QUALITY MEASURES – 5 STARS

“NOT NEW BY NOW”

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PRESENTERS

Rhonda L. Anderson, RHIAPresident, AHIS, Inc.

Gayle Edell, RHITHI Consultant, AHIS, Inc.

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OBJECTIVE

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

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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)

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Facility Quality Measures Report

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Facility Quality Measures Report -2

5 most identified key measures not consistent with state average– Develop your Action Plan

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Resident Level Quality Measures Report

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Tools to Assist

Admission MonitorChange of ConditionWeekly Treatment AuditRounds of Care ReviewCP Meeting – Is it action oriented or reviewed?– Think out of the box or routine?

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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”)

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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

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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

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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

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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

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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

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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

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LONG Stay Measures -3

% assessed or given pneumococcal vaccine% who receive an antipsychotic

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Display of New Quality Measures

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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

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Comparing % of Facilities Receiving Star Rating

Between old vs. new MDS case mix adjustment

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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

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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

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New Quality Measures Used in 5 Star -2

Long Stay Measures (cont.)–% who physically restrained–% who need help with daily activities has

increased

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QM Values for Percentile Rankings

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Overview of Quality Measures

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Measure Calculations

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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

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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

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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

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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

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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

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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

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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

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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/Downloads/MDS30QM-Manual.pdf

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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

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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,-,^])

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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])

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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

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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

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LONG Stay Measures -3

% assessed or given pneumococcal vaccine% who receive an antipsychotic

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Reference – Manual – Survey QM

See Handout #1

Stay NQF Definition Facility Resident Surveyor Manual Pg

Preview # 5-Star Preview

Long 0674 Falls with Major Injury 7 7 YES 19 10 3Short 0676 Self-Reported Moderate/Severe Pain 1 1 9 20Long 0677 Self-Reported Moderate/Severe Pain 2 2 20 2 4Short 0678 New/Worsened Pressure Ulcers 4 4 YES 10 21Long 0679 High-Risk Residents with Pressure

Ulcers3 3 21 3 5

Short 0680 Assessed& Appropriately Given the Seasonal Influenza Vaccine

11 22

Short 0680A Received the Seasonal Influenza Vaccine

12 23

Short 0680B Offered and Declines Seasonal Influenza Vaccine

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Short 0680C Did Not Receive Seasonal Influenza Vaccine Due to Contraindication

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Long 0681 Assessed& Appropriately Given the Seasonal Influenza Vaccine

` 22 11 1

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Psychotrophic Drugs

MDS/IDT – not only a nurseCP = use of CAAMental Health EvaluationIDT Evaluation-CP (looking at alternatives not

just medication-causative factors)MD involved in CPCP interventions – Psych drugs use, side

effects, reduced doses, drug effectiveness alternatives

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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

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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

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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?

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Your Action Plan

List:– – – – –

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Quality Measures Checklist

See Handout #2