Building the Capacity for QAPI Plans: Making Data Work For You- LTC Trend Tracker with AHCA Publication MO-14-33-NH GEN This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy
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Introducing: Show-Me Quality Games
6 Gold Level Homes Columbia Healthcare Center Cuba Manor Dixon Nursing & Rehab Lacoba Homes Madison Medical Center Villages of St. Peters Eldon Nursing & Rehab Fulton Manor Care Center Hartville Care & Rehabilitation Center
Show-Me Quality Games 5 Simple Steps to Gold: 1. Select improvement project, a project team, and send us a team photo. 2. Attend Show-Me Quality educational offerings. 3. Fill out the QAPI Self Assessment Tool. 4. Complete the Using PDSA for QAPI worksheet. Because quality improvement projects are always a work in progress, submit a second Using PDSA for QAPI worksheet. 5. Submit a story of your home s success (or lessons learned).
Get Started: Going for the Gold Find the complete program guide,worksheets for submission and a short video detailing the program at http://primaris.org/services/quality-improvementorganization/show-me-quality-qapi-in-action Contact your Program Manager with questions!
Regional Affinity Groups Watch for announcements
Keeping You Up-to-Date: Monthly Newsletter Emailed QAPI-related tips Provider highlights: hear from colleagues about what works Updates on available tools, resources, and trainings Upcoming events
Keeping You Up-to-Date: On the Web Newsletters Event calendar Event registry Resources Archived webinars www.primaris.org
Our Show-Me Quality: QAPI in Action Consultant Team Pam Guyer BS, LNHA Alexis Roam MSN, RN Judy Halley RN BC, BSN, LNHA Peggy Neale-Lewis BSN, RN, CPHQ Kent McGeeney LNHA, MPA, MSE
Building the Capacity for QAPI Plans: Making Data Work for You - LTC Trend Tracker with AHCA Peggy Connorton, Director Quality & LTC Trend Tracker pconnorton@ahca.org
Objectives Describe how a comprehensive system for monitoring data is used to establish targets for improvement and acceptable performance parameters. Identify the sources of data that can be monitored through this tracking system Identify who could benefit from receiving the data and how this sharing of data is critical to QAPI efforts.
AHCA Quality Initiative Goals Safely reduce 30-day hospital readmissions by 15% by 2015 Reduce clinical staff turnover by 15% by 2015 Increase customer satisfaction to 90% by 2015 Safely reduce the off-label use of antipsychotics by 15% by the end of 2013
Data that you collect MDS Financial Data Resident, family, staff satisfaction Turnover data Clinical Survey Census Workers Comp Rehospitalization RUG info
2011 and 2012 MDS Submissions 2011 19,660,164 2012
These reports become public Resident Census and Condition Report Application for MCR and MCD QM Report Cost Report Survey Report
What people know about you Five Star ProPublica can read your 2567 Hospitals track your data Yelp Google
How often do you look? Five Star Data? Resident Condition and Census Report QM Report QI Report Application for MCR and MCD
QAPI and Data
QAPI Meetings
QAPI Basics 5 elements of for QAPI 1. Design and Scope 2. Governance and Leadership 3. Feedback, Data Systems and Monitoring 4. Performance Improvement Projects 5. Systematic Analysis and Systemic Action
Feedback, Data Systems, and Monitoring Monitor care and services Process for feedback using performance indicators Monitor wide range of care processes and outcomes Review findings against facility benchmarks Track, investigate and monitor adverse events Implement plans to prevent recurrence
Benchmarking Use LTCT for external and internal Allows you to check your performance to others Are you higher or lower than your peers? The basis for your QAPI program
LTCTT and QAPI Use in Element 3 Feedback, Data Systems and Monitoring Benchmarking Look at historical trends Set your goals Print Graphs or download data into excel for correlation analysis
QAPI Meetings CASPER Reports Staffing, Survey History, Resident Characteristic Reports NH QM Five Star Reports Cost Report Medicare Utilization Report Rehospitalization Report
PDSA
Frame the problem 1. Recognition 2. review previous findings
Communicate results Communicate the results of the issue Present action
How do you solve? You collect data And analysis the data
Why is data important? Allows you to set priorities on what you are going to work on Allow you to track and trend the good things in your building Essential to QAPI
Stuff you already do Frame the problem Solve the problem Communication and acting on the results
Tools to Track Data Advancing Excellence LTC Trend Tracker Spreadsheets
Share your outcomes Share outcomes with staff, residents and families Show progress in the break room Talk about outcomes at meetings, resident and family council
How to use to LTC Trend Tracker
The Basics LTC Trend Tracker provides members with the ability to benchmark their quality, clinical and financial data Staffing, Resident Characteristics, Five Star Ratings, Five Star Staffing, Survey Findings, Medicare Cost Report, Rehospitalization, Off-label Antipsychotics, Retention and Turnover Includes data for all MCR SNFs in US
Data Sources The information in reports are uploaded by AHCA for facilities (identified by their Medicare provider number) CASPER Reports collected at time of survey Medicare Patient Days by RUG Category LTC Trend Tracker participants Cost Report- from the full cost report submitted to your FI/MAC Rehospitalization- MDS 3.0 On-Point 30 FIVE Star and Quality Measures Nursing Home Compare Antipsychotic MDS 3.0 Turnover and Retention- Annual AHCA Staff Vacancy, Retention, and Turnover Report
Peer Group Selection First Pick your Area Next pick your peer group National State For Profit Not for Profit Chain Facility County City Zip Code Single Facility All Peers CCRC Own Organization Veterans Homes Many More Develop a custom peer group
Dashboard The landing page Quality, Medicare, Staffing, Regulatory Use for QA/PI and Board Meetings
Edit my dashboard changes the dashboard and report builder takes you to the reports
Anti-Psychotic
Rehospitalization data New MDS 3.0 Based Measure Adjusted Expected Actual Use in telling your story to the hospitals Benchmark your Rehospitalization to your peers
Data Source MDS 3.0 Over a 12 month period Based on admission assessment (5 day or OBRA) Discharge Assessment
Risk Adjustment CMS uses Risk Adjustment in QMs Allows to compare Case-Mix and Acuity Compare performance between different providers
How Risk Adjustment Works Provider A Low Acuity Provider B High Acuity 100 admissions in a year 100 admissions in a year Monthly d/c to hospital 10 Monthly d/c to hospital 25 Actual Rehospitalization rate 10% Actual Rehospitalization rate 25% Risk adjusted rate 25% Risk adjusted rate 10%
How to use Rehospitalization Report ACOS Hospital discussion Referral Sources
Discharge to Community Determine how you compare in your d/c to community rate Private home, apartment, board/care, assisted living, or group home as indicated on MDS discharge assessment Uses MDS Data from the d/c assessment
How to use DC to Community See how you are doing on your dc rate to home and other nonclinical settings It can also tell you if you are sending more or fewer than expected individuals back to the community given the clinical characteristics of the population of individuals admitted to your center Use negotiations with hospitals, Manage Care organizations and others.
How to read the reports 1. Look at your actual Rate 2. Compare to your expected Rate 3. Then look at Risk Adjusted Rate
Higher or Lower If your actual rate is lower than the expected than then your risk adjusted rate will be lower than the national average If your actual rate is higher than expected than the risk adjusted rate will be higher than the national average
LTCTT example
Should this building be concerned?
Five Star Rating Reports Overall Five Star Rating Report Five Star Staffing Rating Report CMS QM Five Star Rating Report
Overall Five Star Rating Compare ranking in categories: Overall Rating Health Inspection Rating Direct Care Staffing Rating Registered Nurse Staff Rating CMS Quality Measure Data
Five Star Rating QM Report Identify focus QMs for quality improvement Predict impact of QM improvements on Five Star QM Rating
Five Star QM Report Click here to enter you data
Quality Measures Compare Quality Measures New July 2012 Information Old prior to Oct 2010 Information Exclusive AHCA 1 quarter view Evaluate resident characteristics: Post-Acute Care Chronic Care Advancing Excellence 2/18/2014
Antipsychotic Antipsychotic- Short Stay off label resident data Long Stay off label resident data MDS 3.0
NH Compare QM Report
Long Stay Antipsychotic
Resident Report Based on OSCAR/CASPER data This report can assist you in Quality Improvement efforts Compare and contrast resident characteristics: 1+ assistance in ADLS Bowel/bladder status Mobility Skin integrity Special care Behaviors Other
Has acuity changed?
Regulatory Reports Standard Health Survey, Combined Health Survey, Complaint and Life Safety Code Information Identify the frequency a certain F- or K-Tag was citied Compare percentage of peer facilities with the same F-Tag or K- Tag Set up Organization focus tags See top 15 tags for your state Track survey trends in the market
Should you prep for this tag?
Turnover and Retention Report Information from the AHCA annual Turnover and Vacancy Survey Compare organization s turnover and retention rate to your peers for: Admin DON Staff RN CNA
Was there a decrease in Turnover?
Your LTCTT Report Upload Timeline RUG and Five Star data- Monthly OSCAR/CASPER Data- Quarterly NH Compare Quality Measures-Quarterly Medicare Cost Report Quarterly 2/18/2014
Where to find your data: Clinical/Resident Information- CASPER Resident Characteristics, NH QM Report Rehospitalization AHCA Outcome Report Antipsychotic Dashboard and QM Report Regulatory Compliance Standard Health Survey, Complaint, Combined, and Life Safety Code Financial and Marketplace results Cost Report, Five Star, CASPER Staffing Report and Medicare Utilization Report
Summary of LTC Trend Tracker LTC Trend Tracker provides members with Clinical, Quality, 5-Star, Staffing and Financial Data FREE AHCA member service Use in QAPI, Marketing and discussions with hospitals.
Summary You are already collecting data Referral Sources are making decisions based on your information Use LTC Trend Tracker as a resource
Questions
Peggy Connorton pconnorton@ahca.org 202-898-2833 www.ltctrendtracker.com Contact Info
13 QAPI at a Glance Guide for Developing a QAPI Plan Publication MO-14-33-NH GEN This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy
14 QAPI: Feedback, Data Systems, & Monitoring Identify the sources of data you will monitor Describe the process for collecting the data Describe the process for analyzing the data Describe the process to communicate data - one method for doing this is a dashboard Describe who will receive this information
15 A comprehensive systems enables us to: Analyze patterns and trends Set parameters for performance Communicate quality outcomes to various audiences such as board members, QAPI guiding team, staff, and others
16 REMEMBER YOUR data reflects YOUR organization Thank you for attending our webinar today
17 Next Webinar (#4 in series of 6) Building the Capacity for QAPI Plans: Making Data Work for You CASPER Reports With AANAC Date - February 25, 2014 1:00 pm - 2:00 pm https://www3.gotomeeting.com/register/782468478