Quality Indicators: FY 2015 July 8, 2014 Kristen Smith, MHA, PT
Objectives Review upcoming IRF-PAI changes effective October 1, 2014 Discuss the new quality reporting items as part of the Medicare Quality Reporting Program (QRP) Provide clinical applications of the new pressure ulcer and influenza vaccination data requirements
Background IRF Quality Reporting Program (QRP) Affordable Care Act (ACA) Section 3004 Data collection began October 2012 Current Quality Measures New or Worsened Pressure Ulcers- IRF-PAI Catheter Associated Urinary Tract Infections- NHSN FY 14 Final Rule Finalized one measure impacting FY 16 payment Three additional quality measures impacting FY 17 payment
Current Quality Measures CAUTI Data collection began October 2012 Monthly data submission, encouraged to submit within 30 days after the end of the reporting month (due 4 ½ months after end of quarter) One-year delay of 2% penalty (originally to occur FY 2014) FY 2015 payment reductions for non-reporting Based on CY 2013 data submitted New or Worsened Pressure Ulcers Data collection began October 2012 Medicare and Medicare MCO patients Admission and discharge data entered on the IRF-PAI One-year delay of 2% penalty (originally to occur FY 2014) FY 2015 payment reductions for non-reporting Based on CY 2013 data submitted
IRF QRP: FY 15 Measures Influenza Vaccination: Personnel NHSN Database Data collection begins October 1, 2014 or when the vaccine becomes available (whichever occurs first) through March 31, 2015 Required data submission is once per vaccination season, due May 15 Non-compliance affects FY 16 payment determination Influenza Vaccination: Patients IRF-PAI Data collection begins October 1, 2014 or when the vaccine becomes available (whichever occurs first) through March 31, 2015 Medicare and Medicare MCO patients Non-compliance effects FY 17 payment determination All Cause Unplanned Re-admissions Data collection begins January 2015 Re-admitted to STACH or LTCH within 30 days post discharge from an IRF Claims based measure Not used to determine compliance with the IRF QRP
IRF QRP: FY 15 Measures Adoption of the NQF Endorsed Pressure Ulcer Measure Percent of Residents/Patients with Pressure Ulcers that are New or Worsened (NQF #0678) Revisions to the IRF-PAI Effective October 1, 2014 Non-compliance effects FY 17 payment determination
IRF-PAI Revisions: Quality Indicator Section http://www.cms.gov/medicare/medicare-fee-for Service- Payment/InpatientRehabFacPPS/Downloads/IRF-PAI- FINAL-for-Use-Oct2014-updated-v4.pdf Clinical Applications: Flu Vaccination
Quality Indicators- Admission Assessment Unhealed Pressure Ulcer(s)- Admission *M0210.Does this patient have one or more unhealed pressure ulcer(s) stage I or higher at admission? No, skip to question I0900 on admission assessment Yes, continue to question M0300A on admission assessment M0300.- Current number of unhealed pressure ulcer(s) at each stageadmission: M0300A1. Stage I *M0300B1. Stage II *M0300C1. Stage III *M0300D1. Stage IV M0300E1. Unstageable due to non-removable dressing/device M0300F1. Unstageable due to slough and/or eschar M0300G1. Unstageable with suspected deep tissue injury * Mandatory reporting items
Quality Indicators- Admission Assessment I0900.- Pressure Ulcer Risk Conditions- Admission Indicate below if the patient has any of the following pressure ulcer risk conditions: *I0900A. Peripheral Vascular Disease (PVD) *I0900B. Peripheral Artery Disease (PAD) *I2900A. Diabetes Mellitus (DM) If I2900A.= No, skip to I2900B-D I2900B. Diabetic Retinopathy I2900C. Diabetic Nephropathy I2900D. Diabetic Neuropathy * Mandatory reporting items
Quality Indicators- Discharge Assessment *M0210.Does this patient have one or more unhealed pressure ulcer(s) stage I or higher at discharge? No, skip to question M0900A on discharge assessment Yes, continue to question M0300A on discharge assessment M0300.- Current number of unhealed pressure ulcer(s) at each stage- Discharge M0300A1. Stage I Mo300A2. Stage I present on admission and remained Stage I M0300A3. Stage I NOT present on admission *M0300B1. Stage II M0300B2. Stage II present on admission and remained Stage II Mo300B3. Stage II present on admission as unstageable, staged as a Stage II, remained Stage II at discharge *M0300B4. Stage II NOT present on admission or were at a lesser stage at admission and worsened to a Stage II * Mandatory reporting items
Quality Indicators- Discharge Assessment M0300.- Current number of unhealed pressure ulcer(s) at each stage- discharge: *M0300C1. Stage III Mo300C2. Stage III present on admission and remained stage III M0300C3. Stage III present on admission as unstageable, staged as a stage III, remained stage III at discharge *M0300C4. Stage III NOT present on admission or were at a lesser stage at admission and worsened to a Stage III or were unstageable at admission and initially staged at a lesser stage and progressed to a Stage III by the time of discharge * Mandatory reporting items
Quality Indicators- Discharge Assessment M0300. (Cont.)- Current number of unhealed pressure ulcer(s) at each stage- discharge: *M0300D1. Stage IV M0300D2. Stage IV present on admission and remained stage IV Mo300D3. Stage IV present on admission as unstageable, staged as a Stage IV, remained Stage IV at discharge *M0300D4. Stage IV NOT present on admission or were at a lesser stage at admission and worsened to a Stage IV or were unstageable at admission and initially staged at a lesser stage and progressed to a Stage IV by the time of discharge * Mandatory reporting items
Quality Indicators- Discharge Assessment M0300. (Cont.)- Current number of unhealed pressure ulcer(s) at each stage- discharge: M0300E1. Unstageable due to non-removable dressing or device Mo300E2. Present on admission as unstageable due to nonremovable dressing or device and remained unstageable due to non-removable dressing or device M0300E3. Present on admission as a stageable pressure ulcer and then became unstageable due to a non-removable dressing or device and remained unstageable due to non-removable dressing or device at time of discharge
Quality Indicators- Discharge Assessment M0300. (Cont.)- Current number of unhealed pressure ulcer(s) at each stage- discharge: M0300F1. Unstageable due to slough and/or eschar M0300F2. Present on admission as unstageable due to slough and/or eschar and remained unstageable due to slough and/or eschar M0300F3. Present on admission as a stageable pressure ulcer and then became unstageable due to slough and/or eschar and remained unstageable due to slough and/or eschar at time of discharge
Quality Indicators- Discharge Assessment M0300.- Current number of unhealed pressure ulcer(s) at each stage- discharge: M0300G1. Unstageable with suspected deep tissue injury Mo300G2. Present on admission as unstageable with suspected deep tissue injury and remained unstageable with suspected deep tissue injury M0900.- Healed pressure ulcer(s)- discharge Indicate the number of pressure ulcers present on admission that have completely closed (resurfaced with epithelium) upon discharge M0900A. Stage I M0900B. Stage II M0900C. Stage III M0900D. Stage IV
Pressure Ulcers: Clinical Considerations Identification Rule out other types of wounds Staging Unstageable on admission Healed at discharge Timing Assessment reference periods Voluntary Reporting
Pressure Ulcers: Identification CMS Pressure Ulcer Definition A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Adapted from the NPUAP 2007 definition of a pressure ulcer
Identification: IAD vs. Pressure Ulcer? Location Etiology Shape Pressure Ulcers Bony prominence Pressure or combination of pressure with shear/friction Round or oval shaped if shear is involved Incontinence-Associated Dermatitis Perineal, inner thighs, buttocks Bladder and/or bowel incontinence Irregular and widespread Borders Distinct Indistinct
Identification: Diabetic Ulcer vs. Pressure Ulcer? Location Etiology Shape Borders History & Assessment Pressure Ulcer Bony prominence Immobility Round or oval if shear is involved Distinct Prolonged immobility, location on heel due to pressure Diabetic Foot: load bearing surfaces Neuropathy, vascular compromise Round and regular Distinct Review past medical history. Assess both feet. Assess foot deformities, pulse presence, and swelling.
Clinical Scenarios: Staging Scenario A patient has two Stage II pressure ulcers on the left heel, present on admission. During the patient s stay, the two ulcers merge. Do you still record these as two Stage II pressure ulcers or one Stage II pressure ulcer? Staging Pressure ulcers that merge count as one pressure ulcer
Clinical Scenarios: Staging Scenario A patient is admitted with a stage III pressure ulcer that heals during their rehabilitation stay but re-opens, prior to discharge, as a stage II pressure ulcer Staging Admission assessment coded as stage III, present on admission Discharge assessment coded as stage III, present on admission
Clinical Scenarios: Timing Scenario A patient is admitted with a Stage II pressure ulcer identified on the day of admission. On day three, the wound nurse assesses the patient and the pressure ulcer has progressed to a full thickness wound, Stage III. Timing- Assessment Reference Period Admission assessment coded as a Stage II, present on admission Discharge assessment coded as a Stage III under M0300C4. B (at a lesser stage at admission and worsened to a Stage 3 during the IRF stay).
Clinical Scenarios: Timing Scenario Patient unexpectedly transfers to acute care emergently and does not return with three days. There was no skin assessment conducted by the wound coordinator within the three-day discharge assessment reference period. Patient had a Stage III at admission and a Stage III on the weekly wound care nurse assessment. Timing-Documentation Utilize RN daily assessment of skin Leave blank and record notes on why the assessment was not conducted
Pressure Ulcers: Clinical Processes Identification (present on admission) Skin assessments Timing Roles/Responsibilities Supporting documentation Prevention Risk assessment (Braden; predictive modeling) Interventions Surfaces Nutrition Turning teams Mobility Patient/Family education Intervention Wound Healing
Reporting: Pressure Ulcers Documentation- Risk Factors Consistent with co-morbidity section Documentation- Skin Source and location of information Structure of the questions Validation Mirror the IRF-PAI questions IRF-PAI and medical record
Quality Indicators- Influenza Vaccination O0250. Influenza Vaccine- Discharge *O0250A. Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season? No- skip to O0250C Yes-continue to O0250B *B. Date influenza vaccine received MM/DD/YYYY *C. If influenza vaccine not received, state reason: Patient not in facility during flu season Received outside of this facility Not eligible - medical contraindication Offered and declined Not offered Inability to obtain influenza vaccine due to a declared shortage None of the above * Mandatory reporting items
Clinical Applications: Influenza Vaccination Data Collection Process Clinical liaisons during pre-admission assessment Nurse report upon admission Documentation Location of information Structure of the questions Mirror the IRF-PAI questions Clinical Standards of Care: Acute care admissions Clinical decision making Availability of information Standards of clinical practice Competencies
Reporting: Influenza Vaccination Data entry/reporting Timelines Flu vaccination season Accuracy Validation Supporting documentation
IRF QRP: What Lies Ahead FY 15 Proposed Rule Two new quality measures for FY15 NHSN Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF#1716) NHSN Clostridium difficile infection (CDI) outcome measure (NQF#1717) Data collection through the CDC NHSN Database Data collection to begin January 2015 Non-compliance impacts FY 17 payment determination Additional proposed quality measures for future years Falls with major injury (NQF#0674) Self-reported moderate to severe pain (NQF#0676) Functional outcome measures* Change in mobility score Change in self-care score Discharge mobility score Discharge self-care score Draft specifications available here: http://www.cms.gov/medicare/quality-initiatives- Patient-Assessment-Instruments/IRF-Quality-Reporting/Downloads/Draft- Specifications-for-the-Functional-Status-Quality-Measures-for-Inpatient-Rehabilitation- Facilities-Version-2.pdf * Not NQF endorsed/under development
IRF QRP: What Lies Ahead FY 15 Proposed Rule Data Completion Threshold 95% of the IRF-PAIs submitted must have 100% of the mandatory items completed 100% for quality measure data submitted through the CDC s NHSN Data Validation Process Random sample of 260 providers Five IRF-PAI assessments Request submission of five Medicare patient charts that correspond with the randomly selected IRF-PAI assessments Comparison of patient charts with the quality data submitted to CMS Failure to meet a 75% data accuracy threshold results in 2% payment reduction
IRF QRP: What Lies Ahead Notification of non-compliance Reconsideration and Appeals Procedures IMPACT ACT of 2014 Value-based purchasing/post-acute bundling Public Reporting Hospital Compare
Resources CMS Training http://www.cms.gov/medicare/quality-initiatives- Patient-Assessment-Instruments/IRF-Quality- Reporting/Training.html CDC Resources http://www.cdc.gov/nhsn/cms Operational guidance for inpatient rehabilitation facilities Hospital Compare http://www.medicare.gov/hospitalcompare/search.html
Questions? Kristen Smith ksmith@flemingaod.com Next call: The New IRF-PAI: Wednesday, September 9th