WHAT S IN THE STARS FOR YOUR FACILITY

WHAT S IN THE STARS FOR YOUR FACILITY LIBBY YOUSE, BS, LNHA LEADERSHIP COACH CRYSTAL PLANK, BSN, RN QIPMO CLINICAL EDUCATOR BACKGROUND December 18, 2008-5-Star Quality Rating System was added to the Nursing Home Compare website Onsite inspections Quality Measures Staffing Levels 1

ONSITE INSPECTIONS Nursing homes (NH) are compared to each other Higher star rating if they improve relative to other NHs WHY? WHY? WHY? The rule would also update performance and baseline periods for the 2021 value-based payment program and adjust the scoring methodology. The 2.4% market basket increase is slated to go into effect Oct. 1, the Patient Driven Payment Model (PDPM) a year later. The rate hike, mandated by the 2018 Bipartisan Budget Act, will infuse the industry with an additional $850 million. McKnights April 27, 2018 2

TECHNICAL DETAILS STAR RATINGS STAR RATING CALCULATIONS CMS creates the overall star rating for nursing homes from 3 parts: 1) Health inspections 2) Quality of resident care measures and 3) Staffing. star ratings for each part and for the overall rating range from 1 star to 5 stars, with more star indicating better quality. CMS assigns the overall star rating in these steps: Step 1: Start with the health inspections rating. Step 2: Add 1 star if the staffing rating is 4 or 5 stars and greater than the health inspections rating. Subtract 1 star if the staffing rating is 1 star. TECHNICAL DETAILS STAR RATINGS Step 3: Add 1 star if the quality of resident care rating is 5 stars; subtract 1 star if the quality of resident care measures rating is 1 star. Step 4: If the health inspections rating is 1 star, then the overall rating cannot be upgraded by more than 1 star based on the staffing and quality of resident care ratings. Step 5: If a nursing home is a special focus facility, the maximum overall rating is 3 stars. 3

4 CATEGORIES = OVERALL QUALITY STAFFING STARS 4

TWO STAFFING LEVELS = WEIGHT #1 RNs per resident per day #2 Total staffing hours for RNs, LPNs and CNAs per resident per day GOODBYE SURVEY FORM 671 (AT LEAST THE STAFFING PORTION!) In April CMS replaced the existing staffing measures posted on Nursing Home Compare and replaced them with PBJ data submitted for October 1 to December 31. Resident Census derived from MDS Assessments Case mix based on RUG-IV 5

STAFFING RATING IS COMBINATION OF TOTAL NURSE RATING COMBINATION OF RN THERAPY = X LPN CNA CALCULATE RN COVERAGE The MO average RN coverage per resident during that time was 27 minutes per resident per day MO Average for RN coverage = 27 minutes per resident per day One 8-hour shift = 480 minutes 480 27 minutes = 18 residents that one RN can take care of in an 8-hour shift to meet the MO state average THAT IS HOW TO GET 5 STAR UNDER RN STAFFING 6

LET S JUST SAY IT... *CMS KNOWS AND *YOU KNOW THERE IS CONSIDERABLE EVIDENCE OF A NURSING HOME STAFFING LEVELS AND RESIDENT QUALITY OF CARE CALCULATION RN hours: RNs (job code 7), RN director of nursing (job code 5) and nurses with administrative duties - this does include MDS coordinator if does not perform direct care functions (job code 6) LPN hours: include LPN (job code 9) and LPN with administrative duties (job code 8) Nurse aide hours: certified nurse aides (job code 10), aides in training (job code 11), and medication aides/technicians (job code 9) PER RESIDENT PER DAY Not included are: private duty, hospice staff, and feeding assistants 7

HOURS PER RESIDENT PER DAY (HRD) Total hours for each nursing discipline/resident census/14 days Each done separately and then added to together to calculate total nursing hours DOING THE MATH Hours adjusted: (hours reported hours expected) x hours national average Total Nurse Example: 3 reported 6 expected = ½ x 4.0309 = 2.0154 adjusted hours National Average Hours Per Resident Day Calculated: April 2018 Total Nurse: 3.2285 RN: 0.3804 8

DO THE MATH TO GET YOUR STAR RATING Staffing star = RN + total nursing staff RN 0.379 + total nursing staff 3.67 = 4.049 RN = 3 stars + 3 stars = 3 stars for staffing Technical User s Guide: http://www.cms.gov/medicare/provider- Enrollment-and- Certification/CertificationandComplianc/Down loads/usersguide.pdf 9

GOAL DO THE MATH TO GET YOUR STAR RATING Both staffing stars are in the bottom of the range RN - 0.383 with a range of 0.383 to 0.586 All staff - 3.67 with a range 3.552 to 4.009 10

DO THE MATH TO GET YOUR STAR RATING Staffing star fix MDS accuracy to ensure the acuity is calculated out correctly Hire staff BUT take care of current staff and the newbies Orientation Retention Work environment: pleasant or toxic Flexibility with hours EXPECTED NUMBER OF HOURS Nursing time (from CMS time study) connected to RUG category across all residents Hours then are divided by the number of residents included in the calculation Result is the expected number of hours for the nursing home 11

ADJUST Adjust Staffing Algorithms Must earn 4 stars on either the individual RN only or the staffing caregivers to receive overall 4 stars on the Overall Staffing rating Can have no less than a 3-star rating on any of those dimensions QUALITY MEASURES 12

HERE IT IS!!! Quality measures are tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide highquality health care and/or that relate to one or more quality goals for health care. These GOALS include: effective, safe, efficient, patientcentered, equitable, and timely care. INTENT OF QM REPORTS Quality measures reports are designed as feedback reports to facilities Quality improvement efforts Guide survey These reports are NOT publicly accessible Available to facilities via the secured intranet 13

QUALITY MEASURES INTENT FOR PUBLIC REPORTING Intended to provide consumers an additional data source to use when selecting a nursing facility www.medicare.gov Assist facilities to more effectively focus on quality improvement to ensure that systems are in place for consistent quality care for residents MDS Quality Improvement Evaluation System (QIES) DO THE MATH TO GET YOUR STAR RATING The points of the Quality Measures are not created equally Each QM is measured from 20-100 points Physical restraint and short stay pressure ulcer QM s have a lower threshold of acceptance and it is a smaller number over all Scores overall range from 220 to 1100 14

QMS (CONTINUED) QMs are process and outcome Processes are goal directed interrelated series of actions, events, or steps (care delivery) I.e. Catheters, restraints, help with ADLs increased Outcomes are what happens as a result of care delivery I.e. Falls, urinary tract infection DO THE MATH TO GET YOUR STAR RATING Review your QM s monthly & correct coding errors timely. Corrections today will help for next year Staffing and other duties as assigned Training for your MDS coordinator MDS support group meetings Webinars Formal training 15

IMPROVE Raise Performance Expectations Raised the threshold for nursing homes to achieve a high rating on all measures 16 OF 24 QM S QMs Measures based on MDS and claimsbased quality measures (QMs): Facility ratings for the quality measures are based on performance on 16 of the 24 QMs that are currently posted on the Nursing Home Compare web site, and that are based on MDS 3.0 assessments as well as hospital and emergency department claims. These include nine long-stay measures and seven short-stay measures. 16

9 LONG STAY (OVER 100 CDIF) ADL decline (Bed mobility, toilet, transfer, eating) Ability to move independently worsened (Locomotion) High-risk residents with pressure ulcers (St 2, 3 and 4 only) Indwelling catheter (exclusions: Neurogenic bladder, obstructive neuropathy) Physically restrained (daily) UTI (Evidence Based Criteria such as McGreer, NHSN, or Loeb in the last 30 days) Prevent through hygiene and drinking Self-report moderate to severe pain (From MDS interview only) Fall with major injury (Fracture, dislocation, closed head injury w/altered consciousness, subdural hematoma) Antipsychotic Use (Exclusions: Schizophrenia, Tourette's, Huntington s) Reduction is the focus of several CMS initiatives. 4 SHORT STAY (< OR = 100 CDIF) FROM MDS ASSESSMENTS Physical function improves from admissions to discharge New/worsened pressure ulcers (St 2, 3, 4 only) Self-report moderate to severe pain (From MDS interview only) Newly received antipsychotic medication (Exclusions: Schizophrenia, Tourette's, Huntington s) 17

3 SHORT STAY < OR = 100 FROM MDS ASSESSMENTS AND CLAIMS DATA Re-hospitalized after a nursing home admission Outpatient emergency department visit Successfully discharged to the community CHECK POINT Expand Targeted Surveys Assess adequacy and accuracy of information on the MDS 18

QUALITY MEASURES USED IN 5 STAR (PRIOR TO JULY 2016) QUALITY MEASURE SCORING RATING Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users Guide Revised August 1, 2016 accessed September 30, 2016 https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/usersguide.pdf QUALITY MEASURES USED IN 5 STAR (JULY 2016) QUALITY MEASURE SCORING RATING Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users Guide Revised August 1, 2016 accessed September 30, 2016 https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/usersguide.pdf 19

QUALITY MEASURES USED IN 5 STAR (APRIL 2018) QUALITY MEASURE SCORING RATING TERMINOLOGY Target Period Span of time that defines the QM reporting period (quarter) Stay The period of time between a resident s entry and either a discharge or end of the target period Starts with admission or reentry Ends with discharge, death or end of the target period Episode The period of time spanning one or more stays Starts with admission Ends with discharge return not anticipated; or anticipated and did not return in 30 days; death or end of the target period 20

TERMINOLOGY Stay vs. Episode An episode can have multiple stays Key is admission as opposed to reentry Episodes always start with admission Stays start with Admission or Reentry DAYS IN THE BUILDING Cumulative days in facility (CDIF): total number of days within an episode during which the resident was in facility Sum of days resident was in the building during an episode Determines if resident is counted in a short-stay or long-stay measure Short Stay: an episode that has a total of cumulative days in facility that is less than or equal to100 days at the end of the target period Long Stay: an episode that has a total of cumulative days in facility that is more than 100 days at the end of the target period 21

LOOK BACK SCAN Scans all assessments within the current episode that have target dates no more than 275 days prior to the target assessment Short-stay residents which it indicates one or more new or worsening Stage II-IV pressure ulcers Long stay residents with one or more lookback scan assessment(s) that indicate(s) one or more falls that resulted in major injury SURVEY STAR 22

CHANGES IN THE HEALTH INSPECTION DOMAIN Based on the most recent 2 standard surveys; not 3 anymore Results from any complaint investigation during the most recent 24 months; not 36 months anymore Any repeat revisits needed to verify that required corrections have brought the facility back into compliance HEALTH INSPECTION RESULTS Points assigned to deficiencies according to scope and severity More points for more serous, widespread deficiencies Fewer points for less serious, isolated deficiencies Substandard quality of care means additional points assigned Life safety surveys are not included Federal Monitoring surveys are not reported on Nursing Home Compare or included in Five Star calculations 23

Severity Scope Isolated Pattern Widespread Immediate jeopardy to resident health or safety J 50 points* (75 points) K 100 points* (125 points) L 150 points* (175 points) Actual harm that is not immediate jeopardy G 20 points H 35 points (40 points) I 45 points (50 points) No actual harm with potential for more than minimal harm that is not immediate jeopardy D 4points E 8 points F 16 points (20 points) No actual harm with potential for minimal harm A 0 point B 0 points C 0 points DO THE MATH TO GET YOUR STAR RATING Survey star Current survey 1 G (20), 2 Ds (4x2=8) Passed on first revisit star score 28 First prior year survey 2 Gs (40), 1 F (20) Passed on first revisit star score 60 2 year prior survey: 1 IJ (50), 1 H (35) 2 Gs (40) Passed with second revisit (50%) 125+68=193 24

REPEAT REVISITS No points are assigned for first revisit Points assigned only for 2 nd, 3 rd, and 4 th revisits More revisits are associated with more serious quality problems WEIGHTS FOR REPEAT REVISITS 1 st = 0 2 nd = 50 percent of health inspection score 3 rd = 70 percent of health inspection score 4 th = 85 percent of health inspection score Includes standard and complaint survey 25

TOTAL DOMAIN SCORE Most recent survey has 1/2 of the weight of the score Previous survey (13-24 months ago) has a weight factor of 1/3 Second prior survey has a weight factor of 1/6 COMPLAINT SURVEYS Based on calendar year Most recent 12 months preceding current update date weights in at 1/2 Complaint surveys 13-24 months weight in at 1/3 25-36 months weight factor of 1/6 26

TOTAL SCORE Weighted deficiency score + number of repeat revisits needed Lower survey score corresponds to fewer deficiencies and revisits DUPLICATION Complaint survey within 15 days of standard survey (prior or after) with same deficiencies are only counted once If score differs between the 2 surveys, the highest scope will apply 27

STATE VARIATIONS Survey management: skill sets of surveyors and supervision of surveyors State licensure: different expectations for nursing homes Medicaid policy: varies from state STATE VARIATIONS Top 10% will receive a 5 star rating Middle 70% will receive a 2, 3, or 4 star rating(23.33 %) Bottom 20% will receive a 1 star rating Providers can increase their star rating regardless of where other nursing homes improve 28

CUT POINTS Recalculated each month Individual facility star is held constant until there is a change in the facility survey NOW WHAT? Changes made now will not have immediate affect but we must start now! Improve the care via the QMs won t change the Star now but possibly improve the next survey Look at the suggested staffing by CMS - where do you stand Are you capturing the staffing correctly? - PBJ has started and needs to be in place and submitted. Have you looked at the level of staffing that CMS is expecting? Have you looked at how to make that happen? Are you survey ready everyday or only during your survey window? 29

SURVEY READY Monitor your QMs monthly Use PIP teams to focus on problems that arise Review past deficiencies and ensure that bad habits haven t come back Mock surveys either by your corporation or QIPMO Leadership Coaches Keep current with trends in the survey process Watch for administrator support group meetings on www.nursinghomehelp.org MINIMUM DATA SET WHAT DO WE DO NOW??? 30

SUPPORTING DOCUMENTATION The chart must support the MDS coding decision Good clinical practice is an expectation of CMS If staff interviews are done must be documented during the look back period REGULATION REQUIREMENTS Assessment accurately reflects the resident's status RN conducts or coordinates each assessment with appropriate participation of health professionals LPN role Process include direct observation, as well as communication, with resident and direct care staff on all shifts Nursing homes determine Who participates How the process is completed How the information is documented while remaining in regulation requirements and manual instructions RAI Manual page 1-7-8 31

MANUAL The CMS Long-Term Care Facility Resident Assessment Instrument User s Manual is the primary source of information for completing an MDS assessment Residents should be the primary source of information for resident assessment items; should the resident not be able to participate in the assessment, the resident s family, significant other, and guardian or legally authorized representative should be consulted SHORT STAY MEASURES 32

% OF RESIDENTS WITH PU THAT ARE NEW OR WORSENED (SS) Numerator: look back scan indicates one more new or worsened Stage II-IV PU (275 days) Denominator: all residents with one or more assessments that are eligible for a scan unless the data is incomplete WHAT CAN WE DO?? Ensure thorough skin assessments are done on admission and are thorough Review with licensed staff the importance of the skin assessment and subsequent documentation Remember once the initial skin assessment is completed anything that is found will be shown in this measure or if anything is worse Worse is not about size, but about the staging Stage 1 to Stage 2: Worse A 3x3cm Stage 3 that is now a 5x8cm Stage 3 = not worse, just bigger 33

% OF RESIDENTS WHO SELF REPORT MODERATE TO SEVERE PAIN (SS) Numerator: target assessment meets either or both 1. Daily pain with at least one episode of moderate to severe Almost constant or frequent pain AND At least one episode of moderate to severe pain 2. Resident reports very severe /horrible pain of any frequency Denominator: all, except incomplete interviews or incomplete data WHAT DO WE DO??? Ensure you have the pain medication available upon admission Is the pain med routine or PRN? Discuss alternatives with resident: nap after lunch, hot packs, music etc. Problem: It is what the resident says it is, no matter what the chart has Accurate or not, pain is subjective and there is no objective way to view it 34

% OF SS RESIDENTS WHO NEWLY RECEIVED AN ANTIPSYCHOTIC MED Numerator: One or more assessments in look-back scan not including initial assessment indicates that antipsychotic med received Denominator: All SS residents without exclusions, or the target assessment is not the same as the initial assessment % OF SS RESIDENTS WHO NEWLY RECEIVED AN ANTIPSYCHOTIC MED Exclusions Information is dashed Any of the conditions on any assessment in the look-back scan Schizophrenia Tourette s Syndrome Huntington s Disease On an antipsychotic upon admission or antipsychotic use is unknown 35

WHAT CAN WE DO????? Short-Stay Do we have the appropriate diagnosis? Compare diagnosis list with medication list Be sure we have an accurate picture/list of meds prior to admission What have we tried before we go to the drug? DOCUMENTATION!! PERCENTAGE OF SHORT STAY RESIDENTS WHO MADE IMPROVEMENTS IN FUNCTION The purpose of the Percentage of Short-stay Residents Who Made Improvements in Function measure is to determine, among short-stay nursing home residents who are discharged from the nursing home, the percentage of residents who gain more independence in transfer, locomotion, and walking during their episodes of care. The measure assesses the percentage of short-stay nursing home residents of all ages with improved independence on these mobility functions (i.e., transfer: self-performance; locomotion on unit: selfperformance; walk in corridor: self-performance) from the earliest initial assessment (admission or 5-day assessment) to the discharge assessment (specifically, the discharge assessment when return to the nursing home is not anticipated). 36

PERCENTAGE OF SHORT STAY RESIDENTS WHO MADE IMPROVEMENTS IN FUNCTION PERCENTAGE OF SHORT STAY RESIDENTS WHO MADE IMPROVEMENTS IN FUNCTION 5-Day Assessment MDS ADL Score = 7 3 3 3 2 3 2 37

PERCENTAGE OF SHORT STAY RESIDENTS WHO MADE IMPROVEMENTS IN FUNCTION Discharge Assessment-Return Not Anticipated MDS ADL Score=6 2 2 2 2 2 2 LONG STAY MEASURES 38

PERCENTAGE OF LONG STAY RESIDENTS WHOSE ABILITY TO MOVE INDEPENDENTLY WORSENED The long-stay locomotion measure evaluates the quality of nursing home care with regard to the loss of independence in locomotion among individuals who have been residents of the nursing home for more than 100 days. Loss of independence in locomotion is itself an undesirable outcome. Additionally, it increases risks of hospitalization, pressure ulcers, musculoskeletal disorders, pneumonia, circulatory problems, constipation, and reduced quality of life. Residents who have declined in independence in locomotion also require more staff time than those who are more independent. PERCENTAGE OF LONG STAY RESIDENTS WHOSE ABILITY TO MOVE INDEPENDENTLY WORSENED 39

PERCENTAGE OF LONG STAY RESIDENTS WHOSE ABILITY TO MOVE INDEPENDENTLY WORSENED PERCENTAGE OF LONG STAY RESIDENTS WHOSE ABILITY TO MOVE INDEPENDENTLY WORSENED Quarterly Assessment (Current or Target Assessment) 3 2 Annual Assessment (Prior Assessment) 2 2 Resident would qualify for this QM since Self-Performance Score Increased 40

PERCENTAGE OF LONG STAY RESIDENTS WHO RECEIVED AN ANTIANXIETY OR HYPNOTIC MEDICATION The use of antianxiety and hypnotic medications among older adults has been linked to increased risk of adverse outcomes such as cognitive impairment, delirium, falls, and fractures. The long-stay antianxiety or hypnotic medication use measure assesses the percentage of long-stay residents in a nursing home who receive antianxiety or hypnotic medications. The measure is intended to prompt nursing homes to re-examine their prescribing patterns in order to encourage practice consistent with clinical recommendations and guidelines (i.e., preventing and stopping long-term use of benzodiazepine). During a target period, it is expected that facilities may have residents receiving antianxiety and hypnotic medications for a short term who have appropriate clinical indications or are under a gradual dose reduction program. PERCENTAGE OF LONG STAY RESIDENTS WHO RECEIVED AN ANTIANXIETY OR HYPNOTIC MEDICATION 41

PERCENTAGE OF LONG STAY RESIDENTS WHO RECEIVED AN ANTIANXIETY OR HYPNOTIC MEDICATION N0410B and/or N0410D > 0 CODING MEDICATIONS IN SECTION N Medications should be coded according to classification, not why they are given. DO NOT code over the counter (OTC) sleeping medications as hypnotics, as they are not categorized as hypnotic medications. Diphenhydramine (Benadryl) Melatonin Herbal and alternative medicine products are considered to be dietary supplements by the Food and Drug Administration (FDA). These products are not regulated by the FDA and their composition is not standardized. Therefore, they should not be counted as medications 42

RESIDENTS WHOSE NEED FOR HELP WITH ADLS HAS INCREASED Numerator: Late loss ADLs only - bed mobility, transfer, eating and toileting; comparing target assessment to prior assessment An individual ADL changed 2 levels Two ADLs each changed 1 level Denominator: All residents with selected target and prior assessment except those with exclusions RESIDENTS WHOSE NEED FOR HELP WITH ADLS HAS INCREASED Exclusions: All 4 late loss ADL items are dependent 3 late loss ADLs were total dependent and the 4 th was extensive Resident is comatose Prognosis of life expectancy is less than 6 months Hospice care is marked ADL items are dashed away 43

WHAT DO WE DO?? Is the information accurate? Do the staff who complete the documentation know what they are doing? Do you have complete documentation? HIGH RISK RESIDENTS WITH PRESSURE ULCERS Numerator: meet both: Is considered high-risk as defined in the denominator Has a Stage II to IV Denominator: high risk if meet one or more of the following: Impaired bed mobility or transfers either or both Extensive, dependent, happened only 1-2 times or the activity didn t occur Comatose Malnutrition or at risk for malnutrition Exclusions: Admission assessment, or PPS 5 day, or readmission return assessment Items in are dashed 44

WHAT DO WE DO?? Thorough assessment of skin and/or wounds Accurate assessment of the wounds Thorough documentation Accurate documentation of ADLs specifically bed mobility and transfers RESIDENTS WHO HAVE/HAD A CATHETER INSERTED AND LEFT IN THEIR BLADDER Numerator: Target assessment indicates the use of indwelling catheter Denominator: Everybody except with exclusions Exclusions: Target assessment is admission, PPS 5 day or readmission/return assessment Indwelling catheter status dashed away Neurogenic bladder or item is dashed Obstructive uropathy or item is dashe 45

RESIDENTS WHO HAVE/HAD A CATHETER INSERTED AND LEFT IN THEIR BLADDER Covariates Frequent bowel incontinence of prior assessment (frequent or always) Pressure ulcers at stages II, III, IV on prior assessment All covariates are missing if no prior assessment is available WHAT DO WE DO? Do we have appropriate documentation? Diagnosis obtained Is proper Foley catheter care being performed? Is catheter changed as ordered (as needed, not by calendar)? 46

RESIDENTS WITH A URINARY TRACT INFECTION Numerator: Selected target assessment indicates a UTI in Section I Denominator: Everybody except those with exclusions Exclusions: Target assessment is admission, PPS 5 day, or readmission/return assessment Item is dashed in section I WHAT DO WE DO???? Is the MDS coding accurate? How do the residents stay hydrated? Are we offering thorough peri-care being done correctly? Do we have documentation to support the evidence based criteria necessary to code UTI? 47

RESIDENTS WHO SELF REPORT MODERATE TO SEVERE PAIN Numerator: Target assessment meets either or both: Reports almost constant or frequent moderate to sever pain in the last 5 days; both of the following must occur: Almost constant or frequent pain AND At least one episode of moderate to severe pain Resident reports very severe horrible pain of any frequency Denominator: Everybody unless has exclusions RESIDENTS WHO SELF REPORT MODERATE TO SEVERE PAIN Exclusions: Target assessment is admission assessment or a PPS 5 day Incomplete pain assessments for pain frequency or intensity 48

RESIDENTS WHO SELF REPORT MODERATE TO SEVERE PAIN Covariates (extra math) Independence or modified independence in daily decision making on the prior assessment Staff assessment on daily decision making is independent of modified independent OR BIM score is 13-15 WHAT DO WE DO?? Is the pain med routine or PRN? Discuss alternatives with resident, nap after lunch, hot packs, music, etc. Take credit for alternatives Problem: It is what the resident says it is, no matter what the chart has Accurate or not, pain is subjective and there is no objective way to view it 49

RESIDENTS EXPERIENCING ONE OR MORE FALLS WITH MAJOR INJURY Numerator: Look-back scan indicates one or more falls with major injury (275 days) Denominator: All long-stay residents unless has exclusions Exclusions: Excluded if one of the following is true for ALL of the look back scan assessments Falls not assessed Fall occurred but number of falls with major injury not assessed FALLS DEFINITIONS Unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat) The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground; falls include any fall, no matter whether it occurred at home, while out in the community, in an acute hospital or a nursing home Falls are not a result of an overwhelming external force (e.g., a resident pushes another resident) An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person this is still considered a fall 50

FALLS DEFINITIONS Injury (except major): includes skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or all fall related injury that causes the resident to complain of pain Major injury: includes bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma DEFINITION: FRACTURE RELATED TO A FALL Any documented bone fracture (in a problem list from a medical record, an x- ray report, or by history of the resident or caregiver) that occurred as a direct result of a fall or was recognized and later attributed to the fall Do not include fractures caused by trauma related to car crashes or pedestrian versus car accidents or impact of another person or object against the resident 51

WHAT CAN WE DO??? Review your current fall program Does your staff really know the resident? Ask yourself with EVERY fall, what was the resident trying to do? Look at basic needs: Bathroom Food Tired/weak Lonely Bored WHAT CAN WE DO???? Raise staff awareness of meeting those basic needs How noisy are your units/floors? (Alarms, overhead paging, staff talking music, TV, etc.) Who is the resident?? What did he/she do before becoming a resident??? Pharmacy reviews to ensure medications are not part of the problem All activities should not be just groups Self-directed based on their assessments 52

RESIDENTS WHO RECEIVED AN ANTIPSYCHOTIC MEDICATION Numerator: Target assessment showed antipsychotic medication was received Denominator: All residents except those exclusions Exclusions: Items on MDS were dashed away Have related conditions Schizophrenia Tourette s Syndrome Huntington s Disease ANTIPSYCHOTICS Record the number of days an antipsychotic medication was received by the resident at any time during the 7 day look-back period (or since admission/entry, or reentry if less than 7 days) Code medications therapeutic category and or pharmacological classification, not how it is used 53

WHAT CAN WE DO??? Long-Stay Be sure we have the correct diagnosis within the body of section I Have we done or tried a dose reduction?? Are we documenting the behaviors that caused the medication to be started? Get rid of PRNs Consistent staffing Care plans that reflect what causes the behavior, what calms them down with specific ideas Do you know your residents? DOCUMENTATION CLAIMS BASED MEASURES RE HOSPITALIZATION, ER VISIT, AND DISCHARGE TO COMMUNITY 54

CLAIMS BASED MEASURES Measures include Medicare fee-for-service beneficiaries only (No Medicare Advantage or other payers included). Data will be mainly collected from Medicare claims Submitted (Risk adjustment will be calculated using data from MDS, claims and the enrollment database). All are short-stay measures (Residents must be admitted to the SNF following an inpatient hospitalization). CLAIMS BASED MEASURES Percentage of short-stay residents who were successfully discharged to the community Percentage of short-stay residents who have had an outpatient emergency department visit Percentage of short-stay residents who were rehospitalized after a nursing home admission 55

PERCENTAGE OF SHORT STAY RESIDENTS WHO HAVE HAD AN OUTPATIENT EMERGENCY DEPARTMENT VISIT The short-stay outpatient ED visit measure determines the percentage of all new admissions or readmissions to a nursing home from a hospital where the resident had an outpatient ED visit (i.e., an ED visit not resulting in an inpatient hospital admission) within 30 days of entry or reentry. Note that higher values of the short stay outpatient ED visit measure indicate worse performance on the measure. PERCENTAGE OF SHORT STAY RESIDENTS WHO HAVE HAD AN OUTPATIENT EMERGENCY DEPARTMENT VISIT 56

PERCENTAGE OF SHORT STAY RESIDENTS WHO HAVE HAD AN OUTPATIENT EMERGENCY DEPARTMENT VISIT CLAIMS BASED QUALITY MEASURES MDS BASED RISK ADJUSTMENT COVARIATES MDS Based Covariates constructed from the MDS items and used in the final risk adjustment model for the claims based quality measures are available at: https://www.cms.gov/medicare/provider Enrollment and Certification/CertificationandComplianc/Download s/new Measures Technical Specifications DRAFT 04 05 16.pdf 57

PERCENTAGE OF SHORT STAY RESIDENTS WHO WERE SUCCESSFULLY DISCHARGED TO THE COMMUNITY The short-stay successful community discharge measure determines the percentage of all new admissions to a nursing home from a hospital where the resident was discharged to the community within 100 calendar days of entry and for 30 subsequent days, they did not die, were not admitted to a hospital for an unplanned inpatient stay, and were not readmitted to a nursing home. Note that lower values of the short stay successful community discharge measure indicate worse performance on the measure. LET S JUST DO IT 58

STAR MAY CHANGE WHEN New health inspection survey Complaint investigation A 2 nd, 3 rd, 4 th revisit Resolution of IDR or IIDR The aging of complaint deficiencies CASE MIX ADJUSTMENT RUG data: target of 7 days prior to the most recent standard survey date 59

CMS EXPECTATIONS http://www.cms.gov/medicare/provid er-enrollment-and- Certification/CertificationandComplian c/fsqrs.html Very large file Scroll down till you find MO homes Locate your home SHOOT FOR THE STARS More stars indicates better quality 60

RESOURCES RAI Manual: https://www.cms.gov/medicare/quality- Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/MDS30RAIManua l.html Quality Measures: https://www.cms.gov/medicare/quality-initiatives- Patient-Assessment- Instruments/NursingHomeQualityInits/Downloads/MDS- 30-QM-Users-Manual-V11-Final.pdf 5-Star: https://www.cms.gov/medicare/provider- Enrollment-and- Certification/CertificationandComplianc/downloads/user sguide.pdf RESOURCES PBJ Information https://www.medicare.gov/nursinghome Compare/Data/About.html 61

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