Using the Composite Score to Guide Your Quality Efforts Scott Gibson Quality Improvement Advisor
Composite Score CMS Goal for all Nursing Homes = 6.00 or lower Calculated with 13 long stay quality indicators Composite Score Cards sent quarterly (6 month delay)
MDS 3.0 Data: Basic QM Calculation Numerator (residents with problems) Denominator (all residents who could have the problem) X 100 = Percentage 3
10.0 Trends in Composite Scores 9.5 9.0 8.5 8.0 7.5 7.0 6.5 6.0 5.5 4 5.0 Collab I&II (224 as of AUG 2017) KY Statewide (293 as of AUG 2017) 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4 2017Q1 8.57 8.41 8.54 8.55 8.46 8.33 8.27 8.31 8.65 8.52 8.60 8.59 8.52 8.37 8.34 8.37 CMS Goal 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00
10.0 Trends in Composite Scores 9.5 9.0 8.5 8.0 7.5 7.0 6.5 6.0 5.5 5 5.0 Collab I&II (224 as of AUG 2017) KY Statewide (293 as of AUG 2017) 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 2016Q4 2017Q1 8.57 8.41 8.54 8.55 8.46 8.33 8.27 8.31 8.65 8.52 8.60 8.59 8.52 8.37 8.34 8.37 CMS Goal 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00
100% 2017Q1 National Ranking: % of recruited homes with Composite Score < 6.00 KY Rank: 48 of 51 90% 80% 70% 60% 50% 40% National 40.5% 30% 20% 10% 0% HI AK CT WI RI NY DE LA MO MT IA ID OH AL WV SD NE ME IN OR GA NC ND KY WA KS
7 Antipsychotic Medications Moderate To Severe Pain Seasonal Flu Vaccine Pneumococcal Vaccine Urinary Tract Infections High-Risk Pressure Ulcers Top 3 Areas for Improvement Based on Composite Scores from Q1, 2017 (JAN-MAR 2017) Incontinence ADL Decline Weight Loss Falls With Injury Depression Indwelling Catheter Physical Restraints 10 5 7 2 16 17 14 13 8 13 8 KY Statewide (293 as of AUG 2017) 26 41 39 31 27 36 52 61 66 Collab I&II (224 as of AUG 2017) # of nursing homes with these clinical areas ranking in Top 3 missed opportunities 160 173 181 194 218 224
100% 2017Q1 National Ranking: % of recruited homes with Composite Score < 6.00 KY Rank: 48 of 51 90% 80% 70% 60% 50% 40% National 40.5% 30% 20% 10% 0% HI AK CT WI RI NY DE LA MO MT IA ID OH AL WV SD NE ME IN OR GA NC ND KY WA KS
9 Antipsychotic Medications Moderate To Severe Pain Pneumococcal Vaccine Urinary Tract Infections High-Risk Pressure Ulcers Top 3 Areas for Improvement Based on Composite Scores from Q1, 2017 (JAN-MAR 2017) Incontinence ADL Decline Weight Loss Seasonal Flu Vaccine Falls With Injury Depression Indwelling Catheter Physical Restraints 10 5 7 2 16 17 14 13 8 13 8 KY Statewide (293 as of AUG 2017) 26 41 39 31 27 36 52 61 66 Collab I&II (224 as of AUG 2017) 160 173 181 194 218 224
10 CASPER Report: Facility
11 CASPER Report: Resident Level
Calculator Tool
Calculator Tool Sample #1
Exclusions Some Quality Measures have diagnoses that exclude the resident from triggering on your Casper/composite reports: Antipsychotic Med use with dementia residents: Schizophrenia, Tourette s syndrome, Huntington s disease Catheter Use: neurogenic bladder and obstructive uropathy (need MD order) Flu and Pneumonia Vaccinations are impacting your scores: document the immunizations given at your facility and the ones that are given outside your facility (Walgreens, Physician office) 14
Weight Loss Exclusions Weight Loss: Physician Prescribed Weight Loss Regimen 1. calorie restricted diet 2. Diuretics 3. end of life 4. palliative care 5. diagnosis that usually causes weight loss Be sure to have the physician write an order that states weight loss is expected Example Mrs. Jones is on a diuretic, weight loss is expected
Incontinence: Effects Interferes with activities Embarrasses resident Increases feelings of dependency Increases risk of long-term institutionalization Increases risk of skin breakdown/rashes Increases risk of UTI Increases risk of falls/injuries
Incontinence: Definitions Always Continent: no episodes of incontinence Occasionally Incontinent: less than seven episodes of incontinence Frequent Incontinence: seven or more episodes of urinary incontinence; at least one episode of continent voiding Always Incontinent: no episodes of continent voiding Not Rated: catheter (indwelling, condom), urinary ostomy or no urine output for entire seven days
Restorative Programs/Therapy Possible interventions when assessing incontinence: Medication review Toileting programs Involving therapy History review
Tips for Documentation to Support Incontinence Three-day voiding diaries Toileting programs Continuous education
Low Risk Residents who lose B/B control Lo-Risk residents who lose B/B control: Review your Resident level report to identify if the resident is low risk or high risk 1. Severe Cognitive Impairment= 7 or lower BIM score or 99- Cannot complete BIM interview 2. Total Dependence in Bed Mobility 3. Total Dependence in Transfers 4. Total dependence in locomotion 5. comatose or use of catheter or ostomy
Low Risk Bowl Bladder Exclusion
Total Dependence/ Incontinence
BIM Score/ Incontinence
ADLs: Definition Measures what the resident actually did, not what they are capable of doing.
ADLs: Steps for Assessment Review documentation in medical record for seven-day look-back period Talk with direct care staff from each shift Review records, interview staff, observe resident Ask probing questions from general to specific
Late Loss ADLs
MDS ADL Coding Definitions Independent: no help or staff oversight at any time Supervision: oversight, encouragement or cueing is needed Limited Assistance: resident highly involved in activity; staff provides guided maneuvering of limbs or nonweight-bearing assistance Extensive Assistance: resident involved in activity; staff provides weight-bearing support Total Dependence: full staff performance; resident not involved in activity EVERY time during 7 day period
ADL Scoring Independent 0 Score No talk No Touch Supervision 1 Score Talk No Touch Limited Assistance 2 Score Touch No Lift Extensive Assistance 3 Score Touch with Lift Push Total Assistance 4 Score Total Assist Download ADL Scoring Sheet at www.atomalliance.org/lsscc
Rule of Three When an activity occurs three times at any one given level, code that level. When an activity occurs three times at multiple levels, code most dependent.
Rule of Three: Exceptions Total dependence activity must occur at this level every time during observation period Activity did not occur activity must not have occurred at all during observation period
ADL: Quality Measure (QM) Calculation Numerator Residents who met the definition of increased need for help with late loss ADLs Denominator All residents with a selected target and prior assessment except those with exclusions
ADL: Exclusions All four late-loss ADLs items indicate total dependence on prior assessment Three late-loss ADLs indicate total dependence AND the fourth indicates extensive assistance Resident is comatose Life expectancy less than six months Hospice care Resident not in numerator AND one of the four ADLs was dashed in prior or target assessment
Correcting ADL Coding Review ADL coding for seven-day look-back If entry is coded incorrectly, follow up by interviewing CNA regarding resident If determined that there is a discrepancy in coding, change code to the correct one and enter a progress note
Check your Resident Level reports and discuss
Leading and Sustaining Systemic Change Collaborative (LSSCC) II: Creating a Culture of Safety
Collaborative II Participants by State April 2016 Sept. 2018 402 216 169 152 1190+ 251
New Regulations
New Regulations Phase 1: November 28, 2016 Facilities should be able to demonstrate compliance with Phase 1 requirements including updated policies, procedures, training needs, staff knowledge, resident information, updates and more. Phase 2: November 28, 2017 Quality Assurance and Performance Improvement QAPI Plan Infection Control and Antibiotic Stewardship Principles and Practices Phase 3: November 28, 2019 Provide proof that facility has performed at least one performance improvement project following all the elements of the new and revised regulations.
QAPI Plan CMS mandate for QAPI PIP by November 28, 2017 Provide proof of implementation plan for QAPI to surveyors
Infection Prevention and Antibiotic Stewardship Changes finalized in the new ruling include: Updating the facility s infection prevention and control program Implementing the facility s antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Managing Medication to Improve Lives and Composite Scores Cindy Todd Quality Improvement Advisor
Top 3 Areas for Improvement: Based on Composite Scores from Q3, 2016 (JUL-SEP) Antipsychotic Medications Incontinence ADL Decline Weight Loss Moderate To Severe Pain Pneumococcal Vaccine Urinary Tract Infections Seasonal Flu Vaccine High-Risk Pressure Ulcers Falls With Injury Depression Indwelling Catheter Physical Restraints 10 6 6 2 19 14 15 11 13 10 19 18 25 33 30 41 39 37 64 63 112 138 144 178 216 228 KY Statewide (291 as of JAN 2017) Collab I&II (173 as of JAN 2017) # of nursing homes with these clinical areas ranking in Top 3 missed opportunities 44
Medications: Help or Harm? Can you answer these 5 Whys? Why is my patient taking this medication? Why is my patient taking this medication? Why is my patient taking this medication? Why is my patient taking this medication? Why is my patient taking this medication? 45
Medications: Help or Harm? Polypharmacy and inappropriate medication use in elderly is known to contribute to : Adverse drug reactions Falls Cognitive impairment Non-compliance Hospitalization Death Haijer ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatric Pharmacotherapy. 2007. 46
Medications: Help or Harm? Does the benefit out weigh the harm? Diagnosis still pertinent? What are the side effects? Are the side effects causing bigger problems? Things to consider: Necessity? Can I stop the medication? Can I reduce the medication? 47
Medications: Help or Harm? Barriers to Change Reluctance to investigate Reluctance to change Time element Family concerns Patient concerns 48
Costs $$$$ Time Medications: Help or Harm? Quality of Life Composite Scores 49
Medications: Help or Harm? References deprescribing.org https://psnet.ahrq.gov/primers/primer/23/medication-errors http://journals.plos.org/plosone/article?id+10.1371/journal.p one atomalliance.org 50
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Contact Information Scott Gibson Quality Improvement Advisor scott.gibson@area-g.hcqis.org 502-680-2669 This material was prepared by atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama under a contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services. Content does not necessarily reflect CMS policy. 16.SS.KY.C2.06.002