Skilled Nursing Facility Quality Reporting Program (SNF QRP) IMPACT ACT 2014 Skilled Nursing Facility Quality Reporting Program (SNF QRP) Are you ready? August 9, 2016

Learning Objectives Understand the IMPACT Act Overview of proposed MDS changes for Oct 1st Explain new section GG and new required MDS item sets Functional impact of LTC Nursing Home Proposed Rule on RAI assessment and care planning Clinical Operational strategies to prepare for these upcoming regulations and next steps

IMPACT Act of 2014 Improving Medicare Post Acute Care Transformation Requires SNF to collect and report standardized patient assessment data through use of Post Acute Assessment Instrument within the MDS Obama Administration set goal of 50% of Medicare payments tied to outcomes by 2018. Politico, 7/22/15 Going Live October 1st!

Why? Post Acute Care Settings Uniform data collection Standardize payment across all Med A levels of care SNF, IRF, LTCH, HH Shift towards payment for Quality vs FFS SNFs - 2% rate reduction (FY 2018) for not providing data

Section GG ADLs - mid loss ADLs Self ADLs (GG0130) Eating Oral hygiene Toileting hygiene Mobility ADLs (GG0170) Sit to lying Lying to sitting on side of bed Sit to stand Chair/bed to chair transfer Toilet transfer Walk 50 feet with 2 turns Walk 150 feet Wheel 50 feet with 2 turns Wheel 150 feet Does not include: family, hospice, private duty, student nurses/nurses aide

GG0130 - Self Care PPS 5 day and/or Admission assessment (A0310B) Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B.

Functional Abilities, Goals & Discharge Performance GG0130A Eating Ability to use suitable utensils to bring food to mouth & swallow food once presented on table/tray Includes modified food consistency GG0130B Oral Hygiene Ability to use suitable items to clean teeth or dentures GG0130C Toileting Hygiene Ability to maintain perineal hygiene including adjusting clothes before & after Toilet, commode, bedpan or urinal Ostomy management, include wiping the opening but not managing equipment

GG0170 Mobility PPS 5 day and/or Admission assessment (A0310B) Assessment period is days 1 through 3 of the SNF PPS Stay starting with (A2400B)

Functional Abilities, Goals & Discharge Performance GG0170B Sit to Lying Ability to move from sitting on side of bed to lying flat on the bed GG0170C Lying to sitting side of bed Ability to safely move from lying on back to sitting on side of the bed with feet flat on the floor and no back support GG0170D Sit to Stand Ability to safely come to a standing position from sitting in a chair or on side of bed GG0170E Chair/Bed to Chair Transfer Ability to safely transfer to and from a bed to a chair or wheelchair GG0170F Toilet Transfer Ability to safely get on & off toilet or commode

Functional Abilities, Goals & Discharge Performance GG0170J Walk 50’ with 2 turns Once standing, the ability to walk at least 50’ and make 2 turns GG0170K Walk 150’ Once standing, the ability to walk at least 150’ in a corridor or similar space GG0170R Wheel 50’ with 2 turns Once seated in wheelchair/scooter (manual or motorized), can wheel at least 50’ and make 2 turns GG0170S Wheel 150’ Once seated in wheelchair/scooter (manual or motorized), can wheel at least 150’ in a corridor or similar space

Section GG IDT Collaboration: Usual Performance 3 day/24 hour Admission & Discharge status as well as Goal for Discharge Nursing: All Shifts Admission & Discharge Assessments Routine observations during treatments, med pass, etc Direct Care: All Shifts Overall Mobility, Bathing, Dressing, Eating assessment & needs Rehab and Restorative Nursing Evaluation with goals & discharge status Mobility & Self Care Social Services Discharge Plan Need a Team Lead & Back up!

Section GG Does and Does Not DASH - equals NO INFORMATION! = 2% payment reduction!!! Does: Use a Six Point Scale Capture Usual Performance Use a 3 day lookback IDT collaboration Does Not: Use the “Rule of 3” Use a “7 day lookback” Require rehab evaluation, goals, days or minutes

01 Dependent Helper does ALL the effort or 2 helpers (ex. following behind with wheelchair while helper is holding gait belt) 02 Substantial/Maximal Assistance Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs. 03 Partial/Moderate Assistance Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs. 04 Supervision or touching Assistance Helper provides VERBAL CUES or TOUCHING, STEADYING assistance as resident completes activity. May be provided constantly or intermittently 05 Setup or Cleanup Assistance Helper SETS UP (prior) or CLEANS UP (follow-up); resident completes the activity. 06 Independent Resident completes the activity by him/herself with no assistance from a helper.

If Activity was not Attempted: Refusal vs Medical &/or Safety Use ONLY for Admission and Discharge Performance 07 Refused (Resident or Staff) 09 Not applicable - Resident did not perform this activity prior to the current illness, exacerbation, or injury 88 Not attempted due to medical condition or safety concern. Documentation expected. (Ie. Coma, SOB, Pain uncontrolled) No Dashes!!

Discharge Assessment

Section A0310 section H Will be required regardless of whether the resident discharges from the facility or stays long term under another payment source (Level of Care Change).

Section GG - Discharge Assessment Team consultation for observation Nursing, Rehab, & Direct Care Staff initiates discharge assessment while continuing to review status Nursing, Rehab, Direct Care Staff complete discharge assessments & consolidate information for observation period & determine final scores MDS coordinator/CRC completes MDS section GG 72 hours prior 48 hours prior 24 hours prior Discharge from Medicare

Operational Considerations

Start Now Plan for change? MDS support/review? Look at efficient & Accurate Processes Can you meet the 3 day deadlines? Quality checks? Team involvement and training? Nursing documentation to address mobility and self care? Evaluation information from Rehab and/or Restorative? Plan for change? MDS support/review? Daily monitoring Skilled documentation Daily dashboard review Stand up meeting? Daily UM? Shift to Shift communication? Restorative Nursing oversight? PCC monitoring of dashboard Data Capture worksheet? Backups for key positions of IDT Don’t use dashes!

Who is your GG Expert? Starting practicing Back ups? What if Rehab is not in? PCC?

Compliance items Time frames! Unable to go back & modify when completing other items Review & discuss with IDT “usual” score for each item & decide on appropriate goal CRC completes MDS section GG and documents rationale by day 3 Know the definitions and scoring guidelines on Collection Tools

Data Ethics Leadership is key to accountability NO BACKDATING! Data Ethics Leadership is key to accountability Gray area when it comes to ethical collection, use and analysis of resident driven data and outcomes Must demonstrate reporting integrity, with outcomes that directly reflect the health, and functional status of the resident Data collected from MDS is used for Medicare/Medicaid reimbursement and monitoring quality of care Do not be tempted to manipulate MDS data to avoid negative outcomes!

Summary & FAQ-- Med A vs Managed Care? Unplanned discharge to hospital? Unable to complete 3 day observation? If missed capturing observation? Are there still changes that can occur within the RAI? No rehab? What’s the plan? Communication systems? Do I need an assessment if benefit’s exhaust? Who can assess care needs for GG? When do we start?

Resources QRP Manual updated April 2016 https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/Downloads/Skilled-Nursing-Facility-Quality-Reporting- Program-Quality-Measure-Specifications-for-FY-2016-Notice-of-Proposed-Rule-Making-report.pdf Draft MDS 3.0 RAI Manual v1.14 May 2016 https://www.cms.gov/Medicare/Quality/Initiatives-Patient-Assessment- Instruments/NursinghomeQualityInits/MDS30RAIManual.html Section GG Tools Link: www.AANAC.org/Section-GG-Resources

C Kendra Coco MPT, NHA, RAC-CT Director of Clinical Reimbursement Andrea Rogers BSN, MSHA, RN, RAC-CT, NHA Clinical Reimbursement Specialist Cynthia Beach RN, RAC-CT