Any Willing Qualified Provider Appeal Request and Quality Performance Plan (QPP) Report Webinar

Transcription

1 Any Willing Qualified Provider Appeal Request and Quality Performance Plan (QPP) Report Webinar Division of Aging Services (DoAS) and Division of Medical Assistance and Health Services (DMAHS) 1

2 Agenda Criteria for Measures Benchmarking Methods What is an Appeal Request? Overview of the Quality Performance Standards (QPS) Report What is a QPP Report and when should a facility create one? Timeline of AWQP Quality Cycles Question and Answer Next Steps Helpful Links 2

3 NJ Department of Human Services Representatives Division of Aging Services Elizabeth Brennan Director, Long Term Services and Supports Leah Rogers Quality Assurance Coordinator Division of Medical Assistance and Health Services Neha Chopra Analyst 1 Research and Evaluation, Office of Business Intelligence 3

4 CRITERIA FOR LONG-STAY QUALITY MEASURES QPS # 1-5 Elizabeth Brennan 4

5 Quality Performance Standards (QPS) QPS Measures Data Source QPS 1 QPS 2* QPS 3* Is the percentage of long-stay residents who are immunized against influenza annually at or above the statewide average? (calculated annually during influenza season) Is the percentage of long-stay residents receiving antipsychotic medication at or below the statewide average on a quarterly basis? Is the percentage of long-stay, high risk residents with a pressure ulcer at or below the statewide average on a quarterly basis? MDS QPS 4* QPS 5* Is the percentage of long-stay residents who are physically restrained at or below the statewide average on a quarterly basis? Is the percentage of long-stay residents experiencing one or more falls with major injury at or below the statewide average on a quarterly basis? QPS 6** Resident/family experience in the NF. CoreQ Composite Score QPS 7** Is the facility using INTERACT, Advancing Excellence tools, LTC Trend Tracker sm, or another validated tool to measure 30-day hospitalizations and hospital utilization so that it can share data with the MCOs? Selfreported *To meet any of these four individual standards, NFs must be at or below the DHS established benchmark for at least four out of six quarters for the most recently publicly available data. ** Collected every six months by Dr. Castle. 5

6 MDS 3.0 Quality Measures User s Manual QPS measures # 1-5 are collected from the Minimum Data Set (MDS) 3.0 and are reported by the Centers for Medicare & Medicaid Services (CMS). The criteria for QPS measures # 1-5 is defined in the MDS 3.0 Quality Measures User s Manual issued by CMS. 6

7 Criteria for QPS #1: Influenza 7

8 Criteria for QPS # 2: Antipsychotic Medication 8

9 Criteria for QPS # 3: Pressure Ulcers 9

10 Criteria for QPS # 4: Physically Restrained 10

11 Criteria for QPS # 5: Falls with Major Injury 11

12 NF Considerations The AWQP designee for the NF is responsible for being knowledgeable of the MDS 3.0 measure criteria. Appeal requests should not be based on exclusions. These have already been considered in the results by CMS. NFs can access the measure criteria at: Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-Users-Manual-V11- Final.pdf 12

13 CRITERIA FOR SURVEY DATA QPS # 6 & 7 Elizabeth Brennan 13

14 QPS # 6 & 7 The QPS # 6 & 7 are collected every six months through survey processes. The measures include: CoreQ (resident/family experience survey) Hospital Utilization Tracking Tool (self-reported survey) 14

15 QPS # 6: CoreQ The CoreQ long-stay resident experience survey is a short, reliable, and valid questionnaire to calculate a quality measure for long-stay residents of NFs. A long-stay resident is defined as a resident whose cumulative days in the facility are equal to or greater than 100 days. The survey is administered to both residents and families. 15

16 CoreQ Data Collection CoreQ surveys can be distributed and collected by: NF Vendor DHS Vendor 16

17 Preliminary Survey NFs have received a preliminary survey from Dr. Castle to determine NFs with vendors and NFs without vendors to determine the next steps for each NF. Pre-surveys will be sent each data collection period to receive updated information and collect Hospital Utilization Tracking tool data. When you receive the preliminary survey, NF timely response is essential to the data collection process. 17

18 NF Vendor Collection and Reporting Process The vendor will collect and report out as per the timeline. NF vendors will use a formatted Excel spreadsheet to report data to Dr. Castle. Dr. Castle can NF vendors the Excel spreadsheet. NF vendors must sign a release of information with Dr. Castle. Timeframe August-November 2018 August-October 2018 November 2018 November 30, 2018 December 2018 February-May 2019 February-April 2019 May 2019 May 31, 2019 June 2019 Collection, Transmission, and Reporting Period 2 for data collection Vendor collects CoreQ information from long-stay residents and families of long-stay residents Vendor provides Dr. Castle with the number of long-stay residents and families of long-stay residents given CoreQ surveys and CoreQ data Deadline for period 2 data transmission from vendors to Dr. Castle Dr. Castle reports to DHS Period 3 for data collection Vendor collects CoreQ information from long-stay residents and families of long-stay residents Vendor provides Dr. Castle with the number of long-stay residents and families of long-stay residents given CoreQ surveys and CoreQ data Deadline for period 3 data transmission from vendors to Dr. Castle Dr. Castle reports to DHS 18

19 DHS Vendor Collection and Reporting Process Date parameters for each data collection period are listed below. NFs will identify all eligible residents in the facility and provide info if applicable. A random sampling of eligible long-stay residents and the families of eligible long-stay residents is selected by Dr. Castle. o Random sampling is defined as a part of the sampling technique in which each sample has an equal probability of being chosen. A sample chosen randomly is meant to be an unbiased representation of the total population. The resident CoreQ survey is administered/collected from the eligible residents in the facility (see exclusion slide). Since surveys cannot be administered to all residents at the same time, a maximum two-month time window is used to administer the survey. The CoreQ survey is administered to families of long-stay residents in the facility (see exclusion slide). A two-month time window is used to allow surveys to be returned from the family. Timeframe August-November 2018 December 2018 January 2019 February-May 2019 June 2019 Collection, Transmission, and Reporting Period 2 for data collection Dr. Castle to mail and collect the surveys; tally the responses; and obtain NF scores Dr. Castle reports to DHS NFs to apply the exclusions and provide demographics to Dr. Castle Period 3 for data collection Dr. Castle to mail and collect the surveys; tally the responses; and obtain NF scores Dr. Castle reports to DHS 19

20 Criteria for Valid CoreQ Sample A CoreQ score is calculated based on the results of the questionnaires that meet the valid sample criteria. A valid sample is defined as: 1) A minimum of 60 total residents/families eligible to be surveyed. 30 residents and 30 families 2) A NF must have a minimum of 40 total useable surveys (e.g., the numerator must be > 40) 20 residents and 20 families 20

21 CoreQ Composite Score Benchmark DHS will use the higher score of the most recent two data collection periods as the NF s benchmark. There are two data collection periods annually. AWQP Benchmark Score: 75% has been established as the initial threshold for CoreQ. This benchmark is subject to change. Historically, CoreQ composite scores range 60% 100% and average 85%. Failure to obtain a valid sample will result in the NF not meeting the measure for the applicable time period, i.e., every six months. 21

22 QPS # 7: Hospital Utilization Tracking Tool The hospital utilization tracking tool question asks each NF to attest to its use of a specific validated type of tool that allows a NF to track, trend, and implement interventions based on NF residents hospital inpatient utilization. This information is collected by Dr. Castle every six months via Survey Monkey. Please answer the following question: Do you track and trend hospital inpatient utilization? YES NO If yes, what tool do you use? INTERACT Advancing Excellence LTC Trend Tracker sm Other 22

23 Hospital Utilization Tracking Measure A facility must attest to and respond Yes in order to meet the Hospital Utilization Tracking Tool measure. A facility must respond at each data collection period (twice annually). Failure to respond will result in No Data regardless of prior reporting periods. 23

24 Criteria for a Validated Hospital Utilization Tracking Tool A validated hospital utilization tracking tool must have the following capabilities: Reports Numerator/Denominator Claims Risk Adjustment Collect All Resident Data The hospital utilization tracking tool should not be a home grown tool. At this time, we are not asking what level you are doing. Just that your software has the capability. 24

25 BENCHMARKING METHODS Elizabeth Brennan 25

26 Benchmarking Methods DHS has received feedback on using a current statewide average to analyze prior quarters. 1. DHS took this into consideration when implementing a one year rollout Allows older data periods to be replaced with newer ones 2. Research of other states Weighted analysis and incentives 3. DHS & CHCS looked at each month in that given quarter and calculated an average for that quarter using the monthly statewide average for each month from the CMS Archive datasets. The Findings: Quarterly statewide averages resulted in fewer providers meeting the benchmark for the QPS analyzed. Different methods, different results but some number of nursing facilities are always impacted. DHS is committed to continued analysis and consideration as the program matures. 26

27 WHAT IS AN APPEAL REQUEST? Leah Rogers 27

28 Overview of Appeals The AWQP Initiative utilizes seven quality performance standards measures which are reported to the NFs twice annually via the QPS Report. Interim (August) Annual (February) Each reporting period provides data results that are compared to the statewide benchmark. Statewide Average (QPS # 1-5) Composite Score 75% (QPS # 6) Positive Response to Hospital Utilization Tracking tool software (QPS # 7) During each reporting period, there is an opportunity for the NF to appeal results of the QPS data. Allows NFs to address the data results. The appeal request is submitted to DHS for review and determination. The QPS Report is revised to reflect approved appeals and impact on the QPS measures. The annual report is utilized to provide an AWQP designation. 28

29 Reasons for Appeal Do s A NF may appeal any of the seven QPS measures. Must be based on the current QPS report data. The NF may present evidence that due to unique populations served or services provided (i.e., memory impaired units or NFs that specialize in the treatment of complex wounds), the results of a particular measure cannot be benchmarked to the statewide average. A NF can appeal results if the CoreQ survey results or the self-reported hospital utilization tracking tool response is inaccurate. Appeal approval is valid for the current reporting period only (interim or annual). Don ts Cannot be based on future data period not reflected on the QPS Report. Cannot be applied to specific data quarters and carried over. o A new appeal request must be submitted for each data collection period if a NF chooses to appeal the data. 29

30 How To File an Appeal Appeals for QPS # 1-5 must be submitted within 15 business days of QPS Report mailing date on letter. Appeals for QPS # 6 & 7 may be submitted in advance of the QPS report date as these measures are captured by the DHS vendor. (Prior to February or August) All requests for appeals must be submitted using the DHS Appeal Request Form. Available on the AWQP webpage Appeal requests are submitted to DHS.Awqpinitiative@dhs.state.nj.us with Appeal Request in the subject line within 15 business days of mailing date. The appeal request will be reviewed and a final decision will be made within 15 business days of receipt. 30

31 Appeal Request Form NJ Department of Human Services Managed Long Term Services and Supports Any Willing Qualified Provider (AWQP) Initiative NF Appeal Request Form 31

32 Supporting Documentation for the Appeal Request The definition of supporting documentation is to provide proof or evidence of something, or are a record of something. The purpose of supporting documentation is to provide backup and depth to the discussed items. Supporting documentation for the appeal request needs to be clear and concise. Be sure your NF is providing the correct supporting documentation for the appropriate time period. Should be a report that identifies a numerator and dominator within the report. Do not include member specific information. i.e. names and identifiers 32

33 Example of Supporting Documentation Appeal Request Area: Influenza Reason: High percentage of residents who were unable to receive due to unstable medical condition or short stay. Supporting Documentation: NF had 150 residents during flu vaccine cycle of October 20xx- March 20xx 105 residents offered and vaccinated 15 residents offered and refused 5 residents vaccinated prior to admission 10 contraindicated 15 unstable o 5 with physician s documentation to hold off until medical condition stabilizes o 10 in facility fewer than 3 days but greater than 1 day 33

34 DHS Review and Determination Outcomes for the appeal request include: Approved: An appeal request approval means a NF meets the measure regardless of data for the current reporting cycle only. The QPS Report will be revised with a plus sign (+) for the measure. Not Accepted: for the current data period only. There is no impact on the QPS Report. The appeal request will be reviewed and a final decision will be made within 15 business days of receipt. Once a determination is made, the NF will receive an notification and a letter via US Postal mail. 34

35 OVERVIEW OF QUALITY PERFORMANCE STANDARDS (QPS) REPORT Neha Chopra 35

36 Overview of Quality Performance Standards (QPS) Report The QPS Report identifies the five MDS measures, two survey measures, and the AWQP Designation. Each NF has a second line underneath their data line to indicate appeal request approval if applicable. CoreQ has two columns. The first column represents the first data collection period of 2018 and the second column represents the second data collection period of The Hospital Utilization Tracking will either have a "Yes," "No," or No Response (NR) in the column. A facility must attest to and respond Yes in order to meet the Hospital Utilization Tracking Tool measure. The AWQP Designation does not begin until February 2019 and is not applicable at this time. 36

37 CMS Symbols on the QPS Report Symbols Definition Impact on QPS Asterisk Symbol (*) Three Dashes Symbol (---) Down/Up Arrow Symbol ( / ) Indicates CMS had a footnote of The number of residents is too small to report. Call the facility to discuss this quality measure. Indicates CMS had a footnote of The data for this measure is missing. Call the facility to discuss this quality measure. The down arrow ( ) symbol indicates the data result must be at or below the statewide average to meet the measure. The up arrow ( ) indicates the data result must be at or above the statewide average to meet the measure. A data period with asterisks will be considered as having met the State benchmark due to an insufficient number of residents. A data period with dashes will be considered as not having met the State benchmark due to the facility s failure to report. Depending on the statewide average, NFs may or may not meet the standard for the measure. 37

38 DHS Symbols on the QPS Report Symbols Definition Impact on QPS Plus Symbol (+) No Response (NR) No Score (NS) Indicates an appeal request approval by DHS for the current bi-annual reporting cycle (interim or annual). Indicates the NF or vendor did not respond/provide data to the DHS designee. Indicates the NF was not able to meet the minimum amount of residents and families to be surveyed. A NF must have a minimum of 30 surveyable residents and 30 surveyable family members. An appeal request approval means a NF meets the measure regardless of data for the current reporting cycle only. A data period with NR will be considered as not having met the statewide benchmark due the NF or vendor s failure to respond/provide data. A data period with NS has the opportunity to appeal the CoreQ measure for this data collection period. 38

39 WHAT IS A QPP REPORT AND WHEN SHOULD A FACILITY CREATE ONE? Leah Rogers 39

40 Quality Performance Plan (QPP) Report What is a QPP Report? The QPP Report is an action plan created by the NF to address measures that fall outside the State benchmark. The QPP Report is used to support the NF s continuous quality improvement efforts. QPP Reports will indicate areas needing improvement, and report the NFs actions for improvement. Will guide collaborative quality improvement efforts offered by MCOs, the NF Industry, and other entities. 40

41 When Should a Facility Create One? Any NF not meeting at least four of the seven AWQP measures is required to submit a QPP Report. DHS encourages all NFs to create a QPP Report regardless of the AWQP designation for any areas not meeting the benchmark. QPP Report is submitted to DHS by NF. 41

42 NF Notification of Reports DHS notifies the NFs of reports through various means: Postal Mail to the Administrator As identified on the Department of Health (DOH) website AWQP Webpage Only after appeals have been processed 42

43 QPP Report Timeframes After distribution of QPS Report, the NF has 30 business days to submit a QPP Report. QPS submission may await appeal request and outcome. After notification letter of appeal determination, the NF has 15 business days to submit a QPP Report for measures not meeting the benchmark excluding approved appeal areas. QPP Reports will be shared with the MCOs for each reporting period. 43

44 Sample: QPP Report Cover Page Any NF not meeting at least four of the seven AWQP measures must submit a Quality Performance Plan (QPP) Report to DHS. All QPP Reports must be submitted to DHS.Awqpinitiative@dhs.state.nj.us with QPP Report in the subject line. NF Information NF Name: CMS Provider ID #: Address with County: Main Phone Number: Date of Submission: Type of Submission: Interim Annual /Year: Administrator's Name: Administrator s Address: Designated AWQP Point Person: Designated AWQP Point Person's Address: Phone #: Contracted MCOs Aetna Amerigroup Horizon United WellCare Healthcare Average Weekly Census at the Time of Reporting Total Licensed Bed Count: Skilled Medicare Residents: Private Pay/Other Residents: MCO Residents: Non-Skilled Fee for Service Residents: MCO Residents: Private Pay/Other Residents: MLTSS Residents: Identified Areas Not Meeting Benchmark QPS #1: Influenza QPS #2: Antipsychotic QPS #3: Pressure Ulcers QPS #4: Physical Restraints QPS #5: Falls with Major Injury QPS #6: CoreQ QPS #7: Hospital Utilization Tracking Tool 44

45 Sample: QPP Report GUIDELINES FOR NARRATIVE: Quality Performance Measure #5: Falls with Major Injury (Statewide Average as of September 2017: 2.04%) STEP OBJECTIVE DESCRIPTION TIMEFRAME(S) 1 ANALYZE & What is wrong? Identify the root causes of the problem PLAN 2 IMPLEMENT Fix the problem Refine and prioritize the improvement opportunities & IMPROVE Detailed actions/changes taken to Initiate the project, create a plan and project manager address the deficiency after the QPP Report implementation/designation 3 MAINTAIN Maintain the gains Control measures put in place to ensure results are achieved and maintained 45

46 TIMELINE OF AWQP QUALITY CYCLES Leah Rogers 46

47 AWQP Quality Cycles The AWQP Quality Performance Standards data will be released twice annually. The AWQP designation will be applied annually. February Annual Data Release and Designation The designation is valid for one year August Interim Data Release Designation does not change; opportunity for NF to track progress 47

48 Timeline of AWQP Quality Cycles Timeline Key DMAHS and DoAS Activities August 2018 QPS baseline interim data is released to NFs NFs (without vendors) provide patient demographics to Dr. Castle for CoreQ surveys September 2018 DHS receives Quality Performance Plan (QPP) Reports from NFs DHS receives and reviews Appeal Requests related to data CoreQ survey and Hospital Utilization Tracking distribution and collection continues Oct/Nov 2018 CoreQ survey distribution and collection continues December 2018 DHS receives CoreQ and Hospital Utilization Tracking report from Dr. Castle January 2019 DHS prepares QPS data for distribution to NFs NFs (without vendors) provide resident demographics to Dr. Castle for CoreQ surveys February 2019 QPS annual data is released to NFs CoreQ survey distribution and collection begins March 2019 DHS receives Quality Performance Plan (QPP) Reports from NFs DHS receives and reviews Appeal Requests related to data CoreQ survey and Hospital Utilization Tracking distribution and collection continues April 2019 AWQP annual designation is provided to NFs for the first time Designation status shared with MCOs and posted publically Progressive Accountability action for non-designated facilities MLTSS member notification of facility designation by MCOs 48

49 Question and Answer 49

50 Next Steps QPS Report distribution in August 2018 Appeal Request and QPP Reports are due in September 2018 CoreQ and Hospital Utilization Tracking Next Steps CoreQ and Hospital Utilization Tracking tool surveys begin in August 2018 o Pre-survey for NFs with no response to first data collection period o Survey of Hospital Utilization Tracking for NFs who responded to first data collection period NF CoreQ vendors to outreach Dr. Castle for guidance on data parameters and submission NFs without vendors to provide demographics to Dr. Castle for survey distribution and collection 50

51 Nursing Home Quality Improvement Initiative: Frequently Asked Questions for Providers: Frequently Asked Questions for Consumers: CMS Nursing Home Long-Stay Quality Measures Website: CMS MDS State Averages: MDS 3.0 Quality Measures User s Manual: CoreQ: Helpful Links 51

52 Contact Information For questions regarding the AWQP Initiative, please contact: Leah Rogers Quality Assurance Coordinator Division of Aging Services (Please note the new number) 52