MDS 3.0 Quality Measures Update• Answer polls when they are provided ›Groups • Group leader is the person who registered & logged on to the webinar • Answer polls when they

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MDS 3.0 Quality Measures UpdateJuly 2, 2019

› Individuals• Participate in entire webinar• Answer polls when they are provided

› Groups• Group leader is the person who registered & logged on to the webinar• Answer polls when they are provided• Complete group attendance form • Group leader sign bottom of form• Submit group attendance form to [email protected] within 24 hours of webinar

› If all eligibility requirements are met, each participant will be emailed their CPE certificate within 15 business days of webinar

TO RECEIVE CPE CREDIT

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Suzy Harvey, RN-BC, RAC-CT

Managing [email protected]

Presenter

Objectives

› Describe recent changes to the Five-Star Rating

› Learn why Quality Measures (QMs) are important to your facility

› Understand how each QM is determined

› Learn proactive ways that can help improve your facility’s QMs

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Brief History

› 1998: Nursing Home Compare (NHC) website was launched› 2008: CMS enhanced NHC website with the Five-Star Rating

Program› 2014–2016: CMS significantly modifies QMs› 2018: CMS replaces the traditional staffing data using the Payroll-

Based Journal (PBJ)› 2019: CMS updated thresholds for assigning stars for staffing &

quality components

April 2019 Updates to Five-Star & NHC

› Health Inspection Rating “freeze” ended April 2019• Return to three survey cycles

› Cycle 1 (most recent period) will have a weight factor of 1/2

› Cycle 2 (previous period) will have a weight factor of 1/3

› Cycle 3 (third period) will have a weight factor of 1/6

› CMS will suppress star ratings for Special Focus Facilities

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› New PBJ staffing thresholds • Updated total staffing hours per resident day (HPRD) & RN staffing

HPRD cut points for the overall staffing & RN staffing

› Terminology change• Expected nursing hours per resident are now case-mix adjusted

staffing hours per resident


› Staffing star rating methodology changed effective April 2019• Changes to scoring exceptions

› 4 or more days in quarter with no RN staffing hours• Was 7 days

• Results in 1 star for Staffing Domain

• New thresholds for staffing ratings› Increase the weight that RN staffing has on rating

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Staffing Star Thresholds Adjusted Hours

Staff Type 1 Star 2 Stars 3 Stars 4 Stars 5 Stars

RN < 0.246 0.246 – 0.382 0.383 – 0.586 0.587 – 0.883 ≥ 0.884

Total < 3.176 3.176 – 3.551 3.552 – 4.009 4.010 – 4.237 ≥ 4.238

April 2018

April 2019

Staff Type 1 Star 2 Stars 3 Stars 4 Stars 5 Stars

RN < 0.316 0.316 – 0.500 0.501 – 0.723 0.724 – 1.041 ≥ 1.042

Total < 3.107 3.107 – 3.573 3.574 – 4.037 4.038 – 4.403 ≥ 4.404


› Update to Quality Measures• Long stay (LS) restraints will no longer be factored into the QM rating• Short stay (SS) pressure ulcer & SS discharge community measures

replaced with Quality Reporting Program (QRP) measures • LS hospitalizations & LS outpatient emergency department measures

added• Separate QM rating for short-stay & long-stay measures

› Overall QM rating = adjusted short-stay measure + adjusted long-stay measure

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Quality Measure Domain – NHC

› Uses data from the MDS & Medicare claims› Five-Star Quality Rating System

• 17 QMs posted on NHC site› 12 MDS-based QMs & 5 Medicare claims-based measures

› QMs provide information on quality of care in specific resident areas that are important to future residents & families

› Looks at data recorded & the type of MDS assessment to calculate QMs

8 Long Stay› ADL Decline

› High-Risk Resident with pressure ulcers

› Indwelling catheter

› UTI

› Self-reported mod/severe pain

› Fall with injury

› Antipsychotic medication

› Ability to move independently worsened

4 Short Stay› SNF residents with new or worsened pressure

ulcers

› Self-reported mod/severe pain

› New incidence of antipsychotic medication

› Functional improvement

MDS-Based Quality Measures

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Claims-Based Quality Measures

› Short Stay• Percentage of residents who were re-hospitalized after a nursing home

admission• Percentage of residents who had an outpatient Emergency Department (ED)

visit• Rate of successful return to community from a SNF

› Long Stay• Number of hospitalizations per 1,000 LS resident days• Number of outpatient ED visits per 1,000 LS resident days

Methodology

› Two different sets of weights & updated thresholds• Previously all measures scored 0–100 points• April 2019

› 9 measures score 00–150 points› 8 measures score 00–100 points› QM thresholds updated every 6 months

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Methodology

› 9 measures score of 0–150 points• LS ADL worsening• LS antipsychotic medication• LS mobility decline• 2 new LS claims-based measures

› LS hospitalizations & ED visits

• SS functional improvement• 3 claims-based SS measures• SS rehospitalizations, ED visits & successful return to the

community

15 90

30 105

45

60

120

135

75 150

Methodology

› 8 measures score 00–100 points• LS self-reported moderate/severe pain• LS pressure ulcer• LS catheter use• LS UTI• LS falls with major injury• SS self-reported moderate/severe pain• SS pressure ulcer• SS antipsychotic medication

20

40

60

80

100

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Methodology

Stay Definitions

› Target Period• The span of time that defines the QM reporting period• Typically a calendar quarter

› Stay• The period of time between a resident’s entry into a facility & either a

discharge or the end of the target period, whichever comes first

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Stay Definitions

› Episode• A period of time spanning one or more stays. An episode begins with

an admission & ends with either a discharge or the end of the target period, whichever comes first. As episode starts with –

› An admission entry (A0310F = 1 & A1700 = 1)

Stay Definitions

› Episode• The end of an episode is the earliest of the following

› A discharge assessment with return not anticipated (A0310F = 10) OR

› A discharge assessment with return anticipated but the resident did not return within 30 days (A0310F = 11) OR

› A death in facility tracking record (A0310F = 12) OR› The end of the target period

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Stay Definitions

› Target date• The event date for an MDS record, defined as follows

› For an entry record (A0310F = [01]), the target date is equal to the entry date (A1600)

› For a discharge record (A0310F = [10, 11]) or death-in-facility record (A0310F = [12]), the target date is equal to the discharge date (A2000)

› For all other records, the target date is equal to the assessment reference date (A2300)

Stay Definitions

› Short Stay • Cumulative days in facility less than or equal to 100 days at the end of

the target period

› Long Stay• Cumulative days in facility greater than or equal to 101 days at the end

of the target period

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Look-Back Scan

› Target assessment• Short stay = Most recent assessment in last 6 months (short stay target

period)• Long stay = Most recent assessment in last 3 months (long stay target period)

› Look back scan• Short stay – all assessments in the current episode (may span more than one

stay)• Long stay – all assessments in the current episode that have target dates no

more than 275 days prior to the target assessment

Look-Back Scan

› Initial assessment• Used for short stay residents • First assessment following the entry record at the beginning of the

resident’s episode

› Prior assessment • Used for long stay residents• Latest assessment that is 46 to 165 days before the target assessment

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Short Stay Five-Star Measures

› Percent of Residents Who Self-Report Moderate to Severe Pain

• Uses target assessment• 2 conditions, either or both;• 1st condition

› Almost constant or frequent pain

› At least one episode of moderate or severe pain

• 2nd condition› Very severe/horrible pain



› Exclusions• Pain interview not completed (J0200)• Pain presence (J0300) not completed• Pain presence (J0300) completed but

› Pain frequency not completed (J0400 = 9,-, ^)› Neither pain intensity was completed (J0600A or J0600B)› Numeric pain intensity indicates no pain (J0600A = 00)

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Managing Pain Interviews› Managing pain interviews

• Ensure staff is trained› Periodic evaluation of interviewers

• Per RAI manual› MDS form instructs attempt on all residents

• Conduct close to end of observation period – ARD or day before – schedule with resident

• Introduce interview properly• Set the stage on admission

Managing Pain Interviews

› Managing pain interviews• Don’t switch pain scales back & forth• Do not fight resident answers

› Follow-up› Care plan

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› Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

• Replaced October 1, 2018› Percent of Residents or Patients with Pressure Ulcers that are New or Worsened

› Reports the percentage of Medicare Part A SNF Type 1 stays with stage 2–4 or unstageable pressure ulcers due to slough/eschar, non-removable dressing/device or deep tissue injury that are new or worsened

› Calculated by starting with the number of pressure ulcers/injuries at discharge (M0300B1 – M0300G1) & subtracting the number present on admission


› Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

• Medicare Part A SNF stays are excluded if › Missing data, i.e., dash [ - ], on new or worsened Stage 2, 3, 4 & unstageable

pressure ulcers, including deep tissue injuries, at discharge

› Resident died during the SNF stay, i.e., Type 2 SNF stays

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› Two Types of SNF Stays


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Pressure Ulcers

› Long stay/Short stay• Ensure identification of PU on admission• Ensure staff are tracking & documenting pressure ulcers accurately• Provide education to all nursing staff responsible for documenting PU


› Percent of Residents Who Newly Received an Antipsychotic Medication

• Uses target assessment• MDS items – N0410A = 1, 2, 3, 4, 5, 6, 7• Note that residents are excluded from this measure if their initial

assessment indicates antipsychotic medication use or if antipsychotic medication use is unknown on the initial assessment

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› Percent of Residents Who Newly Received an Antipsychotic Medication

• Exclusions› Antipsychotic use is not assessed (N0410A = [-])› Initial assessment indicates antipsychotic use (N0410A is 1 or greater)› Diagnoses of the following on any assessment in look-back scan

• Schizophrenia (I6000 is checked)• Tourette’s Syndrome (I5350 is checked)• Huntington’s Disease (I5250 is checked)


› Percent of Residents Who Made Improvements in Function

• Must have a valid discharge-return not anticipated & a valid PPS 5-day or OBRA admission assessment

• Must have a change in performance that is negative• Performance calculated using self-performance in the following ADLs

› Transfer (G0110B1)

› Locomotion on Unit (G0110E1)

› Walk in Corridor (G0110D1)

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› Percent of Residents Who Made Improvements in Function

• Exclusions › Comatose› Life expectancy of less than 6 months› Hospice› Missing transfer, locomotion on unit & walk in corridor› No impairment in transfer, locomotion on unit & walk in corridor› Residents with an unplanned discharge

Long Stay Five-Star Measures› Percent of Residents Experiencing One or More Falls with Major Injury

› Reports the percent of residents who have experienced one or more falls with a major injury in the target period

• Uses look-back scan of 275 days• MDS items

› Major injury at J1900 = 1 or 2• Exclusions

› Occurrence of falls not assessed (J1800 = [-]) OR› Assessment indicates fall occurred (J1800 = 1) but number of falls with injury was not

assessed (J1900C = -)

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Long Stay Five-Star Measures


• Uses target assessment• 2 conditions, either or both;• 1st condition

› Almost constant or frequent pain

› At least one episode of moderate or severe pain

• 2nd condition› Very severe/horrible pain

Long Stay Five-Star Measures› Percent of Residents Who Self-Report Moderate to Severe Pain

› Exclusions› 1. Target Assessment is admission or 5-day PPS assessment› 2. Resident not included & any of following true

• Pain interview not completed (J0200)• Pain presence (J0300) not completed• Pain presence (J0300) completed but

› Pain frequency not completed (J0400 = 9,-, ^)› Neither pain intensity was completed (J0600A or J0600B)› Numeric pain intensity indicates no pain (J0600A = 00)

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Long Stay Five-Star Measures› Percent of High-Risk Residents with Pressure Ulcers

› Uses target assessment (admission & 5-day PPS excluded)› High-risk residents (meet one or more of the following)

• Impaired bed mobility (G0110A1 = 3, 4, 7 or 8)• Impaired transfers (G0110B1 = 3, 4, 7 or 8)• Comatose (B0100 = 1)• Malnutrition (I5600 is checked)

› Stage 2–4 pressure ulcers are present• M0300B1 = 1–9 or• M0300C1 = 1–9 or• M0300D1 = 1–9


› Percent of High-Risk Residents with Pressure Ulcers

• Exclusions› Target assessment is OBRA admission or 5-day PPS

› Resident does not meet the pressure ulcers conditions described in previous slide or M0300B1 – G1 = [-]

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› Percent of Residents with a Urinary Tract Infection

• LS residents with a target assessment that indicates a UTI in the last 30 days (I2300)

• Exclusions› Target assessment is an admission or 5-day PPS

› UTI value is missing


› Percent of Residents Who Have/Had a Catheter Inserted & Left in their Bladder

• Uses target assessment

• Indwelling catheter indicated (H0100A is checked)

• Exclusions

› Target assessment an admission or 5-day PPS

› Indwelling catheter status missing

› Neurogenic Bladder (I1550) or Obstructive Uropathy (I1650) checked on target assessment

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› Percent of Residents Whose Need for Help with ADLs Has Increased

• Uses target assessment that is compared to the prior assessment• MDS items

› Uses 4 late-loss ADLs – bed mobility, transfers, eating & toileting (self-performance)

› Increase in 2 or more coding points in one late-loss ADL item or› One point increase in coding points in two or more late-loss ADL

items


› Percent of Residents Whose Need for Help with ADLs Has Increased

› Exclusions• All 4 late-loss ADL items indicate total dependence on prior

assessment• 3 late-loss ADLS are dependent & the fourth is extensive on prior

assessment• Resident is comatose • Prognosis of life expectancy is less than 6 months • Hospice care indicated on target assessment• Late-loss ADL items are not assessed on target or prior assessment

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› Percent of Residents Who Received an Antipsychotic Medication

• Uses target assessment• MDS items

› Antipsychotic medication received N0410A = 1, 2, 3, 4, 5, 6 or 7


› Percent of Residents Who Received an Antipsychotic Medication

› Exclusions› Antipsychotic use is not assessed (N0410A = [-])› Any of the following present on the target assessment

• Schizophrenia (I6000 is checked)• Tourette’s Syndrome (I5350 is checked)• Huntington’s Disease (I5250 is checked)

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› Percent of Residents Whose Ability to Move Independently Worsened

• Uses selected target assessment & at least one qualifying prior assessment

• An increase of one or more points in self-performance in locomotion on the unit (G0110E1)


› Percent of Residents Whose Ability to Move Independently Worsened

• Exclusions› Comatose or missing data on comatose at prior MDS

› Prognosis of less than 6 months of life

› Hospice

› Missing value for prognosis & hospice

› Totally dependent on locomotion on prior MDS

› Missing data on locomotion on prior MDS

› Prior MDS is a discharge with or without return anticipated

› No prior MDS available

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Claims-Based Five-Star Measures

› Percent of SS Residents Who Were Rehospitalized After a Nursing Home Admission

• Includes residents who newly entered or reentered the nursing home within one day of discharge from a hospital & were readmitted to a hospital for an unplanned inpatient stay or observation stay within 30 days of the start of the nursing home stay

• Planned hospital readmission identified using principle discharge diagnosis & procedure codes on claims for hospital stay

• Includes stay that started over a 12-month period› Data updated every quarter with a lag time of 6 months


› Percent of SS Residents Who Were Rehospitalized After a Nursing Home Admission

• Exclusions› Residents not enrolled in Part A or B

› Residents never enrolled in hospice during their stay

› Comatose or missing comatose data

› Missing data from claim or MDS used in the numerator or dominator

› Resident did not have an initial MDS assessment

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› Number of Hospitalizations per 1,000 LS Resident Days• Number of unplanned inpatient admissions or all-cause outpatient

observation stays at an acute care or critical access hospital occurring in the target period & while the individual is a long-term nursing home resident

• All days after the resident’s 100th cumulative day in the nursing home or the beginning of the 12-month target period (whichever is later) & until day of discharge, day of death or end of the 12-month target period (whichever is earlier)

• Not a planned hospital admission


› Number of Hospitalizations per 1,000 LS Resident Days

• Exclusions› Not a Medicare beneficiary or enrolled in Medicare Advantage program anytime

during the stay

› Enrolled in hospice care during the stay

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› Percentage of Short-Stay Residents Who Have Had an Outpatient Emergency Department Visit

• The percent of short-stay residents who entered or reentered the nursing home from a hospital & visited an emergency department within 30 days of the start of the nursing home stay, & this visit did not result in an inpatient or observation stay

• Includes stay that started over a 12-month period› Data updated every quarter with a lag time of 6 months

• Outpatient ED visits are identified using Medicare Part B claims


› Percentage of Short-Stay Residents Who Have Had an Outpatient Emergency Department Visit

• Exclusions› Residents not enrolled in Part A or B

› Residents never enrolled in Hospice during their stay

› Comatose or missing comatose data

› Missing data from claim or MDS used in the numerator or dominator

› Resident did not have an initial MDS assessment

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› Number of Outpatient Emergency Department Visits per 1,000 Long-Stay Resident Days

• Number of all-cause outpatient ED visits occurring in the target period & while the individual is a long-term nursing home resident. Outpatient ED visits are ED visits that do not result in an outpatient observation stay or inpatient hospital stay

• All days after the resident’s 100th cumulative day in the nursing home or the beginning of the 12-month target period (whichever is later) & until day of discharge, day of death or end of the 12-month target period (whichever is earlier)


› Number of Outpatient Emergency Department Visits per 1,000 Long-Stay Resident Days

• Exclusions› Not a Medicare beneficiary or enrolled in Medicare Advantage program anytime

during the stay

› Enrolled in hospice care during the stay

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Claims-Based Five-Star Measures› Rate of Successful Return to Home & Community from a SNF

• This measure reports the rate at which residents returned to home & community with no unplanned hospitalizations & no deaths in the 31 days following discharge from the SNF

• Estimate starts with the observed discharges to the community & is risk-adjusted for patient/resident characteristics & a statistical estimate of the facility effect beyond case mix


› Rate of Successful Return to Home & Community from a SNF

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Five-Star RatingHealth

InspectionHealth

Inspection

StaffingStaffing

QualityMeasures

QualityMeasures

Five-Star

Rating

SNF QRPA Brief Look at the Other Measures

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SNF Quality Reporting Program

› SNFs must have no less than 80% of the MDS assessment having 100% completion of the required SNF QRP data elements

› Failure to meet the minimum threshold may result in a two (2) percentage point reduction in the SNF’s Annual Payment Update (APU)

› New items added to the MDS effective October 1, 2018, will impact FY 2020

FY 2020 SNF QRP Measures

Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (National Quality Forum (NQF) #0674)

Percentage of Residents with Pressure Ulcers That Are New or Worsened (NQF #0678)

Application of Percent of Long-Term Care Hospital Patients with an Admission & Discharge Functional Assessment & a Care Plan That Addresses Function (NQF #2631)

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FY 2020 SNF QRP MeasuresChanges in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

Drug Regimen Review Conducted with Follow-Up for Identified Issues – PAC SNF QRP

Application of Functional Outcome Measure: Change in Self-Care for Medical Rehabilitation Patients (NQF #2633)

Application of Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634)

Application of Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635)

Application of Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636)

Current Claims-Based Measures

Discharge to Community – Post Acute Care (PAC) SNF QRP

Potentially Preventable 30-Day Post-Discharge Readmission Measure for SNF QRP

Medicare Spending per Beneficiary – PAC SNF QRP

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Data Collection Periods

Calendar Year Data Collection

Quarter

Data Collection/Submission

QRP

Quarterly Review & Correction Periods

Deadline Date

Quarter 1 January 1 to March 31 April 1 to August 15 August 15

Quarter 2 April 1 to June 30 July 1 to November 15 November 15

Quarter 3 July 1 to September 30 October 1 to February 15 February 15

Quarter 4 October 1 to December 31 January 1 to May 15 May 15

SNF VBPAnother Measure

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SNF Value-Based Purchasing

VBPRequired by 2014 Protecting Access to Medicare Act

2% withhold to fund program

Medicare payment incentive based on performance(SNF 30-Day All-Cause Readmission Measure)

Potential rate increase based on performance

Baseline vs. Performance Year

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CASPERCertification and Survey Provider Enhanced Reports

Accessing CASPER

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Assessing Reports

MDS 3.0 QM Reports

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MDS 3.0 QM Reports

› MDS 3.0 Facility Characteristics Report

› MDS 3.0 Facility Level Quality Measure Report

› MDS 3.0 Resident Level Quality Measure Report

› MDS 3.0 Monthly Comparison Report

SNF QRP

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SNF QRP

› SNF Facility Level Quality Measure Report

› SNF Provider Threshold Report

› SNF Resident Level Quality Measure Report

› SNF Review and Correct Report

SNF VBP

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Quality Measures› Solutions for success

• Take time to become familiar with the QM User’s Manual (v8.0)• Know the numerator criteria • Know the exclusions, risk groups or covariates for each measure• Understand what assessments are in play—target assessment or look-back

scan• Review facility level QM reports frequently

› Facility Characteristics Report› Facility Level QM Report› Resident Level QM Report

Quality Measures

› Solutions for success• Target MDS coding• Examine facility QI/QM processes if coding is accurate• Use 5-Star QMs as a starting point for more immediate impact• Up-to-date RAI manual• Ensure coordinators are trained• Internal or external audits• Software “pre-population”

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Quality Measures› Solutions for success

• ADL coding & “Rule of 3”• Proper use of definitions for falls & restraints• Section M & documentation of pressure ulcers• Effective fall, restraint & pressure ulcer prevention/reduction programs• Reliable medication reference

› Appendix PP (page 431)• Monitor Missing Assessment Report• Limit use of dashes [-]

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CONTINUING PROFESSIONAL EDUCATION (CPE) CREDIT

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• For questions, concerns or comments regarding CPE credit, please email the BKD Learning & Development Department at [email protected]

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The information contained in these slides is presented by professionals for your information only & is not to be considered as legal advice. Applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor or legal counsel before acting on any matters covered.

Documents

MDS 3.0 Quality Measures Update• Answer polls when they are provided ›Groups • Group leader is the person who registered & logged on to the webinar • Answer polls when they