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Changing Your Ways – Changing Your Outcomes
July 29, 2015
presented by Jane C. Belt, MS, RN, RAC-MT
Plante Moran, PLLC614-222-9020
Coming Together for America’s Heroes NASVH 2015 SUMMER CONFERENCE
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NASVH’ Mission
The National Association State Veterans Homes' primary mission is to ensure that each and every eligible U.S. veteran receives the benefits, services, long term health care and respect which they have earned by their service and sacrifice. The organization also ensures that no veteran is in need or distress and that the level of care and services provided by state veterans homes meets or exceeds the highest standards available.
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My Salute to You and Your Mission
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Thank you for serving those who
served
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Objectives+ Delineate the Affordable Care Act as the nation’s
quality of care call to action
+ Identify the mindset of healthcare reform and how it fits into quality outcomes
+ Review the multiple federal initiatives aimed to improve quality of care
+ Describe practical solutions to impact the quality of care for our veterans
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Having the Right Mindset
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“It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.”
Charles Darwin
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The Change Process Begins…
+The current regulatory system was established under Omnibus Budget Reconciliation Act (OBRA) 1987
1. Resident Rights, including patients to be called residents
2. Residents are to receive care and services to help them attain or maintain the highest level of function – physical, mental, psychosocial
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OBRA Was Expected to:+ Improve monitoring of poor performing facilities
+ More effective enforcement strategies
+ Encourage Quality Improvement
+ Increase knowledge and expectations of nursing facility performance
+ Change the system to link the level of the seriousness of the deficiency with the appropriate penalty allowed by legislation
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Change Expected
+Quality of care legislation with OBRA:+F520: Quality Assessment and Assurance defined as a
management process that is “ongoing, multi-level and facility wide.”
+Encompasses all managerial, administrative, clinical and environmental services as well as the performance of outside providers and suppliers of care and services
+Facility to have a system to identify issues or concerns and put corrections into place
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+A facility must maintain a quality assessment and assurance (QAA) committee consisting of – +The director of nursing services;+A physician designated by the facility; and+At least 3 other members of the facility’s staff
+The QAA committee:+Meets at least quarterly to identify issues with respect to
which QAA activities are necessary+Develops and implements appropriate plans of action to
correct identified quality deficiencies
F520 Quality Assessment and Assurance
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+For over 20 years the regulations for QAA specified the facility had a committee with certain members and would met at least quarterly and develop plans of action for identified deficiencies ----- but no specifications as to the means and methods taken or the action plan to implement the QAA regulations
+March 23, 2010, Affordable Care Act passed – nation’s quality of care call to action
Something Was Missing
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Patient Protection and Affordable Care Act
+Key provisions:+Expand access to insurance
+Increase consumer protections
+Emphasize prevention and wellness
+Improve quality and system performance
+Expand the health workforce
+Curb rising health care costs
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Healthcare Reform = The Triple Aim
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Improve Access Improve Quality Control Costs with Payment
Reform
Manage Population HealthCoordinate Care and Reduce Redundancy
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+Section 6102 (c) of the ACA contained provisions for establishing and implementing a QAPI program for nursing homes so that outcomes are monitored and analyzed correctly and improvement sustained
+Program to include:
+Establishing standards (regulations)
+Providing technical assistance to homes on the development of best practices
ACA Provision for Quality Changes
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+QAPI is required in other federally certified health care programs – hospitals, transplant programs, dialysis centers, ambulatory care, hospice
+NH QAPI is to be consistent with other settings at a high level, but also take into account issues unique to the nursing home setting
+QAPI – new realm of quality – systematic, comprehensive, data-driven, proactive to performance management and improvement
Fitting into the BIG Picture
continuous
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+The ultimate goal is to provide person-centered care – to focus on the person living in the nursing home
+Quality Assurance and Performance Improvement (QAPI) does not refer to a program; rather, this is the way we do our work
+An effective QAPI plan creates a self-sustaining approach to improving safety and quality while involving all caregivers in practical and creative problem solving
The BIG Picture
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Continued Change Initiatives
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Nursing
Home Qualit
y Care Collaborati
ve
Federal and State
Quality Improvem
ent Initiatives
Quality Assurance Process Improvem
ent
Person-Centered
Care Practices
Advancing
Excellence Nursing
Home Campaig
n
Partnership to
Improve Dementia
Care
Change Ways
Change Outcomes
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Performance for Facilities and Consumers+State Veteran Home commitment to customer service
quality and a desire to improve performance:+Consumer satisfaction
+Meeting state survey standards
+Participating in the Advancing Excellence in America’s Nursing Homes Campaign
+Resident review compliance
+Standard and Compliance Surveys
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The Future of Healthcare
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Providers will need to increasingly assume financial
risk
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Traditional Payment (FFS) Not Working+Viewed as insufficient at containing costs+Volume was rewarded+Limited shared risk
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Where are we
headed?
+Value-based purchasing+Direct link between payment and outcome+Bundled payments+Greater focus on care coordination and prevention
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Organized System of Delivering Care
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ImproveOutcomes
Reduce and Control Costs
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Change in the NewsApril 20, 2015CMS published in Federal Register proposed rule for SNF PPS beginning October 1, 2015. Laying out future plans to transition SNFs to quality-based payments
+ SNF payment rate increase of 1.4% (10/1/15)
+ SNF Quality Reporting Program (10/1/17) – 3 post-acute, cross setting quality measures to be reported to receive full payment under SNF PPS
+ SNF 30-day all-cause readmission measure for incentive payments (10/1/18)
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Proposed: SNF Quality Reporting
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Data Collection Source: MDSProposed Data Collection Period: 10/1/16 through 12/31/2016Proposed Submission Deadline for FY18 Payment Determination: 05/15/2017
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CMS develops an all-cause, all-condition readmission measure
• CMS develops all-condition, risk adjusted potentially preventable readmission measure
• SNFs start receiving results from CMS
Public reporting of readmission measure on Nursing Home Compare
SNF VBP begins and incentives and penalties applied
Incentive pool created by Medicare rate reduction of 2%. Only 50-70% of pool may be distributed back to SNFs.
High performance levels = receive incentive; low performing = penalty
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Latest News.…July 16, 2015: Federal Register CMS-3260-P (403 pages)
HHS proposes to improve care and safety for NH residents
+Revisions mark first major rewrite of long-term conditions of participation since 1991 (24 years!)
+Quality and safety requirements for more than 15,000 nursing homes and skilled nursing facilities to improve quality of life, enhance person-centered care and services for residents in nursing homes, improve resident safety, and bring these regulatory requirements into closer alignment with current professional standards
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Latest News.…July 16, 2015: Federal Register CMS-3260-P
+ In addition to the rewrite of the long-term COP:
+Long-awaited regulations QAPI regulations – facility staff will be required to present a comprehensive, data-driven QAPI plan to surveyors at the first annual survey after the effective date of the regulation. Focus on indicators of outcomes of care and quality of life
+Facility staff must develop a compliance and ethics program that prevents criminal, civil, and administrative violations and promotes quality care
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Latest News.…+ In addition to the rewrite of the long-term COP:
+Facility assessment – development of a formal, documented facility-wide assessment to determine what resources a facility would need to care for its residents competently during day-to-day operations and in emergencies. Assess competencies of licensed nurses to care for assessed resident needs
+Resident rights – very detailed. Also report suspicion of bodily harm within 2 hours and within 24 hours events that did not cause bodily harm
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Latest News.…+ In addition to the rewrite of the long-term COP:
+Transitions of Care – replaces admission, transfer, and discharge terms. Information required when resident goes from one care setting to another. Compliance can be satisfied with discharge summary containing required components.
+Discharge to another provider (community with HHA, IRF, or LTCH) – facility must assist in selecting provider. Data from standardized post-acute assessment, QMs, other
+Comprehensive resident-centered care plans – baseline within 48 hours. IDT spelled out
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Latest News.…+ In addition to the rewrite of the long-term COP:
+ Infection Control Officer – designate an Infection Prevention and Control Officer (IPCO) employed at least part-time by the facility; has specialized training in infection prevention and control programming. Antibiotic stewardship program
+Physician services – should be a physician, PA, NP, CNS available (in person) to evaluate residents for non-emergency transfer to a hospital; physician can delegate task of writing dietary orders to a qualified dietitian and the task of writing therapy orders to a qualified therapist
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Avalanche of Change Continues
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QUALI
TY
MDS
QMs
Five-Star
Life Safety
Regulations
Medicare
Medicaid
Managed Care
Standards of Care
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Have We Changed Our Practices?
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“I did then what I knew then, when I knew better, I did better.”
~ Maya Angelou
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We Have Been Learning About Quality – It Fits With the Mission
Level of care and services provided by state veterans homes meets or exceeds the highest standards available
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Quality Measures
State and Federal surveys
Resident choice
Resident satisfactionFamily satisfaction
Participates in Advancing Excellence
Five-Star rating program
Home-like environment
Reducing unnecessary
hospitalizations
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+Changing regulations+Changing reimbursement methodologies+Root cause analysis and critical thinking+Risks associated with psychoactive medications+Risks of over use of antibiotics+Potential negative outcomes from falls+Importance of reduction of pain and pain management+Person-centered care+Avoiding unnecessary hospitalizations+Proper skin care
We Are Finding More to Learn
33And much more…
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+Reducing unnecessary hospitalizations+ INTERACT® Quality Improvement Program
+Quality improvement tools – tracking, root cause analysis
+Communication tools – Stop and Watch, SBAR
+Decision-support tools – care path protocols
+Advanced care planning
+Advancing Excellence Toolkit
+STate Action on Avoidable Rehospitalizations (STARR)
Impacting Quality of Care for Our Veterans with Practical Solutions
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We’ve learned some
hospitalizations are not necessary
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Five-StarQuality Measures
Long stay measures (8)
+ADL help needs have increased+High-risk pressure ulcers+Long-term catheter use+Physical restraints+UTIs+Pain – self-report moderate to severe
pain+Fall with major injury+Antipsychotic medication
Short stay measures (3)+ Pain – self-report
moderate to severe+ Pressure Ulcers – new or
worsened+ New antipsychotic
medication use
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All 11 QMs based on national percentile ranking, with the exception of the ADL measure, which is based
on State ranking
Use 3 most recent quarters of MDS
data
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Surveyor Quality MeasuresLong Stay+ Self-reported moderate/severe pain
+ High-risk residents w/ PUs
+ Physical restraints
+ Falls
+ Falls with major injury
+ Psychoactive med use in absence of psychotic or related condition
+ Antianxiety/hypnotic med use
+ Behavior symptoms affection others
+ Depressive symptoms+ Urinary tract infections+ Catheter inserted and left in bladder+ Low-risk residents who lose control
of bowel/bladder control+ Excessive weight loss+ Need for ADL help has increased
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Short stay+ Self-reported moderate/severe pain+ New/worsened PU+ New antipsychotic med use
Used for 5-star
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+Understanding process versus outcome
+Looking at more than just the numbers
+Root cause analysis
+Critical thinking
+Identifying risks with the risk
We’ve Learned from Quality Measures
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PROCESS = course of action and procedures taken in response to the resident’s assessed needs and condition. Technical and interpersonal activities that occur in the delivery of care and services
Include activities that go on within and between staff and residents.
For example: residents with dementia exhibiting behavioral symptoms
Process Versus Outcome
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OUTCOME = indication of the resident’s status in terms of functional ability or clinical condition
An outcome represents the results of the applied processes
For example, an incontinent resident with pressure ulcers
Process Versus Outcome
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It’s Not The Numbers - It’s What You Do With Them
+ Seeing the score is only the first step – QMs indicate potential problems
+ Using the reports requires consideration of how the QMs are scored, what residents are excluded and which MDS items were used to calculate each measurement
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+ Retrospective data and methods indicate potential problems that need further review
+ Concurrent methods examine actual care and clinical practices
+ QMs assess performance of whole systems and parts of systems for defined episodes of care so QM efforts can be targeted
Consider
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+ Analyze the underlying systems and processes and determine where redesign might reduce risk
+ Identify risk areas and their potential contributions to the event
+ Determine the human and other factors most directly associated with the event
Consider
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+ Determine potential improvement in processes or systems that would tend to decrease likelihood of such events in future, or decide after analysis, that no improvement opportunities exist
+ Include participation by managers and the direct care givers closely involved in the processes and systems under review
Consider
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QM scores are often interrelated+ The analytical and critical thinking involved in
identifying whether systems, knowledge or performance problems exists and are the causes of the negative outcome is one of the most beneficial uses of the CMS QM tools
Root Causes - Identification
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+ Multiple factors can contribute to a resident’s susceptibility to negative outcomes. If a facility addresses the risk factors within the risk, they will be attempting to intervene in areas contributing to the resident’s overall risk for avoidable negative outcomes
Cause Identification
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Risks within the Risk for Incontinence+UTIs+Indwelling catheters+Falls+Falls with major injury+Pressure Ulcers+Dehydration +Depression/anxiety/isolation+Restraints+Pain and discomfort+Need for ADL help has increased
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+Restraints were safe and kept folks from falling
+Bed rails are required on every resident bed
+Indwelling catheters were needed if incontinence could not be contained
+Antibiotics were effective in fighting bacterial infections
+Every resident should be turned every 2 hours
+Check and change every 2 hours
What Were We Taught?
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+Urinary incontinence (UI) is a common and potentially disabling condition affecting up to 30% of those aged 65 years and older. In nursing facilities up to 70% of residents are admitted with urinary incontinence and an additional condition of some type of skin breakdown
+ In nursing facilities incontinence contributes to quality of care complications. For example residents can experience skin irritation, develop pressure ulcers difficult to heal, experience falls with fractures, and are predisposed to urinary tract infections.
+The adverse psychological effects for incontinent residents are pain, embarrassment and frustration.
What Do We Know about Urinary Incontinence
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+Quality care and quality of life concern and QMs to be measured against:+ Incidence of pressure ulcers+Worsening pressure ulcers+Urinary tract infections+Falls
+Is there an opportunity available for a solution to help with all of these concerns?
Impact on Our Veterans
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Consider improved, quality moisture management
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+Research and technology has introduced new information, tools, and solutions as we work to reduce adverse events and manage moisture+Normal urine void = 8 to 12 fluid ounces
+We can now measure the absorbency level of incontinence products
+We know what happens when pressure applied to the product and it is already wet
What Have We Learned?
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+The design of an incontinence product can improve clinical outcomes+Fragile skin can be protected against skin irritation and
rashes (moisture associated skin damage)
+Reduction of incidents of UTIs and skin breakdown
+Reduction in slips and falls related to incontinent episodes
+Caregivers protected from strain or injury due to combative behavior or lifting
What Have We Learned
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+Consider: how do you feel the next day if you get a phone call during the night?
+Research has shown improved night time sleep+ Improves veterans’ function
+ Improves mood and decrease behavioral episodes
+ Increases socialization
+Promotes healing
What Have We Learned
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We have learned the importance and impact of sleep
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Confession of an Old Nurse
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+I will not use disposable paper briefs
+I will leave residents “open to air” at night
+Residents need changed every 2 hours or the facility will smell
+Residents need changed every 2 hours or they develop a UTI
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+There are products that offer improved clinical outcomes and bottom line savings
+I watched the demo, I talked to nurses who had used the high absorbency products, I read the research, I read the testimonials
+Technology does improve the quality of life for veterans --- and who deserves it more than our veterans?
Forgive me… I Learned Better
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+High absorbency product +Unsurpassed capacity protects against leaks and odors
+Sleep through the night protection
+Design eliminates feeling of wetness, cold, discomfort, and associated night time falls
+Less fatigue for caregivers especially with veterans with dementia, impaired mobility, morbid obesity
+Decreased skin breakdown
+Decreased sleep disruption (night time sleep)
Quality of Life -- What If
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+What is the cost of incontinence?+Brief, pull ups+Barrier creams and lotions+Wipes, gloves, bed pads+Linen / clothing changes – detergents, utilities, waste, trash+Skin breakdown, wound healing complications, UTIs+Employee morale and turnover – workers comp, lost time+Veteran, staff, visitor falls+ Interrupted sleep – decreased healing
The Cost Would be Millions!?!
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+Overall cost savings: fewer changes, fewer units purchased, fewer units to dispose and less labor required
+Laundry savings: fewer bedding changes, fewer clothing changes, less detergent and water usage, longer linen life and less labor
+Less impact on the environment – fewer units to dispose
What If – Change in CostEffectiveness?
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Keys to Change – What We Learned
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“It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.”
Charles Darwin
“I did then what I knew then, when I knew better, I did better.”
Maya Angelou
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Are You Willing?
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To change your ways to
change your outcomes
for your veterans?
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Questions??
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Jane BeltPlante Moran Clinical [email protected]
Contact Information:
THANKS for ATTENDING
THANKS to our SPONSOR
1-800-467-3224Booth #16-17
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+ RAI MDS Manual http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html
+Advancing Excellence : www.nhqualitycampaign.org
+Medicare Quality Improvement Community www.medqic.org
+Rotterman, Program Director for the Institute for Person-Centered Care. “Personal Alarms: Another Form of Restraint and Oppression Among the Frail and Elderly? You Decide” July 30, 2013
Resources
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Resources
+ Fact sheet – Proposed fiscal year 2016 payment and policy changes for Medicare Skilled Nursing Facilities http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-04-15.html
+ Press Release 7/13/15: HHS proposes to improve care and safety for nursing home residents. http://www.hhs.gov/news/press/2015pres/07/20150713d.html
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+ MDS 3.0 Quality Measures - USER’S MANUAL (V8.0) http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/downloads/MDS30QM-Manual.pdf
+ QAPI web page: http://go.cms/gov/Nhqapi
+ QAPI at a Glance: http://tiny.cc/QAPI
+ Kulus, Judy RN, NHA, MAT, RAC-MT, C-NE. “Proposed Changes to Nursing Home Rules: Biggest Changes in 24 Years.” AANAC LTC Leader, 7/20/15
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Resources