Action Period Office Hours: Understanding Data

Transcription

1 Action Period Office Hours: Understanding Data Meghan Donohue Clinical Outcomes Analyst August 19, 2015

2 Qualis Health A leading national population health management organization The Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington The QIO Program One of the largest federal programs dedicated to improving health quality at the local level 2

3 Housekeeping Items There will be a 40-minute presentation and a 20-minute question and answer period You can type your questions into the Chat box to All Participants. Otherwise, phone lines will be opened at the end of the presentation. 3

4 Objectives Demonstrate process for downloading Qualis Health Nursing Home Performance Reports Discuss different methods of measuring re-hospitalization performance Enhance understanding of Quality of Care Composite drivers Explain how to interpret select charts and graphs Answer questions 4

5 Introduction: Why We Produce Performance Reports

6 Gathering Momentum: CMS Value-Based Purchasing *Pilot in 9 states, including Washington 6

7 Implications of SNF VBP Approximately 40% of SNFs will be penalized based on performance on one re-hospitalization measure Re-hospitalization rates will be publically posted on Nursing Home Compare to influence consumer choices 7

8 Measure Definition Measure of interest: Risk-Adjusted, Unplanned 30-Day Re-Hospitalization Rate for Post-Acute SNF Residents Includes entire 30-day window, including individuals already discharged from SNF Eventually to be replaced by measure relating to avoidable re-hospitalizations 8

9 Qualis Health Nursing Home Performance Report Quarterly report includes: Re-hospitalization data for post-acute residents Short-stay QMs Long-stay QMs Breakdown of Quality of Care Composite Regional and state benchmarking 9

10 Accessing Your Report

11 What is sftp? Secure File Transfer Protocol Secure, encrypted method of sharing data over the Internet Username and Password provided by Qualis Health staff 11

12 Finding the Report 12

13 Downloading the Report 13

14 Drill-Down on Rehospitalization Metrics

15 Rehospitalization Trend Tracking 15

16 Rankings Put Home Performance in Statewide Perspective Percent of Post-Acute Residents Re-Hospitalized, by SNF, WA

17 Non-Traditional Quality Measures 17

18 Sample Drill-Down Report offers re-hospitalization breakdowns by age, race, residence rurality, acute conditions, and chronic conditions. Region and state benchmarking enable peer comparisons to determine improvement opportunities. 18

19 Nursing Home Collaborative Quality of Care Composite

20 Quality of Care Composite Measure Antipsychotics Catheter Left in Bladder Depression Falls with Injury Incontinence Increased ADL Assistance Influenza Vaccination Moderate/Severe Pain Physical Restraints Pneumonia Vaccination Pressure Ulcers Urinary Tract Infection Weight Loss Composite=[Sum(Numerators)/Sum(Denominators)]*100 20

21 Sample Composite Calculation Sample Calculation Sum(Numerators)= =82 Sum(Denominators)= =1146 Sum(Numerators)* Sum(Denominators) 82*100 = =

22 Distribution of Composite Scores Data from April

23 Overlap with NH Compare 23

24 Interpreting Charts and Graphs

25 Composite Breakdown 25

26 Composite Score Benchmarking 26

27 Tracking Data Over Time 27

28 Trends to Look For 1. Six or more consecutive points above or below the median 2. Five or more consecutive points trending in the same direction 3. Outlier points significantly different from the norm 28

29 Q & A 29

30 Action / Next Steps Find your facility s top 3 composite drivers Examine potential gaps in care related to those three drivers Plan and conduct one small test of change (PDSA cycle) to improve performance on one of those measures 30

31 Questions? Meghan Donohue Clinical Outcomes Analyst For more information: This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. ID/WA-C2-QH