LEVEL 2 REPORTING IN PACE.

Transcription

1 LEVEL 2 REPORTING IN PACE. MEDICAL DIRECTOR ROLE AND RESPONSIBILITIES, Stephen Ryan, MD, MPH Sr Medical Director PACE & Managed LTC Medical Director ElderONE, RRH

2 WHO ARE WE? Geriatrician Medical Director viahealth Independent Living for Seniors Primary Care Physician Physician Assistant (PA) provider Advance Practice Provider (APP) Nurse Practitioner (NP) WHAT IS OUR ROLE?

3 Audience : PACE Medical Directors and Colleagues Objectives. All attendee will be able to: > Articulate an overview of the CMS Level 2 reporting requirements, assessment process, and their role in that process > Review an illustrative Level II case including initial report, evaluation, IDT work and Root Cause Analysis. > Have a reference understanding with the specifics of the CMS revised Level 2 definitions > Describe the overall process a PO is expected to go through when a Level 2 event occurs 3

4 Progress NOT Perfection "If you can't fly then run, if you can't run then walk, if you can't walk then crawl, but whatever you do you have to keep moving forward." Martin Luther King Jr.

5 PACE Level II Report: Case 1 > Issue: PACE Level II Repot > Type of incident and date incident occurred: Unwitnessed fall with fracture and hospitalization. > Location of incident: Incident occurred in participant s bedroom at the congregate setting where she resides. > Participant s Current Status: Participant is currently hospitalized at RG Hospital where she is undergoing surgery on 4/23 for a compression hip screw for a closed left hip fracture. > Significant diagnoses: Dementia, GERD, HTN, Depression, Hypothyroidism, Hypercholesterolemia, Osteoporosis, Hx Trigeminal Neuralgia, Glaucoma, Macular Degeneration. > Summary of the care history: Participant enrolled in PLAN 10/1/12. She resides in the Mother House where she receives services of home health aides 2 hours per day 7 days per week, Restorative Physical Therapy 1-2 times per week, and Skilled Nursing visits once per month and additionally as needed. She has a history of falls and is an identified falls risk due to unsteady gait and poor vision. She is independent with dressing and eating, requires assistance with bathing and toileting. She is 1 assist with transfer and ambulation, uses an ATW, but does not always call for assistance. She has a chair alarm and hip saver pads.

6 PACE Level II Report: Case 1 Summary of the event: > On 4/22/15 Participant was found on the floor at 8:15 AM in her bedroom. She stated she was going into the bathroom and had not called for assistance. She was assisted up by 2 staff into the wheelchair. She complained of left groin pain and had a laceration to the back of the head. She was sent to ED where she was admitted and diagnosed with closed left hip fracture, closed left Olecranon Avulsion fracture, and a 1 cm laceration on the scalp. Surgery is underway for hip screw currently as of 4/23. She received 2 sutures to the scalp wound and a left arm sling. No further intervention is currently deemed necessary for the elbow.

7 PACE Level II Report: Case 1 > Was case presentation clear? > What level 2 definition was the report based on? > What the underlying causal reason(s) clear from the report? > What would you as the PACE Medical Director feel should happen next? > Does this happen at your program today?

8 What is a Level II Event? Definition discrete subset of unusual incidents in which the occurrence has a significant impact on the health and/or safety of a PACE participant, or the PACE program in the case of media-related events Replaces sentinal events, revised Q 2-3 yrs Difference between Level I and II Significance Objective for CMS Monitor health & safety of the PACE participants and the effectiveness of the PACE organization s risk management and quality assurance programs (PACE Level Two Reporting Guidance; CMS, July 2015) INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law. 8

9 You reported it, now what.... Data Gathering > Immediate action? > Compliance with existing polices? > What were potential causes Root Cause > Conduct with IDT and relevant partners o System factors o Leading factors o WHY?, WHY? Many tools to consider ( fishbone) 9

10 Rules/Techniques of Basic Steps: Fishbone Analysis 1. Draw the fishbone diagram List the problem/issue/goal to be studied in the "head of the fish". (1 st level main line) 3. Label each "bone" of the "fish". (2 nd level). List each 2 nd level cause to the 1 st level. 4. The major categories for the 2 nd level are typically utilized as:

11 An example of a fishbone diagram An example: Problem - Not meeting deadline

12 How is data interpreted? HPMS (DataPACE 2) Data - FALLS > Baseline data (PMPM) for FALLS is being established for national PACE > Limited to those programs submitting HPMS data

13 NPA Survey Jan April 2011 (61 / 75 sites participated) 194 Level II incidents > Pressure ulcers (Stage III/IV) = > Falls with injury = > Unexpected deaths = > Infectious disease outbreaks = > Other (traumatic injuries, etc.) = 44% 33% 7% 5% 16%

14 PACE LEVEL II REPORT: CASE 1 FINAL REPORT Immediate Actions Taken: As noted above. IDT main concerns related to participant prior to event: > Participant has had a history of frequent falls, with 2 falls without injury occurring in 3/2015. > In March 2015, physical therapy noted mild functional decline and poor transfer status. Restorative PT being provided. > On 4/1/15, IDT noted difficulty transferring and added pressure alarm and hip saver pads to her care plan. Care plan revised to 1 assist for transfer and ambulation. > Participant was refusing to wear the hipsters because of bulkiness, snaps, general discomfort with them. Physical therapy was working to solve the problems and had ordered a second set which had not yet arrived at the time of the fall. > Precipitating/Contributing Factors: The participant had evidenced a mild functional decline. She did not want to call for the assistance of 1 that had been ordered because she was used to being independent. She did not want to wear the hipsters and the team had not been able to solve this issue before the fall occurred, since her noted mild decline had been only of approximately 3 weeks duration. She had had no changes in her medical status or medications that could have been contributory. 14

15 PACE LEVEL II REPORT: CASE 1 FINAL REPORT Participant s involvement/actions surrounding the event: As noted. Following the fall, the participant voiced wishing she had had the hipsters on. Participant s degree of involvement in PACE program: As previously described. Working relationship with contracted facility/contracted services (if applicable): N/A Compliance with organization s established policies and procedures: Compliant with the falls policy and procedure. Identification of risk points and their potential contribution to the event: > The participant had been on every 2 hour checks but there appeared to be no documentation of any check between 3:15 AM and 8:15 AM, the time she was found on the floor. > The refusal of the hipsters was a risk point and risks of refusal were reportedly discussed with the participant but not documented. The team felt the waiting period for the second set of hipsters was too long. > The team felt there could have been clearer education with caregivers regarding the use of the hipsters, with a demonstration. > The care plan did not specify exactly what hours the hipsters should have been worn. 15

16 PACE LEVEL II REPORT: CASE 1 FINAL REPORT As appropriate, proposed improvements in policies, training, procedures, systems, processes, physical plant, staffing level, etc. to reduce future risks. > Re-education with caregivers regarding the requirements of safety checks and improved documentation of these checks, including what was done or offered to the participant during the check (i.e. toileting) > Both medical staff and physical therapy staff will firm up the discussion of risks of not following the care plan with participants, and document these discussions in the medical record. > Physical and occupational therapy staff will bring the issue of the wait time for receiving the hipsters with the Director of Rehabilitation to see what can be done. > The team will check with other participants who have hipsters ordered to check on compliance and to also be sure clear instructions are documented in the care plan and on the caregiver s care card regarding hours they need to be worn. Verbal instructions with demonstration will be provided to caregiver 16

17 PART II: INCIDENTS AND REPORTING THRESHOLDS 17

18 Incidents and Reporting Thresholds > 17 Incident-specific thresholds > For incidents meeting the threshold, reporting to CMS is required within 2 working days. > CMMS responds with a tracking ID number (32char) which is included with all subsequent documentation > A final report is submittedafter the root cause analysis is completed 18

19 Incidents and Reporting Thresholds (cont d) > Most of the incidents will require a root cause analysis (RCA) > After consultation with the Regional Office may decide to conduct a less rigorous internal investigation > Described in detail in Table 1 of the guidance on pages 4 to 6 > Appendix B provides specific examples 19

20 Incidents and Reporting Thresholds Incident Death Thresholds > Homicide/ Suicide > Unexpected and with active coroner investigation > Unexpected outcome from any Level II incident > Delay or suspected inappropriate care 20

21 Incidents and Reporting Thresholds (cont d) Incident Falls Thresholds Resulted in: > Death > Fracture requiring surgery > Injury requiring hospitalization [admission or observation stay more than 23 hours] related directly to a fall 21

22 Incidents and Reporting Thresholds (cont d) Incident > Infectious Disease Outbreak Thresholds > Resulted in Death > Three or more cases > Linked to the same infectious disease agent > Occur within the same time frame > Reportable to the State and local public health authority > May also be reportable to CDC ( 22

23 Incidents and Reporting Thresholds (cont d) Incident > Pressure ulcer Thresholds > Unstageable > Stage IV o Necrosis of soft tissue o Involves underlying > Stage III > Muscle, Tendon, Bone o Full thickness skin loss o Subcutaneous tissue damage or necrosis 23

24 Increases in Level II reporting Prior (2013) A: 100/1000 B: 5.2/2000 C: 8/site E: 14 (Jan Jun 2013) Current (2014 / 15) > 500/1 > 16.7/2000 > 18/site > 42 (2014) 24

25 RCA OVERVIEW 2016 YTD Medical Quality Assurance Data non-discoverable 25

26 Level II Trend Source: Level II Tracking Worksheet Adverse Drug Reaction Adverse Outcome Burn Elopement Fall Injury requiring hospitalization Outbreak Pressure ulcer Restraint Injury Suicide Attempt Fire/ Other Disaster Abuse 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% _1 2015_2 2015_3 2015_4 2015_5 2015_6 2015_7 2015_8 2015_9 2015_ _ _12 26

27 2015 LEVEL 2 EVENT BY CATEGORY Medical Quality Assurance Data non-discoverable 27

28 An Engaged TEAM Teamwork is the ability to work together toward a common vision. The ability to direct individual accomplishments toward organizational objectives. It is the fuel that allows common people to attain uncommon results. - Andrew Carnegie 28