1. David Gifford SVP Quality & Regulatory Affairs Congressional briefing Washington DC June 23 rd, 2014 IMPACT ACT OF 2014

2. “IMPACT ACT OF 2014” Legislation has four parts : 1. Incorporate standardized assessment 2. Public reporting of common quality measures 3. Provide quality measures to consumers when transitioning to a PAC provider 4. HHS and MedPAC to conduct several

3. “IMPACT ACT OF 2014” Part 1 Incorporate standardized assessment(s) (e.g. CARE tool) into existing assessment tools across PAC providers (LTCH, IRF, SNF, & HH) and acute care hospitals for Pressure ulcers Functional status Cognitive status Special Services Collect data at admission and discharge Applies also to acute care hospitals

4. “IMPACT ACT OF 2014” Part 2 Develop & Publicly report quality measures across settings Rehospitalizations & hospitalizations Hospitalizations after discharge from PAC provider Discharge to community Pressure ulcers Medication reconciliation Incidence of major falls Patient preferences Efficiency measure(s): Avg Total Medicare Spend per Beneficiary Plus any other measures Secretary wants Measures must be approved by National Quality Forum Public reporting starting in Oct 2018

5. Using information across settings Clinical Care Quality Improvement Accountability measurement Public reporting Network selection Payment (e.g. Value Based Purchasing) Policy evaluations & decisions

6. Questions to ask about measures Data source Is it reliable and valid? Is consistent and comparable Wording of assessment Rating scale used Frequency of assessment Measure definition Who does the measure apply to (e.g. denominator) Who is counted in the measure (e.g. numerator) Does the measure need to be risk adjusted? What are clinical and non-clinical characteristics used in risk adjustment Is the measure reliable and valid? How to compare providers based on measure results How do you use measure results for Quality improvement Network selection Payment

7. ADL Questions & Ratings Vary IRFHHSNFLTCHHospitals Bathing0-70-60-4; 0-3None Eating0-70-50-4; 0-3None Grooming0-70-30-4;0-3None Dressing - Total - Upper body - Lower body NA 0-7 NA 0-3 0-4;0-3 NA None Transfers bed, chair0-70-30-4;0-3None Toileting - Overall - Transferring - Hygiene 0-7 0-4 0-3 0-4;0-3 NA None

8. Rating of questions IRF 7 = completely independent 6 = modified independence 5 = supervision (subject = 100%) 4 = minimal assistance (subject = 75% of more) 3 = moderate assistance (subject = 50% or more) 2 = max assistance (25% or more) 1= total assistance 0 activity did not occur OASIS 0 = able to bath self independently 1 = with the use of devices, is able to bath self 2 = able to bathe in shower or tub with the intermittent assistance of another person 3 = able to participate in bathing self in shower or tub but requires presence of another person 4 = unable to use the shower to tub but table to bathe self independently with or without the use of devises at the sink, in chair or on commode 5 = unable to use the shower or tub but able to participate in bathe self in bed, at the sink or in bedside chair with assistance or supervision of another person 6 = unable to participate effectively in bathing and is bathed totally by another person

9. Rating of questions MDS IRF – average function OASIS – typical ability MDS – most dependent 0 = independent– no help provided 1 = supervision– oversight help only 2 = physical help limited to transfer only 3 = physical help in part of bathing activity 4 = total dependence 8 = activity did not occur Rating Instructions

10. Wording of questions: Bathing IRF-PAI: “Bathing” OASIS: “Current ability to wash entire body safely, Excludes grooming (washing face, washing hands, and shampooing hair)” MDS: “How resident takes full-body bath/shower, sponge bath, and transfers in /out of tub/shower (excludes washing of back and hair)”

11. Cognitive Function Assessment IRF-PIAOASISMDSLTCH Hospital s Memory Rate assistance Is it ok >1x wk Recall 3 words None Orientationnoneyes Yr, month, day None Decision Making Problem Solving 1-7 Ok with ADLs 0,1 Decision Making 1-4 None

12. Pressure Ulcer Ratings IRF HH SNFLTCHHospitals Countyes None Stage for worst ulcer yes None DimensionsL x WL x W x D None Tissue Type Yes (0-4 ) Yes (0-3) Yes (1-4) None Presence at admission yes None

13. Tissue Type ratings differ IRF 1 = epithelial tissue 2 = granulation tissue 3 = slough 4 = necrotic tissue HH 0 = newly epithelialized 1 = fully granulating 2 = early/partial granulation 3 = not healing SNF 1 = epithelial tissue 2 = granulation tissue 3 = slough 4 = necrotic tissue

14. SAMPLE SIZE

15. Focus on all cause all disease National Quality Forum & CMS require minimum number of patients in each measure (e.g. minimum denominator size) which is usually 25-30 Implications for measures that are not all cause or disease specific

16. # of Facilities vs # of Part A Admissions 200920102011 Number of Facilities % of Total Number of Facilities % of Total Number of Facilities % of Total TOTAL 15,45315,44915,395 Low volume (≤ 100 stays/ year) 6,76644% 6,74444% 7,77350% Moderate volume (101-200 stays/ year) 4,67830% 4,59130% 4,44929% High volume (201-300 stays/ year) 2,06113% 2,10314% 1,78412% Very high volume (>300 stays/ year) 1,94813% 2,01113% 1,389 9% 16

17. # Part A admissions for Top 15 Hospital DRGs by Facility annual volume of Part A admissions Low Vol (<100/yr) Mod Vol (100-200/yr) High Vol (200-300/yr) Very High Vol >300/yr DRG Categories SNF stays 2009 % of All SNF Stays SNF stays 2009 % of All SNF Stays SNF stays 2009 % of All SNF Stays SNF stays 2009 % of All SNF Stays TOTAL451,1192,230,389637,9202,230,389437,2732,230,389704,0772,230,389 1. Orthopedic surgery on lower extremity55,3092.5%81,1563.6%65,4952.9%135,0746.1% 2. Respiratory67,7143.0%83,6953.8%50,5322.3%67,7253.0% 3. Cardiac surgery9,8840.4%15,8170.7%12,6790.6%25,2331.1% 4. Cardiac medical management37,7281.7%54,0672.4%35,9061.6%54,7662.5% 5. GI hospitalizations (surgical and medical)31,4221.4%44,5802.0%30,8251.4%48,3802.2% 6. Renal failure11,8200.5%17,9630.8%11,6270.5%16,8260.8% 7. Amputations3,7040.2% 5,2280.2%3,3460.2%4,9730.2% 8. Spinal surgery2,6630.1% 4,2580.2%3,8800.2%8,4840.4% 9. Other major musculoskeletal surgery4,9160.2% 8,1810.4%6,8110.3%13,1050.6% 10. Other musculoskeletal medical mgmt23,1261.0%34,9401.6%25,7681.2%44,1362.0% 11. Multiple significant trauma1,2420.1% 1,7970.1%1,2260.1%1,9770.1% 12. Infections & parasitic dis. (plus sepsis)52,4282.4%74,2473.3%47,1222.1%64,9472.9% 13. Psychiatric6,1460.3% 7,5090.3%4,2330.2%5,2980.2% 14. Stroke and related conditions18,8630.8%26,8401.2%17,5220.8%25,8191.2% 15. Other124,1545.6%177,6428.0%120,3015.4%187,3348.4% 17

18. Average volume Medicare Admissions per SNF for #1 Admitted diagnosis Low Vol (<100/yr) Mod Vol (100-200/yr) High Vol (200-300/yr) Very High Vol >300/yr # of SNFs (%) 7,773 (50%)4,449 (29%)1,784 (12%)1,389 (9%) DRG Categories SNF stays 2009 % of All SNF Stays SNF stays 2009 % of All SNF Stays SNF stays 2009 % of All SNF Stays SNF stays 2009 % of All SNF Stays TOTAL451,1192,230,389637,9202,230,389437,2732,230,389704,0772,230,389 1. Orthopedic surgery on lower extremity55,3092.5%81,1563.6%65,4952.9%135,0746.1% Avg # of Medicare Admissions per year 7.118.236.796.6

19. RISK ADJUSTMENT

20. Change in Decile Rank from Actual to Risk Adjusted SNF Rehospitalization Change in decile rank between Actual vs Risk adjusted rate# SNFs % of Total No data 261918.59 -810.01 -720.01 -550.04 -4510.36 -32181.55 -26934.92 181812.90 0427230.32 1271719.28 211267.99 34012.85 41160.82 5330.23 6150.11 740.03 810.01