A Training Program for LTSS Providers Part One: Quality Improvement in Long-Term Services and Supports (QuILTSS) Bridge Payment Submission

A Training Program for LTSS Providers

Part One: Quality Improvement in Long-Term Services and Supports

(QuILTSS) Bridge Payment Submission

What is QuILTSS?• A TennCare initiative to promote the delivery of

high quality LTSS for TennCare members (NF as well as HCBS)

• Identify performance measures that are most important to people who receive LTSS and their families

• Creation of a new payment system (aligning payment with quality) for NFs and certain HCBS based on performance on those measures

Part One: QuILTSS Overview

A Definition of Quality in LTSS:

Providing the right care in the right place at the right time—

with the best possible outcome that helps people live the lives

they want to live


The QuILTSS Journey

• Technical Assistance Report– Click here to access full report– Stakeholder input– Literature review– Key informant interviews– Recommendations

• Quality Framework Stakeholder Meetings– Convened twice a month for three months


http://www.lipscomb.edu/transformaging/tareport

Framework Contributors

• Tennessee Health Care Association

• LeadingAge Tennessee • National HealthCare

Corporation • Signature HealthCARE • Tennessee Association for

Home Care • AARP • Alzheimer’s Tennessee, Inc. • Tennessee Council on

Developmental Disabilities

• Tennessee Disability Coalition • The Arc Tennessee • Qsource • Tennessee Department of

Health • Tennessee Commission on

Aging and Disability • Area Agencies on Aging and

Disability • Alexian Brothers Community

Services (PACE) • Lipscomb University School of

TransformAging


Part Two: The QuILTSS Nursing Facility Value-Based

Purchasing Quality Framework

• Framework sent to Medicaid NF Providers on August 5, 2014 by Patti Killingsworth

• Click to access memo and framework

Part Two: Quality Framework

http://www.tn.gov/tenncare/forms/QuiltssMemo.pdf

http://www.tn.gov/tenncare/forms/QuiltssFramwork.pdf

Value-Based Purchasing

• Threshold Measures– Must be met by the facility in order to be

eligible for the quality payment portion of their reimbursement rate

• Quality Measures– Used to determine the amount of quality

payment that a facility would receive


Value-Based Purchasing Model


Threhold MeasuresMust be achieved in order to receive any portion of quality payment

Quality MeasuresSatisfaction 35 points

Resident Satisfaction 15 pointsFamily Satisfaction 10 pointsStaff Satisfaction 10 points

Culture Change/Quality of Life 30 pointsRespectful Treatment 10 pointsResident Choice 10 pointsMember/Resident & Family Input 5 pointsMeaningful Activities 5 points

Staffing/Staff Competency 25 pointsRN Hours Per Day 5 pointsCNA Hours Per Day 5 pointsStaff Retention 5 pointsConsistent Staff Assignment 5 pointsStaff Training (On-boarding & Continuing) 5 points

Clinical Performance 10 pointsAntipsychotic Medication 5 pointsUrinary Tract Infection 5 points

Total Possible Points 100 points

Flexibility for Adjustmentsto Model’s Design

• Anticipate adjustments will be made over time • Based on experience, system-wide

performance, stakeholder feedback, and priorities

• Expect to see changes to threshold and quality measures, categories, elements, definitions, benchmarks and point values


Calculating Payment for Quality Portion of Rate

Total number of

points earned on all quality measures

Divided by the total possible

number of points

Equals percentage of quality payment eligibility


Implementation: Two Phase Process

Transition/Bridge Model

Payment Date Range

Q1 July 1, 2013-June 30, 2014

Q2 July 1, 2014-Sept 30, 2014

Q3 Oct. 1 – Dec. 31, 2014

Q4 Jan. 1 – Mar. 31, 2015

Value-Based Purchasing Model

Full implementation of acuity- and quality-

adjusted reimbursement rates is expected to begin

during FY 2016


Bridge Model

• Periodic interim payments to NFs to adjust the existing cost-based NF rates based on two acuity-based case-mix approaches and a 20% quality component, using an abbreviated version of the quality framework

• Transitional - recognize efforts toward quality improvement and quality performance


Bridge Model

• Aligned as closely to value based purchasing model as possible

• No threshold measures– Encourage participation– Increase quality improvement initiatives

• Quality measures will be explained in greater detail in Parts 4-8 of training materials


Part Three: Brief Overview of the Submission Process

Beginning the training with the end in mind.

Part Three: Submission Process

Organizing Your Submission


18 Possible Attachments

What You Need

• Reliable Internet Access • Form is available online at

https://tenncare.wufoo.com/forms/quiltss-bridge-payment-for-nursing-facilitiesq1/– Write this link down for future reference

• Click here for submission form– Print a copy of the submission form– Review it frequently to become familiar


http://www.tn.gov/tenncare/forms/QuILTSSBridgePaymentSubmissionFormPrintOut.pdf

Possible Attachments• Click here to access the “Survey Tool List

of Attachments”– Print this list and follow it closely

• Potential for 18 attachments– When preparing your submission, determine how

many attachments you will submit.– If you want to submit multiple documents for a

particular response, you must combine them into a single attachment.

• Attachments must be titled correctly– For example, [facility name]2.pdf


http://www.tn.gov/tenncare/long_quiltss.shtml

Creating a PDF document

• With one exception, attachments must be in .pdf format– If you have Adobe Acrobat on your computer,

you should be able convert word or excel documents to pdf using the “save as” a pdf function.

– Otherwise, you should consider downloading a pdf creator, pdf writer, or pdf printer software, that can allow you to create a pdf.

– Many free software programs available online.


A Few Cautions to Keep in Mind

1. You must complete the submission form in one sitting, as you can not save and exit the form.

2. Important to attach the correct document during the submission process.

3. All submissions must be completed by the stated deadline so start preparing your submission immediately.


Deadlines

• All submissions must be received before 4:30 p.m. central time on 9/15/14– Late submissions will not be allowed.– Only one submission is allowed.– No modifications will be allowed to

submissions, even if the modification could be made by the deadline.


Part Four: Documenting Quality

Measures - Satisfaction

Part Four: Documenting Quality Measures - Satisfaction

Satisfaction• Most important aspect of quality from the

consumers’ perspective• Highest point value at 35 points• Comprised of three different perspectives

on satisfaction:– Member/Resident– Family– Staff


What is a Member/Resident Satisfaction Survey?

• Instrument designed to determine level of satisfaction with the services and supports provided by NF

• Must have gathered information from member/resident’s perspective– Respondent could be the resident himself/herself, or their proxy– A member/resident satisfaction survey answered by a family

member on behalf of the resident counts as a member/resident survey and not a family satisfaction survey


Member/Resident Satisfaction

Did the facility conduct a member/resident satisfaction survey between July 1, 2013 and June 30, 2014?


ASK

If Yes,

If No,

Conduct a member/resident satisfaction survey during a subsequent quarter and receive points for the following quarters of the bridge year for this measure.

Submit documentation and receive five points for the current quarter and every subsequent quarter of the bridge year for this measure.

Required DocumentationMember/Resident Satisfaction Survey

• Create a pdf of a blank copy of the member/resident satisfaction survey– Title the document “[facility name]1.pdf”

• Create a pdf of the survey results report– Title the document “[facility name]2.pdf”

• You will also need:– Description of methodology for conducting survey– Sample size and number of respondents– How responses were gathered– Dates– Results of data analysis


If You Conducted a Survey…

Did the facility utilize the results of the survey to pursue improved member/resident satisfaction?


ASK

If Yes,

If No,

Submit copy of documentation and receive ten points for current quarter. Each subsequent quarter will require documentation of improvement efforts occurring during that time period. NFs do not have to pursue different and distinct areas of improvement each quarter.

Conduct a member/resident satisfaction survey and utilize the results to pursue improvement during the remaining subsequent quarters where documentation of new improvement efforts can be provided.

Required DocumentationMember/Resident Satisfaction Improvement

• Document showing NF pursued improvement in at least ONE area identified in the member/resident satisfaction survey as needing improvement– Example: Member/Resident Survey showed “staff

teamwork” was a significant issue. NF launched a monthly training program on teamwork.

– Must be during applicable time period

• Create a pdf of a document – Title the document “[facility name]3.pdf”


Family Satisfaction

Did the facility conduct a family satisfaction survey between July 1, 2013 and June 30, 2014?


ASK

If Yes,

If No,

Submit a copy of documentation and receive five points for every quarter of the bridge year for this measure.

Conduct a family satisfaction survey during a subsequent quarter and receive points for the following quarters of the bridge year for this measure.

Submit a copy of documentation and receive five points for the current quarter and every subsequent quarter of the bridge year for this measure.

What Counts as Family Satisfaction Survey?

• Must be completed from the family member’s perspective

• Specific to family’s experience and involvement– EX: Satisfaction with opportunities to participate in

plan of care development, the facility’s communication with the family, the facility’s responsiveness to family complaints or concerns

• NOT a member/resident satisfaction survey completed by a family member on behalf of the resident.


Required DocumentationFamily Satisfaction Survey

• Create a pdf of a blank copy of the family satisfaction survey– Title the document “[facility name]4.pdf”





Did the facility utilize the results of the survey to pursue improved family satisfaction?


ASK

If Yes,

If No,

Submit copy of documentation and receive five points for current quarter. Each subsequent quarter will require documentation of improvement efforts occurring during that time period. NFs do not have to pursue different and distinct areas of improvement each quarter.

Conduct a family satisfaction survey and utilize the results to pursue improvement during the remaining subsequent quarters where documentation of new improvement efforts can be provided.

Required DocumentationFamily Satisfaction Improvement

• Document showing NF pursued improvement in at least ONE area identified in the family satisfaction survey as needing improvement– Example: Family Survey showed “communication

between staff and family members ” was a significant issue. NF implemented new communication policies and procedures and trained staff on better methods of communication.




Staff Satisfaction

Did the facility conduct a staff satisfaction survey between July 1, 2013 and June 30, 2014?


ASK

If Yes,

If No,


Conduct a staff satisfaction survey during a subsequent quarter and receive points for the following quarters of the bridge year for this measure.

Submit a copy of documentation and receive five points for the current quarter and every subsequent quarter of the bridge year for this measure.

Required DocumentationStaff Satisfaction Survey

• Create a pdf of a blank copy of the staff satisfaction survey– Title the document “[facility name]7.pdf”





Did the facility utilize the results of the survey to pursue improved staff satisfaction?


ASK

If Yes,

If No,

Submit copy of documentation and receive five points for current quarter. Each subsequent quarter will require documentation of improvement efforts occurring during that time period. NFs do not have to pursue different and distinct areas of improvement each quarter.

Conduct a staff satisfaction survey and utilize the results to pursue improvement during the remaining subsequent quarters where documentation of new improvement efforts can be provided.

Required DocumentationStaff Satisfaction Improvement

• Document showing NF pursued improvement in at least ONE area identified in the staff satisfaction survey as needing improvement– Example: Staff Survey showed “assistance with job

stress” was a significant issue. NF conducted focus groups to better understand issue and to identify stressors. Then, they created a new program to assist staff in this area.




• Click here to access Advancing Excellence’s listing of “Survey Instruments Available for Measuring Satisfaction of Nursing Home Residents, their Family Members or Staff”

• Please note that this is not an exhaustive listing of acceptable instruments, but directs facilities toward instruments that may be useful in their initial quality improvement efforts.

Haven’t Measured Satisfaction?


https://www.nhqualitycampaign.org/files/Resident_Satisfaction_SurveyTools.pdf

Part Five: Documenting Quality Measures- Culture Change/Quality of Life

Part Five: Documenting Quality Measures – Culture Change

Culture Change/Quality of Life

• Second most important aspect of quality from the consumers’ perspective

• Significant point value at 30 points• Comprised of two different areas:

– Person-centered/culture change (PC/CC) practices

– Member/resident & family input


What is a PC/CC Practices Assessment?

• Assessment to determine whether care is being delivered in an individualized way based on the needs and preferences of each resident, and which supports each resident’s choice and autonomy.

• Fundamental aspects include a “homelike” environment and care practices which support residents in exercising choice in their daily lives.


How does it differ from satisfaction survey?

• A culture change/person-centered practices assessment evaluates various aspects of the facility environment, care practices for all residents, the facility’s staffing practices, and opportunities for family and community involvement.


PC/CC Practices Assessment

Did the facility conduct a PC/CC Practices Assessment between July 1, 2013 and June 30, 2014?

ASK

If Yes,

If No,


Conduct a PC/CC practices assessment during a subsequent quarter and receive points for the following quarters during the bridge year for this measure.

Submit copy of assessment and receive five points for the current quarter and every subsequent quarter of the bridge year for this measure.


Required DocumentationPC/CC Practices Assessment

• Create a pdf of a blank copy of the PC/CC Practices Assessment– Title the document “[facility name]10.pdf”

• Create a pdf of the PC/CC Practices Assessment report– Title the document “[facility name]11.pdf”



If You Conducted an Assessment…Did the facility utilize the results of the assessment to pursue improved PC/CC practices?

ASK

If Yes,

If No,

Submit copy of documentation and receive ten points for current quarter. Each subsequent quarter will require documentation of improvement efforts occurring during that time period. NFs do not have to pursue different and distinct areas of improvement each quarter.

Conduct a PC/CC practices assessment and utilize the results to pursue improvement during the remaining subsequent quarters where documentation of new improvement efforts can be provided.


Required DocumentationPC/CC Practices Improvement

• Document showing NF pursued improvement in at least ONE area identified in the PC/CC Practices assessment as needing improvement– Must have done a PC/CC practices assessment to get points– Example: Assessment showed “home-like environment” was a

significant issue. NF modified facility to create a more home-like environment by purchasing sofas, coffee tables, and chairs for central areas.


• Create a pdf of a document showing how the NF pursued improvement based on the PC/CC practices assessment– Title the document “[facility name]12.pdf”


• Consider tools such as:– Artifacts of Culture Change – Culture Change Staging Tool (used by My Innerview)– Advancing Excellence in America’s Nursing Homes includes Person-

Centered Care as an Organizational Goal. – Facilities can complete the Probing Questions identified under

Examine Process

• Please note that this is not an exhaustive listing of acceptable instruments, but directs facilities toward instruments that may be useful in their initial quality improvement efforts.

Haven’t Assessed Culture Change/Person-Centered Practices?


http://www.artifactsofculturechange.org/ACCTool/



https://www.nhqualitycampaign.org/goalDetail.aspx?g=PCC

Member/Resident & Family InputDid the facility have an active resident/family council or advisory committee between July 1, 2013 and June 30, 2014?

ASK

If Yes,

If No,


Establish an active resident/family council or advisory committee during a subsequent quarter and receive points for the following quarters during the bridge year for this measure.

Submit proof of an active council or committee and receive five points for the current quarter and every subsequent quarter of the bridge year for this measure.


Required DocumentationResident/Family Council or Advisory Committee

• Create a pdf of document proving the existence of an active council or committee– EX: Meeting schedule and meeting minutes or other

meeting outcome documentation – Title the document “[facility name]13.pdf”

• Need to know the number of active council/committee members, including whether member/resident or family.– Do NOT submit names or other identifying information


If You Have Council/Committee…Did the facility receive input from the council/committee and use the input to address concerns or improve quality?

ASK

If Yes,

If No,

Submit documentation and receive five points for current quarter. Each subsequent quarter will require documentation of improvement efforts occurring during that time period.

Establish a council/committee and utilize input to pursue improvement during the remaining subsequent quarters where documentation of new improvement efforts can be provided.


Required DocumentationMember/Resident & Family Input for Improvement

• Create a pdf of a copy or description of the input received from council/committee– Include date of receipt– Title the document “[facility name]14.pdf”

• Create a pdf document showing how the NF addressed input and pursued quality improvement.– Example: Resident council requested facility provide choice in

meals. NF has begun providing at least two menu alternatives at each meal and can provide evidence/attestation that has occurred.

– Must be during applicable time period– Title the document “[facility name]15.pdf”


Member/Resident & Family InputDid the facility actively seek resident/family input in the development of individual care plans, including sufficient notice and accommodations of schedules, between July 1, 2013 and June 30, 2014?

ASK

If Yes,

If No,

Submit a copy of documentation and receive five points for every quarter of the bridge year for this measure.Adjust policies and procedures to actively seek resident/family input in the development of individual care plans during a subsequent quarter and receive points for the following quarters during the bridge year for this measure.

Submit proof of actively seeking resident/family input in the development of individual care plans and receive five points for the current quarter and every subsequent quarter of the bridge year for this measure.


Required DocumentationResident/Family Input in Development of

Individual Care Plans

• Create a pdf showing that the facility strives to encourage and accommodate resident/family input in care plan meetings– Could be internal procedural document and proof of

active and good faith to follow procedure– Title the document “[facility name]16.pdf”


Part Six: Documenting Quality Measures-

Staffing/Staff Competence

Part Six: Documenting Quality Measures – Staffing

StaffingRN/CNA Hours Per Day

• TennCare will obtain data on the RN and CNA hours per resident day from Nursing Home Compare for the facility's performance and comparison against:– State Average– National Average

• Points will be awarded to facilities with staffing levels above average


Staff Retention

• “Staff” is defined as any employee or contracted worker who is paid, directly or by contract, by the NF– Retention of contracted staff is based on the length of service of

each staff person, and not the length of the contract.

• Calculated by dividing the number of staff continuously employed (or contracted) for the past 12 months divided by the total number of facility staff

• All data based on facility staff as of July 1, 2014, as measured against staff on July 1, 2013


Staff Retention

Retention Ranking

Facilities above 75th percentile (75.1 and above) 5 points

Facilities above 50th and up through 75th percentile (50.1 to 75.0)

3 points

Facilities above 25th and up through 50th percentile (25.1 to 50.0)

1 point


Points earned in Q1 will be carried forward to all subsequent quarters of the Bridge payment.

Facilities will be ranked by retention percentage for point awards.

Required DocumentationStaff Retention

• Complete the “Staff Roster for Value-Based Purchasing Submission” Excel spreadsheet– Click here to access the form– All employees (full-time, part-time, directly or by contract)



Required DocumentationStaff Retention

• This is the ONLY non-pdf document allowable in your submission– Title the document “[facility name]17.xls”


Part Seven: Documenting Quality Measures-

Clinical Measures

Part Seven: Documenting Quality Measures – Clinical

Clinical Measures

• TennCare will obtain data on anti-psychotic medications and urinary tract infections from Nursing Home Compare for the facility's performance and to determine the national average

• You do not need to submit any documentations for this category


Clinical Measures

Facility Performance Points Awarded

Facility performs better than national average per Nursing Home Compare on anti-psychotic medications

5 points

Facility performs better than national average per Nursing Home Compare on urinary tract infections

5 points

Total Possible Clinical Performance Points 10 points

• Performance will be calculated each quarter of the Bridge payment, averaging data from the most recent three quarters.

• Facilities will be awarded points for performing better than the national average.


Part Eight: Bonus Points


Bonus Points• A NF may earn up to 10 bonus points to its total

quality score upon verification of the following as of December 31, 2013:– Active participation in the Advancing Excellence Campaign per

their participation definition;– Facility’s membership in the Eden Registry;– Achievement of a Malcolm Baldrige quality award, AHCA

Bronze, Silver or Gold Quality Award, Tennessee Center for Performance Excellence Award;

– Joint Commission Accreditation; or– CARF Accreditation

• Title the document “[facility name]18.pdf”


“Active Participation”• A facility must have selected two goals to pursue by 12/31/13:

organizational (consistent assignments, staff stability, reducing hospitalizations or person-centered care) with monthly data submissions regarding that goal to AEC and clinical (pain, pressure ulcers, mobility, infections or medications), for which monthly data entry to AEC is optional during the first year but compulsory during the second year.

• Active participant status on a goal requires at least six consecutive months of monthly data submissions to AEC on the goal. [If the facility is in the first year of participation, the rule regarding six months of consecutive data submissions will only be applied to the organizational goal.]

• Proof of data goal identification and data submissions must be submitted to TennCare in order to achieve bonus points.


Part Nine: Completing the Online Submission Process

Part Nine: Completing the Online Submission Process

Complete Printed Copy of Submission Form

• Click here for submission form– Print a copy of the submission form– Manually complete the answers to assist with

data entry– Saves time and ensures accuracy!

Part Nine: Completing Online Submission Process

http://www.tn.gov/tenncare/forms/QuILTSSBridgePaymentSubmissionFormPrintOut.pdf

Verify Attachments are Ready

• Click here to access the “Survey Tool List of Attachments”– Print this list and follow it closely– Determine which attachments you will submit– Ensure all attachments are ready

• All PDF files and one Excel file • Properly titled according to instructions



Review Submission Instructions• For your convenience, instructions print on every page of

the survey.• The submission form cannot be saved so if you exit the

form, your information will be lost.• Deadline for submitting the online form and all

attachments is before 4:30 p.m. CT on 9/15/14. • All attachments should be submitted with this form and

should comply with the item instructions about how to name the file. All files (except the Excel template provided by TennCare) should be saved and sent as a .pdf (Adobe Acrobat). The template from TennCare should be saved and sent as an Excel file.


Review Submission Instructions• You are limited to a single file upload for each question

that requests for you to "Choose File." If you wish to include multiple documents in your response they must be combined into a single document before uploading them.

• Before you attach a file, be sure it is the correct file. If you move to the "Next Page," you will not be able to change the file that you attached. If you attach the wrong file, simply click the "Choose File" button again to choose a different file before you move to the "Next Page.”


Review Submission Instructions• Answer each question. In order to receive credit for any

item listed below, the entire section must be filled out and/or requested attachments must be submitted.

• Unless otherwise instructed, performance prior to July 1, 2014 is being measured on this submission. Performance since July 1, 2014 will be measured on future submissions.

• Some questions display additional guidance when you hover over the question or click in the response area. Please pay attention to this guidance as it may assist you.


Review Submission Instructions• Please make sure your submission is final before you

press the "Submit" button at the end. If you submit the form as "Actual Submission" and indicate the "Confirmation" on the final page, the submission will be considered your final version of the submission and amendments, alterations, and additions to your submission will not be accepted. Alternatively, if you select "Practice Submission" your submission will not be considered by TennCare.– You may want to start out as a “practice submission” and change

to “actual submission” if you are satisfied with your submission.


Reliable Internet Coverage

Since the form does not save, make sure:1. You have enough time to complete the

process in one sitting;

2. Your internet connection is reliable and won’t be lost during the upload process; and

3. When you are completely ready to submit, click on the link and begin the process.


https://tenncare.wufoo.com/forms/quiltss-bridge-payment-for-nursing-facilitiesq1/

Questions?

CONTACT:

LTSS Call Center(877) 224-0219

between the hours of

8:00 a.m. and 4:30 p.m. CT

Documents

A Training Program for LTSS Providers Part One: Quality Improvement in Long-Term Services and Supports (QuILTSS) Bridge Payment Submission