of the survey to pursue improved staff satisfaction? Part Four: Documenting Quality Measures - Satisfaction ASK If Yes, If No, Submit copy of documentation and receive five points for current quarter. Each subsequent quarter will require documentation of improvement efforts occurring during that time period. NFs do not have to pursue different and distinct areas of improvement each quarter. Conduct a staff satisfaction survey and utilize the results to pursue improvement during the remaining subsequent quarters where documentation of new improvement efforts can be provided.

36. Required Documentation Staff Satisfaction Improvement Document showing NF pursued improvement in at least ONE area identified in the staff satisfaction survey as needing improvement –Example: Staff Survey showed “assistance with job stress” was a significant issue. NF conducted focus groups to better understand issue and to identify stressors. Then, they created a new program to assist staff in this area. –Must be during applicable time period Create a pdf of a document –Title the document “[facility name]9.pdf” Part Four: Documenting Quality Measures - Satisfaction

37. Click here to access Advancing Excellence’s listing of “Survey Instruments Available for Measuring Satisfaction of Nursing Home Residents, their Family Members or Staff”here Please note that this is not an exhaustive listing of acceptable instruments, but directs facilities toward instruments that may be useful in their initial quality improvement efforts. Haven’t Measured Satisfaction? Part Four: Documenting Quality Measures - Satisfaction

38. Part Five: Documenting Quality Measures- Culture Change/Quality of Life Part Five: Documenting Quality Measures – Culture Change

39. Culture Change/Quality of Life Second most important aspect of quality from the consumers’ perspective Significant point value at 30 points Comprised of two different areas: –Person-centered/culture change (PC/CC) practices –Member/resident & family input Part Five: Documenting Quality Measures – Culture Change

40. What is a PC/CC Practices Assessment? Assessment to determine whether care is being delivered in an individualized way based on the needs and preferences of each resident, and which supports each resident’s choice and autonomy. Fundamental aspects include a “homelike” environment and care practices which support residents in exercising choice in their daily lives. Part Five: Documenting Quality Measures – Culture Change

41. How does it differ from satisfaction survey? A culture change/person-centered practices assessment evaluates various aspects of the facility environment, care practices for all residents, the facility’s staffing practices, and opportunities for family and community involvement. Part Five: Documenting Quality Measures – Culture Change

42. PC/CC Practices Assessment Did the facility conduct a PC/CC Practices Assessment between July 1, 2013 and June 30, 2014? ASK If Yes, If No, Submit a copy of documentation and receive five points for every quarter of the bridge year for this measure. Conduct a PC/CC practices assessment during a subsequent quarter and receive points for the following quarters during the bridge year for this measure. Submit copy of assessment and receive five points for the current quarter and every subsequent quarter of the bridge year for this measure. Part Five: Documenting Quality Measures – Culture Change

43. Required Documentation PC/CC Practices Assessment Create a pdf of a blank copy of the PC/CC Practices Assessment –Title the document “[facility name]10.pdf” Create a pdf of the PC/CC Practices Assessment report –Title the document “[facility name]11.pdf” You will also need: –Description of methodology for conducting survey –Sample size and number of respondents –How responses were gathered –Dates –Results of data analysis Part Five: Documenting Quality Measures – Culture Change

44. If You Conducted an Assessment… Did the facility utilize the results of the assessment to pursue improved PC/CC practices? ASK If Yes, If No, Submit copy of documentation and receive ten points for current quarter. Each subsequent quarter will require documentation of improvement efforts occurring during that time period. NFs do not have to pursue different and distinct areas of improvement each quarter. Conduct a PC/CC practices assessment and utilize the results to pursue improvement during the remaining subsequent quarters where documentation of new improvement efforts can be provided. Part Five: Documenting Quality Measures – Culture Change

45. Required Documentation PC/CC Practices Improvement Document showing NF pursued improvement in at least ONE area identified in the PC/CC Practices assessment as needing improvement –Must have done a PC/CC practices assessment to get points –Example: Assessment showed “home-like environment” was a significant issue. NF modified facility to create a more home-like environment by purchasing sofas, coffee tables, and chairs for central areas. –Must be during applicable time period Create a pdf of a document showing how the NF pursued improvement based on the PC/CC practices assessment –Title the document “[facility name]12.pdf” Part Five: Documenting Quality Measures – Culture Change

46. Consider tools such as: – Artifacts of Culture Change Artifacts of Culture Change –Culture Change Staging Tool (used by My Innerview) –Advancing Excellence in America’s Nursing Homes includes Person- Centered Care as an Organizational Goal. –Facilities can complete the Probing Questions identified under Examine ProcessProbing Questions Please note that this is not an exhaustive listing of acceptable instruments, but directs facilities toward instruments that may be useful in their initial quality improvement efforts. Haven’t Assessed Culture Change/Person-Centered Practices? Part Five: Documenting Quality Measures – Culture Change

47. Member/Resident & Family Input Did the facility have an active resident/family council or advisory committee between July 1, 2013 and June 30, 2014? ASK If Yes, If No, Submit a copy of documentation and receive five points for every quarter of the bridge year for this measure. Establish an active resident/family council or advisory committee during a subsequent quarter and receive points for the following quarters during the bridge year for this measure. Submit proof of an active council or committee and receive five points for the current quarter and every subsequent quarter of the bridge year for this measure. Part Five: Documenting Quality Measures – Culture Change

48. Required Documentation Resident/Family Council or Advisory Committee Create a pdf of document proving the existence of an active council or committee –EX: Meeting schedule and meeting minutes or other meeting outcome documentation –Title the document “[facility name]13.pdf” Need to know the number of active council/committee members, including whether member/resident or family. –Do NOT submit names or other identifying information Part Five: Documenting Quality Measures – Culture Change

49. If You Have Council/Committee… Did the facility receive input from the council/committee and use the input to address concerns or improve quality? ASK If Yes, If No, Submit documentation and receive five points for current quarter. Each subsequent quarter will require documentation of improvement efforts occurring during that time period. Establish a council/committee and utilize input to pursue improvement during the remaining subsequent quarters where documentation of new improvement efforts can be provided. Part Five: Documenting Quality Measures – Culture Change

50. Required Documentation Member/Resident & Family Input for Improvement Create a pdf of a copy or description of the input received from council/committee –Include date of receipt –Title the document “[facility name]14.pdf” Create a pdf document showing how the NF addressed input and pursued quality improvement. –Example: Resident council requested facility provide choice in meals. NF has begun providing at least two menu alternatives at each meal and can provide evidence/attestation that has occurred. –Must be during applicable time period –Title the document “[facility name]15.pdf” Part Five: Documenting Quality Measures – Culture Change

51. Member/Resident & Family Input Did the facility actively seek resident/family input in the development of individual care plans, including sufficient notice and accommodations of schedules, between July 1, 2013 and June 30, 2014? ASK If Yes, If No, Submit a copy of documentation and receive five points for every quarter of the bridge year for this measure. Adjust policies and procedures to actively seek resident/family input in the development of individual care plans during a subsequent quarter and receive points for the following quarters during the bridge year for this measure. Submit proof of actively seeking resident/family input in the development of individual care plans and receive five points for the current quarter and every subsequent quarter of the bridge year for this measure. Part Five: Documenting Quality Measures – Culture Change

52. Required Documentation Resident/Family Input in Development of Individual Care Plans Create a pdf showing that the facility strives to encourage and accommodate resident/family input in care plan meetings –Could be internal procedural document and proof of active and good faith to follow procedure –Title the document “[facility name]16.pdf” Part Five: Documenting Quality Measures – Culture Change

53. Part Six: Documenting Quality Measures- Staffing/Staff Competence Part Six: Documenting Quality Measures – Staffing

54. Staffing RN/CNA Hours Per Day TennCare will obtain data on the RN and CNA hours per resident day from Nursing Home Compare for the facility's performance and comparison against: –State Average –National Average Points will be awarded to facilities with staffing levels above average Part Six: Documenting Quality Measures – Staffing

55. Staff Retention “Staff” is defined as any employee or contracted worker who is paid, directly or by contract, by the NF –Retention of contracted staff is based on the length of service of each staff person, and not the length of the contract. Calculated by dividing the number of staff continuously employed (or contracted) for the past 12 months divided by the total number of facility staff All data based on facility staff as of July 1, 2014, as measured against staff on July 1, 2013 Part Six: Documenting Quality Measures – Staffing

56. Staff Retention Retention Ranking Facilities above 75 th percentile (75.1 and above)5 points Facilities above 50 th and up through 75 th percentile (50.1 to 75.0) 3 points Facilities above 25 th and up through 50 th percentile (25.1 to 50.0) 1 point Part Six: Documenting Quality Measures – Staffing Points earned in Q1 will be carried forward to all subsequent quarters of the Bridge payment. Facilities will be ranked by retention percentage for point awards.

57. Required Documentation Staff Retention Complete the “Staff Roster for Value-Based Purchasing Submission” Excel spreadsheet –Click here to access the formhere –All employees (full-time, part-time, directly or by contract) Part Six: Documenting Quality Measures – Staffing

58. Required Documentation Staff Retention This is the ONLY non-pdf document allowable in your submission –Title the document “[facility name]17.xls” Part Six: Documenting Quality Measures – Staffing

59. Part Seven: Documenting Quality Measures- Clinical Measures Part Seven: Documenting Quality Measures – Clinical

60. Clinical Measures TennCare will obtain data on anti- psychotic medications and urinary tract infections from Nursing Home Compare for the facility's performance and to determine the national average You do not need to submit any documentations for this category Part Seven: Documenting Quality Measures – Clinical

61. Clinical Measures Facility PerformancePoints Awarded Facility performs better than national average per Nursing Home Compare on anti-psychotic medications 5 points Facility performs better than national average per Nursing Home Compare on urinary tract infections 5 points Total Possible Clinical Performance Points10 points Performance will be calculated each quarter of the Bridge payment, averaging data from the most recent three quarters. Facilities will be awarded points for performing better than the national average. Part Seven: Documenting Quality Measures – Clinical

62. Part Eight: Bonus Points

63. Bonus Points A NF may earn up to 10 bonus points to its total quality score upon verification of the following as of December 31, 2013: –Active participation in the Advancing Excellence Campaign per their participation definition; –Facility’s membership in the Eden Registry; –Achievement of a Malcolm Baldrige quality award, AHCA Bronze, Silver or Gold Quality Award, Tennessee Center for Performance Excellence Award; –Joint Commission Accreditation; or –CARF Accreditation Title the document “[facility name]18.pdf” Part Eight: Bonus Points

64. “Active Participation” A facility must have selected two goals to pursue by 12/31/13: organizational (consistent assignments, staff stability, reducing hospitalizations or person-centered care) with monthly data submissions regarding that goal to AEC and clinical (pain, pressure ulcers, mobility, infections or medications), for which monthly data entry to AEC is optional during the first year but compulsory during the second year. Active participant status on a goal requires at least six consecutive months of monthly data submissions to AEC on the goal. [If the facility is in the first year of participation, the rule regarding six months of consecutive data submissions will only be applied to the organizational goal.] Proof of data goal identification and data submissions must be submitted to TennCare in order to achieve bonus points. Part Eight: Bonus Points

65. Part Nine: Completing the Online Submission Process

66. Complete Printed Copy of Submission Form Click here for submission formhere –Print a copy of the submission form –Manually complete the answers to assist with data entry –Saves time and ensures accuracy! Part Nine: Completing Online Submission Process

67. Verify Attachments are Ready Click here to access the “Survey Tool List of Attachments”here –Print this list and follow it closely –Determine which attachments you will submit –Ensure all attachments are ready All PDF files and one Excel file Properly titled according to instructions Part Nine: Completing Online Submission Process

68. Review Submission Instructions For your convenience, instructions print on every page of the survey. The submission form cannot be saved so if you exit the form, your information will be lost. Deadline for submitting the online form and all attachments is before 4:30 p.m. CT on 9/15/14. All attachments should be submitted with this form and should comply with the item instructions about how to name the file. All files (except the Excel template provided by TennCare) should be saved and sent as a.pdf (Adobe Acrobat). The template from TennCare should be saved and sent as an Excel file. Part Nine: Completing Online Submission Process

69. Review Submission Instructions You are limited to a single file upload for each question that requests for you to "Choose File." If you wish to include multiple documents in your response they must be combined into a single document before uploading them. Before you attach a file, be sure it is the correct file. If you move to the "Next Page," you will not be able to change the file that you attached. If you attach the wrong file, simply click the "Choose File" button again to choose a different file before you move to the "Next Page.” Part Nine: Completing Online Submission Process

70. Review Submission Instructions Answer each question. In order to receive credit for any item listed below, the entire section must be filled out and/or requested attachments must be submitted. Unless otherwise instructed, performance prior to July 1, 2014 is being measured on this submission. Performance since July 1, 2014 will be measured on future submissions. Some questions display additional guidance when you hover over the question or click in the response area. Please pay attention to this guidance as it may assist you. Part Nine: Completing Online Submission Process

71. Review Submission Instructions Please make sure your submission is final before you press the "Submit" button at the end. If you submit the form as "Actual Submission" and indicate the "Confirmation" on the final page, the submission will be considered your final version of the submission and amendments, alterations, and additions to your submission will not be accepted. Alternatively, if you select "Practice Submission" your submission will not be considered by TennCare. –You may want to start out as a “practice submission” and change to “actual submission” if you are satisfied with your submission. Part Nine: Completing Online Submission Process

72. Reliable Internet Coverage Since the form does not save, make sure: 1.You have enough time to complete the process in one sitting; 2.Your internet connection is reliable and won’t be lost during the upload process; and 3.When you are completely ready to submit, click on the link and begin the process.link Part Nine: Completing Online Submission Process

73. Questions? CONTACT: LTSS Call Center (877) 224-0219 between the hours of 8:00 a.m. and 4:30 p.m. CT