CASPER Reports By Cindy Skogen, RN Oasis Education Coordinator at MDH Contact #: 651-201-4314 E-mail: Health.OASIS@state.mn.us Source: Center for Medicare/Medicaid Services (CMS). Objectives: Following the training the participant will: Understand what the Casper reports are; Learn how to read the Casper reports; Use the reports for quality improvement through adherence to best practice measures; and Understand the importance of educating staff on best practices. Slide 2 What is Casper? Certification And Survey Provider Enhanced Reports Slide 3 1
Quality Measures 3 types of Home Health Quality Measures based on OASIS-C data: 1. Outcome measures 2. Process measures 3. Potentially avoidable events Slide 4 Outcome Measures Report change (or lack of change) in pt. condition during episode of care. Types: 1.Utilization outcome (prefer lower values here.) 2.End result outcomes (prefer higher values here.) Slide 5 OASIS-based Outcome Measures END-RESULT OUTCOMES a Clinical Status Improvement: Improvement in Anxiety Level Improvement in Behavior Problem Frequency Improvement in Bowel Incontinence Improvement in Confusion Frequency Improvement in Dyspnea (b) Improvement in Pain interfering with Activity (b) Improvement in Speech and Language Improvement in Status of Surgical Wounds (b) Improvement in Urinary Incontinence Improvement in Urinary Tract Infection (b) These outcomes are publicly reported on Home Health Compare. Slide 6 2
OASIS-based Outcome Measures END-RESULT OUTCOMES (cont.) Clinical Status Stabilization: Stabilization in Anxiety Level Stabilization in Cognitive Functioning Stabilization in Speech and Language Slide 7 OASIS-based Outcome Measures END-RESULT OUTCOMES (cont.) Functional Status Improvement: Improvement in Ambulation/Locomotion (b) Improvement in Bathing b Improvement in Bed Transferring (b) Improvement in Dressing Lower Body Improvement in Dressing Upper Body Improvement in Eating Improvement in Grooming Improvement in Mgmt. of Oral Medication s (b) Improvement in Light Meal Preparation Improvement in Phone Use Improvement in Toileting Hygiene Improvement in Toilet Transferring (b) These outcomes are publicly reported on Home Health Compare. Slide 8 OASIS-based Outcome Measures END-RESULT OUTCOMES (cont.) Functional Status Stabilization: Stabilization in Bathing Stabilization in Bed Transferring Stabilization in Grooming Stabilization in Light Meal Preparation Stabilization in Management of Oral Medications Stabilization in Phone Use Stabilization in Toileting Hygiene Stabilization in Toilet Transferring Slide 9 3
OASIS-Based Outcome Measures (cont.) UTILIZATION OUTCOMES Acute Care Hospitalization (b) Discharged to Community Emergency Department Use without Hospitalization (b) Emergency Department Use with Hospitalization (b) These outcomes are publicly reported on Home Health Compare. Slide 10 Risk Adjustment Statistically accounts for differences in one agency's pts. vs. the reference sample or pts. from a prior time period. Minimizes possibility that differences in outcomes between comparison groups are due to factors other than care provided by the agency. All outcome measures (except Emergency Department Use without Hospitalization) are risk adjusted. Slide 11 Why do we need Risk Adjustment? To track quality, (internally or across facilities), over time, by establishing a valid baseline. Necessary in outcomes studies (to ascertain effectiveness of specific health care treatments/interventions.) Helps providers quantify their patients illness burdens and predict resource needs/costs accordingly. Slide 12 4
Outcome Report Slide 13 Home Health Quality Measures -Outcomes Measure Title Measure Description OASIS C Item(s) Used Improvement in Grooming Stabilization in Grooming Improvement in Upper Body Dressing Improvement in Lower Body Dressing which patients improved in ability to groom self. which patients improved or stayed the same in ability to groom self. which patients improved in ability to dress upper body. which patients improved in ability to dress lower body. (M1BOO) Grooming (M1800) Grooming (M1810) Current Ability to Dress Upper Body (M1820) Current Ability to Dress Lower Body Page 1 of 7 Improvement in Bathing Stabilization in Bathing which the patient got better at bathing self. which the patient improved or stayed the same in the ability to bathe. (M1830) Bathing (M1830) Bathing Slide 14 Home Health Quality Measures -Outcomes Measure Title Measure Description OASIS C Item(s) Used which (M1840) Toilet Transferring Improvement in in Toilet patients improved in ability to get to and from and on and Transferring off the toilet. Page 2 of 7 Stabilization in Toilet Transferring which (M1840) Toilet Transferring patients improved or stayed the same in ability to get to and from and on and off the toilet. Improvement in Toileting Hygiene which patients improved in ability to manage toileting hygiene. (M1845) Toileting Hygiene Stabilization in Toileting Hygiene which patients improved or stayed the same in ability to manage toileting hygiene. (M1845) Toileting Hygiene Improvement in Bed Transferring which the patient improved in ability to get in and out of bed. (M1850) Transferring Slide 15 5
Home Health Quality Measures -Outcomes Page 3 of 7 Measure Title Measure Description OASIS C Item(s) Used Stabilization in Bed Transferring Improvement in Ambulation-Locomotion which the patient improved or stayed the same in ability to get in and out of bed. which the patient improved in ability to ambulate. (M1850) Transferring (M1860) Ambulation/Locomotion Improvement in Eating which the patient got better at feeding self. (M1870) Feeding or Eating Improvement in Light Meal Preparation which patients improved in ability to fix or reheat light meals or snacks. (M1880) Current Ability to Plan and Prepare Light Meals which Stabilization in Light Meal patients improved or stayed the same in ability to fix or Preparation reheat light meals or snacks. (M1880) Current Ability to Plan and Prepare Light Meals Slide 16 Home Health Quality Measures -Outcomes Page 4 of 7 Measure Title Measure Description OASIS C Item(s) Used Improvement in Phone which (M1890) Ability to Use Telephone Use the patient improved in ability to use the telephone. Stabilization in Phone which (M1890) Ability to Use Telephone Use the patient improved or stayed the same in ability to use the telephone. Improvement in which (M2020) Management of Oral Management of Oral the patient improved in ability to take their medicines Medications Medications correctly (by mouth). Stabilization in which (M2020) Management of Oral Management of Oral the patient improved or stayed the same in ability to take Medications Medications their medicines correctly (by mouth). Improvement in Dyspnea which the patient became less short of breath or dyspneic. (M1400) When is the patient dyspneic? Improvement in Pain Interfering with Activity which the patient's frequency of pain when moving around improved. (M1242) Frequency of Pain Interfering with Activity Slide 17 Home Health Quality Measures -Outcomes Page 5 of 7 Measure Title Measure Description OASIS C Item(s) Used Improvement in Speech (M1230) Speech and Oral (Verbal) Expression of Language and Language which patients improved in ability to speak clearly and be understood. Stabilization in Speech (M1230) Speech and Oral (Verbal) Expression of Language and Language which patients improved or stayed the same in ability to speak clearly and be understood. Improvement in Status of (M1340) Does this patient have a Surgical Wound? Surgical Wounds which the patient demonstrates an improvement in (M1342) Status of Most Problematic the condition of surgical wounds. (Observable) Surgical Wound Improvement in Urinary which the patient's urinary tract infection at (M1600) Urinary Tract Infection Tract Infection start/resumption of care was resolved before discharge. Improvement in Urinary (M1610) Urinary Incontinence or Urinary Catheter Presence: (M1615) When does Urinary Incontinence which the patient had less frequent urinary Incontinence occur? incontinence, or had a urinary catheter removed. Slide 18 6
Home Health Quality Measures -Outcomes Page 6 of 7 Measure Title Measure Description OASIS C Item(s) Used Improvement in Bowel Incontinence (M1620) Bowel Incontinence Frequency which patient's bowel control improves. Improvement in Confusion Frequency which patients are confused less often. (M1700) Cognitive Functioning Stabilization in Cognitive which patients get better or remain the same at Functioning understanding and remembering things. Improvement in Anxiety Level which the patient's anxiety became less frequent. Stabilization in Anxiety Level which the patient's anxiety became less frequent or stayed the same as at admission. Slide 19 Home Health Quality Measures -Outcomes Page 7 of 7 Measure Title Measure Description OASIS C Item(s) Used Improvement in Behavior (M1745) Frequency of Disruptive Behavior Symptoms Problem Frequency which patients have less behavior problems such as yelling, hitting or getting lost. Emergency Department which the patient needed urgent, unplanned (M0100) Reason for Assessment Use without medical care from a hospital emergency (M2300) Emergent Care Hospitalization department, without admission to hospital. Emergency Department which the patient needed urgent, unplanned (M0100) Reason for Assessment Use with Hospitalization medical care from a hospital emergency (M2300) Emergent Care department, immediately followed by hospital admission. Acute Care Hospitalization Percentage of home health episodes of care that ended with the patient being admitted to the hospital. (M0100) Reason for Assessment (M2410) Inpatient Facility Admission (M2430) Reason for Hospitalization Discharged to Community Percentage of home health episode after which patients remained at home. (M0100) Reason for Assessment (M2420) Discharge Disposition Slide 20 Agency Patient-Related Characteristics Report Slide 21 7
Instructions for Reading Agency-Patient Related Characteristics Report 1.Current Mean: Values here reflect agency patient-related characteristics averages (means) based on data collected during the actual current period indicated in the upper right corner. These values correspond to means or averages at SOC/ROC for all patients discharged (or transferred to a facility, or death at home) during the report period. Slide 22 Instructions for Reading Characteristics Report (cont.) 2. Prior Mean: Values here reflect agency patient-related characteristics averages (means) based on data collected during the prior period indicated in the upper right corner. These values correspond to means or averages at SOC/ROC for all patients discharged (or transferred to a facility, or death at home) during the report period. Slide 23 Instructions for Reading Characteristics Report (cont.) 3. Reference Mean: Values in this column reflect agency patient-related characteristics averages based on a nationally representative sample of patients from all agencies submitting OASIS data. Slide 24 8
Instructions for Reading Characteristics Report (cont.) 4. Significance: Indicates whether or not a statistically significant difference exists between the "current" and "reference" means or the current and prior means. Significance levels of.01 or lower are marked with a single asterisk (*) and levels of.001 or lower are marked with a double asterisk [**]. For the current and prior comparison, plus signs (+, ++) are used to indicate significance values. When a significance value is low (for example,.01), the results may be important because there is only a small probability that the difference is due to chance. We suggest you examine only differences where the significance value is 1% or less, as indicated by the asterisks. In fact, primarily because of the large reference sample, Agency Patient- Related Characteristics Reports may contain a substantial number of significant differences. When this occurs (as it frequently does, particularly for agencies with large numbers of patients), you should be attentive only to large differences between the means within the total group of asterisked (or plus sign) differences. Slide 25 Instructions for Reading Characteristics Report (cont.) 5. Agency Patient-Related Characteristics Attributes Measured Using Scales: Results for attributes measured using a health status scale (for example, a scale that takes on values between 0 and 5 as indicated by "0-5" after the attribute name) are expressed in terms of the average scale value for the attribute. The scale values are determined by the answer options provided for the specific data item in the OASIS. In general, higher scale values represent more impairment or a more severe condition than lower numeric values for the same measure. Slide 26 Instructions for Reading Characteristics Report (cont.) 6. Agency Patient-Related Characteristics Attributes Measured as Prevalences: Results for attributes measured not by scales, but by simply presence or absence, have a "%" next to them. The values in the "Current Mean," Prior Mean, and "Reference Mean" columns provide the percentage of patients with a given attribute. Slide 27 9
Oasis M items for Pt. Related Characteristic Report Agency Patient-Related Measures OASIS-C Item PATIENT HISTORY Demographics Age (years) M0066, M0030/ M0032 Gender: Female (%) M0069 Race: Black (%) M0140 Race: White (%) Race: Other (%) Payment Source Any Medicare (%) M0150 Any Medicaid (%) Any HMO (%) Medicare HMO (%) Other (%) Episode Start Episode timing: Early (%) M0110 Episode timing: Later (%) Episode timing: Unknown (%) Slide 28 Process Measures Evaluate rate of HHA s use of evidence-based process of care, as documented in the OASIS data (47 process measures). Focus on high-risk, high-volume problem-prone cares. Involves most home care pts. Evaluates measures of specific diagnoses and care plan/clinical interventions for pts. with specific symptoms (pain, depression). Not risk adjusted. Slide 29 How Should HHAs Use M Items to Generate the Process Quality Measure Reports? To evaluate elements of care under an HHA s control To promote the use of specific evidence-based care practices To evaluate the impact of use of best care practices on patient outcomes For use in agency-level performance improvement activities For use in public reporting to assist consumers in across-agency comparisons For potential use in future quality-based purchasing systems, and To promote improvements in patient care across settings. Slide 30 10
Process Quality Measure Report Timely Figure Care 2.1 Timely Initiation here of Care form Percentage PBQI of home health manual episodes Process Measure Title Measure Description OASIS C Item(s) Used (M0102) Date of Physician-ordered Start of of care in which the start or Care (M0104) Date of Referral resumption of care date was either (M0030) Start of Care Date on the physician-specified date or (M0032) Resumption of Care Date within 2 days of the referral date or (M0100) Reason for Assessment inpatient discharge date whichever (M1000) Inpatient Facility Discharge is later. (M1005) Inpatient Discharge Date Care Coordination Physician Notification Percentage of home health episodes (M2250) a. Patient-specific parameters for Guidelines Established of care in which the physicianordered plan of care, at notifying physician plan of care start/resumption of care, establishes parameters (limits) for notifying the physician of changes in patient status. Assessment Depression Assessment Percentage of home health episodes (M1730) Depression Screening Conducted1 of care in which patients were screened for depression (using a standardized depression screening tool) at start/resumption of care. Slide 31 Reading the Process Quality Measure Report Requested Current Period: 12-month time interval selected by the user for inclusion of current episodes of care. Requested Prior Period: Previous time interval requested by the user. Actual Current Period: Time interval represented by current episodes actually included in the report. (Same as the requested current period except when there are no episodes of care at the beginning or end of the requested period.) Actual Prior Period: Time interval immediately preceding the current period for which episodes of care contribute to this report. The prior period =twelve months unless no episodes of care at the beginning of the time interval requested. Number of Cases in Current Period: Total number of episodes of care from HHA contributing to the report for the specified time interval. Slide 32 Reading the Process Quality Measure Report (cont.) Number of Cases in Prior Period: Total number of episodes of care from the HHA contributing to the report for the actual prior period. Number of Cases in Reference Sample: Total number of episodes of care nationally contributing to the report for the specified time interval. Eligible Cases: Total number of episodes of care contributing to the specific process measure listed, after measure-specific exclusions. For each measure, number of eligible cases is shown for the home health agency and for the national reference sample. Slide 33 11
Reading the Process Quality Measure Report (cont.) Significance: Probability that observed difference between the HHA s current value on the process measure and the national reference value could be due to chance. Significance values below 10% are indicated with a single asterisk (*), while values less than 5% are indicated with a double asterisk (**). For the current value and the prior value comparison, plus signs are used to indicate significance values. Significance values below 10% are indicated with a single plus sign (+), while values less than 5% are indicated with a double plus sign (++). Percent (Number) of Cases where Process Followed: HHA and national percentages are represented graphically by "Current," Prior, and "National Reference" bars. The percentage is shown next to the bar for each measure and for the current agency value, the actual number of patients for whom the measure was achieved is displayed in parentheses. Slide 34 PBQI and OBQI: What is the difference? OBQI begins with measurement of agency-level clinical outcomes, then: 1. Selection of specific outcomes from the Outcome Reports; 2. Evaluation of care that produced these outcomes in your agency; 3. Development of a plan of action to improve care (or reinforce care where outcomes are superior to the reference), focusing on best care practices; and 4. Implementation/monitoring of the plan of action. Slide 36 12
PBQI/OBQI differences (cont.) PBQI starts from the measure of agency-level rates of compliance with best practices, then: 1. Selection of specific care processes from the Process Quality Measure Report; 2. Assessment of reasons for low rates of compliance with best practice care processes; 3. Development of a plan of action to improve rates of compliance with best practice care processes; and 4. Implementation of a plan of action/monitoring for improvement in rates of compliance with best practice care processes. Slide 37 Outcome example: Potentially Avoidable Event/Associated Process Measures Outcome/Potentially Avoidable Event Measure Improvement in Oral Medication Management Improvement in Pain Interfering with Activity. Acute Care Hospitalization Emergent Care for Hypo/Hyperglycemia Associated Process Quality Measure Drug Education on All Medications Provided to Patient/Caregiver During All Episodes of Care Pain Assessment Conducted Pain Interventions in Plan of Care Pain Interventions Implemented During All Episodes of Care Timely Initiation of Care Potential Medication Issues Identified and Timely Physician Contact During All Episodes of Care Drug Education on High Risk Medications Provided to Patient/Caregiver at Start of Episode Physician Notification Guidelines Established Multifactor Fall Risk Assessment Conducted for Patients 65 and Over Heart Failure Symptoms Addressed During All Episodes of Care Physician Notification Guidelines Established Increase in Number of Unhealed Pressure Ulcers Pressure Ulcer Risk Assessment Conducted Pressure Ulcer Prevention in Plan of Care Pressure Ulcer Prevention Implemented During All Episodes of Care Slide 38 Potentially Avoidable Event Measures Defined as a low-frequency negative or untoward event that potentially reflects a serious health problem or decline in health status for an individual patient. Important to include in HHA's overall quality measurement program (due to their serious and potentially preventable nature) as indicators of quality of care. HHA s need to investigate how/why the event occurred for pts. under their care, then attempt to lower the incidence of the untoward event to the extent possible. Slide 39 13
Definition of Potentially Avoidable Events: Measure Title Measure Description OASIS C Item(s) Used Emergent Care for Injury Caused Percentage of patients who need urgent, (M2300) Emergent Care by Fall unplanned medical care due to an injury (M2310) Reason for Emergent Care caused by fall. Emergent Care for Wound Infections, Deteriorating Wound Status Emergent Care for Improper Medication Administration, Medication Side Effects Emergent Care for Hypo/Hyperglycemia Percentage of home health episodes of (M2300) Emergent Care care during which the patient required (M2310) Reason for Emergent Care emergency medical treatment from a hospital emergency department related to a wound that is new, is worse, or has become infected. Percentage of home health episodes of (M2300) Emergent Care care during which the patient required (M2310) Reason for Emergent Care emergency medical treatment from a hospital emergency department related to improper medication administration or medication side effects. Percentage of home health episodes of (M2300) Emergent Care care during which the patient required (M2310) Reason for Emergent Care emergency medical treatment from a hospital emergency department related to hypo/hyperglycemia. Slide 40 Definition of Potentially Avoidable Events: Measure Title Measure Description OASIS C Item(s) Used Development of Urinary Tract Percentage of home health episodes of (M1600) Urinary Tract Infection Infection care during which patients developed a bladder or urinary tract infection. Increase in Number of Pressure Ulcers Percentage of home health episodes of (M1306) Unhealed Pressure Ulcer at care during which the patient had a larger Stage II or Higher number of pressure ulcers at discharge (M1308) Current Number of Unhealed than at start of care. Pressure Ulcers at Each Stage Substantial Decline in 3 or More Activities of Daily Living Substantial Decline in Management of Oral Medications Percentage of home health episodes of care during which the patient became substantially more dependent in at least three out of six activities of daily living. Percentage of home health episodes of care during which the patient's ability to take their medicines correctly (by mouth) got much worse. (M1800) Grooming (M1830) Bathing (M1B40) Toilet Transferring (M1845) Toileting Hygiene (M1850) Transferring (M1860) Ambulation/Locomotion (M2020) Management of Oral Medications Slide 41 Definition of Potentially Avoidable Events: Measure Title Measure Description OASIS C Item(s) Used Discharged to the Community Percentage of home health episodes of (M2100) Types and Sources of Assistance Needing Wound Care or care at the end of which the patient was (M2420) Discharge Disposition Medication Assistance ` discharged, with no assistance available, (M1324) Stage of Most Problematic Unhealed needing wound care or medication (Observable) Pressure Ulcer assistance. (M1342) Status of Most Problematic (Observable) Surgical Wound (M2020) Management of Oral Medications Percentage of home health episodes of Discharged to the Community care at the end of which the patient was Needing Toileting Assistance discharged, with no assistance available, needing toileting assistance. Percentage of home health episodes of Discharged to the Community with care at the end of which the patient was Behavioral Problems discharged, with no assistance available, demonstrating behavior problems. Percentage of home health episodes of Discharged to the Community with care at the end of which the patient was an Unhealed Stage II Pressure discharged with a stage II pressure ulcer Ulcer that has remained unhealed for 30 days or more. (M2100) Types and Sources of Assistance (M1B40) Toilet Transferring (M1845) Toileting Hygiene (M2420) Discharge Disposition (M2100) Types and Sources of Assistance (M2420) Discharge Disposition (M1740) Cognitive. behavioral. and psychiatric symptoms (M2420) Discharge Disposition (M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge (M0030) Start of Care Date (M0032) Resumption of Care Date (M0906) Discharge/Transfer/Death Date Slide 42 14
Potentially Avoidable Event Report Slide 43 (Graphical) Potentially Avoidable Event Report Instructions 1. Requested/Actual Current Period: This period is defined by two dates (Requested and Actual that encompass all episodes of care based on discharge/transfer date, which contributed to the Potentially Avoidable Event Report. Note: These are reported in calendar month increments only, and the time period is inclusive of the starting and ending months. Agencies may specify other timeframes for the report. Slide 44 (Graphical) Potentially Avoidable Event Report Instructions (cont.) 2. Number of Cases in Current and Prior Period: The number of patients in the current and prior reporting periods for whom data were analyzed to produce the Potentially Avoidable Event Report. If a patient was admitted and discharged more than once in the period, each episode of care is counted as a case. For agencies that place patients admitted to an inpatient facility on "hold" status (meaning that patients who are admitted to an inpatient facility for 24 hours or longer are not discharged from the agency), an episode of care ends with an admission to the inpatient facility. A new episode of care begins at resumption of care. Slide 45 15
(Graphical) Potentially Avoidable Event Report Instructions (cont.) 3. Number of Cases in Reference Sample: The total number of reference or comparison cases used to derive the reference incidence rates for the Potentially Avoidable Event Report. This is a national sample of home health episodes. Slide 46 (Graphical) Potentially Avoidable Event Report Instructions (cont.) The following terms pertain to each of the separate potentially avoidable events for which findings are presented (e.g., emergent care for falls, emergent care for wounds/infections). 4. Eligible Cases: Number of pts. for whom each specific potentially avoidable event could have occurred. Number varies from one specific potentially avoidable event to another, primarily due to the selective inclusion of patients determined to be "at risk" for specific avoidable events. Slide 47 (Graphical) Potentially Avoidable Event Report Instructions (cont.) 5. Agency Incidence: Number of potentially avoidable events that occurred in the agency sample divided by the number of eligible cases for that potentially avoidable event measure, expressed as a percentage. Slide 48 16
(Graphical) Potentially Avoidable Event Report Instructions (cont.) 6. Reference Incidence: Number of potentially avoidable events that occurred in the reference group divided by the number of eligible cases for the reference group, expressed as a percentage. Slide 49 Potentially Avoidable Event Report: Patient Listing Slide 50 (Tabular) Potentially Avoidable Event Report Instructions 1. Requested/Actual Current Period: This period is defined by two dates (Requested and Actual ) that encompass all episodes of care (based on discharge/ transfer date), which contributed to the Potentially Avoidable Event Report. Note: these are reported in calendar month increments only, and the time period is inclusive of the starting and ending months. HHA s may specify other time periods (e.g., one quarter). Slide 51 17
(Tabular) Potentially Avoidable Event Report Instructions (cont.) 2. Number of Cases in Current Period: Number of pts. in the current reporting period for whom data were analyzed to produce the Potentially Avoidable Event Report. If a patient was discharged more than once in the period, each episode of care is counted as a case. For agencies that place patients admitted to an inpatient facility on "hold" status (meaning that patients who are admitted to an inpatient facility for 24 hours or longer are not discharged from the agency), an episode of care ends with an admission to the inpatient facility. A new episode of care begins at resumption of care. Slide 52 (Tabular) Potentially Avoidable Event Report Instructions (cont.) 3. Number of Cases in Reference Sample: Total number of reference or comparison cases used to derive the reference incidence rates for the Potentially Avoidable Event Report. This is a national sample of home health care patients. Whenever reports are generated, the time span for selection of reference sample cases will match the time span for selection of agency cases (current period). Slide 53 (Tabular) Potentially Avoidable Event Report Instructions (cont.) The following terms pertain to each of the separate potentially avoidable events for which findings are presented (e.g., Emergent Care for Injury Caused by Falls, Substantial Decline in Management of Oral Medications). 4. Complete Data Cases: Number of patients for whom specific potentially avoidable event could have occurred. Number varies from one specific potentially avoidable event to another, primarily due to selective inclusion of patients "at risk" for a specific potentially avoidable event. Slide 54 18
(Tabular) Potentially Avoidable Event Report Instructions (cont.) 5. Number of Events: Number of times the indicated potentially avoidable event occurred among pts. for the time period covered by the report. Slide 55 (Tabular) Potentially Avoidable Event Report Instructions (cont.) 6. Agency Incidence: Number of potentially avoidable events that occurred in the agency sample divided by the number of complete data cases for that potentially avoidable event measure, expressed as a percentage. 7. Reference Incidence: Number of potentially avoidable events that occurred in the reference group divided by the number of complete data cases for the reference group, expressed as a percentage. Slide 56 (Tabular) Potentially Avoidable Event Report Instructions (cont.) 8. Patient ID, Name, Gender, Birth Date, SOC/ROC, DC/Transfer: The (agency-defined) identification numbers of all patients for whom the potentially avoidable event occurred in the agency are enumerated, along with name, gender, date of birth, the start of care or resumption of care (SOC/ROC) date and discharge or transfer date (DC/Transfer) for each such patient. Patients discharged to an inpatient facility may contribute to a specific potentially avoidable event count or incidence rate. Patient-specific information is enumerated so that agency staff can investigate circumstances associated with the potentially avoidable event for individual patients of their choosing. Slide 57 19
Potentially Avoidable Events chart Outcome/Potentially Avoidable Event Measure Emergent Care for Injury Caused by Fall Emergent Care for Wound Infections, Deteriorating Wound Status Associated Process Quality Measure (M2300) Emergent Care (M2310) Reason for Emergent Care (M2300) Emergent Care (M2310) Reason for Emergent Care Emergent Care for Improper Medication Administration, Medication Side Effects Emergent care for Hypo/Hyperglycemia Development of Urinary Tract Infection Increase in Number of Pressure Ulcers (M2300) Emergent Care (M2310) Reason for Emergent Care (M2300) Emergent Care (M2310) Reason for Emergent Care (M1600) Urinary Tract Infection (M1306) Unhealed Pressure Ulcer at Stage II or Higher (M1308) Current Number of Unhealed Pressure Ulcers at Each Stage Slide 58 Potentially Avoidable Events chart (cont.) Outcome/Potentially Avoidable Event Measure Substantial Decline in 3 or more Activities of Daily Living Substantial Decline in Management of Oral Medications Discharged to the Community Needing Wound Care or Medication Assistance Associated Process Quality Measure (M1800) Grooming (M1830) Bathing (M1840) Toilet Transferring (M1845) Toileting Hygiene (M1850) Transferring (M1860) Ambulation/Locomotion (M1870) Eating (M2020) Management of Oral Medications (M2100) Types and Sources of Assistance (M2420) Discharge Disposition (M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer (M1342) Status of Most Problematic (Observable) Surgical Wound (M2020) Management of Oral Medications Slide 59 Potentially Avoidable Events chart (cont.) Outcome/Potentially Avoidable Event Measure Discharged to the Community Needing Toileting Assistance Discharged to the Community with Behavioral Problems Discharged to the Community with an Unhealed Stage II Pressure Ulcer Associated Process Quality Measure (M2100) Types and Sources of Assistance (M1840) Toilet Transferring (M1845) Toileting Hygiene (M2420) Discharge Disposition (M2100) Types and Sources of Assistance (M2420) Discharge Disposition (M1740) Cognitive, behavioral, and psychiatric symptoms (M2420) Discharge Disposition (M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge (M0030) Start of Care Date (M0032) Resumption of Care Date (M0906) Discharge/Transfer/Death Date Slide 60 20
Process Measures Slide 61 Quality Measures: Logistic Regression Models For Risk Adjustment Started 1/1/10. Used to predict outcome results for three utilization outcomes, 22 functional improvement outcomes, 11 functional stabilization outcomes, and 12 potentially avoidable events. Slide 62 Use of Risk Models in Risk-Adjusted Outcome Reports Used for HHA s outcome-based quality improvement (OBQI) Includes (for each outcome measure): 1. HHA s observed/actual outcome rate (number of patients who achieved a particular outcome, divided by the number of patients eligible for that outcome, for episode of care that ended during the previous 12 months.) 2. HHA s risk-adjusted national reference rate (calculated based on observed national outcome rate for the same time period as the agency observed outcome rate, adjusted to reflect case mix differences between the HHA s patients and home health patients nationally). Slide 63 21
Reading the Prediction Model Tables Each table contains: 1. Table Title: identifies the name of the outcome measure model presented. 2. Risk Factor Measured at SOC/ROC: lists risk factors included in the prediction model pertaining to SOC or ROC after inpatient stay. If applicable, number of values in the measurement scale for each risk factor is in parentheses. A 0 risk factor value indicates the absence of attributes and 1 denotes the presence of the attribute. Risk factors that pertain to health or functional status and defined using a scale that takes on more than two values are associated with greater impairment or severe illness. 3. Coefficient: considered significant at probability<0.05 due to the large developmental sample used to create the models, resulting in more stable models. Slide 64 Reading Prediction Model (cont.) 4. Odds Ratio: For a 0-1 risk factor, the likelihood of the outcome when the risk factor is present divided by the outcome likelihood when risk factor is absent. Indicates strength of relationship between a risk factor and the outcome measure. The larger or smaller an odds ratio is for an individual risk factor, the more influence the risk factor has on the outcome measure. 5. 95% CI: 95% confidence limits of the odds ratios in the previous column. Slide 65 Reading Prediction Model (cont.) 6. Number of Risk Factors: number of risk factors used in the logistic regression model for predicting outcome measures. 7. R2: squared correlation between predicted and observed values for all patients in the developmental (250,000 patients depending on pt. eligibility) or validation samples (1,000,000 for all models.) Pertains to both R2 and C- statistic. 8. C: C-statistic - area under the Receiver Operating Characteristic curve. Slide 66 22
Reading Prediction Model (cont.) 9. Hosmer-Lemeshow: used for low frequency outcomes (i.e., the potentially avoidable events) to assess quality of the prediction model. Divides the predicted values into 10 equal size groups and identifies the frequency of observed outcomes in each group with a Chi-Square test (tests hypothesis of an equal frequency across the 10 groups.) Slide 67 48 Table Titles included in the Risk Adjusted Prediction Model Report: TABLE 1: IMPROVEMENT IN AMBULATION / LOCOMOTION TABLE 2: IMPROVEMENT IN ANXIETY LEVEL TABLE 3: IMPROVEMENT IN BATHING TABLE 4: IMPROVEMENT IN BED TRANSFERRING TABLE 5: IMPROVEMENT IN BEHAVIOR PROBLEM FREQUENCY TABLE 6: IMPROVEMENT IN BOWEL INCONTINENCE TABLE 7: IMPROVEMENT IN CONFUSION FREQUENCY TABLE 8: IMPROVEMENT IN DYSPNEA TABLE 9: IMPROVEMENT IN EATING TABLE 10: IMPROVEMENT IN GROOMING TABLE 11: IMPROVEMENT IN LIGHT MEAL PREPARATION TABLE 12: IMPROVEMENT IN LOWER BODY DRESSING TABLE 13: IMPROVEMENT IN MANAGEMENT OF ORAL MEDICATIONS TABLE 14: IMPROVEMENT IN PAIN INTERFERING WITH ACTIVITYTABLE TABLE 15: IMPROVEMENT IN PHONE USE TABLE 16: IMPROVEMENT IN SPEECH / LANGUAGE Slide 68 48 Table Titles (cont.) TABLE 17: IMPROVEMENT IN STATUS OF SURGICAL WOUNDS TABLE 18: IMPROVEMENT IN TOILET TRANSFERRING TABLE 19: IMPROVEMENT IN TOILETING HYGIENE TABLE 20: IMPROVEMENT IN UPPER BODY DRESSING TABLE 21: IMPROVEMENT IN URINARY INCONTINENCE TABLE 22: IMPROVEMENT IN URINARY TRACT INFECTION TABLE 23: ACUTE CARE HOSPITALIZATION TABLE 24: DISCHARGED TO COMMUNITY TABLE 25: EMERGENCY ROOM USE WITH HOSPITALIZATION TABLE 26: STABILIZATION IN ANXIETY LEVEL TABLE 27: STABILIZATION IN BATHING TABLE 28: STABILIZATION IN BED TRANSFERRING TABLE 29: STABILIZATION IN COGNITION TABLE 30: STABILIZATION IN GROOMING TABLE 31: STABILIZATION IN LIGHT MEAL PREPARATION TABLE 32: STABILIZATION IN MANAGEMENT OF ORAL MEDICATIONS Slide 69 23
48 Table Titles (cont.) TABLE 33: STABILIZATION IN PHONE USE TABLE 34: STABILIZATION IN SPEECH / LANGUAGE TABLE 35: STABILIZATION IN TOILET TRANSFERRING TABLE 36: STABILIZATION IN TOILETING HYGIENE TABLE 37: DEVELOPMENT OF URINARY TRACT INFECTION TABLE 38: DISCHARGED TO COMMUNITY NEEDING TOILETING ASSISTANCE TABLE 39: DISCHARGED TO COMMUNITY NEEDING WOUND CARE OR MEDICATION ASSISTANCE TABLE 40: DISCHARGED TO COMMUNITY WITH UNHEALED STAGE II PRESSURE ULCER TABLE 41: DISCHARGED TO COMMUNITY WITH BEHAVIORAL PROBLEMS TABLE 42: EMERGENT CARE FOR HYPO/HYPERGLYCEMIA TABLE 43: EMERGENT CARE-IMPROPER MEDICATION ADMINISTRATION AND/OR SIDE EFFECTS TABLE 44: EMERGENT CARE FOR INJURY CAUSED BY FALL TABLE 45: EMERGENT CARE FOR WOUND INFECTION, DETERIORATING WOUND STATUS TABLE 46: INCREASE IN PRESSURE ULCERS TABLE 47: SUBSTANTIAL DECLINE IN 3 OR MORE ADLS TABLE 48: SUBSTANTIAL DECLINE IN MANAGEMENT OF ORAL MEDICATIONS Slide 70 Partial Sample of Risk Adjustment Prediction Model Table Table 22: Improvement in Urinary Tract Infection Risk Factor Measured at SOC/ROC¹,² Coefficient³ Odds ratio³ (95% CI) Acute Condition: IV Therapies -0.887 0.412 (0.342-0.496) Frequency of ADL /IADL Assistance: At least daily 0.253 b 1.288 (0.983-1.686) Frequency of ADL /IADL Assistance: Three or more times per week 0.445 1.561 (1.133-2.149) Frequency of ADL/IADL Assistance: One or two times per week 0.039b 1.362 (0.962-1.945) Frequency of ADL /IADL Assistance: Received less than weekly -0.014 c 0.982 (0.635-1532) Patient is male 0.155 1.168 (1.053-1.269) Home Care Diagnosis: Circulatory system diseases 0.139 1.149 (1.038-1.272) Number of Risk Factors: 26 Developmental Sample R² = 0.071 Validation Sample R² = 0.063 Developmental Sample C-statistic = 0.675 Validation Sample C-statistic = 0.660 1 SOC = Start of Care, ROC = Resumption of Care after inpatient stay. Risk factors values are based on SOC/ROC assessment values for the episode of care. 2 Most risk factors take on the values 0 and 1; 1 denotes the presence of the attribute and 0 denotes its absence. In virtually all cases, each response option for an OASIS item is a risk factor. In a small number of cases (e.g., number of pressure ulcers at Stage III), the actual number provided in the assessment is used. 3 Because all response option values for an OASIS item are included as risk factors in a model even if only one option value is statistically significant, the following superscripts are used to denote the statistical significance for each risk factor coefficient: Blank = significant at probability<.01 a = significant at.01<probability<.05 b = significant at.05<probability<.10 c = not significant, probability>.10 Slide 71 References MDH Website (contains rules/statutes, news/announcements for HHA s): http://www.health.state.mn.us/divs/fpc/profinro/licensure.html CMS internet-only manuals: http://www.cms.hhs.gov/manuals/iom/list.asp Conditions of Participation: http://www.accwss.gpo.gov/nara/cfr/waisidx_99/42cfr484_99.html Home Health Compare: http://www.medicare.gov/hhcompare/home.asp OBQI manual: http://www.cms.hhs.gov/homehealthqualityinits/16_hhqioasisobqi.asp#topof Page OBQM manual: http://www.cms.hhs.gov/homehealthqualityinits/18_hhqioasisobqm.asp#top OfPage PBQI/Process Measures: http://www.cms.gov/homehealthqualityinits/15_pbqiprocessmeasures.asp#top OfPage State by state comparison of measures: http://www.cms.hhs.gov/oasis/09b_hhareports.asp#topofpage Slide 72 24
Guidelines and Best Practices Home Health Best Practice Intervention Packages (QIO): http://www.homehealthquality.org/hh/hha/interventi onpackages/default.aspx Falls Prevention Best Practice Intervention Package: http://www.qualitynet.org/dcs/contentserver?cid+120 0602385264&pagename=Medqic%2FMQTools52FToolT emplate&c=mqtools Evidence-Based Practice Guidelines, University of Iowa, College of Nursing: http://www.ahrg.gov/clinic/cpgonline.htm Slide 73 Guidelines/Best Practices National Guideline Clearinghouse (NGC): http://www.guideline.gov/browse/guideline_i ndex.aspx VNSNY Geriatric Home Excellence: http://www.champ-program.org/ Slide 74 Questions? Contact information: Cindy Skogen, RN, BSN; OASIS Education Coordinator at MDH 651-201-4314 Rich Kooyer OASIS Automation Coordinator 651-201-3818 Health.oasis@state.mn.us 25