HSAG the QIN-QIO NHQCC II and CDI Initiative Kick-off

Transcription

1 (HSAG) the Quality Innovation Network-Quality Improvement Organization Ohio National Nursing Home Quality Care Collaborative II (NHQCC II) Introduction James H. Barnhart III, BSH, LNHA Quality Improvement Project Lead, Nursing Home Presentation Goals 2 1

2 What is a QIN-QIO? Funded by the Centers for Medicare & Medicaid Services (CMS) QIN-QIO in each state Dedicated to improving health quality at the community level Ensures people with Medicare get the care they deserve, and improves care for everyone Department of Health & Human Services Centers for Medicare & Medicaid Services 3 New National QIN-QIO Structure 4 2

3 HSAG s QIN-QIO Responsibility Nearly 25 percent of the nation s Medicare beneficiaries HSAG is the Medicare QIN-QIO for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands. 5 Medical Case Review Structural Changes CMS separated medical case review from quality improvement work creating two separate structures: Medical Case Review Beneficiary Family Centered Care-QIOs (BFCC-QIOs) Quality Improvement Quality Innovation Network-QIOs (QIN-QIO) 6 3

4 New National BFCC-QIO Structure Area BFCC- QIO 1 LIVANTA 2 KEPRO 3 KEPRO 4 KEPRO 5 LIVANTA 7 KEPRO Helpline: QIN-QIO Areas of Focus 4

5 Manage Diabetes Improve Coordination of Care Improve Medication Safety Improve Cardiac Health Improve Health Through Health Information Technology Patient is at the center of care. Reduce Hospital Infections Improve Nursing Home Quality 9 Manage Diabetes Improve Coordination of Care Improve Medication Safety Improve Cardiac Health Improve Health Through Health Information Technology Patient is at the center of care. Reduce Hospital Infections Improve Nursing Home Quality 10 5

6 Improve Nursing Home Quality All Ohio nursing homes are invited to join Medicare s National Nursing Home Quality Care Collaborative (NNHQCC). An all-teach, all-learn quality improvement effort designed to ensure residents receive the highest quality of care Collaborate with peer nursing homes and expert speakers through face-to-face meetings and webinars while earning no-cost continuing education units (CEUs) 11 Collaborative I vs. Collaborative II Second Phase of 11 Scope of Work Opportunity for homes that missed Collaborative I Assist homes that did not reach their Collaborative I goals Assist homes that did reach Collaborative I goals maintain those achievements. Collaborative II objectives are the same as Collaborative I objectives. All Collaborative I homes are automatically included as Collaborative II participants. All NHs participating in the National Healthcare Safety Network Clostridium difficile (CDI) Initiative are included in Collaborative II. 12 6

7 Ohio Nursing Home Quality Care Collaborative I Outcomes Overall Recruitment Total for Collaborative I 14 7

8 NHQCC Go for the Gold Collaborative I: Achievement Count Go for the Gold! Ohio NHQCC Recognition Program NHQCC Go for the Gold Collaborative I Achievement Count (cont.) Go for the Gold! Ohio NHQCC Recognition Program Trailblazer: 23 Achieving 6% or better 6 month Quality Composite Score within first two months Antipsychotic Medication: 338 Achieving a 15% relative improvement by the end of Collaborative I 16 8

9 Ohio QAPI Self-Assessment Scores Almost There Doing Great Have Not Started Just Starting On Their Way (average response) Completed Self-Assessment 17 Relative Improvement in Antipsychotic Medication Usage AVERAGE ANTIPSYCHOTIC MEDICATION QM SCORES TREND Collaborative Participants State National Antipsychotic Medication Scores Weighted Average Aug'15 - Jan'16 Sep'15 - Feb'16 Oct'15 - Mar'16 Nov'15 - Apr'16 Dec'15 - May'16 Jan'16 - Jun16 Reporting Time Period (Rolling 6 Months) 18 Source: National Coordinating Center (NCC) Composite Data, Rolling 6 months (Jan Jun. 2016) 9

10 Relative Improvement in Antipsychotic Medication Usage (cont.) Weighted Average Antipsychotic Medication QM Scores 19 Source: NCC Composite Data, Rolling 6 months (Jan Jun. 2016) Quality Measure (QM) Composite Score Progress AVERAGE QM COMPOSITE SCORES TREND 9.00 Collaborative Participants State National 8.80 Composite Scores Weighted Average Aug'15 - Jan'16 Sep'15 - Feb'16 Oct'15 - Mar'16 Nov'15 - Apr'16 Dec'15 - May'16 Jan'16 - Jun16 Reporting Time Period (Rolling 6 Months) 20 Source: NCC Composite Data, Rolling 6 months (Jan Jun. 2016) 10

11 QM Composite Score Progress (cont.) Weighted Average QM Composite Scores 21 Source: NCC Composite Data, Rolling 6 months (Jan Jun. 2016) Ohio Nursing Home Quality Care Collaborative II and the Clostridium difficile Infection (CDI) Initiative 11

12 Ohio Nursing Home Quality Care Collaborative II Improve resident mobility. Integrate QAPI* practices. Reduce antipsychotic medication use. Decrease QM composite scores. 23 *QAPI=Quality Assurance & Performance Improvement Improved Resident Mobility Activities of daily living (ADLs), resident falls, physical restraint use, etc. Goal - TBD 24 12

13 Reduce/Eliminate Antipsychotic Medication Use Percent of long-stay residents who received an antipsychotic medication Goal 15% relative improvement 25 Integrate QAPI Quality Assurance Reactive: Comply with regulations Performance Improvement Proactive: Exceed standards or address issues before noncompliance 26 13

14 Five Elements of QAPI Performance Improvement Projects Systematic Analysis and Systematic Action Feedback, Data Systems, and Monitoring Design and Scope Governance and Leadership Quality of Care, Quality of Life, Resident Choice 27 QAPI Self-Assessment Collaborative II: QAPI Self-Assessment Complete online at:

15 Decrease QM Composite Scores Derived from long-stay QMs Relatively unknown/unused 29 How Do I Find My QM Composite Score? Call or HSAG nursing home representative (Official Data) or Derive a modified QM Composite Score (up-to-date, but not as accurate) 30 15

16 QMs in the Composite Score 1. Percent of residents with one or more falls with major injury 2. Percent of residents with a urinary tract infection 3. Percent of residents who selfreport moderate to severe pain 4. Percent of high-risk residents with pressure ulcer 5. Percent of low-risk residents with loss of bowels or bladder 6. Percent of residents with catheter inserted or left in bladder 7. Percent of residents physically restrained 8. Percent of residents whose need for help with activities of daily living has increased 9. Percent of residents who lose too much weight 10. Percent of residents who have depressive symptoms 11. Percent of residents who received antipsychotic medications 12. Percent of residents assessed and appropriately given flu vaccine 13. Percent of residents assessed and appropriately given Pneumococcal vaccine 31 QM Composite Score Calculation 1. Run CASPER* report. 2. Utilize latest immunization data. 3. Add numerators together. 4. Add denominators together. 5. Divide the sum of the numerators by the sum of denominators. 6. Multiply by 100 to find the answer in the form of a percentage. 32 *CASPER=Certification and Survey Provider Enhanced Reports 16

17 Your Modified QM Composite Score Numerators Denominators / 1116 = X 100 = 7.26% 34 17

18 Ohio Nursing Home Quality Care Collaborative II Structure Ohio NHQCC Go for the Gold Program Structure for quality improvement Recognition for homes hard work Recognized by ODH/ODA* as an acceptable quality improvement program ( ty/nfs/qualityimprovementpro jects.aspx) 36 *ODH/ODA=Ohio Department of Aging/Ohio Department of Health 18

19 Ohio NHQCC Go for the Gold Program (cont.) Sign Participation Agreement Submit facility team roster Meet bronze-level criteria Submit completed QAPI Self- Assessment Submit discovery form Meet silver-level criteria Achieve a Quality Measure Composite Score of 6 percent or lower at least once in a 6 month period Submit Summary Form Meet gold-level criteria Achieve a Quality Measure Composite Score of 6 percent or lower in a calendar quarter Challenge is to sustain 37 The CDI Initiative 19

20 CDI Initiative 185 participating nursing homes in Ohio NHSN enrollment 10-month data collection for baseline Quality improvement Starting in early CDI Initiative Education Opportunities NHSN TeamSTEPPS =Team Strategies and Tools to Enhance Performance and Patient Safety Infection Control Antibiotic Stewardship 40 20

21 What is NHSN? National Healthcare Safety Network (NHSN) Operated by the Centers for Disease Control and Prevention (CDC) Currently utilized by hospitals Secure federal mainframe Need for Secure Access Management Services (SAMS) card 41 How Do I Get a SAMS Card? Secure Access Management Services (SAMS) SAMS card is proof of your identity Two SAMS card holders per home SAMS card stays with you, not the facility Steps to receiving your SAMS card: Watch training/prep videos Register facility with NHSN Register w/sams (identity verification) 42 21

22 HSAG NHSN Resources 43 Ohio NHQCC Collaborative II and CDI Initiative Timeline 44 22

23 Other Updates and Information Advancing Excellence Quality Care Connection (QCC) newsletter HSAG website Advancing Excellence is now the Changes to Advancing Excellence National Nursing Home Quality Improvement Campaign Same goals. New resources! 23

24 Are You Receiving Monthly Updates? us to be added! 47 Visit

25 While Great Strides Have Been Accomplished Further Progress on Behalf of Our Patients is Essential. Need Help? Have Questions? Jim Barnhart, LNHA Quality Improvement (QI) Project Lead Debbie Shaeffer, LPN QI Specialist Dora Taylor, RN QI Specialist Trish Borntrager, RN QI Specialist Angila Anderson, LPN QI Specialist

26 Thank you! Questions????? 52 26

27 This material was prepared by, the Medicare Quality Improvement Organization for Ohio, 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. Publication No. OH-11SOW-C