Building the Capacity for QAPI Plans: Making Data Work For You- LTC Trend Tracker with AHCA

Transcription

1 Building the Capacity for QAPI Plans: Making Data Work For You- LTC Trend Tracker with AHCA Publication MO NH GEN This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy

2 GoToWebinar The Questions Chat Box

3 GoToWebinar Raise Hand Button

4 Set your audio option

5 Introducing: Show-Me Quality Games

6 6 Gold Level Homes Columbia Healthcare Center Cuba Manor Dixon Nursing & Rehab Lacoba Homes Madison Medical Center Villages of St. Peters Eldon Nursing & Rehab Fulton Manor Care Center Hartville Care & Rehabilitation Center

7 Show-Me Quality Games 5 Simple Steps to Gold: 1. Select improvement project, a project team, and send us a team photo. 2. Attend Show-Me Quality educational offerings. 3. Fill out the QAPI Self Assessment Tool. 4. Complete the Using PDSA for QAPI worksheet. Because quality improvement projects are always a work in progress, submit a second Using PDSA for QAPI worksheet. 5. Submit a story of your home s success (or lessons learned).

8 Get Started: Going for the Gold Find the complete program guide,worksheets for submission and a short video detailing the program at Contact your Program Manager with questions!

9 Regional Affinity Groups Watch for announcements

10 Keeping You Up-to-Date: Monthly Newsletter ed QAPI-related tips Provider highlights: hear from colleagues about what works Updates on available tools, resources, and trainings Upcoming events

11 Keeping You Up-to-Date: On the Web Newsletters Event calendar Event registry Resources Archived webinars

12 Our Show-Me Quality: QAPI in Action Consultant Team Pam Guyer BS, LNHA Alexis Roam MSN, RN Judy Halley RN BC, BSN, LNHA Peggy Neale-Lewis BSN, RN, CPHQ Kent McGeeney LNHA, MPA, MSE

13 Building the Capacity for QAPI Plans: Making Data Work for You - LTC Trend Tracker with AHCA Peggy Connorton, Director Quality & LTC Trend Tracker pconnorton@ahca.org

14 Objectives Describe how a comprehensive system for monitoring data is used to establish targets for improvement and acceptable performance parameters. Identify the sources of data that can be monitored through this tracking system Identify who could benefit from receiving the data and how this sharing of data is critical to QAPI efforts.

15 AHCA Quality Initiative Goals Safely reduce 30-day hospital readmissions by 15% by 2015 Reduce clinical staff turnover by 15% by 2015 Increase customer satisfaction to 90% by 2015 Safely reduce the off-label use of antipsychotics by 15% by the end of 2013

16 Data that you collect MDS Financial Data Resident, family, staff satisfaction Turnover data Clinical Survey Census Workers Comp Rehospitalization RUG info

17 2011 and 2012 MDS Submissions ,660,

18 These reports become public Resident Census and Condition Report Application for MCR and MCD QM Report Cost Report Survey Report

19 What people know about you Five Star ProPublica can read your 2567 Hospitals track your data Yelp Google

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21 How often do you look? Five Star Data? Resident Condition and Census Report QM Report QI Report Application for MCR and MCD

22 QAPI and Data

23 QAPI Meetings

24 QAPI Basics 5 elements of for QAPI 1. Design and Scope 2. Governance and Leadership 3. Feedback, Data Systems and Monitoring 4. Performance Improvement Projects 5. Systematic Analysis and Systemic Action

25 Feedback, Data Systems, and Monitoring Monitor care and services Process for feedback using performance indicators Monitor wide range of care processes and outcomes Review findings against facility benchmarks Track, investigate and monitor adverse events Implement plans to prevent recurrence

26 Benchmarking Use LTCT for external and internal Allows you to check your performance to others Are you higher or lower than your peers? The basis for your QAPI program

27 LTCTT and QAPI Use in Element 3 Feedback, Data Systems and Monitoring Benchmarking Look at historical trends Set your goals Print Graphs or download data into excel for correlation analysis

28 QAPI Meetings CASPER Reports Staffing, Survey History, Resident Characteristic Reports NH QM Five Star Reports Cost Report Medicare Utilization Report Rehospitalization Report

29 PDSA

30 Frame the problem 1. Recognition 2. review previous findings

31 Communicate results Communicate the results of the issue Present action

32 How do you solve? You collect data And analysis the data

33 Why is data important? Allows you to set priorities on what you are going to work on Allow you to track and trend the good things in your building Essential to QAPI

34 Stuff you already do Frame the problem Solve the problem Communication and acting on the results

35 Tools to Track Data Advancing Excellence LTC Trend Tracker Spreadsheets

36 Share your outcomes Share outcomes with staff, residents and families Show progress in the break room Talk about outcomes at meetings, resident and family council

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38 How to use to LTC Trend Tracker

39 The Basics LTC Trend Tracker provides members with the ability to benchmark their quality, clinical and financial data Staffing, Resident Characteristics, Five Star Ratings, Five Star Staffing, Survey Findings, Medicare Cost Report, Rehospitalization, Off-label Antipsychotics, Retention and Turnover Includes data for all MCR SNFs in US

40 Data Sources The information in reports are uploaded by AHCA for facilities (identified by their Medicare provider number) CASPER Reports collected at time of survey Medicare Patient Days by RUG Category LTC Trend Tracker participants Cost Report- from the full cost report submitted to your FI/MAC Rehospitalization- MDS 3.0 On-Point 30 FIVE Star and Quality Measures Nursing Home Compare Antipsychotic MDS 3.0 Turnover and Retention- Annual AHCA Staff Vacancy, Retention, and Turnover Report

41 Peer Group Selection First Pick your Area Next pick your peer group National State For Profit Not for Profit Chain Facility County City Zip Code Single Facility All Peers CCRC Own Organization Veterans Homes Many More Develop a custom peer group

42 Dashboard The landing page Quality, Medicare, Staffing, Regulatory Use for QA/PI and Board Meetings

43 Edit my dashboard changes the dashboard and report builder takes you to the reports

44 Anti-Psychotic

45 Rehospitalization data New MDS 3.0 Based Measure Adjusted Expected Actual Use in telling your story to the hospitals Benchmark your Rehospitalization to your peers

46 Data Source MDS 3.0 Over a 12 month period Based on admission assessment (5 day or OBRA) Discharge Assessment

47 Risk Adjustment CMS uses Risk Adjustment in QMs Allows to compare Case-Mix and Acuity Compare performance between different providers

48 How Risk Adjustment Works Provider A Low Acuity Provider B High Acuity 100 admissions in a year 100 admissions in a year Monthly d/c to hospital 10 Monthly d/c to hospital 25 Actual Rehospitalization rate 10% Actual Rehospitalization rate 25% Risk adjusted rate 25% Risk adjusted rate 10%

49 How to use Rehospitalization Report ACOS Hospital discussion Referral Sources

50 Discharge to Community Determine how you compare in your d/c to community rate Private home, apartment, board/care, assisted living, or group home as indicated on MDS discharge assessment Uses MDS Data from the d/c assessment

51 How to use DC to Community See how you are doing on your dc rate to home and other nonclinical settings It can also tell you if you are sending more or fewer than expected individuals back to the community given the clinical characteristics of the population of individuals admitted to your center Use negotiations with hospitals, Manage Care organizations and others.

52 How to read the reports 1. Look at your actual Rate 2. Compare to your expected Rate 3. Then look at Risk Adjusted Rate

53 Higher or Lower If your actual rate is lower than the expected than then your risk adjusted rate will be lower than the national average If your actual rate is higher than expected than the risk adjusted rate will be higher than the national average

54 LTCTT example

55 Should this building be concerned?

56 Five Star Rating Reports Overall Five Star Rating Report Five Star Staffing Rating Report CMS QM Five Star Rating Report

57 Overall Five Star Rating Compare ranking in categories: Overall Rating Health Inspection Rating Direct Care Staffing Rating Registered Nurse Staff Rating CMS Quality Measure Data

58 Five Star Rating QM Report Identify focus QMs for quality improvement Predict impact of QM improvements on Five Star QM Rating

59 Five Star QM Report Click here to enter you data

60 Quality Measures Compare Quality Measures New July 2012 Information Old prior to Oct 2010 Information Exclusive AHCA 1 quarter view Evaluate resident characteristics: Post-Acute Care Chronic Care Advancing Excellence 2/18/2014

61 Antipsychotic Antipsychotic- Short Stay off label resident data Long Stay off label resident data MDS 3.0

62 NH Compare QM Report

63 Long Stay Antipsychotic

64 Resident Report Based on OSCAR/CASPER data This report can assist you in Quality Improvement efforts Compare and contrast resident characteristics: 1+ assistance in ADLS Bowel/bladder status Mobility Skin integrity Special care Behaviors Other

65 Has acuity changed?

66 Regulatory Reports Standard Health Survey, Combined Health Survey, Complaint and Life Safety Code Information Identify the frequency a certain F- or K-Tag was citied Compare percentage of peer facilities with the same F-Tag or K- Tag Set up Organization focus tags See top 15 tags for your state Track survey trends in the market

67 Should you prep for this tag?

68 Turnover and Retention Report Information from the AHCA annual Turnover and Vacancy Survey Compare organization s turnover and retention rate to your peers for: Admin DON Staff RN CNA

69 Was there a decrease in Turnover?

70 Your LTCTT Report Upload Timeline RUG and Five Star data- Monthly OSCAR/CASPER Data- Quarterly NH Compare Quality Measures-Quarterly Medicare Cost Report Quarterly 2/18/2014

71 Where to find your data: Clinical/Resident Information- CASPER Resident Characteristics, NH QM Report Rehospitalization AHCA Outcome Report Antipsychotic Dashboard and QM Report Regulatory Compliance Standard Health Survey, Complaint, Combined, and Life Safety Code Financial and Marketplace results Cost Report, Five Star, CASPER Staffing Report and Medicare Utilization Report

72 Summary of LTC Trend Tracker LTC Trend Tracker provides members with Clinical, Quality, 5-Star, Staffing and Financial Data FREE AHCA member service Use in QAPI, Marketing and discussions with hospitals.

73 Summary You are already collecting data Referral Sources are making decisions based on your information Use LTC Trend Tracker as a resource

74 Questions

75 Peggy Connorton Contact Info

76 13 QAPI at a Glance Guide for Developing a QAPI Plan Publication MO NH GEN This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy

77 14 QAPI: Feedback, Data Systems, & Monitoring Identify the sources of data you will monitor Describe the process for collecting the data Describe the process for analyzing the data Describe the process to communicate data - one method for doing this is a dashboard Describe who will receive this information

78 15 A comprehensive systems enables us to: Analyze patterns and trends Set parameters for performance Communicate quality outcomes to various audiences such as board members, QAPI guiding team, staff, and others

79 16 REMEMBER YOUR data reflects YOUR organization Thank you for attending our webinar today

80 17 Next Webinar (#4 in series of 6) Building the Capacity for QAPI Plans: Making Data Work for You CASPER Reports With AANAC Date - February 25, :00 pm - 2:00 pm