10/22/2015. QIO Program Restructures. QIO Program Restructures ANHA Activities/Social Services Convention Person-Centered Care

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1 2015 ANHA Activities/Social Services Convention Person-Centered Care Beth Greene, MSW, LGSW Quality Improvement Advisor October 28, 2015 QIO Program Restructures New multistate, five-year contract began Aug 1, 2014 Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) awarded 14 nationwide tasked to advance national quality improvement activities atom Alliance 2 QIO Program Restructures 3 1

2 atom Alliance Partners Multistate alliance for powerful change composed of three nonprofit, healthcare quality improvement consulting companies 4 Nursing Home Goals Improve the national nursing home composite quality measure score Improve resident mobility Reduce antipsychotic drug use in dementia residents Increase resident satisfaction and quality of life Ultimate goal: Improve systems to improve care 5 Proposed Reform of Requirements for Long-Term Care Facilities Requirements for Long-Term Care (LTC) Facilities are the health and safety standards that LTC facilities must meet to participate in Medicare or Medicaid Programs Current requirements: found at 42 CFR 483 Subpart B have not been comprehensively updated since

3 Proposed Reform of Requirements for Long-Term Care Facilities (cont.) Proposed revisions: reflect advances in the theory and practice of service delivery and safety implement sections of the Affordable Care Act (ACA) Proposed rule includes a crosswalk to help readers find where existing provisions have been incorporated. 7 Themes of the Rule Person-Centered Care Residents and Representatives: Informed, Involved and In Control Quality Quality of Care and Quality of Life Facility Assessment, Competency-Based Approach Facilities need to know themselves, their staff and their residents 8 Themes of the Rule (cont.) Alignment with the Department of Health and Human Services (HHS) priorities Advancing cross-cutting priorities Comprehensive Review and Modernization Bringing it into the 21 st Century Implementation of Legislation It s the law 9 3

4 Person-Centered Care Residents and Representatives: Informed, Involved and In Control Existing protections maintained Choices Care and Discharge Planning 10 Quality Quality of Care and Quality of Life Additional special care issues: restraints, pain management, bowel incontinence, dialysis services and trauma-informed care Quality Assurance and Performance Improvement based on the pilot Resources available Certification/QAPI/nhqapi.html 11 Facility Assessment and Competency-Based Approach Facilities need to know themselves, their staff and their residents. Not a one-size fits all approach Accounts for and allows for diversity in populations and facilities Focuses on each resident achieving their highest practical physical, mental and psychosocial well-being 12 4

5 Align with Current HHS Initiatives Advancing cross-cutting priorities Reducing unnecessary hospital readmissions Reducing the incidences of healthcare acquired infections (HAIs) Improving behavioral healthcare Safeguarding nursing home residents from the use of unnecessary psychotropic (antipsychotic) medications 13 Comprehensive Review and Modernization Bringing it into the 21 st Century Reorganized and updated Consistent with current health and safety knowledge; revised care and discharge planning requirements Current infection control standards, including antibiotic stewardship Updated special care issues like pain management and dialysis Allows professionals to perform to their full scope of practice where possible 14 Implementation of Legislation It s the law Section 6102(b) of ACA, compliance and ethics program Section 6102(c) of ACA, quality assurance and performance improvement program (QAPI) Section 6703(b)(3) of the ACA (Section 1150B of the Act), requirements for reporting to law enforcement suspicion of crimes 15 5

6 Implementation of Legislation (cont.) It s the law Section 6121 of ACA, dementia and abuse training Section 2 of the IMPACT Act (adds 1899B to the Act), discharge planning requirements for Skilled Nursing Facilities (SNFs) 16 Disclaimer The information is only intended to be a general summary and is not intended to take the place of either the written law or regulations. We encourage you to review the specific statutes, regulations and other interpretive materials for full, accurate information. 17 Person-Centered Care What is Person-Centered Care? 6

7 What is Person-Centered Care? Creating a home-like environment where residents, staff, family members and volunteers can achieve their highest potential Responding to the needs of the residents, staff, family members and volunteers on a timely basis Enhancing communication to allow for individuality of residents, staff, family members and volunteers New York State Department of Health How Do We Do This? Respect for life and dignity of every person Compassion / Empathy Loyalty Pride Cooperation New York State Department of Health BASICS Hierarchy SIX LEVELS Biological: Feeling safe and physically comfortable Activities of Daily Living: Experiencing a feeling of control Societal: Feeling unique among others Interpersonal: Feeling valued as a person Creative: Experiencing optimal stimulation, living at highest possible level Symbolic: Experiencing pleasure and hopefulness New York State Department of Health 7

8 Caregiver Quality of Life How do you care for each level of your needs on the BASICS hierarchy? What are your preferred ways of satisfying needs on each level of BASICS listed below? Biological Activities of Daily Living Societal Interpersonal Creative Symbolic New York State Department of Health Caregiver Quality of Life Referring to BASICS.. How have your needs changed as you get older? Have you changed the ways in which you meet your needs? New York State Department of Health Caregiver Quality of Life If you were to go into a nursing facility, what would you like the staff to remember when caring for you? Which preferred ways of satisfying your needs (referring to the BASICS Hierarchy) would you like to continue in the nursing facility? How could staff support you to do this in the facility? What would you miss most if you were in a nursing facility? New York State Department of Health 8

9 Quality of Life Goals To feel safe To feel physically comfortable To experience a sense of control To feel valued as a person To experience optimal stimulation To experience pleasure, self-fulfillment and peace New York State Department of Health Supporting Quality of Life Goals Supports Quality of Life in Residents By: Supports Quality of Life in Staff By To Feel Safe Biological Level Biological Level To Feel Physically Comfortable To Experience a Sense of Control To Feel Valued as a Person To Experience Optimal Stimulation To Experience Pleasure Biological and ADL Levels ADL and Societal Levels Interpersonal Creative Symbolic Biological and ADL Levels ADL and Societal Levels Interpersonal Creative Symbolic New York State Department of Health CMS Change Package 9

10 Lessons Learned: 4-State Demo, Strategy 3: Connect with Residents in a Celebration of Their Lives Change Concepts: 3.a Treat Residents as They Want to be Treated, remembering that your facility is their home 3.b Foster Relationships 3.c Great Connections with the Community 3.d Provide Compassionate End of Life Care Change Concept: 3.a Treat Residents as they Want to be Treated Your Facility is Their Home Action Items Welcome New Residents Know Residents as Individuals Set Expectations and Support Staff to Meet Those Provide Structure for Resident Engagement 10

11 Change Concept: 3.b Foster Relationships with Families Action Items Welcome and Encourage Family Members to Communicate with Staff and the Resident Encourage Families & Friends to feel welcome and at home when visiting Provide Family Members with Ideas of Activities to do with Resident & To Attend Activities that the Resident Enjoys Family Members to Witness and Provide Care Routinely Seek Resident / Family Input Change Concept: 3.c Create Connections with the Community Action Items Ask for Suggestions from Residents and Families (Attend / Invite) Encourage Families & Friends to feel welcome and at home when visiting Make use of Available Technology Be Active in Your Local Community Establish Discussion Groups Change Concept: 3.d Provide Compassionate End of Life Care Action Items Provide On-site Training for Staff on Death & Dying Encourage Empathy Support Staff Members as they Provide Care for the Dying Resident Provide Comfort Items for the Family Involve Clergy / Pastoral Care in Support of Staff / Resident / Family Encourage Visitation 11

12 Change Concept: 3.d Provide Compassionate End of Life Care Action Items Honor the Deceased Resident Provide Option for Funeral Service at Nursing Home Provide Meal to Family Annual Memorial Service Personal Greeting as Family Returns to Gather Personal Belongings / Sturdy Boxes for Packing Slide Show Strategy 6: Compassionate Clinical Care that Treats the Whole Person Change Concepts: 6.a Implement Consistent Assignment 6.b Choose and Engage Medical Leadership Wisely 6.c Transition with Care 6.d Strive to Prevent Problems, and Treat when Necessary Change Concept: 6.a Implement Consistent Assignment (CA) Action Items Train/Educate Staff on Benefits of Consistent Assignment Involve Staff in Planning for CA Implement Permanent / Life Time Meet Regularly Regarding Implementation / Feedback Assign all Disciplines Permanently to a Neighborhood 12

13 Strategy 2 and Strategy 4 Strategy 2: Recruit and Retain Quality Staff Strategy 4: Nourish Teamwork and Communication Change Package Bundles Avoidance of Antipsychotic Medications in Residents Living with Dementia Promotion of Resident Mobility Preventing Healthcare Acquire Infections Change Bundle: Avoidance of Unnecessary Antipsychotic Medication in NH Residents Living with Dementia A Healthcare Improvement Bundle The National Partnership to Improve Dementia Care in Nursing Homes National Nursing Home Quality Care Collaborative 13

14 Five Point Bundle: Unnecessary AP Medications Design and Create a Calming Environment Create Meaningful Relationships Provide Meaningful Activities Identify and Treat Physical and Mental Conditions Define a Consistent Approach to Minimize the Use of AP Meds 41 QAPI: A Transformative Approach to Quality in Nursing Homes Quality Assurance Performance Improvement (QAPI) Affordable Care Act requires CMS to establish QAPI standards Nursing homes are mandated to use QAPI strategy 42 14

15 Preparing for QAPI: National Questionnaire May 2012 questionnaire to 4,200 nursing homes Barriers: knowledge, time, finances, ability to sustain and ability to interpret data Technical Assistance Needed: QI concepts/methods, critical thinking skills, communication strategies, leadership skills and using/interpreting data Findings used to: Identify challenges and barriers to implementing QAPI Shape the direction and content of the QAPI tools and resources 43 Lessons Learned : Culture of Quality Know your current culture Assess current QAPI readiness (QAPI Self- Assessment) Define the goals and scope for QAPI Create a structure for supporting QAPI 44 Lessons Learned: Leadership Move beyond the quick fix. Practice root cause analysis. Assess your individual skills, practice and attitudes. Do you gather and use data (input) for decision making? Do you model a proactive approach to improving performance? Do you respond to situations with a solution or work to understand why? 45 15

16 Lessons Learned: Staff Involvement and Engagement QAPI will not be effective if it is imposed from the top down Training and skill building is imperative All levels of staff must be involved in planning and improving systems and processes to get effective results Direct care staff have valuable and unique input 46 Lessons Learned: Data Driven Decision Making Review the data and information you currently have Consider what is missing or what else might be needed Think about how you look at data/information Focus on what it means and where there is room for improvement Assess what systems are in place to monitor once a change has been implemented 47 Lessons Learned: Performance Improvement Projects Gather information systematically to clarify issues and identify opportunities Select meaningful topics Have PIPs be real and relevant so people want them to succeed Test and implement changes Involve people who care about improvements to the process Reminder: you are required to have one PIP a year 48 16

17 Lessons Learned: Tools Use tools to help teach QI processes Maintain knowledge of systems and critical thinking skills QAPI finding: Facilities that systematically reviewed and studied the tools, and chose to use many of the suggested tools provided, were able to implement QAPI more effectively and more quickly 49 Lessons Learned: Tools (cont.) Tools include QAPI at a Glance Change Package 50 Quality Assurance and Performance Assessment (QAPI) In accordance with the statute, CMS proposed to require all LTC facilities to develop, implement and maintain an effective comprehensive, data-driven QAPI program that focuses on systems of care, outcomes of care and quality of life

18 QAPI: Something Different Sustainable Standardized Accountable Promotes PIPs Proactive Ongoing Whole team/facility approach 52 QAPI Maintain effective feedback systems from staff, residents and resident representatives Establish priorities Have a process for identifying, reporting, analyzing and preventing adverse/potential adverse events Systematically determine underlying causes Include Performance Improvement Projects (PIPs) Measure/monitor the success of actions taken and track performance for sustainability 53 QAPI (cont.) Adds to QAA (Quality Assessment and Assurance) Creates governing body to ensure QAPI is defined, implemented, maintained and addresses identified priorities 54 18

19 Proposed QAPI Plan and Documentation QAPI plan to be submitted to SSA or federal surveyor at the first annual recertification survey that occurs at least one year after effective date of regulation Ongoing documentation and evidence of an ongoing QAPI program at each annual survey, or upon request CMS has a mandate of one high risk PIP a year 55 QAPI: QA + PI 56 Fundamental Improvement Questions The Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? Aim Measure What changes can we make that will result in improvement? Change 57 19

20 Aim: Make It SMART Specific Measurable Attainable Relevant Time-bound Example: Reduce use of antipsychotic medications 25 percent by December Download Developing an Aim Statement Worksheet Measure: Develop a Strategy to Collect and Use Data Determine which data to monitor routinely Set targets for performance in the areas you are monitoring Identify benchmarks for performance Develop a data collection plan, including who will collect which data who will review it how frequently it will be collected and reported Download resources for accomplishing Step 7 at 59 Change How do you know the changes will produce the desired outcomes? Root Cause Analysis (RCA) Plan, do, study, act (PDSA) cycles 60 20

21 RCA: Purpose Helps identify the primary cause(s) of a problem to determine what happened determine why it happened determine what to do to reduce the likelihood of it happening again Tools: RCA Five Whys Worksheet Fishbone Diagram 61 PDSA Cycle How do we know changes put into place produce desired outcomes? What changes are to be made? Next cycle? Objective Predictions Plan to carry out the cycle (who, what, where, when) Plan for data collection Analyze data Compare results to predictions Summarize what was learned Carry out the plan Document observations Record data 62 PDSA Cycle (continued) What can we do by next Friday? Download Interactive PDSA Worksheet 63 21

22 Continuous Quality Improvement Monitor and modify effectiveness Changes that result in improvement Learning Hunches, theories, ideas e.g., action plans or interventions 64 QAPI / PDSA By using QAPI and implementing the PDSA cycle, you can help improve your facilities quality measure scores. lp1 Composite Score Calculation Based on the opportunity model concept numerators and denominators are summed across all 13 quality measures to determine the composite numerator and denominator Composite numerator divided by the composite denominator and multiplied by 100 results in the composite score 66 22

23 Slide 66 lp1 Love the graphic!!!!!! hg2493, 6/18/2015

24 Vaccine Measures Since the two vaccination measures are directionally opposite (i.e., higher rate represents better performance), the composite numerator for these two measures is denominator minus numerator. Interpreted as lower missed opportunities = better 67 Example 1: Missed Opportunities vs. Composite Score While this facility seems to be performing well on most measures, use of antipsychotic medications burdens overall composite score. 68 Example 2: Missed Opportunities vs. Composite Score 69 This facility has several opportunities for improvement; focusing on incon (incontinence) and ADL (ADL decline) measures may improve the overall composite score. 23

25 May 2015 NH Data 60% AL IN KY MS TN Goal 6.0% 50% 40% 30% 20% 10% 0% 70 May 2015 NH Data 60% FALLS PAIN PRU FLU PNE UTI INCON CATH RES ADL WTLOSS DEPRESS ANTIPSYCH 50% 40% 30% 20% 10% 0% AL IN KY MS TN 71 May 2015 NH Data: Alabama AL Goal 6.0% Current 8.2% (May 2015) 25% 20% 15% 10% 5% 0% 72 24

26 QAPI Companion Guide QAPI Step 7: Develop a Strategy for Collecting & Using Data 74 QAPI Step 7: Develop a Strategy for Collecting & Using Data Data monitoring: clinical care areas, medications, resident/family complaints, hospitalizations, state survey results and business and administrative processes Targets: long-term as well as short-term goals Benchmarks: look at your performance compared to nursing homes in your state and nationally using Nursing Home Compare 25

27 QAPI Step 8: Identify Your Gaps & Opportunities 76 QAPI Step 8: Identify Your Gaps & Opportunities Measure indicators of care that are relevant and meaningful to the residents you serve Guide and empower staff to solve problems Hold short stand-up meetings with managers and staff to identify concerns, resources, needs, etc. Establish the NH as a learning organization all staff identifies areas for improvements Regularly discuss processes and systems to identify areas for improvement Empower residents to get involved in identifying areas of improvement QAPI Step 9: Prioritize Opportunities & Charter PIPs 78 26

28 QAPI Step 9: Prioritize Opportunities & Charter PIPs Get everyone involved in setting goals Do not settle for this is just the way it has to be Prioritization Worksheet for Performance Improvement Projects 80 Worksheet to Create a Performance Improvement Project Charter 27

29 Performance Improvement Project (PIP) Launch Check List 82 Performance Improvement (PIP) Inventory 83 Storyboard Guide for PIPs 84 28

30 PDSA Cycle Template 85 Guidance for Performing Root Cause Analysis (RCA) with Performance Improvement Projects (PIPs) 86 Guidance for Performing Failure Mode and Effects Analysis with Performance Improvement Projects 87 29

31 Part 2: Antipsychotic Medications 88 Partnership to Improve Dementia Care 89 AIMS of the National Partnership Improve behavioral health using individualized & personcentered approaches to care Safeguard against inappropriate antipsychotic drug use 90 30

32 Partnership to Improve Dementia Care National Goal: Reduce the use of antipsychotic medications in long-stay nursing home residents by 25% by the end of 2015 and 30% by the end of Alabama s Opportunity for Improvement Reporting Period 2011 Quarter 4 Baseline Average for all reporting nursing homes AL Average for all reporting nursing homes US 27.3% 23.8% 92 Alabama s Opportunity for Improvement Reporting Period 2015 Quarter 2 Average for all reporting nursing homes AL Average for all reporting nursing homes US 20.5% 18.0% 93 31

33 Learn More 94 Thank You! Beth Greene, MSW, LGSW Quality Improvement Advisor AQAF Two Perimeter Park South Birmingham, AL ext ext Fax: This material was prepared by atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama under a contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services. Content does not necessarily reflect CMS policy. Final Sharing / Questions This material was prepared by AQAF, the Medicare Quality Improvement Organization (QIO), for the state of Alabama, under a contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services. Contents do not necessarily represent CMS policy. 32