1. Quality Measures Presented for the DOH by Catharine B. Petko, RN BSN Myers and Stauffer LC January 12, 2012

2. References Revised RAI Manual: www.cms.gov/NursingHomeQualityInits/45_NHQIM DS30TrainingMaterials.asp#TopOfPage www.cms.gov/NursingHomeQualityInits/45_NHQIM DS30TrainingMaterials.asp#TopOfPage RAI Manual Errata – 10/7/11 New MDS 3.0 form; Draft QM Manual: www.cms.gov/NursingHomeQualityInits/30_NHQIM DS30TechnicalInformation.asp#TopOfPage www.cms.gov/NursingHomeQualityInits/30_NHQIM DS30TechnicalInformation.asp#TopOfPage Transition document and recorded training: www.cms.gov/SNFPPS/03_RUGIVEdu12.asp#TopOf Page www.cms.gov/SNFPPS/03_RUGIVEdu12.asp#TopOf Page Clarification documents: www.cms.gov/SNFPPS/Downloads/Provider_Call_Fo llowUp082311.pdf and https://www.cms.gov/SNFPPS/Downloads/NPC_No v3_Clarification_FINAL.pdf https://www.cms.gov/SNFPPS/Downloads/NPC_No v3_Clarification_FINAL.pdf

3. Quality Measures Use data from MDS 3.0 to calculate NF performance in various areas Considered valid and reliable; endorsed by National Quality Forum Identify ways NFs differ from each other Not to be considered as benchmarks, thresholds, guidelines, standard of care May be used in Survey and Certification process Will be released on NH Compare

4. Disclaimer Latest information as of 1/13/2012 Draft Manual V. 4.0 9/29/2011 www.cms.gov/NursingHomeQualityInits/ 30_NHQIMDS30TechnicalInformation.as p#TopOfPage

5. Determining Short/Long Stays Target period: The span of time that defines the QM reporting period, e.g., a calendar quarter Short stay: An episode with cumulative days in the facility less than or equal to 100 days as of the end of the target period Long stay: An episode with cumulative days in the facility greater than or equal to 101 days as of the end of the target period

6. Stay The period of time between a resident’s entry into a facility and either a discharge or the end of the target period; or A set of contiguous days in the facility Starts with either an admission entry (A0310F = 01 and A1700 = 1) or a reentry (A0310F = 01 and A1700 = 2) Ends with any discharge (A0310F = 10, 11 or 12) during the target period or the target period ends

7. Episode A period of time spanning one or more stays Starts with an admission entry (A0310F = 01 and A1700 = 1) Ends with a Discharge return not anticipated, or a Discharge return anticipated but the resident did not return within 30 day or a death in facility or the end of the target period

8. Continuous Days in Facility The total number of days within an episode during which the resident was in the facility. Sum of the number of days within each stay included in the episode If there were multiple stays interrupted by hospitalizations, count only the days the resident was in the facility Count day of entry but not day of discharge

9. CDIF Example End of quarter: 12/31 Adm/ReenterDischarge/ End of Quarter Days 9/110/1544 11/1012/3151 Total days95

10. Selecting QM Samples Select all residents whose latest episode either ends during the target period or is ongoing at the end of the target period Compute the CDIF 100 days or less: include in short-stay sample 101 days or more: include in long-stay sample

11. Selecting Short Stay Assessments Target assessment OBRA (A0310A = 01-06), scheduled PPS assessment (A0310B = 01-06) or discharge (A0310F =10 or 11) Target date (A2000 or A2300) no more than 120 days before end of episode Initial assessment Admission (A0310A = 01), PPS 5-day or readmission/return (A0310B = 01 or 06) or discharge (A0310F =10 or 11) First record with target date greater than or equal to the admission date Target date no more than 130 days prior to target date of target assessment Look back scan: Previous assessments are scanned to determine whether certain events or conditions occurred during the look-back period

12. Selecting Long-Stay Assessments Target assessment OBRA (A0310A = 01-06), scheduled PPS assessment (A0310B = 01-06) or discharge (A0310F =10 or 11) Target date (A2000 or A2300) no more than 120 days before end of episode Prior assessment OBRA (A0310A = 01-06), scheduled PPS assessment (A0310B = 01-06) or discharge (A0310F =10 or 11) Target date is 46 – 165 days before the Target assessment Look-back scan: Scan all records with target dates no more than 275 days prior to Target assessment

13. Exclusions Numerator: Defines MDS responses needed to be counted in the QM Denominator: Establishes the population to which the numerator is being compared. May exclude residents with Admission assessments Incomplete data Clinical factors

14. Influenza Vaccination QMs SS #0680/LS #0681: Percent of residents who are given appropriately, the influenza vaccine during the current or most recent influenza season Numerator: Residents meeting any of the following criteria: Received the vaccine during current or most recent influenza season (O0250A In facility = 1 or O250C Outside of facility = 2) or Resident declined vaccine (O0250C = 4) or Resident ineligible (O0250C = 3) Denominator: All short-stay/long-stay residents with a target assessment except those with exclusions Exclusions: O0250C = 1 Resident not in facility during current or most recent influenza season

15. Influenza Vaccination QMs (2) SS #0680A-C/LS #0681A-C: Each QM uses a different numerator A. Received the vaccine during current or most recent influenza season (O0250A = 1 or O250C = 2) OR B. Resident declined vaccine (O0250C = 4) OR C. Resident ineligible (O0250C = 3) Denominator: All short-stay/long-stay residents with a target assessment except those with exclusions Exclusions: O0250C = 1 Resident not in facility during current or most recent influenza season

16. Pneumococcal Vaccination QMs SS #0682/LS #0683: Percent of residents whose pneumococcal polysaccharide vaccine (PPV) status is up to date during the 12-month reporting period Numerator: Residents meeting any of the following criteria: PPV status is up to date (O0300A = 1) or Resident declined vaccine (O0300B = 2) or Resident ineligible (O0300B = 1) Denominator: All short-stay/long-stay residents with a target assessment

17. Pneumococcal Vaccination QMs (2) SS #0682A-C/LS #0683A-C: Each QM uses a different numerator A. PPV status is up to date (O0300A = 1) or B. Resident declined vaccine (O0300B = 2) or C. Resident ineligible (O0300B = 1) Denominator: All short-stay/long-stay residents with a target assessment

18. SS #0675 Decrease in Pain Percentage of short-stay residents who can self-report pain, are on a scheduled pain medication regimen at their initial assessment, and who report lowered levels of pain on their target assessment Numerator: must meet all criteria SS residents with initial and target assessment Can self-report pain (J0200=1) on both On scheduled pain medication regimen on initial assessment (J0100A=1) Report reduced pain on the target assessment J0300 was 1; now 0 OR J0400 response on target > on initial assessment OR J0600A response on target < on initial assessment OR J0600B response on target < on initial assessment

19. SS #0675 Decrease in Pain (2) Denominator: must meet all criteria SS residents with initial and target assessment Can self-report pain (J0200=1) on both On scheduled pain medication regimen on initial assessment (J0100A=1) Exclusions: Not included in numerator and J0300 or J0400 is 9 or dash Not included in numerator and either J0600A or B is not completed on one of the assessments Resident had little/no pain on initial assessment J0300 = 0 OR J0400 = 4 and J0600A/B report no pain

20. SS #0676 Report Moderate to Severe Pain Percent of SS residents with at least one episode of moderate/severe pain or horrible/excruciating pain of any frequency in last 5 days Numerator: meet either or both conditions J0400=1 or 2 and J0600A=05 – 09 or J0600B=2 or 3 and/or J0600A=10 or J0600B=4

21. SS #0676 Report Moderate to Severe Pain(2) Denominator: All SS residents with target assessment Exclusions: Resident not included in numerator and one of the following is true: J0200=0, dash, ^ J0300=9, dash, ^ J0300=1 but J0400=9, dash, ^ or J0600A=99, dash, ^ and J0600B=9, dash, ^ or J0600A=00

22. Covariates Any of two or more random variables exhibiting correlated variation SS#0678 Percent of Residents with Pressure Ulcers That Are New or Worsened LS #0677 Percent of Residents Who Self-Report Moderate to Severe Pain LS #0686 Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder

23. SS #0678 New or Worsened PUs Percentage of short-stay residents with new or worsening Stage 2-4 PUs Uses look-back scan Numerator: Number of worsened PUs must be less than or equal to the number of PUs reported at that stage M0800A >0 and <=M0300BI M0800B >0 and <=M0300CI M0800C >0 and <=M0300DI

24. SS #0678 New or Worsened PUs (2) Denominator: All residents with assessments eligible for look-back scan Excluded if none of the assessments in the look-back scan have usable responses for M0800 (0-9, <= corresponding M0300 item [0-9]) Covariates: Resident required limited or more assistance in bed mobility; has bowel incontinence; has diabetes or PVD; has low BMI

25. LS #0674 Falls with Major Injury Percent of LS residents who have experienced one or more falls with major injury reported in the target period Numerator: LS residents with one or more look-back scan assessments that indicate one or more falls with major injury (J1900C = 1 or 2) Denominator: LS residents with one or more look-back scan assessments Exclude J1800=dash or J1800=1 and J1900C = dash

26. LS #0677 Report Severe to Moderate Pain Percent of LS residents who report either (1) almost constant or frequent moderate to severe pain in the last 5 days or (2) any very severe/horrible pain in the last 5 days Numerator: On target assessment, J0400=1 or 2 AND J0600A=05-09 or J0600B=2 or 3 OR J0600A=10 or J0600B=4

27. LS #0677 Report Severe to Moderate Pain(2) Denominator: All LS residents with target assessment Exclusions: Is admission assessment (A0310A=01 or A0310B=01, 06) OR Not included in numerator AND J0200 or J0300 or J0400 or J0600A/B were completed with 9, dash, ^ (skipped) OR J0600A=00 Covariates: Independence/modified independence in decision making on prior assessment (C0500, C1000)

28. LS #0679 LS High-risk Residents with PUs Percentage of long-stay, high-risk residents with Stage II-IV PUs Numerator: Target assessment with High-risk indicators Bed mobility (G0110A1) or Transfer (G0110B1) = 3, 4, 7, 8 OR Comatose (B0100=1) OR Malnutrition (I5600=1) AND Presence of stage II-IV PUs (M0300B1, C1 or D1 = 1-9 or I8000 has ICD-9 code for PU)

29. LS # 0679 LS High-risk Residents with PUs(2) Denominator: All high-risk residents with a target assessment Exclusions: Is admission assessment (A0310A=01 or A0310B=01, 06) Resident not included in numerator AND any of M0300B1, C1 or D1 = dash

30. LS #0684 Residents with UTI Percentage of LS residents who have a Urinary Tract Infection Numerator: LS residents with I2300 = 1 on target assessment Denominator: All LS residents with a target assessment Exclusions: Is admission assessment (A0310A=01 or A0310B=01, 06) I2300 = dash

31. LS #0685 Low Risk Residents with Incontinence Percent of long-stay low-risk residents who frequently lose control of their bowel or bladder Numerator: LS resident with H0300 or H0400=2 or 3 Denominator: All LS residents with a target assessment except exclusions

32. LS #0685 Low Risk Residents with Incontinence(2) Exclusions: Is admission assessment (A0310A=01 or A0310B=01, 06) Not in numerator and H0300 or H0400=dash Resident is high risk Severe cognitive impairment (C1000=3 and C0700=1 of C0500<=7) OR Total dependence in bed mobility or transfer or locomotion on unit (coded 4, 7, or 8) Not high risk and C0500 and C0700 or C1000 or G0110A1 or B1 or E1 are dash Comatose (B1=1 or dash) Has indwelling catheter or ostomy (H0100A or H0100C = 1 or dash)

33. LS #0686 Catheter Inserted and Left in Bladder Percentage of residents who have had an indwelling catheter in the last 7 days Numerator: LS residents with H0100A=1 on target assessment Denominator: All LS residents with a target assessment Exclusions: Is admission assessment (A0310A=01 or A0310B=01, 06) H0100=dash Neurogenic bladder (I1550) or obstructive uropathy (I1650) = 1 or dash

34. LS #0686 Catheter left in bladder(2) Covariates Frequent bowel incontinence on prior assessment (H0400=2 or 3 Frequently or always incontinent) Pressure ulcers at stages 2 - 4 on prior assessment (M0300B1/C1/D1 = 1-9)

35. LS #0687 Use of Restraints Percent of LS nursing facility residents who are physically restrained on a daily basis Numerator: LS residents with P0100B or P0100C or P0100E or P0100F or P0100G = 2 on target assessment Denominator: All residents with target assessment Exclusions: Not in numerator and P0100B or P0100C or P0100E or P0100F or P0100G = dash

36. LS #0688 Need More Help with ADLs Percent of long-stay residents whose need for help with late-loss ADLs has increased when compared to the prior assessment Numerator “Increase” = 2 or more coding points in one ADL or one point increase in coding points in two or more ADLs Consider late-loss ADLs only 7 and 8 recoded to 4 for comparison

37. LS #0688 Need More Help with ADLs(2) Denominator: All residents with target and prior assessments Exclusions: All late-loss ADLs indicate total dependence (4, 7, 8) Three late-loss ADLs indicate total dependence (4, 7, 8) and one is extensive assistance (3) Comatose (B0100=1) Life expectancy < 6 months (J1400) or Hospice care (O0100K2) are 1 or dash Resident not in numerator and late loss ADLs = dash

38. LS #0689 Lose Too Much Weight Percentage of LS residents who had a weight loss of 5% or more in the last month or 10% or more in the last two quarters who were not on a physician prescribed weight-loss regimen noted in an MDS assessment during the selected quarter Numerator: K0300=2 Weight loss but not on weight loss regimen Denominator: LS residents with target assessment Exclusions: Is admission assessment (A0310A=01 or A0310B=01, 06) K0300=dash on target assessment

39. LS #0690 Depressive Symptoms Percentage of LS residents who have had symptoms of depression during the 2-week period preceding the MDS 3.0 target assessment date Numerator: One of two conditions met D0200A2 or D0200B2=2 or 3 AND D0300 = 10-27 OR D0500A2 or D0500B2=2 or 3 AND D0600 = 10-30

40. LS #0690 Depressive Symptoms(2) Denominator: All LS residents with target assessment Exclusions: B0100 Comatose = 1 or dash Resident not in numerator and some data is missing from the depression items (D0200A2 or D0200B2 or D0300=dash or ^ and D0500A2 or D0500B2 or D0600=dash or ^

41. Questions? qa-mds@pa.gova-mds@pa.gov Next teleconference: April 12, 2012 MDS 3.0 Changes for April 1