1. QUALITY MEASURES – 5 STARS “NOT NEW BY NOW”

2. Presenters  Rhonda L. Anderson, RHIA President, AHIS, Inc. 2

3. Objectives  The participants will: – Review the Quality Measures and how they relate to Five Star – Identify the possible actions that are within your reach – Identify specific tasks for follow up after this workshop 3

4. Review of CASPER  You know your CASPER – focus on what to do with the results.  Three Reports available through CASPER Reporting: – Facility Characteristics Report – Demographics of residents in the facility – Facility Quality Measures Report – Average national %, Facility Percentile – Resident Level Quality Measure Report – Grid showing what resident triggered each of the QMs (both Active and Discharged residents) 4

5. Facility Quality Measures Report 5

6. Facility Quality Measures Report -2  5 most identified key measures not consistent with state average – Develop your Action Plan 6

7. Resident Level Quality Measures Report 7

8. Tools to Assist  Admission Monitor  Change of Condition  Weekly Treatment Audit  Rounds of Care Review  CP Meeting – Is it action oriented or reviewed? – Think out of the box or routine? 8

9. Tools to Assist -2  Are CAA guidelines being used analytically? – Recheck MDS before final and ?? Is the information accurate (e.g., ADL accuracy of reporting medications, pain, psychoactive drugs)  Pain – Evaluate documentation to determine if there is lack of observable or reported indicators of pain when resident reports moderate to severe pain (to document why pain was not “caught and addressed” while still “mild”) 9

10. Tools to Assist -3  Updated Behavior Management Review – Look at psychotrophic with Dementia or Alzheimer’s – Psych Dx??  Monthly Clinical Record Review – key items = focus priorities – Look at Behavior Psychotherapeutic Drugs – Are meds used off label – Behavior to be re-directed 10

11. Tools to Assist -4  Clinical protocols to prevent re: hospitalization? – What have you changed re: care & services to prevent re-admissions? – Myocardial Infarction – Pneumonia – Heart failure – Coming – COPD  Establish either manual and/or computer reports to evaluate the items identified 11

12. Resident Level Quality Measures Report -2  Run reports from computer system weekly/as needed based on key QI or facility  Identify the most common triggered residents and the reasons – Look at the items that need review, with focus towards the five star items first 12

13. SHORT Stay Measures  % with decrease in pain  % who had moderate/severe pain*  % new or worsening pressure ulcer*  % received influenza vaccine  % assessed or given pneumococcal vaccine  % who have antipsychotic started *Used in Five Star 13

14. LONG Stay Measures  % who had moderate/severe pain*  % with pressure ulcer among high-risk residents*  % who had UTI*  % who lose control of bowel or bladder among low risk residents  % who had catheter inserted & left in their bladder* *Used in Five Star 14

15. LONG Stay Measures -2  % who with one or more falls with major injury*  % who physically restrained*  % who lose too much weight  % who need help with daily activities has increased*  % who are more depressed or anxious  % received influenza vaccine *Used in Five Star 15

16. LONG Stay Measures -3  % assessed or given pneumococcal vaccine  % who receive an antipsychotic 16

17. Display of New Quality Measures 17

18. Changes to CMS Five Star  Continue to use three domains – Survey Results (no change) – Staffing new regression model results in new risk adjusted cut point – Quality Measures 9 new measures new scoring methodology with fixed cut offs 18

19. Comparing % of Facilities Receiving Star Rating  Between old vs. new MDS case mix adjustment 19

20. Changes in Quality Measures in 5 Star  New Quality Measures – 9 new measures based on MDS 3.0 – Scoring sets fixed value for each quality measure to achieve each star rating – Each measure counts equal amount toward aggregate QM five star ranking 20

21. New Quality Measures Used in 5 Star  Short Stay Measures – % who had moderate/severe pain – % new or worsening pressure ulcer  Long Stay Measures – % who had moderate/severe pain – % with pressure ulcer among high-risk residents – % who had UTI – % who had catheter inserted & left in their bladder – % who with one or more falls with major injury 21

22. New Quality Measures Used in 5 Star -2  Long Stay Measures (cont.) – % who physically restrained – % who need help with daily activities has increased 22

23. QM Values for Percentile Rankings 23

24. Overview of Quality Measures 24

25. Measure Calculations 25

26. Understanding the Numerator  Can ONLY include people from the denominator group  Pay attention to how the event or disease is defined – e.g.. MDS questions 1 = rating of 3 or 4 26

27. Understanding the Numerator -2  Use of word “AND” or “OR” have significant meaning, e.g. – MDS question 1 = rating of 3 OR 4 OR question 2 = 1 – MDS question 1 = 4 AND question 2 =1 – Example: Diabetes OR hypertension = people with either diagnosis Diabetes AND hypertension = people only with both diagnoses 27

28. Understanding the Numerator -3  Exclusions ONLY apply to the denominator – Most of exclusions are for missing data  Pay attention to how: – the event or disease is defined, e.g. if restricted to certain types of residents (i.e. high risk) – the time frame for inclusion is defined (short vs. long stay)  Size of denominator (<20 residents) may excluded a facility’s results from public reporting 28

29. Episode Definition MDS 3.0 QMs  Episode STARTS with: – An admission entry (A0310F = [01] AND A1700 = [1])  Episode ENDS with the earliest of the following: – A discharge assessment with return not anticipated (A0310F = [10]), OR – A discharge assessment with return anticipated (A0310F = [11]) but the resident did not return (A0310F = [10]) within 30 days of discharge, OR 29

30. Episode Definition MDS 3.0 QMs -2  Episode ENDS with the earliest of the following (cont.) – A death in facility tracking record (A0310F = [12]), OR – The end of the target period 30

31. Improving Your Quality Measures  Lower the number of residents in numerator – Identify residents who trigger quality measure you want to lower – Conduct root cause analysis – review of each person in numerator for opportunities to prevent Early detection of early signs of problems Systems of care Availability of medical resources Interaction with physician Staffing awareness of policies & protocols 31

32. Improve Your MDS Coding  Make sure: – the Numerator MDS items are being coded accurately – MDS items used for risk adjustment are accurate & complete (e.g. Diabetes) – exclusions are accurate (e.g. schizophrenia) – Check on frequency of missing data for items used in QM calculations – You complete the discharge assessment for all residents who leave the facility 32

33. Quality Measure Specifications MDS 3.0 Quality Measures USER’S MANUAL (v5.0 03-01-2012) http://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/Downloa ds/MDS30QM-Manual.pdf 33

34. SHORT Stay Measures  % with decrease in pain  % who had moderate/severe pain*  % new or worsening pressure ulcer*  % received influenza vaccine  % assessed or given pneumococcal vaccine  % who have antipsychotic started *Used in Five Star 34

35. Moderate/Severe Pain (Short Stay)  Denominator – All short-stay residents except those with exclusions.  Exclusions – pain assessment interview was not completed (J0200=[0,-,^]) – pain presence item was not completed (J0300=[9,-,^]) 35

36. Moderate/Severe Pain (Short Stay) -2  Exclusions (cont.) – For residents with pain or hurting at any time in the last 5 days (J0300 = [1]) AND any of the following are true: pain frequency item was not completed (J0400=[9,-,^]). Neither of the pain intensity items were completed (J0600A=[99,^, -] AND J0600B=[9,^,-]). The numeric pain intensity item indicates no pain (J0600A=[00]) 36

37. LONG Stay Measures  % who had moderate/severe pain*  % with pressure ulcer among high-risk residents*  % who had UTI*  % who lose control of bowel or bladder among low risk residents  % who had catheter inserted & left in their bladder* *Used in Five Star 37

38. LONG Stay Measures -2  % who with one or more falls with major injury*  % who physically restrained*  % who lose too much weight  % who need help with daily activities has increased*  % who are more depressed or anxious  % received influenza vaccine *Used in Five Star 38

39. LONG Stay Measures -3  % assessed or given pneumococcal vaccine  % who receive an antipsychotic 39

40. Reference – Manual – Survey QM  See Handout #1Handout #1 40

41. Psychotrophic Drugs  MDS/IDT – not only a nurse  CP = use of CAA  Mental Health Evaluation  IDT Evaluation-CP (looking at alternatives not just medication-causative factors)  MD involved in CP  CP interventions – Psych drugs use, side effects, reduced doses, drug effectiveness alternatives 41

42. Psychotrophic Drugs -2  SMI / Behavior Reviews for all residents on the Psychiatric Medication – more intense, i.e., similar to the Treatment Review – Look at Diagnosis/SMI – Alzheimer’s or Dementia (Notes? Assessments?) – Not a new form but focused IDT notes with Behavior response – Alternative interventions, side effects, hydration/nutrition, activities plan, information from the family, not just nursing responsible for the interventions 42

43. Behavior Review Physician Involved  Psychotherapeutic Behavior Reviews for all residents on the Medication – more intense, i.e., similar to the Treatment Review – Physician diagnosis identification if behavior manifestation, review and identification of cond. – Not a new form but focused IDT notes with Behavior response – Alternative interventions, side effects, hydration/nutrition, activities plan, information from the family, not just nursing responsible for the interventions 43

44. QAQI  Support compliance and Five Stars  – Use the total Quality Process, i.e., round, focus high priorities = early identification of risks, evaluate food intake % over 3/5/day period? – Frequent pain Why? Behavioral episodes/rounds process each shift? Audit process? Medical Director / other physician roles? 44

45. Your Action Plan  List: – 45

46. Quality Measures Checklist  See Handout #2Handout #2 46

47. Resource Links  http://www.medicare.gov/NHCompare/Static/tabHelp.asp?language=English@activeTab=4&subTab=1 http://www.medicare.gov/NHCompare/Static/tabHelp.asp?language=English@activeTab=4&subTab=1  http://www.medicare.gov/NHCompare/Static/tabHelp.asp?activeTab=2 http://www.medicare.gov/NHCompare/Static/tabHelp.asp?activeTab=2  http://cms.hhs.gov/Medicare/Quality-Initiatives- Patient-Assessment- Instruments/NursingHomeQualityInits/downloads/N HQIQMUsersManual.pdf http://cms.hhs.gov/Medicare/Quality-Initiatives- Patient-Assessment- Instruments/NursingHomeQualityInits/downloads/N HQIQMUsersManual.pdf  http://www.medicare.gov/NHCompare/Static/tabHelp.asp?language=Englishs&activeTab=4&subTab=0 http://www.medicare.gov/NHCompare/Static/tabHelp.asp?language=Englishs&activeTab=4&subTab=0 47

48. Resource Links -2  How to Read a Bar Graph – http://www.medicare.gov/NHCompare/Static/tabHelp. asp?language=Englishs&activeTab=4&subTab=2 http://www.medicare.gov/NHCompare/Static/tabHelp. asp?language=Englishs&activeTab=4&subTab=2 – http://www.medicare.gov/NHCompare/Static/tabHelp. asp?activeTab=5 http://www.medicare.gov/NHCompare/Static/tabHelp. asp?activeTab=5 – http://www.medicare.gov/NHCompare/Static/tabHelp. asp?activeTab=6 http://www.medicare.gov/NHCompare/Static/tabHelp. asp?activeTab=6  Nursing Home Important Information – http://www.medicare.gov/NHCompare/Static/tabHelp.asp? activeTab=2 http://www.medicare.gov/NHCompare/Static/tabHelp.asp? activeTab=2 48