Event ID: Event Started: 5/18/2016 1:40:25 PM ET QuILTSS Consistent Assignment Webinar Series: Session 1 WebEx from May 18 th

Transcription

1 Event ID: Event Started: 5/18/2016 1:40:25 PM ET QuILTSS Consistent Assignment Webinar Series: Session 1 WebEx from May 18 th Please stand by for real-time captions. Good afternoon and welcome to "QuILTSS Consistent Assignment Webinar Series: Session 1. My name is Beth Hercher and I'm a quality improvement advisor for Tennessee and Tennessee is part of our atom Alliance Quality Innovation Network. Before we get started on the content for today want to introduce you to Sarah Potter who was also a quality improvement advisor for Qsource of Tennessee and she will give you information on how you can put questions into the chat feature of the webinar. Sarah, would you give the audience instructions please? Sure, thank you. If you look to the right hand side of your screen, you will see a section for chat as well as below that a Section for Q & A. You can use either of these options to ask questions or give us comments. I will be monitoring both and try to get back with you. We will also read your questions and let the panelists answer them as we go through the webinar. Back to you. Thank you so much, Sarah. We want you to be able to ask questions. We have muted your phone lines because of the volume of the participants on the webinar today. Send in your questions and what we will do today is I will run through the slides acting as the facilitator and once we go through the slides, we will pause to have your questions answered if you have any. On April 20 we kicked off atom Alliance Qsource of Tennessee and Advancing Excellence and are cohosting this five-month activity period for the QuILTSS submission number 8. We felt like this was a great opportunity because of the component around Consistent Assignment for your quarterly submission to help you develop a good foundation in performance improvement while establishing Consistent Assignment. As for our kickoff we had several questions that we were not able to address during the call and a lot of questions came in after the kickoff. You should have gotten from TennCare a document that was entitled kickoff questions Q&A and that is a five page document that addresses several of the questions that came in during the kickoff as well as after the kickoff. You have that to look at as well as we go through some of these other questions. Some of the common questions we got was around please define caregiver as related to Advancing Excellence tracking, and establishing Consistent Assignment as it relates back and QuILTSS criteria. We will be addressing those and I will read some definitions or guidelines for you and then we will pause to see if we have questions. At the end of this webinar today we will give you next steps for the June 15 webinar which is session 2. We have some subject matter experts with us today and we are very excited to have Adrienne Mihelic today was with Advancing Excellence. We also have Jay Taylor is also on standby to answer questions for QuILTSS. And we are very excited to have Barbara Bowers who is the Associate Dean for Research school of nursing University of Wisconsin. Barbara is one of the subject matter experts that helped develop the tracking tool for Advancing Excellence so we are excited to have her with us. These are some of the common questions that we got and some of this is listed on the Q&A document that I mentioned and other areas that we will try to make

2 more clear for you today. Some of these are around the goal of tracking Consistent Assignment and going back to accounts as a caregiver. There were questions around 8 hour shifts versus 12 hour shifts. Also sample group versus whole facility and does the size of facility affect consistent assignment? Some of these are addressed on the document and we will talk through some of those today. What I first want to share with you is to cover the Consistent Assignment goal which is advancing excellent Consistent Assignment goal which is been adopted by TennCare specifically for your QuILTSS program. Advancing Excellence Consistent Assignment goal is to reduce the number of caregivers each resident has. The ultimate goal of Consistent Assignment is for nursing homes participating in this goal is that long-stay residents have a maximum of 12 caregivers over a one-month period. TennCare realizes this is a lofty goal and the interim target for Tennessee facilities should be to increase the percent of long-stay residents with a maximum of 12 caregivers over a one-month period. Just as a tip, remember that you are counting the number of caregivers each resident has over a time period. It is not the count of the number of caregivers in your community, but the goal and the work on this task is to figure out how to get to Consistent Assignment. That can also be looked at further by looking at the common Q&A on the Advancing Excellence tracking tool as well as the pioneer tip sheet. I will pause for just a moment and I apologize and I can't believe my windows are being cleaned outside. They just moved to the side of the building where I am in this meeting and I apologize. I will see if we can stop that background noise. I apologize for it and it is an external noise that I can't do much about at this point. I will try to continue on. Consistent Assignment, what and why? Consistent Assignment clarification for you is from Advancing Excellence and it has been adopted by TennCare specifically for QuILTSS. Consistent Assignment happens when residents are consistently cared for by the same caregivers and in most cases by CNA's and nurses. We will give you some clarification about that. It's not only around a CNA or a nurse. What we want you to think about is the care. Think about the care that is being given to the resident and not necessarily the licensure of the individual providing care. We know Consistent Assignment increases our caregivers relationship both with the resident and with families. The rationale here is to think about how residents are more comfortable with caregivers who know and understand their personal preferences and needs. Think of consistency as you think through your staffing and who is providing direct care to your residence. Another way to view Consistent Assignment is the number of caregivers a resident has to relate to. Let's think about the whole caregiver role. Think of a caregiver as a person who needs to know and understand an individual and their preferences. For each resident, any individual providing direct care must be counted. This is especially important for those assisting with very personal tasks such as reading and eating. If you have downloaded the tracking tool, if you go to the most common Q&A questions, there is additional discussion around that. This slide gives us examples of caregiving. Examples of bathing, feeding, and actually helping the resident get food to the mouth. We're not talking about people trapping or delivering the food. Activities of daily living, so those folks that help with brushing hair, brushing teeth, dressing, toileting, and transferring.

3 This slide shows us non-caregiver examples. Let me clarify this by saying that caregiver definition used in QuILTSS programs follows the one developed by Advancing Excellence in America's nursing homes and that is caregivers are those who provide direct CNA type care to residents. These are the people with the most intimate contact who generally form close relationships with residents and spend most of the time with them. These are also staff most likely to notice early changes in condition, change is most likely to be noticed by a caregiver who knows what is typical for that resident. When we think of non-caregiver examples like Med Pass, wound care, a social worker going into do an interview, business office interaction, volunteers, youth groups, activities, medical director or nurse practitioner, we want you to think about if a nurse is in a residents room with Med Pass administering medications or performing other skilled tasks and stops to take the resident to the bathroom, that nurse is not counted on the tracking tool. However, if a nurse or other staff is working as a CNA because the home and short staffed or because your community of nurses or other staff routinely provide direct care to residents, that person would be included as a caregiver count. It is and individualized thing that you have to think through within your facility. Now I want to pause and we will see if we have any questions, Sarah, from the chat or Q&A panel for Adrienne and Barbara. There are a couple of questions. The first question is, do you count facilities beauticians? and the second is, Do you count therapists? What kind of therapists are you talking about? Is it like a physical therapist? Do we know? I can ask them to please clarify in the chat, they just said therapist generally. They said physical therapist. When we calculate it does let me say first of all reasonable people could disagree on what should be counted as a caregiver but it's important to understand when the calculation was made, getting to 12, we did not count PT's, and OTs and speech therapy. We do not consider them doing CNA like care. I suppose you could make a case that they could be considered direct care but they are not counted. What about the facility beautician I would not count that person either. I have been responding through chat also for those who like to see responses that way, one of the things I clarify also is it's not that the beautician when it's beauty parlor day and you have someone different in or someone who's not doing a good job, having a consistent beautician and very much so with your therapist if you are using or nurses, they are important positions to have consistency. We're not saying that Consistent Assignment and even housekeeping is a terrific discipline to have assigned consistently to residents rooms or checking on additional residence., But for tracking for this goal in this project, you are looking at caregivers and the focus is on the people with those relationships doing personal care and supporting residents in their daily

4 activities. The message is not that it's not important to have consistency throughout because it is, but for this project it's just that CNA type activities and whoever is performing that. I agree with that. I think that was some of the confusion about counting license staff nurses, LPNs and RNs. We're not saying that consistency in any of those people is not important because it's really important. This tracking exercise is about CAN-like workers. And this is Sarah, Adrienne, when you respond in the chat can you please choose all participants so they can see when they -- you respond. We have a few more questions. What about hospice CNA? Absolutely. If a CNA assist with the transfer only and is not assigned to the resident does that count as two caregivers? Let me back up a second, one I said absolutely for the hospice CNA you are talking about a visiting CNA who comes in occasionally as opposed to someone, we may need clarification on that but it's probably quite important regardless of the situation. But if you want to take in more explanation about the context in which that CNA is working with the resident at the end of life, if it's staff appointment. Regarding transfer, and certainly our -- if Barbara comes back on let us know, at the two person transfer or lift is one of the Q & A s addressed within the tracking tool. The phrasing of the question in the chat window had to do with assigned versus actually doing so we have two questions there. What we are tracking of the people actually doing the work regardless of how they were assigned. That is one of the ah-ha moments that we hear from a lot of homes. The question about assist is a resident requires a two person assist and that would be desirable and there is a caregiver who that person is consistently assigned to that person and if they need to pull someone into support that assist, we're not counting the other person because it's a special situation. We don't want to create a disincentive for using two caregivers when it's important for the safety of the resident and caregivers. This is Barbara. I'm sorry my phone disconnected and I am back again. I would agree with what Adrienne was just saying especially at end-of-life care. Caregivers providing CNA type care at that time would certainly count. Another question is what about a laundry person or housekeeper who was assigned consistently to help feed a resident during meals? This raises an interesting issue. In long-term care settings, there has been over the last several years the shift to specialize away from universal workers and looking at having people to feed and walk and do different things. That is one of the things that is challenging for residents which is getting to know new people. It's generally done because of short staffing. I would count that. That is a person doing direct care and certainly require some intimate knowledge about a lot of

5 residents in terms of what they eat and what their preferences are. Yes I would count someone assigned to help a person eat. Thank you. There are a couple of questions about the 8-hour versus 12-hour shifts. Beth, are we going to talk about that coming up? Yes we are. In a few more slides. I think that's it right now for the caregiver type questions. Great. We will move on. We will go want to additional questions that we received one of those is whole house versus partial tracking and this is addressed on the Q&A document. This question came up back in April when we had the kick off because during submission seven, many of you were already tracking using the tool for QuILTSS your whole house. If you are not already tracking assignments for all long-stay residents, one of the recommendations was to start with residents in a single area like one we know or a neighborhood during April or May for tracking purposes. And an additional month you would increase that. By the end of submission number eight you would be ready to track your entire community. This says as required in submission number nine and I don't know that's a requirement and it might be a misquote on my behalf. It might possibly be required to be done in submission number nine but we will have Jay address that later if we need to. Another common question was 12-hour versus eight-hour shift, and the goal was calculated for homes using an 8-hour shift which represents close to the best case scenario assuming consistency in assignments and minimal turnover and absenteeism. The thought is homes using 12-hour shifts would be able to improve on this and could achieve even fewer than 12 caregivers. Another common question was around floats. Are floats increasing your caregiver count? Think from the perspective of each resin and the caregivers they have to relate to during the four week period. Think in terms of minimizing the number of different faces and names from the resident's point of view. An example strategy for increasing consistency with this scenario is if you have two floats for the building on the same shift, consider assigning one float to happen the building and one to the other. Keep the floats for the same group of residents day after day. That gives consistency which is what we are after. So those were the three that came in in addition to the caregiver type questions. We will pause and Sarah, I am sure we have questions that have come in for Adrienne and Barbara. Yes. Let me go back up to this one and see if it was answered. It's a long one. With the eight hour shift such as 3:00-11 and 11:00-7:00 they work as a team. The hall is not split into groups and it's all hands on deck for that shift. With that being said there are three CNA's scheduled for the 3:00-11:00 shift and two scheduled from 11:00-7:00 which add up to five total within 16 hours. On most days these remain consistent as to who is assigned that particular halls but there at least two days these change giving an additional 5. So with those two shifts we already up to 10 within a week. How do you get around this?

6 This question about teams has come up a number of times. I think if we go back to what was said earlier about the issue being how many caregivers the resident has to relate to and sometimes you need somebody like another CNA to help with things, but keeping the count down would require you to not have just anybody from the team going to help a resident. Some things you might think about is having a primary person who is available most of the time in the first person to go in the room of that set of residents. Having it be any of the three, you are correct that that does increase the number of caregivers. I think we have gotten into a lot of staffing models that are more efficient for us, or better for the staff but continued to increase the number of caregivers that people have to relate to. So yes, it would be very difficult to achieve this or get close to this with a model that has a group of people responding to a group of residents rather than an individual assigned. If we think about additionally the amount of communication points we have, when we have a team environment it seems like a great idea from one perspective but if we think about the continuity of care for that resident and the need to communicate changes unique to the situations when they arise for one or two people for all those residents creates inefficiency and opportunities for pieces of information to get lost. Let me add something from a study we just recently finished looking at the national greenhouse programs. Probably most of you are familiar with the greenhouse where there is a very small group of CNA's assigned to a group of residents and they don't change. They don't call staff if there is an absence. If someone is out for two weeks they just have to adapt and it keeps the level of consistency. It shows that in -- that it increases the quality of life for residents and we found in the latest study there is a significant difference in how quickly change of condition is identified. Of all the CNA's that we interviewed 84 (out of 85) of them said the main issue for them is the level of familiarity with residents and the ability to identify subtle preferences and very subtle changes in condition. That converts into better quality of care and better quality of life. It's challenging and I think this will suggest a lot of the way we currently structure staffing has to change somewhat. It's worth it. If you look at it from the resident and families point of view and I think most staff want what is best for the resident, these changes are pretty important. I think we have another similar question and I'm not sure who is asking it but it's related to individuals on bathing teams. So maybe you can help me locate this. We include bath aids and restorative aides, so could you talk about that too? First let me say not everyone will reach 12 all the time. That's a nice goal to shoot for but what is probably more important to think about is reducing the number of caregivers that residents have to deal with. So with bath aids and restorative aides, the first way that people could reduce that and still keep that which I think needs to be changed is their teams of aides, because as soon as you get a team of people doing intimate care you have a lot of people and people feel uncomfortable having new people bathe them and also are not picking up subtle cues of changes. Those two count. I can't think of anything that's much more intimate than bath aides and also restorative aid so the challenge is to figure out how we reintegrate those changes into care with assigning a primary CNA to someone who covers more functions for fewer people. But we've

7 done now is covered fewer functions for more people and we need to worry -- to reverse that. It's the only way we will get there. As we start to think about how we are going to get to 12 or fewer caregivers for most of our residents most of the time, the starting point is if we start with a blank page, a simple step would be Monday through Fridays with eight hour shifts and three caregivers. And Saturday and Sunday I have three more caregivers and that is 6. Now whether you do Monday through Friday or three days and then four days but that start with a basic set of 6. Let's say you have two additional, when you use the term floats were talking about consistent floats, so additional helpers and we have an outstanding question and Barbara I don't know if you are on or not but maybe when your call dropped, if the co--- if the home has a CNA that comes three days a week, that's an important factor to have consistent and it raises an interesting question. For now I will include it that you still have room there. We've gotten to eight would two floats and you have to add two more floats for the other ship and that's 10 and there's still a little bit of wiggle room there. That goes back to what Barbara was just saying about fewer people doing more things so we have that consistency in the relationship. I will jump to the hospice CNA and I think it's an interesting question. So one of the obstacles I have heard homes express has to do with the use of agency staff. You may have heard that in some of the work you have been involved in as well. There is a sense and it feels like it's not in our control and that they should not be counted and there are a few different reasons. Hospice staff, if it's agency staff you are short staffed and there's an underlying turnover issue and that is a root cause and that's a situation to address. I think there's an opportunity to work with hospice agency with the other agency that you might use for callouts when you are short staffed to talk with them about your goals and work at getting consistency in the people they send. I agree. You go ahead. That is something that a lot of homes do. The person comes to feel like the staff because even though they are formally employed by an agency, they are consistent. I don't recommend it and it's probably not cost effective but a lot of the agencies are able to do that. If homes insist, they will do that. That certainly one way to do it. Those are things that can be negotiated in the other thing I want to say is I think this is a system wide issue. When you have turnover for example, of course the nurses and frontline staff are not in control of the number of people. You have to have more staff so you keep hiring staff or you get agency staff to fill in. What that does is keep putting your numbers up. As long as your turnover is high, you won't have good numbers. Those two things are not possible to put together. In a situation like that as a dream was saying in terms of root cause analysis it's not about the staffing model but what's going on that's causing turnover. That takes you to another area to look at to find out what is the cause of the turnover. So you're not looking at what causes you to have a lot of staff and do we need to deploy them differently but why are they leaving? That's another issue and it's not the frontline staff that should be held accountable for that. There was something else going on in the organization.

8 We have one other question and it is about people answering call lights. We have three CNA's per hall and they all have assigned residents. They frequently answer each other's call lights. How does that work and how can she keep track of back? -- How can she keep track of the that? That's a bit of an issue. Certainly we would never advocate making people wait longer in order to get the CNA was primarily a signed to them. As Adrienne said, there is wiggle room and I think people need to back away from you always need to have less than 12. It's a goal that we hope people will try to achieve. I believe this program is set up to look at the quartiles and how you were doing. I would suggest that people at this point think more about the ways you have to reduce said and not focus quite as much as the things that get in the way of getting it down exactly to 12. I would respond specifically to this question that yes, it will happen occasionally. I think if you -- if someone can wait, it's ideal that a person who is most familiar with them actually does direct care. Obviously you won't wait to take someone to the toilet who needs to go if someone else is available but there is wiggle room and there. If you had a really consistent assignment, low turnover, don't use floats or agencies, and don't use team responses and Bath aides and Restorative aides, there's a lot of room for improvement. Once that is done, even the situation that is being described here won't get you past 12. There's a lot of low hanging fruit and I suggest people go after that first. Similar to the question about transfers, responding to a call light in a timely manner is important. Sometimes there is a quick check in to see if it's urgent or if you want to wait for a specific person. There's a quick check into triage the call light. We don't want to extend call light times but as Barb says we don't think that needs to be sacrificed. Certainly having consistent teams, even if you have teams as long as it's consistent, that person is only adding above your sets really. I heard the question coming in about private sitters and I want to make sure we address how that is different. I heard another voice. There's another question. What about residents who employ private sitters? That's an interesting question. Frankly I have to admit we didn't talk about that. That would seem to be a pretty consistent person in the room. If the family is employing different sitters which usually is not the case and it's usually a pretty consistent person, it's an interesting question and I guess I can't answer it right now. We did not consider that. That would be something completely out of the steps control unless this is something where someone needs a center and the home has decided is needed. In that case the same issues apply which is to have consistency in who comes. Some homes do it from within and some do it by contracting with an agency. In either case there are a lot of ways to have consistency. You might add two people a week unless you have 24 hour sitting which is pretty unusual. Adrienne, do you have anything to add? I'm also thinking about resident and family preference and also what their situation is. I am aware of situations with there has been private paid caregivers working within the home to supplement staff. These are difficult questions to ask and even if we don't really know the

9 answer, if it's just the families preference or is there really an issue with staff availability? Sometimes it's just and -- it's just a desire for additional layers. I would say for this project, it's a great topic for conversation. I will take that back to the group. I don't know if you have a mechanism for feedback from people but I would love to hear from the group out there how often it's an issue and as Adrienne said, is a generally family preference where the home would not have done it? I think anything that's done because of low staffing whether it's an OT working as CNA or a housekeeping feeding someone because no one is available or a sitter, if all these things are done because of low staffing, then it's important to count the extra people because it really is the CNA care replacement. If on the other hand this is just family preference and you like someone in the room all the time, that's a different issue. Thank you for the question and we will take that up with the team and get back to you. One thing we are excited about to hear about what you are running up against and special situations you have. If there's any way we can help you to come up with solutions, and you are on the ground and on the floor and working in the situations. It's continuous quality improvement for all of us and we appreciate that. Let me get to this PBJ question. PBJ is quite different and while it addresses staffing, the actual session is are you trying to increase or reduce hours for this? What we're talking about with this goal is different than what PBJ measures. My recommendation is that PBJ be in a different department and that is related to hours per resident. It's more that sort of question. This is reducing the number of different caregivers each resident has. There can be many contacts between one resident and one caregiver and that doesn't change this. So in one of our Q&A's we talked about how you complete your spreadsheet if Mrs. Smith has Maria as a caregiver and 29 times in the course of the month she gets one X. If Mrs. Smith has John one-time in the course of the month, she gets one ask for him. So they both count as a caregiver. And they both count just once no matter how many times. That tells us that sometimes it's just one person and if we kept the float consistent in the area of the home it would have brought everybody down. I agree completely with what she's saying about focusing on our staff and staff assignments and you will start seeing the numbers change as we do that work. So going on what you were saying, the last few questions are related to how do they track these caregivers? Is it by the schedule or is it by charting or do they just include every step -- staff member on the unit who may have answered the call light? What is the best strategy? We're not doing it at assignment. You will tell us what you have and I just lost my connection so I can't see the chat, but you have some kind of sign-out sheet for your resident that shows who actually works with the resident. To some extent, you may need to modify how that works so others who end up having contact like if it's mid-shift and somebody came over from a different area as a substitute, that their names would appear on it but it's really the person that worked. We did a comparison of a record of who worked and who was assigned. There was actually a considerable difference between those two lists of staff. That's another reason to do it as it happens rather than try to re-created at the end of the month because that's difficult to do.

10 And if there is no question then you won't know that someone went in her room. We don't expect you to follow people around. There are ways you can keep track at the end of the shift about who provided direct care. Things like Bath aides, Restorative aides, and people assigned to feed are clearly accountable. And the nurse is in the room and helping someone to the toilet when they are passing that doesn't count so no need to keep track of that. I want to say keep track of the things that you can keep track of now. There is a learning curve here and it takes a while to get used to this. The goal is to reduce the number at this point. One last question. What if you have a CNA class going on and they are training on the floor? Would you count them? Are you saying they are student? They are on the floor. That is the question. If they are assigned to take care of a resident and providing direct care, yes. If they are shadowing someone and learning the job by following someone else around, I would not count them. Thank you. I think we are caught up on caregiver questions. If we missed anything we will go back through these and get them answered. So Beth, if you want to move on I think there were QuILTSS questions. I want to give Adrienne and Barbara an opportunity because there are still some questions around hospice caregivers. Perhaps you can clarify hospice caregivers who are not under the control of the facility are counted in the consistent staffing tracking? Can you speak to that Adrienne and Barbara around hospice caregivers? I think those questions all are saying these are people who were not employed by the facility so should we count them? There was also a good comment around MDS. They are not counting them as caregivers on MDS. Can you speak to that please for more clarification? Importantly not to confuse things, this is not MDS. I want to say because many of you are working on other goals as well, the outcomes are meant to be complementary but intentionally different from MDS. So MDS items are used in a different way that give you a different perspective on the information. In the interest of time I can't give examples on that but we want to stay focused on this. Rather than, as Barbara was saying, getting too caught up in deciding whether or not to count someone, this is different than agency staff. This is different than agency staff when you have to use call out because you don't have a large enough pace of employees but however to your quality improvement project and your intention to improve the situation for your residence and create consistency of reinforce relationships, it's a great opportunity to work with the hospice agency and use it as an educational moment. If you see this resident is having different hospice CNAs regularly, it matters for you and your clinical care as well. If you get multiple points of contact it's difficult for that resident. So regardless of what Barb told you about your technical response to this, I will say from a quality improvement perspective and a

11 philosophical and cultural we are creating in the home, it's a great opportunity to work with a hospice agency. For the purposes of tracking would you count? Barbara had to sign off. She had to leave early. That's right. I think earlier when Barb was talking about this, I think she was saying to go ahead and count them because we have that room. Why don't you let us know what that situation looks like and if you see an issue with hospice having multiple caregivers. I just don't know what that situation looks like specifically but thinking that it may fall into two categories. It's like a family situation having an additional person and also to some extent it may be outside your domain. It's an opportunity for improvement even if you don't count them on your spreadsheet. It would be something that you want to make consistent and would make a tremendous difference. Because the individual is coming in three days a week, that sounds a little bit more like an OT, PT type relationship. It's very important that they are consistent but not a relationship that we count on this particular tracking tool. That is all subject to revision as we learn more about the situation and we get Barb's input as well. We can follow up by . Great. Thank you Adrienne. For the sake of time as we shared in the beginning we will add it to this document as Adrienne just shared and we will taking the questions and adding to it. We will move on now to some QuILTSS and I know we have several questions for point attainment for submission number 8. We have provided which you were given already. You are aware of the point submission part of submission eight so I won't read over the two slides and we would just jump right to Jay. Sarah, can you address some questions that we got for QuILTSS? Let me go back up. He did answer some in the chat but to reiterate them, there was a question about in the last submission they were told to count RNs and LPNs and can this be corrected? It's sort of the same question saying we tracked our whole facility but didn't know we could track a smaller subset. Can we go back and fix this? So Jay, Cozart the same type of question. So a reminder to everyone that the points and number seven were attached to whether or not you tracked consistent staff assignment for four out of five measured months and you had to send us your tracking sheet. Recognizing that everyone tractate a little bit differently from each other and number seven, the points and number seven are not awarded based on performance but just did you track it for 405 months. A number eight, part of the benefit of the webinar series is to get everyone tracking it in a consistent way. A number eight, you can earn two points for tracking it for six months in Advancing Excellence website and a lab being -- and allowing TennCare for Advancing Excellence. The other points are divided among the facilities that are in the two points. Such that those who perform at the highest level will receive an additional three points. And those at the next highest level get an additional two points and the second to the lowest level I. and the lowest level only get the two points for tracking and nothing for performance. These conversations with Advancing Excellence, at exactly the right time so that all facilities are consistent in who you including your tracking. No need to go back to any number seven stuff because that wasn't about percentages. It was just about what -- whether you were measuring yourself. I hope that helps.

12 There was also a question that related to what documentation should we have to demonstrate the submitted number? For submission number eight we received the data directly from Advancing Excellence. Nursing facilities don't have to submit anything for number eight we get that directly from Advancing Excellence. But TennCare may decide that an audit is necessary and that could be for a wide variety of reasons. If we decide an audit is necessary, it will probably be on-site and you need to pull together whatever documentation you have that supports the numbers you submitted. It might be schedules, work logs, documentation of a specific record, or from interviewing staff. Keep your documentation so that you have it but you don't need to submit that. I'm trying to see if there are any other QuILTSS points related questions. The only other one I saw was asking about improving over time. I'm glad you mentioned that. Related to questions about number seven, number seven did not serve as a baseline. We are not currently looking at changing performance over time. That's an interesting suggestion in one we will put in the hopper as we go forward. For number eight, it's not did you improve or not improved but really a peer to peer comparison for the additional three points. It's as simple as are you tracking it with Advancing Excellence and will you allow TennCare to see it? We just got another question. If we have submitted for the month of April for submission number eight, can we go in and make changes based on what we learned today? I'm not sure if that is a technical question. This is Adrienne. First of all, if you have entered something in error on the website, it's possible to edit that. And there was a question when someone asked if we are tracking long-stay and short stay. There is a memo, both include really useful basic information that will simplify peoples lies. We are tracking long-stay only. When you are on the data entry page you can toggle and you have the Excel workbook to track week by week and at the end of the month its complete. Use the outcome tab and then you transfer that data to the website. When you were on the website, if you have a typo or you enter the wrong statement information on the short stay page of the website, you can go through and clear and correct it. If you have eye-opening information today like if you in a vertically counted all staff for all residents and you need to adjust the amount, you can certainly do that. That is technically available it I would be interested to know what you learned today that would cause you to update those numbers? That would be helpful for us going forward. The answer was counted nurses. If you have a situation where nurses are actually filling in for a caregiver or staffed to do caregiver type work, there are certain staffing structures where that happens. Then you would count them. If it's a nurse working as a nurse and there's another caregiver type, most typically a CNA, doing personal-care work you will not count the nurse. This is Jay. There was a question about is it 12 caregivers for a month or during the five months? Each page is different and not sure which is meant. When you use the Advancing Excellence tool and you get to the tab for data for website and traders of percentage that is calculated with a percent of residents who had no more than 12 caregivers during that month period. We will use

13 that measurement and it is averaged over the period. So that measurement average across the months so that we can compare facilities to facilities. I am just catching this question about counting Consistent Assignment by room number and residents name. There are two reasons not to do that. One is that residents can change rooms and it's about the resident. And this is really about residents and residents need to be recognized as people. Every time we reference them it needs to be by their name. These are the relationships we're talking about. It's important for us in terms of understanding what we are doing. Obviously part of the reason you are doing this is you can earn points with your QuILTSS project and that's very important. And the reasons why they are giving money for this is because it's so important we recognize our residents and ensure these relationships which are important for quality of life and quality of care. This is Jay. The big picture here is an going back to the origin of QuILTSS, what we heard from residents, family members and other LT SS recipients is that the quality of life in staffing was extremely important. Consistent staffing is extremely important. This goes all the way back to resident centers and quality outcomes. It is our belief and Advancing Excellence's belief that the more consistent you assign staff and come -- and the more consistent staff providing care are, not only will you achieve better outcomes on this measure but other outcomes relating to QuILTSS will improve. Its about resident satisfaction. Think about some of the other quality-of-life areas and it's important and not easy by any stretch of the imagination. But it is important. Thank you Jay. Adrienne and Jay we're at the top of the hour and we want to be cognizant of everyone's time. I know we will have a few more questions in but we will collect them and get those answered and put those on the document. As we close, we are going to be doing another webinar and session 2 is June 15. We will again looking at your questions that you have sent us and hopefully be able to provide answers for you. PDSA's and variations is something the team thought about providing for you but one thing I want to share with you is we have one of your peers that has agreed to do some sharing on June 15. This individual has implemented Consistent Assignment for several years and utilizing Advancing Excellence tracking tool. She will share her some lessons learned and perhaps addressing things that have been discussed today like the challenges and opportunities. So we're working on that and will be providing that peer to peer sharing for you on June 15. Because of the time, Jay or Adrienne, unless you have anything to add we will let everyone adjourned for today and again we will collect the questions. Do you have any closing thoughts? This is Jay and I do not. Thank you everyone for participating. And Beth if I can take a quick second. This might be a good time on the website when you are in the Consistent Assignment area, if you click on the ENGAGE page we have fact sheet for nursing home leadership, residents and their families, consumers, and staff. They are printed on one page double-sided and this is a team project. This might be a time that would be opportune to look at those and share them to get others on board. Keep writing to us with your questions and obstacles that you encounter.

14 Great. Thank you. Thanks to everyone for your questions. I apologize for the background noise that you are currently hearing and what you heard before. With that we want to adjourned the meeting and thank you for your time and input. And for all you do for the quality of life for the residents within your facility. [ Event concluded ]