Understanding Your Quality Measures. Craig Bettles Data Visualization Manager Consonus Healthcare

Transcription

1 Understanding Your Quality Measures Craig Bettles Data Visualization Manager Consonus Healthcare

2 The CMS Challenge The CMS five star and quality measures are vital to retain referrals and to get a seat at the table as ACOs form in your market. You know you provide quality care, right? So why is not showing in the measures from CMS? The devil is in the details. Understanding how the five star and quality measures are calculated helps you to understand, and communicate to your partners, what the CMS data is showing and not showing about the quality of care in your building. Below are notes from the Understanding Your Quality Measures presentation at the 2017 Leading Age Washington conference. Please contact Craig Bettles at cbettles@consonushealth.com if you want to learn more. Calculating the Overall and Survey Five Star Ratings The Survey Five Star rating is the starting point for calculating your Overall Five Star rating as shown below. Both the Staffing and Quality Five Star can add or subtract 1 star to the Overall Five Star.

3 Calculating the Survey Five Star The Survey Five Star rating, also referred to as the Health Inspection Score, is based entirely on unannounced, onsite inspections of nursing homes conducted by state agencies. All nursing homes that participate in Medicare and/or Medicaid have annual inspection. Timing of the inspections may vary with very rarely more than 15 months elapsing between surveys. Violations generate citations with different severity and scope (see below). More widespread and severe deficiencies receive more points. Sub standard care will add an additional penalty to a violation of between 4 and 25 points. State Survey Agency determinations made during a Federal Oversight Survey are also included. CMS calculates the Survey Five Star rating over three survey cycles: Points in the most recent survey cycle comprised 1/2 the total score. Points in the next most recent survey cycle comprise 1/3 of the total score. Points in the most distant survey cycle comprise 1/6 of the total score.

4 Severe violations of nursing home regulations can spark additional compliance surveys. Deficiencies identified during a compliance survey contribute to the overall point total for a facility on a sliding scale based on the number of compliance surveys conducted in a given survey period (usually a year). A compliance survey can spark additional compliance surveys in the same year if there are still severe violations of nursing home regulations on the site. CMS generates the final Survey Five Star rating by taking the facility s score and comparing it against all other nursing homes in the state. The top 10% of nursing homes receive five Stars. CMS splits the middle 70% three ways with each group receiving two, three or four Stars. The bottom 20% of nursing homes receive one Star. Calculating the Staffing Five Star CMS bases the Staffing Five Star measure from form 671 (Long Term Care Facility Application for Medicare and Medicaid). Facilities fill out form 671 during the annual survey and includes payroll hours from the previous two weeks. To calculate the measure, CMS uses: Total Nursing Hours per Resident Day (RN+LPN+Nurse Aid Hours) RN Hours per Resident Day RN hours have an oversized impact on the Survey Five Star. It includes all registered nurses working in the facility at the time of the assessment, the RN director of nursing and nurses with administrative duties. Therapeutic services are included as part of the total staffing measure.

5 CMS adjusts the two measures based on the case mix of the patients in the facility. CMS uses the Resource Utilization Group (RUG III) case mix system to generate the expected hours for the patient population. The expected values are based on MDS data in the quarter closest to the date of the most recent standard survey. CMS compares the case mix adjusted hours for each of the two measures to five fixed cut off points. CMS developed the cut off points using data available as of December The Staffing Five Star rating is determined using both the total nurse staffing measure and the RN staffing measure. CoPilot shows both the Staffing Five Star and the RN Staffing Five Star Measure which contributes to the Staffing Five Star. Calculating the Quality Five Star The Quality Five Star rating uses a point based system to compare and rank facilities across the nation. The chart below shows the latest point cut offs for each of the star rankings. The point ranges change on a regular basis so only the top 25% of facilities receive a five star quality ranking. CMS calculates the points using 16 short and long stay based quality measures (see below). All of the measures have a point value between 20 and 100 points. CMS calculates and risk adjusts eleven measures based entirely on MDS assessments. CMS calculates three short stay measures on claims data and risk adjusts the same measures using both claims and MDS data.

6 To generate the points, CMS compares each facility against other nursing homes across the nation. Most quality measures use a quintile system where CMS even distributes nursing homes into five groups and assign points based on those groups. Three quality measures have a large number of facilities with a perfect rating. For these measures, all facilities that have a perfect rating get the maximum points and CMS then splits the remaining facilities into component groups to assign points. Lastly, CMS uses different measures to risk adjust the quality measures. In general, the newer the measure, the more extensive and complex the risk adjustment used. These are the techniques used by CMS to risk adjust the quality measures: Exclusions: CMS will exclude patients with certain conditions out of the data set prior to calculating the measure. MDS Covariates: CMS also uses a logistic regression model using covariates based on MDS assessments. The impact of the covariates on the model vary with some covariates having a large impact and some having a minor impact. Claims Covariates: The new claims based measures also use a logistic regression model that combines MDS based covariates and claims based covariates. The new measures use many more MDS based covariates than claims based covariates. This means the new measures, while claims based, are highly dependent on MDS assessments. All of the risk adjustment measures benefit facilities with a higher level of acuity in their patient population. The risk adjustment depends heavily on accurate data in the MDS assessment. Risk adjusted measures are developed using the following formula:

7 Long Stay Quality Measures Quality Measure Source Risk Adjustment Point Calculation Method Ability to Move Independently MDS Exclusions, MDS Covariates National Quintiles Even Distribution Activities of Daily Living MDS Exclusions National Quintiles Even Distribution Hi Risk Pressure Ulcer MDS Exclusions National Quintiles Even Distribution Cath Inserted/Left in Bladder MDS Exclusions, MDS Covariates National Quintiles Even Distribution Urinary Tract Infections MDS None National Quintiles Even Distribution Moderate to Severe Pain MDS Exclusions, MDS Covariates National Quintiles Even Distribution Injurious Falls MDS None National Quintiles Even Distribution Antipsychotic Medication MDS Exclusions National Quintiles Even Distribution Physical Restraints MDS Exclusions National Perfect (~60%)/ Remaining pool split 2 ways (~20% each) Short Stay Quality Measures Quality Measure Source Risk Adjustment Point Calculation Method Rehospitalization Claims (MDS) Exclusions, MDS Covariates National Quintiles Even Distribution Outpatient ED Visit Claims (MDS) Exclusions, MDS Covariates National Quintiles Even Distribution Discharge to Community Claims (MDS) Exclusions, MDS Covariates National Quintiles Even Distribution Physical Function Improvement MDS Exclusions, MDS Covariates National Quintiles Even Distribution Moderate to Severe Pain MDS Exclusions National Quintiles Even Distribution Hi Risk Pressure Ulcer MDS Exclusions, MDS Covariates Antipsychotic Medication MDS Exclusions National Perfect (~33%)/ Remaining pool split 3 ways (~22% each) National Perfect (~20%)/Bottom (~20)/ Remaining pool split 3 ways