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NursingHomeQualityCompositeScoreandQualityMeasures

MelodyMalone,PT,CPHQ,MHAQualityImprovementConsultantTMFHealthQualityInstitute

Objectives§ DefinetheNationalNursingHomeQualityCareCollaborative(NNHQCC)QualityCompositeMeasureScore(CS)

§ IdentifytherelationshipbetweentheCS,theMinimumDataSet(MDS)andtheQualityMeasures(QMs)

§ UnderstandhowtousetheCompositeScoreforQualityImprovement(QI)

§ JumpstartElement3ofQAPI 2

AbouttheTMFQIN-QIOTMFHealthQualityInstitutehaspartneredwiththeArkansasFoundationforMedicalCare,PrimarisinMissouriandtheQualityImprovementProfessionalOrganization,Inc.inPuertoRicotoformtheTMFQualityInnovationNetworkQualityImprovementOrganization(QIN-QIO),undercontractwiththeCentersforMedicare&MedicaidServices(CMS).TheTMFQIN-QIOworkswithprovidersacrossallcaresettingstoprovidequalityimprovementservicesinthestatesofArkansas,Missouri,OklahomaandTexas,andtheterritoryofPuertoRico.

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QIN-QIOKeyRoles§ Championlocal-level,results-orientedchange§ Facilitatelearningandactionnetworks(LAN)§ Teachandadviseastechnicalexperts§ Provideintegratedcommunicationsacrossprovidertypesandhealthcaresegments

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Goalsforthisfive-yearprojectending2019include:§ AchieveascoreofsixorlessontheNationalNursingHomeQualityCompositeMeasureScore

§ Decreaseantipsychoticmedicationuse§ Decreasehealthcare-associatedinfectionsandotherhealthcare-acquiredconditions

§ Decreasepotentiallyavoidablehospitalizations§ TrackandpreventClostridiumdifficile

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Disclaimer§ IamnotanMDSexpert§ Alwaysusethe:› ResidentAssessmentInstrumentUser’sManual(RAI)

› MDS3.0QMUser’sManual› NursingHomeCompare(New)QualityMeasureTechnicalSpecifications,April2016

› Five-StarQualityRatingSystemTechnicalUsers’Guide

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Resources§ Five-StarQualityRatingSystem:TechnicalUsers’Guide

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/FSQRS.html

§ MDS3.0RAIManualhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

§ QMManualhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html

§ NursingHomeCompare(New)QualityMeasureTechnicalSpecifications,April2016https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/New-Measures-Technical-Specifications-DRAFT-04-05-16-.pdf

***Subjecttochangeinlocationandmanualcontent***7

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OklahomaMDSProgramStaffMDSAutomationandQIESCoordinatorForassistancewithMDSreportingschedule,datafilesubmission,Texas-specificrequirements,validationreports,datacorrection,QIESaccess,CASPERReports,QMReportsanddatarequests:

BobBischoffEmail:Robertb@health.ok.govPhone:(405)271-5278

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OklahomaMDSProgramStaffMDSClinicalCoordinatorForassistancewith theMDSRAIManual,specificMDSsectionsoritems,RUGs,CAAs,RAPs,careplansandSwingBedMDS:

DianeHenryEmail:DianeH@health.ok.govPhone:(405)271-5278

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Data=aPerson

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HowareQMsused?QMsdevelopedbytheNationalQualityForumand/orCMS:§ CASPERQMreporthas17QMs› Five-StarQMRatinguses16QMs:› NineMDS-basedlong-stayQMs› FourMDS-basedshort-stayQMs› Threeclaims- andMDS-basedmeasures

§ NNHQCCQualityCompositeMeasureScoreuses13QMs§ Surveyprocess

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OtherWaystheQMsandMDSAreUsed§ Research§ Funding› RUGsandnewpaymentmethodologies› AccountableCareOrganizations› Preferredproviderstatus› VeteransAffairs(VA)contracts

§ Whatelse?

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ByYOU!§ Identifywhatmightbeaproblem§ Prioritizeimprovementopportunities§ SearchforcorrelationsintheQMs§ Benchmark

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Five-StarQualityRatingSystemLong-stayresidents:§ Percentofresidentswhoself-reportmoderatetoseverepain§ Percentofresidentsexperiencingoneormorefallswithmajorinjury§ Percentofhigh-riskresidentswithpressureulcers/sores(PU)§ Percentofresidentswhowerephysicallyrestrained§ Percentofresidentswithurinarytractinfections(UTI)§ Percentofresidentswhohave/hadacatheterinsertedandleftinbladder§ PercentofresidentswhoseneedforhelpwithADLshasincreased§ Percentageofresidentswhoseabilitytomoveindependently worsened

Short-stayresidents:§ Percentofresidentswhoself-reportmoderatetoseverepain§ PercentofresidentswithPUsthatareneworworsened§ Percentageofresidentswhonewlyreceivedanantipsychoticmedication§ Percentageofresidentswhosephysicalfunctionimprovesfromadmission

todischarge14

NNHQCCQualityCompositeMeasureScoreThecompositescoreiscomprisedof13 long-stay QMs:1. Percentofresidentswhoself-reportmoderatetoseverepain2. Percentofhigh-riskresidentswithpressureulcer3. Percentofresidentsphysicallyrestrained4. Percentofresidentswithoneormorefallswithmajorinjury5. Percentofresidentswhoreceivedantipsychoticmedications6. Percentofresidentswhohavedepressivesymptoms7. PercentofresidentswithaUTI8. Percentofresidentswithcatheterinsertedorleftinbladder9. Percentoflow-riskresidentswithlossofbowelsorbladder10. Percentofresidentswholosetoomuchweight11. PercentofresidentswhoseneedforhelpwithADLhasincreased12. Percentofresidentsassessedandappropriatelygivenfluvaccine*13. Percentofresidentsassessedandappropriatelygivenpneumococcalvaccine*

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HowistheCompositeMeasureScoreused?§ NNHQCCmeasuresprogressofthefacilitiesintheaggregateandatthestatelevel

§ CMSmeasuresprogressintheQIN-QIOprojectwork

§ TMFqualityimprovementconsultantshelpguidefacilitiesinQIprojectselection

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‘OpportunityModel’ConceptEachQMnumerator(residentswhotriggered)isapotential“missedopportunity”todelivergoodcare.

Forexample:

Whowantstobeinpain?Noone– thereforenotmanagingsomeone’spainisourmissedopportunitytodelivergreatcare.

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CalculatingtheCompositeScore§ Sumthe13measurenumeratorstoobtainthecompositenumerator

§ Sumthe13measuredenominatorstoobtainthecompositedenominator

§ Dividethecompositenumeratorbythecompositedenominator

§ Multiplyby100

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CalculatingtheCompositeScore

Numerator(missedopportunities/residentsthattriggered)

Denominator(totalopportunities/residentswhocouldtrigger)X100=CS%

*ReverseFluandPneumoniaNumerators!

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FluandPneumoniaVaccinations§ ArenotontheQMfacilityreport§ Arenotreportedtothefacility§ Requirethefacilitytotrackindividually§ And,youhaveto“flip”thenumeratortofindthemissedopportunities

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CompositeScoreFacilityReport

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IndividualRunCharts

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DataisOklahoma’swithaReportPeriod:02/01/17- 07/31/17

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QAPIElement3Feedback,DataSystemsandMonitoring

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Element3:Feedback,DataSystemsandMonitoring§ Usesystemstomonitorcareandservices,drawingdata

frommultiplesources.§ Usefeedbacksystemstoactivelyincorporateinputfrom

staff,residents,familiesandothersasappropriate.§ Useperformanceindicatorstomonitorawiderangeofcare

processesandoutcomes,andreviewfindingsagainstbenchmarksand/ortargetsthatthefacilityhasestablishedforperformance.

§ Usetracking,investigatingandmonitoringofadverseeventsthatmustbeinvestigatedeverytimetheyoccur,andimplementactionplanstopreventrecurrences. 30

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Jump-StartingElement3Somuchdata…

…Solittletime

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Jump-StartingElement3§ Whatismostimportanttoyou?§ Whatiscostingyou(andtheresident)themost:› Time› Talent› Dollars› Painandsuffering

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Jump-StartingElement3Whatdoyoudothatis:§ Highvolume§ Problemprone§ Highcost§ Highrisk§ Lowvolume

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Jump-StartingElement3Don’tforgetnon-clinicalissues:§ Turnover§ Payingbills§ Emergencyprep/drills§ Maintenanceworkrequests§ Vendors

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DevelopaStrategyforCollectingandUsingQAPIData§ Setperformancetargetsandidentifyperformancebenchmarks› performancetargets=goals› performancebenchmarks=industrybests

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DevelopaStrategyforCollectingandUsingQAPIData§ Setperformancetargetsandidentifyperformancebenchmarks

§ Identifywhatperformancemetricswillbemonitored(yourorganization'sactivitiesandperformance)

§ Identifywhoandhowdatawillbecollected,analyzedandused

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DevelopaStrategyforCollectingandUsingQAPIData§ Developaprocessfororganizingandinterpretingdata› Graphs› Charts› Sharingwithteams› Transparency

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QAPIWrittenPlanHow-ToGuide

PotentialQAPIDataSources§ QMsandCompositeScore§ Newmobilitymeasures§ 24-hourreport§ Interact4.0Tools(SBARCommunicationForm,StopandWatch)

§ AHCALTCTrendTracker§ Surveyhistoryandprepreports

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PotentialQAPIDataSources§ Readmissionreports§ Stafferrorandnear-missreports§ Non-clinicalreports› Turnover› Satisfactionsurveys› Visitorandvendorreports› Family/residentcomplaints/comments

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QAPIDataMeasureSpecifications§ Definethepopulationmeasured§ Who’s inthenumerator§ Who’s inthedenominator§ Who’s excluded§ Timeframefordatacollection§ Whatisthesourcedata(e.g.MDS)§ UsetheQMmanualasanexample

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Element3:Usetracking,investigatingandmonitoringofadverseeventsthatmustbeinvestigatedeverytimetheyoccur,andactionplansareimplementedtopreventrecurrences.

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ThinkDeepandWide§ Notjustforthisoneresident§ Notjustforthisadverseevent§ Whatwarningsignsdidwemiss/catch§ Whatcanwelearn§ Howdowepushthelearningforward› Newresidentadmission› Newemployeeonhire

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WheretoStart?

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IdentifyGapsandQIOpportunities§ Conductgapanalysestoidentifyareasforimprovement

§ Gapanalysisisastrategicplanningtooltohelpyouunderstand:› whereyouare› whereyouwanttobe,and› howyou’regoingtogetthere

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IdentifyGapsandQIOpportunities§ Determinewhowillreviewdataandhowoften

§ Identifyhowthedatawillbeusedtoimprovetheorganization

§ Selectareasinneedofimprovementtomonitorbasedonestablishedthresholdcomparedtoorganizationperformance

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DataConsiderations§ Integrity:VA’smedicalappointmentwait-timetargetsandill-structuredincentives

§ Measurementisuselessunlessyoufindwaystoimprove

§ Datacanhelpyoumakebetterdecisionsandtakesmarteractions

§ Usersneeddatainaformatthattheycanuse

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What’sYourVision?Whatdatadoyouneedtohelpyouachieveyourvision?

Yourmission?

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Questions?

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JointheTMFQIN-QIOWebsitehttps://www.TMFQIN.org§ ProvidestargetedtechnicalassistanceandwillengageprovidersandstakeholdersinimprovementinitiativesthroughnumerousLearningandActionNetworks(LANs).

§ Thenetworksserveasinformationhubstomonitordata,engagerelevantorganizations,facilitatelearningandsharingofbestpractices,reducedisparitiesandelevatethevoiceofthepatient.

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AllAreWelcome§ Tojoin,createafreeaccountathttps://www.tmfqin.org.VisittheNetworkstabformoreinformation

§ Asyoucompleteregistration,followthepromptstochoosethenetwork(s)youwouldliketojoin

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LANs

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JoinanyofthefollowingTMFQIN.org networksandyoucansignuptoreceiveemailnotificationstostaycurrentonannouncements,emergingcontent,eventsanddiscussionsintheonlineforums.

§ AntibioticStewardship§ BehavioralHealth§ CardiovascularHealth

andMillionHearts§ ChronicCareManagement§ HealthforLife– Everyone

withDiabetesCounts§ Immunizations§ MeaningfulUse

§ MedicationSafety§ NursingHomeQualityImprovement§ PatientandFamily§ QualityImprovementInitiative§ QualityPaymentProgram§ Readmissions§ Sepsis§ Value-BasedImprovement

andOutcomes

Contact

MelodyMalone,PT,CPHQ,MHAQualityImprovementConsultantTMFHealthQualityInstitute

214-632-2238melody.malone@area-B.hcqis.org

https://TMFQIN.org

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ThismaterialwaspreparedbyTMFHealthQualityInstitute,theMedicareQualityInnovationNetworkQualityImprovementOrganization,undercontractwiththeCentersforMedicare&MedicaidServices(CMS),anagencyoftheU.S.DepartmentofHealthandHumanServices.ThecontentsdonotnecessarilyreflectCMSpolicy.11SOW-QINQIO-C.2-17-80

CASPER ReportMDS 3.0 Facility Characteristics Report

Page 1 of 1

Facility ID: XXXXCCN: XXXXXXFacility Name: XXXXXXXXXXX XXXXXXXXX XXXCity/State: XXXXXXXX, XXData was calculated on: 12/03/2012

Report Period: 06/01/12 - 11/30/12Comparison Group: 04/01/12- 09/30/12Run Date: 12/03/12Report Version Number: 1.00

Facility Comparison Group

Num DenomObservedPercent

StateAverage

NationalAverage

Gender

Male 45 116 38.8% 36.7% 35.3%Female 71 116 61.2% 63.3% 64.7%

Age

<25 years old 0 116 0.0% 0.3% 0.4%25-54 years old 9 116 7.8% 6.5% 5.9%55-64 years old 17 116 14.7% 10.5% 9.6%65-74 years old 32 116 27.6% 17.6% 16.6%75-84 years old 34 116 29.3% 29.9% 28.7%85+ years old 24 116 20.7% 35.1% 38.8%

Diagnostic Characteristics

Psychiatric diagnosis 90 116 77.6% 59.6% 55.4%Intellectual or Developmental Disability 0 53 0.0% 1.4% 1.5%Hospice 8 116 6.9% 9.5% 5.9%

Prognosis

Life expectancy of less than 6 months 4 116 3.4% 6.9% 4.3%

Discharge Plan

Not already occurring 106 116 91.4% 76.7% 65.5%Already occurring 10 116 8.6% 23.3% 34.5%

Referral

Not needed 106 116 91.4% 84.3% 86.6%Is or may be needed but not yet made 7 116 6.0% 7.3% 4.5%Has been made 3 116 2.6% 8.4% 8.9%

Type of Entry

Admission 93 116 80.2% 68.4% 71.5%Reentry 23 116 19.8% 31.6% 28.5%

Entered Facility From

Community 7 116 6.0% 13.2% 11.3%Another nursing home 46 116 39.7% 8.6% 6.3%Acute Hospital 56 116 48.3% 73.7% 78.0%Psychiatric Hospital 1 116 0.9% 1.9% 2.1%Inpatient Rehabilitation Facility 0 116 0.0% 0.8% 0.8%ID/DD facility 0 116 0.0% 0.1% 0.1%Hospice 0 116 0.0% 0.3% 0.3%Long Term Care Hospital 0 116 0.0% 0.2% 0.1%Other 6 116 5.2% 1.2% 1.0%

This report may contain privacy protected data and should not be released to the public.

CASPER Report

MDS 3.0 Resident Level Quality Measure Report

Facility ID: XXXX Report Period: 02/01/14 - 07/31/14

Facility Name: XXXXXXXXXXXX XXXXXXXXX Run Date: 08/04/14

CCN: XXXXXX Report Version Number: 2.00

City/State: XXXXXXXXXX

Data was calculated on: 08/04/14

Note: S = short stay, L = long stay; X = triggered, b = not triggered or excluded

C = complete; data available for all days selected, I = incomplete; data not available for all days selected

Resident ID A0310A/B/F SR

Modera

te/S

evere

Pain

(S

)

SR

Modera

te/S

evere

Pain

(L)

Hi-R

isk P

ressure

Ulc

er

(L)

New

/Wors

ened P

res. U

lcer

(S)

Phys R

estr

ain

ts (

L)

Falls

(L)

Falls

w/M

aj In

jury

(L)

Antipsych M

ed (

S)

Antipsych M

ed (

L)

Antianxie

ty/H

ypnotic M

ed (

L)

Behavio

r S

x A

ffect O

thers

(L)

Depre

ss S

x (

L)

UT

I (L

)

Cath

Insert

/Left B

ladder

(L)

Lo-R

isk L

ose B

/B C

on (

L)

Excessiv

e W

t Loss (

L)

Inc A

DL H

elp

(L)

Qualit

y M

easure

Count

C C C C C C C C C C C C C C C C C C

XXXXXX 02/99/99 b b b b b X b b X b X b b b b b b 3

XXXXXX 02/99/99 b b X b b X b b b X b b b b b b b 3

XXXXXX 02/04/99 b b X b b X b b X b b b b b b b b 3

XXXXXX 02/99/99 b b b b b b b b X X b b b b X b b 3

XXXXXX 03/99/99 b X X b b b b b X b b b b X b b b 4

XXXXXX 02/99/99 b X b b b X b b X b b b b b b b X 4

XXXXXX 03/99/99 X b b b b b b X b b b b b b b b b 2

XXXXXX 02/99/99 b X b b b b b b X b b X X b b b b 4

XXXXXX 04/99/99 b b b b b X X b X b b b b b b X b 4

XXXXXX 03/99/99 b b b b b X b b X b b b b b X b b 3

XXXXXX 03/99/99 b X X b b X b b b X b b b b b X b 5

XXXXXX 03/99/99 X b b X b b b X b b b b b b b b b 3

XXXXXX 04/99/99 b b b b b b b X b b b b b b b b b 1

RESIDENT B1

RESIDENT C1

RESIDENT D1

RESIDENT E1

RESIDENT G1

RESIDENT H1

RESIDENT M1

RESIDENT I1

RESIDENT J1

Discharged Residents

Resident Name

Active Residents

RESIDENT K1

RESIDENT L1

Data

RESIDENT F1

RESIDENT A1

CASPER Report

MDS 3.0 Resident Level Quality Measure Report

Facility ID: XXXX Report Period: 02/01/14 - 07/31/14

Facility Name: XXXXXXXXXXXX XXXXXXXXX Run Date: 08/04/14

CCN: XXXXXX Report Version Number: 2.00

City/State: XXXXXXXXXX

Data was calculated on: 08/04/14

Note: S = short stay, L = long stay; X = triggered, b = not triggered or excluded

C = complete; data available for all days selected, I = incomplete; data not available for all days selected

Resident ID A0310A/B/F SR

Modera

te/S

evere

Pain

(S

)

SR

Modera

te/S

evere

Pain

(L)

Hi-R

isk P

ressure

Ulc

er

(L)

New

/Wors

ened P

res. U

lcer

(S)

Phys R

estr

ain

ts (

L)

Falls

(L)

Falls

w/M

aj In

jury

(L)

Antipsych M

ed (

S)

Antipsych M

ed (

L)

Antianxie

ty/H

ypnotic M

ed (

L)

Behavio

r S

x A

ffect O

thers

(L)

Depre

ss S

x (

L)

UT

I (L

)

Cath

Insert

/Left B

ladder

(L)

Lo-R

isk L

ose B

/B C

on (

L)

Excessiv

e W

t Loss (

L)

Inc A

DL H

elp

(L)

Qualit

y M

easure

Count

XXXXXX 02/99/99 b b b b b b b b b b b b b b b b 0 0

XXXXXX 99/99/10 X b b b b b b b b b b b b b b b 1 1

XXXXXX 99/99/11 b X b b b X X b b b X b b b b b 4 4

XXXXXX 99/99/12 b b b b b b b b b b b b b b b b 0 0

XXXXXX 99/99/10 X b b b b b b b b b b b b b b b 1 1

XXXXXX 99/99/12 b b X b X X b b b X b X b b b b 5 5

XXXXXX 99/99/10 b b b b X b b X b b b b b b b b 2 2

XXXXXX 99/99/11 b X b b b b b b b X X X X b b b 5 5

XXXXXX 99/99/10 b b b b b b b b b b b X X b b b 2 2

XXXXXX 99/99/12 b b b b b b b b b b b b b b b b 0 0

XXXXXX 99/99/11 b b X b b b b b b b b b X b X b 3 3

RESIDENT J2

RESIDENT E2

RESIDENT C2

RESIDENT B2

RESIDENT K2

RESIDENT D2

This report may contain privacy protected data and should not be released to the public.

RESIDENT F2

RESIDENT G2

RESIDENT H2

RESIDENT I2

Resident Name

Discharged Residents

RESIDENT A2

Bridgepoint I, Suite 300, 5918 West Courtyard Drive, Austin, TX 78730-5036

512-334-1768 • 1-866-439-5863 • Fax 512-334-1787 • http://texasqio.tmf.org

This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-TX-C7-13-61

Facility ID: XXXX

Note:

*

7.40%

7.60%

26.70%

13.20%

21.70%

7.00%

26.70%

13.20%

21.70%

0.00%

48.00%

4.00%

5.60%

29.60%

19.60%

10.10%

7.90%

1.30%

1.30%

3.00%

3.10%

3 75 4.00%

25.10%

7.10%

7.10%

3.30%

5 68 8.00%7.40%

3.10%

1.70%

1.40%

7.10%

9.20%

19.90%

21.90%

3.70%

4.20%

27.70%

13.30%

7420.20%

7.50%

11.30%

Incr ADL Help (L) N028.01 13 60 16.80%

Excess Wt Loss (L) N029.01 9 68

42.80%

81

43.60%

8.90%

82

Lo-Risk Lose B/B Con (L) N025.01 4 15

4.20%

19

4.30%

60

*Cath Insert/Left Bladder (L) N026.01 5 66

UTI (L) N024.01

Depress Sx (L) N030.01 2 64 499.50%

2227.40%11.80%11.80%

85

Behav Sx affect Others (L) N034.01 8 68

19.60%

80

*Antianxiety/Hypnotic (L) N033.01 11 56

29.60%

85

*Antipsych Med (L) N031.02 21 71

5.60%

66

*Antipsych Med (S) N011.01 1 18

Falls w/Maj Injury (L) N013.01

Falls (L) N032.01 36 75 5648.00% 42.00% 44.40%

0

30.80%

19.00%

11.50%

0.00%

0.00%

0

Phys restraints (L) N027.01 0 75

0.00%

83

New/worse Pres Ulcer (S) N002.01 0 34

11.50%

89

*Hi-risk Pres Ulcer (L) N015.01 6 52

30.80%

30.30%

80

*SR Mod/Severe Pain (L) N014.01 10 33

19.70%

CMS

IDMeasure Description DenomData

*SR Mod/Severe Pain (S) N001.01 4 13

Comparison

Group

State

AverageNum

Comparison

Group

National

Average

Comparison

Group

National

Percentile

Facility

Observed

Percent

Facility

Adjusted

Percent

Data was calculated on: 05/13/2013

Note: Dashes represent a value that could not be computed

Note: S = short stay, L = long stay

Note: I = incomplete; data not available for all days selected

* is an indicator used to identify that the measure is flagged

Facility Name: XXXXXXXXXX Run Date: 05/16/13

City/State: XXXXXXXXXXX Report Version Number: 2.00

CASPER Report

MDS 3.0 Facility Level Quality Measure Report

Report Period: 11/01/12 - 04/30/13

CCN: XXXXXX Comparison Group: 09/01/12 - 02/28/13

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