Jeannette C. Petten RN, MS, RAC-CT eHDS Calculation of QMs Resident Method Interval Method

22 | 9/21/2015| © eHealth Data Solutions Objectives The National Quality Forum The Process – How a QM is ratified eHDS Rules - The 2 Methods - The Overriding rules The QMs The Calculation of the QMs – an explanation

33 | 9/21/2015| © eHealth Data Solutions The National Quality Forum NQF

44 | 9/21/2015| © eHealth Data Solutions WHY The National Quality Forum (NQF) U.S. Department of Health and Human Services Contract #: HHSM C To help establish a portfolio of quality and efficiency measures for use in reporting on and improving healthcare quality to allow the federal government to determine if healthcare spending is achieving the best results for patients and taxpayers The contract is part of a provision in the Medicare Improvements for Patients and Providers Act of 2008

55 | 9/21/2015| © eHealth Data Solutions National Quality Forum Mission A nonprofit organization that to improve the quality of American healthcare by: Building consensus on national priorities and goals for performance improvement and working in partnership to achieve them Endorsing national consensus standards for measuring and publicly reporting on performance Promoting the attainment of national goals through education and outreach programs.

66 | 9/21/2015| © eHealth Data Solutions National Quality Forum Governance and Leadership Board of Directors - 27 Members Key public and private leaders that represent major stakeholders Oversees the entire organization 3 Board Committees Guidance to specific NQF’s mission Work completed in partnership with other key organizations 8 Member Councils Serves as advisors to the Board and the Board committees Diverse multi-stakeholder organizations

77 | 9/21/2015| © eHealth Data Solutions National Quality Forum The 3 Committees Consensus Standards Approval Committee (CSAC) Members - experts in health QI and performance measurement Considers standards recommended for endorsement Submits decision regarding endorsement to the Board Health Information Tech Advisory Committee (HITAC) Provides and offers expertise on HIT projects Provides specification of testing requirements for eMeasures Provides maintenance of the quality data set Leadership Network Members are the 8 elected chair of the member councils AND leaders from the public/private sector Provides guidance on education, and recognition programs

88 | 9/21/2015| © eHealth Data Solutions National Quality Forum The 8 Member Councils Consumer Council Comprised of consumer organizations at the national, state, regional and local levels representing those receiving healthcare services Health Plan Council Comprised of healthcare plans and organizations involved in the administration of health insurance programs directly involved in paying for healthcare services Health Professionals Comprised of doctors, nurses, and clinician organizations who play an integral role in improving the quality of our healthcare system and provide a unique on-the-ground perspective of performance measurement and public reporting

99 | 9/21/2015| © eHealth Data Solutions National Quality Forum The 8 Member Councils Provider Organizations Council Comprised of providers of healthcare that include hospitals, group practices, rehabilitation facilities, ambulatory care centers, long-term care facilities, and pharmacies who most often implement the endorsed measures Public/Community Health Agency Council Comprised of Public/Community Health Agencies that represent the population and community level Purchasers Council Comprised of employers, private corporations and government agencies whose interest is improving the quality, reducing cost, enhancing the health and productivity of the workforce

10 | 9/21/2015| © eHealth Data Solutions National Quality Forum The 8 Member Councils Quality Measurement, Research, & Improvement (QMRI) Council Comprised of organizations that conduct research, education, or initiatives to improve healthcare quality, measurement, reporting, policy and quality centers, and information and data services providers and are essential to NQF members as the organization consider new measures, practices, frameworks, and guidelines for endorsement Supplier and Industry Council Comprised of the Supplier and Industry Council that include consultants, manufacturers of device and diagnostic products, medications, tools and other information and resources, and other service providers

11 | 9/21/2015| © eHealth Data Solutions The PROCESS

12 | 9/21/2015| © eHealth Data Solutions THE RATIFICATION PROCESS

13 | 9/21/2015| © eHealth Data Solutions e Health Data Solutions Rules for QM Calculations

14 | 9/21/2015| © eHealth Data Solutions e Health Data Solutions HAD To Made assumptions because the QMs did not define them either clear and/or consistently We decided on “Overriding rules” guiding all of the QMs for consistency We determined some “interpretive rules” for some of the QMs (fields were not determined) We decided on some rules that seemed to be in opposition of the RAI manual and completion of the MDS 3.0 (symptoms of depression)

15 | 9/21/2015| © eHealth Data Solutions eHDS 2 Methods The Resident Method – includes all assessments including admissions and includes the most current assessment for a resident that is currently in the facility (and discharges if denoted) The Interval Method – only looks at those assessments that are completed by Admission date, ARD date or discharge date that corresponds to the time period being viewed

16 | 9/21/2015| © eHealth Data Solutions New Concept: Long Term Assessment Short Assessment Long Term Resident In the facility >100 days Discharge/returns do NOT count against the 100 days Short Term Resident In the facility ≤100 days  Hypothesis Assessments completed and discharged prior to or 100 days were NOT included in ANY QM

17 | 9/21/2015| © eHealth Data Solutions Overriding/General Rules Long Stay: Current admission date, ARD date or discharge date minus admission date >100 days Short Stay: Current admission date, ARD date or discharge date minus admission date ≤ 100 days Each day at 12:01 a.m. we look at all residents present in the facility to determine the 100 days Discharges do not affect the calculation of the 100 days if no NEW admission assessment

18 | 9/21/2015| © eHealth Data Solutions Overriding/General Rules Will include quarterly assessments after >100 days (% changes in the long/short term QMS) PPS assessments ALWAYS considered Short Stay Will include admission and discharge assessments If resident in the facility 1 day in time period, will be included

19 | 9/21/2015| © eHealth Data Solutions The QMs 18 CLINICAL QMs 3 FACILITY SATISFACTION QMs

20 | 9/21/2015| © eHealth Data Solutions 10 long stay QMS are calculated the same as 2.0 with minor adjustments Percent assessments that self-report moderate to severe pain Percent of high-risk defined assessments w/ pressure ulcers Percent assessments assessed and appropriately given the seasonal influenza vaccine Percent assessments assessed and appropriately given the pneumococcal vaccine Percent assessments w/ reported urinary tract infection (CMS)

21 | 9/21/2015| © eHealth Data Solutions 10 long stay QMS are calculated the same as 2.0 with minor adjustments Percent of low-risk defined assessments with loss of bowel and/ or bladder control Percent assessments w/ reported catheter inserted and left in the bladder Percent assessments w/ reported use of physical restraints (CMS) (defined by bed and chair) Percent of assessments w/ reported help with daily activities has increased Percent assessments w/ reported weight loss (not on physician-prescribed weight-loss regimen)

22 | 9/21/2015| © eHealth Data Solutions The Other 3 Long Stay QMs (2 new 1 revised by MDS 3.0) Physical therapy or nursing rehabilitation/restorative care with new balance problem Percent assessments reporting one or more falls with major injury Percent assessments w/ reported depressive symptoms

23 | 9/21/2015| © eHealth Data Solutions 1 New Short Stay QMs Percent of admission assessments on a scheduled pain medication and reported decrease in pain intensity or frequency in 14-day assessment

24 | 9/21/2015| © eHealth Data Solutions 4 short stay QMS are calculated the same as 2.0 with minor adjustments Percent assessments that self-report moderate to severe pain Percent assessments w/ reported pressure ulcers that are new or worsened (using 14- day PPS OR discharge assessment and will be looking at the fields that describe worsening as well as an increase) Percent assessments assessed and appropriately given the seasonal influenza vaccine Percent assessments assessed and appropriately given the pneumococcal vaccine

25 | 9/21/2015| © eHealth Data Solutions The 3 Satisfaction QMS CAHPS® Nursing Home Survey: Discharged Resident Instrument CAHPS® Nursing Home Survey: Long-Stay Resident Instrument CAHPS® Nursing Home Survey: Family Member Instrument

26 | 9/21/2015| © eHealth Data Solutions Calculation of the QMs

27 | 9/21/2015| © eHealth Data Solutions NUMERATOR/DENOMINATOR THE CALCULATION IS A RATIO OR FRACTION: NUMBERATOR DIVIDED BY THE DENOMINATOR To change the number to a percent divided by 100 Example: 50/100= X100=50% Numerator: The number in the population with the defined criteria (Defined by NQF) Denominator: The defined population (Defined by NQF)

28 | 9/21/2015| © eHealth Data Solutions LONG STAY QM#1: Physical therapy or nursing restorative care with new balance problem Denominator: Current assessment with a decrease in the balance test from a sitting to a standing position Numerator: Physical therapy provided ≤121 days (last 4 months) Walking Nursing restorative program ≤121 days (last 4 months) Exclusions: BIMS score of ≤7 CPS score of ≥5 Life expectancy of less than 6 months Hospice while a resident

29 | 9/21/2015| © eHealth Data Solutions LONG STAY QM#2: Percent assessments reporting one or more falls with major injury Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly assessment or a discharge assessment Numerator: Fall(s) with a major injury Exclusions: Comatose Missing relevant information

30 | 9/21/2015| © eHealth Data Solutions LONG STAY QM#3 AND SHORT STAY QM#15: Percent assessments that self-report moderate to severe pain Denominator: Long Stay: Admission, quarterly, annual, significant change, significant correction of an annual or quarterly assessment or a discharge assessment Short Stay: 14-Day PPS assessments in time period Numerator: Reporting moderate frequency and intensity of pain OR Reporting severe pain Exclusions: None

31 | 9/21/2015| © eHealth Data Solutions LONG STAY QM#4 Percent of high risk defined assessments w/ pressure ulcers Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly assessment or a discharge assessment Numerator: Reporting of a Stage 2, 3 or 4 Pressure Ulcer OR Reporting the ICD-9 for a Stage 2, 3 or 4 Pressure Ulcer Exclusions: None High Risk Resident Comatose A diagnosis of Malnutrition Bed Mobility or Transfer/Extensive Assistance to Did Not Occur

32 | 9/21/2015| © eHealth Data Solutions LONG STAY QM#5 AND SHORT STAY QM#17 Percent assessments assessed and appropriately given the seasonal influenza vaccine Denominator: LONG STAY: All assessments that the ARD or discharge date is >100 days and in the reporting period of October 1 to June 30 SHORT STAY: All assessments that the admission, ARD or discharge date is <100 days during the reporting period of October 1 to June 30 Numerator: The vaccine is reported as given in the facility OR The vaccine was given outside the facility, not eligible or declined when asked Exclusions: None

33 | 9/21/2015| © eHealth Data Solutions LONG STAY QM#6 AND SHORT STAY QM#18 Percent assessments assessed and appropriately given the pneumococcal vaccine Denominator: LONG STAY: All assessments that the ARD or discharge date is >100 days during the reporting period SHORT STAY: All assessments that the admission, ARD or discharge date is <100 days during the reporting period Numerator: The vaccine is reported as being up-to-date OR The vaccine was not given due to not eligible or declined when asked Exclusions: None

34 | 9/21/2015| © eHealth Data Solutions LONG STAY QM#7 Percent assessments w/ reported urinary tract infection Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly or discharge assessment >100 days Numerator: Reported urinary tract infection Exclusions: None

35 | 9/21/2015| © eHealth Data Solutions LONG STAY QM#8 Percent of low-risk defined assessments with loss of bowel and/ or bladder control Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly or discharge assessment >100 days Numerator: Reported frequently or always incontinent of urine Reported frequently or always incontinent of bowel Exclusions: Comatose BIMS score of ≤7 CPS score of 5 or 6 Walk in Room totally dependent to Did Not Occur Reported indwelling urinary catheter

36 | 9/21/2015| © eHealth Data Solutions LONG STAY QM#9 Percent assessments w/ reported catheter inserted and left in the bladder Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly or discharge assessment >100 days Numerator: Reported frequently or always incontinent of urine Reported indwelling urinary catheter Exclusions: Reported diagnosis of a Neurogenic Bladder Reported diagnosis of a Obstructive Uropathy

37 | 9/21/2015| © eHealth Data Solutions LONG STAY QM#10 Percent assessments w/ reported use of physical restraints Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly or discharge assessment >100 days Numerator: Reported use of bed trunk or limb restraints OR Reported use of chair trunk or limb restraints or a chair that prevents rising Exclusions: None

38 | 9/21/2015| © eHealth Data Solutions LONG STAY QM#11 Percent of assessments w/ reported help with daily activities has increased Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly or discharge assessment >100 days Numerator: Reported 2 ADLs performance decreased 1 level OR Reported 1 ADL performance decreased 2 or more levels as compared to the most prior assessment Exclusions: Comatose All the late loss ADLs (bed mobility, transfer, toileting, eating) are totally dependent to Did not occur Reported receiving hospice care while a resident

39 | 9/21/2015| © eHealth Data Solutions LONG STAY QM#12 Percent assessments w/ reported weight loss Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly or discharge assessment >100 days Numerator: Reported weight loss but not on physician-prescribed weight-loss regimen Exclusions: None

40 | 9/21/2015| © eHealth Data Solutions LONG STAY QM#13 Percent assessments w/ reported depressive symptoms Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly or discharge assessment >100 days Numerator: Interview of mood and a PHQ-9© score of ≥10 Staff assessment and a PHQ-9-OV score of ≥10 If missing 3 areas of staff assessment, then D0500A≥2 or D0500≥2 AND a score of ≥2 for five of D0500A-I Exclusions: Comatose

41 | 9/21/2015| © eHealth Data Solutions SHORT STAY QM#14 Percent of assessments on scheduled pain regimen and reported decrease in pain intensity or frequency Denominator: All residents with a 5-day PPS assessment and 14-day assessment or a discharge assessment (whichever comes first) Numerator: On a scheduled pain medication regimen and a decrease in pain frequency OR On a pain medication regimen and a decrease in pain intensity Exclusions: None

42 | 9/21/2015| © eHealth Data Solutions SHORT STAY QM#16 Percent assessments w/ reported pressure ulcers that are new or worsened Denominator: All residents with a discharge assessment ≤100 days with a prior 5-day PPS assessment or an OBRA admission Numerator: Reported new Stage 2, 3 or 4 Pressure Ulcers OR Reported worsening of Stage 2, 3 or 4 Pressure Ulcers as compared to the most prior assessment Exclusions: None

DISCUSSION AND QUESTIONS