March 4, 2014 Minnesota Department of Human Services Nursing Facility Rates and Policy Division Instruction Manual Quality Improvement Incentive Payment (QIIP) Program For the Rate Year Beginning October 1, 2015 1 From DHS on 3 4 14 Check NF Provider Portal for updated versions
Legislation enacted in 2013 creating the QIIP Program reads: Minnesota Statutes, Section 256B.441, Subd. 46c. Quality improvement incentive system beginning October 1, 2015. The commissioner shall develop a quality improvement incentive program in consultation with stakeholders. The annual funding pool available for quality improvement incentive payments shall be equal to 0.8 percent of all operating payments, not including any rate components resulting from equitable cost-sharing for publicly owned nursing facility program participation under subdivision 55a, critical access nursing facility program participation under subdivision 63, or performance-based incentive payment program participation under section 256B.434, subdivision 4, paragraph (d). Beginning October 1, 2015, annual rate adjustments provided under this subdivision shall be effective for one year, starting October 1 and ending the following September 30. The 2013 Statutes are available on line at the following web address: http://www.revisor.mn.gov/statutes This QIIP Instruction Manual has been prepared to assist Nursing Facilities in the Minnesota Medical Assistance Program in selecting a topic for the QIIP program for which they will undertake quality improvement activities. BACKGROUND The QIIP program is intended to recognize quality improvement and all MA certified nursing facilities will have the opportunity to receive financial rewards for improving their quality. Annual funding for QIIP is equal to 0.8% of the statewide average operating rate. Facilities may earn an incentive payment up to $3.50 per day for one year beginning October 1, 2015. To participate in the program, nursing facilities (NFs) will select a topic (quality measure) for which they plan to undertake quality improvement activities from their Minnesota Quality Indicators (MNQIs) or Quality of Life (QOL) domains. Nursing facilities will report the quality measure selected through the provider portal no later than March 31, 2014. Nursing facilities are encouraged to select topics in which they are performing relatively poorly and where a relatively large portion of residents are affected. DHS will calculate the QIIP based on the amount of improvement achieved between baseline and March 31, 2015 on the selected quality measure. The QIIP will equal the amount of improvement as a proportion of the established goal multiplied by $3.50. See the attached concept paper labeled as Appendix A for a more detailed description of the development of QIIP and other Minnesota nursing facility pay for performance strategies. 2 From DHS on 3 4 14 Check NF Provider Portal for updated versions
QIIP Design The design of the QIIP Program specifies that a new cycle of activity will begin annually, and will go for 33 months. The second cycle will overlap with the first cycle, and the third cycle with overlap with both the first and second cycles. In each cycle, all nursing facilities will have the opportunity to select a topic to work on, to work on that topic for about one year and then, if they demonstrate improvement toward their goal, to receive a one year rate increase or Quality Improvement Incentive Payment (QIIP). QIIP Cycles 2014 2015 2016 2017 2018 CYCLE Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 1 S I I I I C R Q Q Q Q 2 S I I I I C R Q Q Q Q 3 S I I I I C R Q Q Q Q 4 S I I I I C R Q 5 S I I I (S = select topic; I = intervention period; C = calculation; R = rate notice; Q = QIIP) The model to be used for the QIIP Program will use a multistep process: 1. GOAL SELECTION: Due March 31, 2014 2. INTERVENTION: Beginning with the selection of the topic and going through March 31, 2015 3. CALCULATION: Between April 1 and August 14, 2015, using data ending March 31, 2015, DHS compares the most recent performance on the selected measure with baseline and applies the incentive payment formula 4. RATE NOTICE: DHS issues rate notices with QIIP included in rates on August 15, 2015 5. QIIP: Rates with QIIP included take effect on October 1, 2015, and remain in effect until September 30, 2016. 6. NEXT CYCLES: The second cycle of this process begins in January 2015, with QIIPs going into effect for the year October 1, 2016 through September 30, 2017. Each year, a new 33 month QIIP Program cycle will begin in January, overlapping the previous two cycles. 3 From DHS on 3 4 14 Check NF Provider Portal for updated versions
QUALITY MEASURES The first step of each annual QIIP cycle is to select a topic on which you will undertake quality improvement activities. You will make your selection from one of 26 MN risk-adjusted quality indicators (QIs) or one of 12 risk-adjusted Quality of Life (QOL) domain scores. Your quality scores for these measures may be obtained through the provider portal at https://nfportal.dhs.state.mn.us If you do not know your user name and password, please check first with your facility administrator. Each facility only has one user name and password. If your administrator does not know your login information, please ask your administrator to email bev.milotzky@state.mn.us to request login information. DHS will only release the login information to the facility administrator on record at the Department. The facility administrator may share the login information with facility staff at his/her discretion. After you are logged in to the provider portal you will be at your home page. Click on the MN Quality Indicators tab at the top of the page. The following view will appear. Note there are links to two documents that can assist you in understanding your quality indicators report. Click on instructions for reading the reports for a comprehensive review of the measures. Click here for definitions of the quality indicators and risk adjusters, a valuable resource which describes which MDS assessment items are used in calculating your score for each measure. The date range of October 1, 2012 through September 30, 2013 is the baseline period which will be used to establish your quality improvement targets. 4 From DHS on 3 4 14 Check NF Provider Portal for updated versions
5 From DHS on 3 4 14 Check NF Provider Portal for updated versions
Click on Resident Quality of Life Ratings at the top of the page at any time to access your QOL scores. It is important to note that the 2013 Risk-Adjusted Quality of Life Scores will be used to establish your quality improvement targets. Click on 2013 Risk- Adjusted Quality of Life Scores. This will bring up your Nursing Home Report Card Data. Scroll to page 2 for your Risk-Adjusted QOL results. It is important that you also review your observed QOL scores in developing your quality improvement strategy. Responses for each of the QOL survey questions are contained in the observed results report. 6 From DHS on 3 4 14 Check NF Provider Portal for updated versions
DHS has compiled your baseline data to be used for selection of your topic on which you will undertake quality improvement activities. In addition, to help you select the one topic to work on for this program, DHS has calculated the goal that will apply for possible topics so you can see the level of performance necessary to earn the maximum incentive payment. The goal is established by one of two methods: 1. The goal is an amount of improvement equal to one standard deviation (SD). For each of these measures, the mean (average) is determined for the data set. The standard deviation for the measure is then calculated. The standard deviation is a statistic that tells how tightly the results are clustered around the average. When the results are tightly bunched together around the average, the standard deviation is small. When the results are more widespread, the standard deviation becomes larger. 2. The goal is an amount of improvement equal to one standard deviation (SD) but at least to the 25 th percentile (or the 75 th percentile for QIs where a lower score is better). This test will only apply to those measures where the baseline score is among the lowest performing (25% of nursing homes) for each measure. Example 1: Frostbite Falls Care Center On the MN QI Prevalence of Physical Restraint, a measure where a lower score is better, the facility has a score of 19.783%, highest in the state. Perhaps this would be a good topic to address. One SD on this measure is 1.992 So the goal would be to reduce their score by 1.992, to 17.791 (which would still be well above the 99 th percentile). Except they must get to at least the 75 th percentile, so their goal is 0.790 (reducing prevalence by 96%). Example 2: Frostbite Falls Care Center Another MN QI that FF CC could select is Incidence of Worsening or Serious Bladder Incontinence, a measure where a lower score is better. The facility has a score of 30.016%, the 67 th percentile. One SD on this measure is 10.491 So the goal would be to reduce their score by 10.491, to 19.525 (the 29 th percentile and a reduction in incidence by 35%). Since this is better than the 75 th percentile, the 75 th percentile method does not apply. 7 From DHS on 3 4 14 Check NF Provider Portal for updated versions
GENERAL INSTRUCTIONS The deadline for submission of the Selected Quality Improvement Topic is 11:59 pm on March 31, 2014. A nursing facility that does not file a selection in a timely manner forfeits the opportunity to earn a quality improvement incentive payment. The Quality Improvement Topic must be selected and filed electronically via the Provider Portal. Login to the provider portal https://nfportal.dhs.state.mn.us and select the QIIP tab at the top of the page. On the QIIP home page you will find links to the Instruction Manual and your data. The baseline scores (risk-adjusted facility scores) and goals for each quality measure have been pre-filled. You can login and review the quality measure data, make a selection from the pull-down menu, save your selection and change your selection at any time. When you are finished deciding on your selection, you may click the Submit QIIP Choice button. This must be done by the deadline. Once you click the submit button, you will not be able to change your selection. 8 From DHS on 3 4 14 Check NF Provider Portal for updated versions
Questions regarding the completion of your selection which are not addressed in this manual should be directed to the following Department staff: Quality Measures Definitions Kimberly.class@state.mn.us 651-431-2274 Incentive Payment Calculations Valerie.cooke@state.mn.us 651-431-2263 9 From DHS on 3 4 14 Check NF Provider Portal for updated versions
If you need technical assistance navigating the web-based application, please contact: Gary C. Johnson gary.c.johnson@state.mn.us 651-431-2279 Administrator s Certification: This is a password protected site. The administrator has been provided a unique user name and password. The password can by changed by the administrator after the initial log in. The facility administrator is responsible for security of the password. If the administrator provides the password to a staff person or other outside designee, they are delegating the authority to those individuals to certify that the selection of the quality topic submitted is valid and approved by the administrator of the nursing facility. QIIP Data This QIIP Data links to a report that contains a number of data elements for your consideration when selecting your improvement topic. Each column heading is described below. Domain: Each of the risk-adjusted quality indicators and QOL questions are grouped by similar topics in domains. For the MN QIs, you are choosing only one indicator regardless of how many indicators there are in a domain. For QOL you are choosing a domain which is a composite of multiple questions within that domain. You can view your results by individual QOL questions using your observed results report. Individual QOL questions are not risk-adjusted. QOL scores are risk-adjusted at the domain level. Quality Indicator: DHS measures 26 quality indicators from nursing facility Minimum Data Set (MDS) assessments. Each of the QIs is labeled as Long Stay (LS) or Short Stay (SS). In calculating the QI scores, DHS counts a resident s cumulative days in the facility during a given episode. An episode stars with an admission and ends with a discharge return not anticipated, return anticipated but resident doesn t return, or death in the facility. If the resident s cumulative days in an episode is less than or equal to 100 days, they are included in the Short Stay QIs. If the resident s cumulative days are greater than or equal to 101 days, they are included in the Long Stay QI. A resident will either be in the SS or LS QIs and will NEVER be in both in any given QI report. In addition, the QIs are labeled as Incidence (I) or Prevalence QIs. Half are Prevalence QIs that trigger if residents have a condition at one point in time, and half are Incidence QIs that trigger if residents conditions get worse or better or stay at the worst or best level over the past 90 days. Information is taken from each resident s last assessment in a given quarter (compared to their assessment 90 days prior for incidence QIs), with items automatically pulled from the last full assessment if needed. You may have a N/A in this column. This is a missing QI meaning your facility did not have enough residents with the condition being measured to record a statistically valid rate. 10 From DHS on 3 4 14 Check NF Provider Portal for updated versions
Risk-adjusted Facility Rate Quality Indicator Rate: The QI rates are the percentage of residents with a condition (# of residents with a condition/# of total observed residents). Some residents are excluded from the QIs due to missing items or predisposing conditions. MN QI rates are statistically adjusted using resident characteristics that put them at particular risk for having the condition. Also, MN QI rates are averaged over four quarters. The rates presented in this worksheet are for the 4 quarters October 1, 2012 through September 30, 2013. Risk-adjusted Facility Quality of Life Rate: During the annual QOL survey, residents answer several questions relating to each of the 12 domains listed. DHS constructs an average score for each domain. The average domain score is then risk-adjusted to level the playing field among all providers, controlling for resident and facility characteristics that are generally not a result of provider performance. Risk adjustments use five resident-level variables age, gender, stay<45 days, Cognitive Performance Score and Activities of Daily Living score (ADL) and two facility-level variables located in the Twin Cities metropolitan area and percentage of short-stay residents. Standard Deviation: The value reported in this column is equal to one standard deviation. The standard deviation is a statistic that tells how tightly the results are clustered around the average. When the results are tightly bunched together around the average, the standard deviation is small. When the results are more widespread, the standard deviation becomes larger. The standard deviation indicates how much improvement is needed to earn the maximum incentive payment provided the 25 th or 75 th percentile test is achieved if applicable. Goal using Standard Deviation Method: This is the goal risk-adjusted facility rate (baseline risk-adjusted facility rate plus or minus one standard deviation depending if it is a positive or negative QI) you must achieve to earn the full incentive payment if the goal is established using the standard deviation method only. If your improvement meets or exceeds one standard deviation and the result is better than the poorest performing 25% of nursing homes in the state, this value will be your goal to earn the full incentive payment of $3.50 per day. For a negative QI, if your risk-adjusted facility rate minus one standard deviation would result in a value less than zero, <0.0% will be shown. For a positive QI or QOL score, if your risk-adjusted facility rate plus one standard deviation would result in a value greater than one hundred, >100.0% will be shown. If your goal risk adjusted rate is less than zero or greater than 100%, N/A will be shown in the goal column. If a topic where N/A is shown is selected, the maximum possible QIIP incentive payment will be less than $3.50. Goal using Percentiles Method: This is the goal you must meet if improving the topic from baseline plus one standard deviation does not result in a rate better than the poorest performing 25% of nursing homes in the state. If there is a N/A in this column, this means this test does not apply to you for that topic area as baseline plus one standard deviation is better than the poorest performing 25% of nursing homes in the state. 11 From DHS on 3 4 14 Check NF Provider Portal for updated versions
Your goal for full incentive payment: This is your target rate to achieve the full incentive payment of $3.50 per day according to which method (standard deviation or percentile) is applicable to your facility for that specific topic area. If a quality improvement topic where N/A is shown is selected, the maximum possible QIIP incentive payment will be less than $3.50. A N/A results indicates your baseline performance is already within one standard deviation of zero or 100%. If your baseline rate minus one standard deviation results in a value less than zero, or if your baseline rate plus one standard deviation is greater than 100%, it would not be possible to earn the maximum incentive payment. Save Current Work: You may save your topic choice and return and edit it any time prior to the submission deadline of 11:59 pm on March 31, 2014. Submit QI Choice: Once you click the submit button, you will not be able to change your selection. Any work saved before the deadline but not yet submitted on the deadline will be automatically submitted. 12 From DHS on 3 4 14 Check NF Provider Portal for updated versions