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Presented by: Judi Kulus, MSN, MAT, RN, NHA, RAC-MT, DNS-CT VP of Curriculum Development jkulus@aanac.org

What's New? What's Changed? Urgent Updates

QM Manual v10

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Faculty Disclosure

• I have no financial relationships to disclose

• I have no conflicts of interests to disclose

• I will not promote any commercial products or services

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Requirements for Successful Completion

• 1.0 contact hour will be awarded for this continuing nursing education activity

• Criteria for successful completion includes attendance for at least 80% of the entire event. Partial credit may not be awarded.

• Approval of this continuing education activity does not imply endorsement by AANAC or ANCC (American Nurses Credential Center) of any commercial products or services.

American Association of Post-Acute Care Nursing (AAPACN)* is accredited as a provider of continuing nursing education by the

American Nurses Credentialing Center’s Commission on accreditation.

*AAPACN d/b/a American Association of Nurse Assessment Coordination

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Learning Objectives

• Describe the components needed to calculate each new Quality Measure

• List 4 specific Quality Measure vulnerabilities related to MDS accuracy

• Discuss clinical system practices needed for achieving competitive Quality Measures

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Medicare Quality Reporting Program and Value-Based Purchasing

2016 Goals

All Medicare FFS Linked to Quality

85%

2018 Goals All Medicare FFS Linked to Quality

90%

Impact Act

QRP

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What to Know

• Six new QMs posted on Nursing Home Compare

• Revised MDS 3.0 QM User’s Manual v10 posted

• Separate draft manual for the claims-based QMs

• Coming soon! Five-Star manual (July, 2016)

– Phase in of 5 of 6 QMS over 6 months beginning in July

– Excludes: Antianxiety/hypnotic Meds QM

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Six New Measures Added to Nursing Home Compare

Discharge to Community

Emergency Department Use

Re-Hospitalization

Improvement in Function Since Admission

Decline in Mobility

Use of Hypnotics/Anxiolytics

Short-Stay Long-Stay

Includes Events that Occur AFTER Discharge

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Six New Measures Added to Nursing Home Compare

Claims Based MDS

Based

Use of Hypnotics/Anxiolytics

Decline in Mobility

Improvement in Function Since

Admission

Re-hospitalizations

Emergency Dept Visits

Return to Community

PROVIDER PREVIEW REPORTS

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Six New Quality Measures

Reported April, 2016 on Nursing Home Compare (Provider Rating Report)

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Accessing the QM Reports (MDS System)

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Get Provider Preview Reports in Folder Titled: “st LTC facid'

Accessing the QM Reports (MDS System)

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Poll Question #1

Has your facility downloaded your Provider Preview Reports?

a. Not yet, but I will do it right after the webinar

b. Yes, I’ve seen them, but we have not had a QAA meeting about them

c. Yes, I’ve seen them and we have begun QAPI Planning to make improvements

d. I’m still unclear about what these reports are and where to find them

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Percent of Short-stay Residents Successfully Discharged to Community1

Measure uses UB-04 claim and MDS assessment

data to identify successful community discharges

within 100 days of admission to the SNF, directly

from the hospital, AND who stayed in community

for 30 days without

• Being hospitalized

• Not readmitted to a nursing home

• Did not die in the 30 days after discharge

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Percent of Short-stay Residents Successfully Discharged to Community2

Numerator and Denominator Window

• The numerator and denominator include episodes that

started over a 12-month period

• The data are updated every six months (in April and

October of each year), with a lag time of nine months

• (i.e., the data posted in April, 2016 will include

episodes that started 9-21 months prior)

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Percent of Short-stay Residents Successfully Discharged to Community3

Numerator

• MDS discharge assessment, Item A2100 = 01, “Community” within 100 calendar days of the start of the episode

AND • UB-04 indicates resident not admitted to a nursing home

within 30 days of the community discharge AND

• No unplanned inpatient hospital stay within 30 days of the community discharge. (Unplanned determined from the principal diagnosis and procedure codes on Medicare claims)

AND • Did not die within 30 days of the community discharge,

as determined from the Medicare Enrollment database

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Percent of Short-stay Residents Successfully Discharged to Community4

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Percent of Short-stay Residents Successfully Discharged to Community5

Occurrence Code 70: Hospital Stay

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Percent of Short-stay Residents Successfully Discharged to Community6

Denominator

• Entered the nursing home within 1 day of

discharge from an inpatient hospitalization

• Entered the nursing home within the target

12-month period

• Identified by using Medicare Part A claims

• Excludes inpatient rehabilitation facility and

long-term care hospitalizations

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Percent of Short-stay Residents Successfully Discharged to Community7

Denominator Exclusions

• Not Fee-for-Service Parts A and B Medicare during risk period

• Excludes Hospice enrollees during the nursing home episode

• Resident was comatose (B0100 =[01]) or missing data on comatose on the first MDS assessment after the start of the episode

• Missing data on claims or MDS items used to construct the numerator or denominator

• Resident did not have an initial MDS assessment to use in constructing covariates for risk-adjustment

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Percent of Short-stay Residents Successfully Discharged to Community8

Covariates

See Tables 8 and 9 in the handouts for the list of

claims-based and MDS-based covariates (pp. 9-11)

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Percent of Short-stay Residents with Outpatient Emergency Department Visit1

Determines the percentage of all new admissions or

readmissions to a nursing home from a hospital

where the resident had an outpatient ED visit

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Percent of Short-stay Residents with Outpatient Emergency Department Visit2

Numerator: Number of residents

• Admitted to an emergency department within 30 days

of entry/reentry to the nursing home

• Includes ED visits that occur after discharged from the

nursing home

• Not admitted to a hospital for an inpatient stay or

observation stay immediately after the visit to the

emergency department

• ER visits are identified using Medicare Part B claims

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Percent of Short-stay Residents with Outpatient Emergency Department Visit3

Denominator: Number of residents who

• Entered or reentered the nursing home within 1 day of

discharge from an inpatient hospitalization

• Entered or reentered the nursing home within the target 12-

month period

• Excludes inpatient rehabilitation facility and long-term care

hospitalizations

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Percent of Short-stay Residents with Outpatient Emergency Department Visit4

Denominator Exclusions

• Not Fee-for-Service Parts A and B Medicare during risk period

• Excludes Hospice enrollees during the nursing home episode

• Resident was comatose (B0100 =[01]) or missing data on comatose on the first MDS assessment after the start of the episode

• Missing data on claims or MDS items used to construct the numerator or denominator

• Resident did not have an initial MDS assessment to use in constructing covariates for risk-adjustment

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Percent of Short-stay Residents with Outpatient Emergency Department Visit5

Covariates

See Tables 5 and 6 of the handouts for the list of

claims-based and MDS-based covariates (p. 6-7).

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Percent of Short-stay Residents Re-hospitalized After a Nursing Home Admission1

The percent of short-stay residents who entered or

reentered the nursing home from a hospital and were

re-admitted to a hospital for an unplanned inpatient

stay or observation stay within 30 days of the start of

the nursing home stay

• Planned inpatient readmissions are excluded

• Includes observation stays

• Includes hospitalizations that occur after nursing home

discharge but within 30 days of the stay start date

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Percent of Short-stay Residents Re-hospitalized After a Nursing Home Admission2

Planned Re-admissions

• Bone marrow, kidney, or other transplants.

• Maintenance chemotherapy and rehabilitation

• Normal pregnancy, Cesarean section; forceps delivery, vacuum, and breech delivery

• Readmissions to psychiatric hospitals or units

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Percent of Short-stay Residents Re-hospitalized After a Nursing Home Admission3

Denominator

• Entered or reentered the nursing home within 1 day of discharge from an inpatient hospitalization; AND

• Entered or reentered the nursing home within the target 12-month period

• Identified by using Medicare Part A claims

• Excludes inpatient rehabilitation facility and long-term care hospitalizations

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Percent of Short-stay Residents Re-hospitalized After a Nursing Home Admission4

Denominator Exclusions

• Not Fee-for-Service Parts A and B Medicare during risk period

• Excludes Hospice enrollees during the nursing home episode

• Resident was comatose (B0100 =[01]) or missing data on comatose on the first MDS assessment after the start of the episode

• Missing data on claims or MDS items used to construct the numerator or denominator

• Resident did not have an initial MDS assessment to use in constructing covariates for risk-adjustment

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Percent of Short-stay Residents Re-hospitalized After a Nursing Home Admission5

Covariates

See Tables 2 and 3 of the handouts for the list of

claims-based and MDS-based covariates (pp. 2-4).

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Percent of Short-stay Residents Who Improved Performance on Transfer, Locomotion,

and Walking in the Corridor1

Captures the percentage of short-stay residents who

were discharged from the nursing home that gained

more independence in transfer, locomotion, and

walking during their episodes of care

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Percent of Short-stay Residents Who Improved Performance on Transfer, Locomotion,

and Walking in the Corridor2 Numerator

• Short-stay residents who: – Have a valid discharge assessment-return not

anticipated (A0310F = [10]) and a valid preceding 5-day assessment (A0310B = [01]) or admission assessment (A0310A = [01]*); AND

– Have a change in performance score that is negative ([Discharge] - [5-day or admission assessment] < [0]), using the earlier assessment if resident has both 5-day and admission assessments

*Uses the earliest assessment if both submitted

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Percent of Short-stay Residents Who Improved Performance on Transfer, Locomotion,

and Walking in the Corridor3 Performance calculation

• Sum of:

– G0110B1 (transfer: self- performance)

Plus

– G0110E1 (locomotion on unit: self-performance)

Plus

– G0110D1 (walk in corridor: self-performance)

• ADL Scores of 7’s (activity occurred only once or twice) and 8's (activity did not occur) recoded to 4's (total dependence)

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Percent of Short-stay Residents Who Improved Performance on Transfer, Locomotion,

and Walking in the Corridor4

• Numerator Example

MDADL 5-Day/ Admission

Discharge Return Not Anticipated

Transfers Self-performance = 3 Self-performance = 2

Locomotion on Unit Self-performance = 2

Self-performance = 1

Walk in corridor Self-performance = 8

Self-performance = 3

Totals 3 + 2 + 4 = 9 2 + 1 + 3 = 6

MDALD Score Improves and Adds to the Numerator

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Percent of Short-stay Residents Who Improved Performance on Transfer, Locomotion,

and Walking in the Corridor5

Denominator

• Short-stay residents who meet all of the

following conditions, except those with

exclusions:

– Have a valid discharge assessment (A0310F =

[10], Discharge Return Not-Anticipated), AND

– Have a valid preceding 5-day assessment

(A0310B = [01]) or admission assessment

(A0310A = [01])

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Percent of Short-stay Residents Who Improved Performance on Transfer, Locomotion,

and Walking in the Corridor6

Exclusions

• Prior assessment is the 5-day or Admission assessment

and coded

– Comatose (B0100 = [1])

– Life expectancy of less than 6 months (J1400 = [1])

– Hospice (O0100K2 = [1])

• Prior assessment and target assessment

– Missing data in G0110B1, G0110D1, or G0110E1

– Residents with no impairment (sum of G0110B1, G0110D1 and

G0110E1 = [0]) on the 5-day target assessment

– Residents with an unplanned discharge on any assessment

during the care episode (A0310G = [2])

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Percent of Short-stay Residents Who Improved Performance on Transfer, Locomotion,

and Walking in the Corridor7 Covariates • (From the 5-day or admission assessment)

• Age (<=54, 55-84, or >84) (A0900)

• Gender (A0800)

• Severe cognitive impairment (C0500, C0700, and C1000)

• Long-form ADL Scale (G0110A1 + G0110B1 + G0110E1 + G0110G1 + G0110H1 + G0110I1 + G0110J1) (categorized by tercile in the quarter)

• Heart failure (I0600)

• CVA, TIA, or stroke (I4500)

• Hip fracture (I3900)

• Other fracture (I4000)

LONG STAY QUALITY MEASURES

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Residents Whose Ability to Move Independently Has Worsened1

Captures long stay residents who experienced a decline in independence in locomotion.

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Residents Whose Ability to Move Independently Has Worsened2

Numerator • Long-stay residents with a selected target assessment and at

least one qualifying prior assessment who have a decline in locomotion when comparing their target assessment with the prior assessment.

• Decline identified by:

– Recoding all values (G0110E1 = [7, 8]) to (G0110E1 = [4])

– Increase of one or more points on the “locomotion on unit: self-performance” item between the target assessment and prior assessment (G0110E1 on target assessment – G0110E1 on prior assessment ≥1)

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Residents Whose Ability to Move Independently Has Worsened3

Denominator

• Long-stay residents who have a qualifying MDS 3.0 target

assessment and at least one qualifying prior assessment,

except those with exclusions (see next slide)

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Residents Whose Ability to Move Independently Has Worsened4

Exclusions (Handout p.13)

• Residents satisfying any of the following conditions: – Comatose or missing data on comatose (B0100 = [1, -])

at the prior assessment.

– Prognosis of less than 6 months at the prior assessment as indicated by:

– Prognosis of less than six months of life (J1400 = [1]), OR

– Hospice use (O0100K2 = [1]), OR

– Neither indicator for being end-of-life at the prior assessment (J1400 ≠ [1] and O0100K2 ≠ [1]) and a missing value on either indicator (J1400 = [-] or O0100K2 = [-])

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Residents Whose Ability to Move Independently Has Worsened5

Exclusions (Handout p.13) (Con’t)

• Residents satisfying any of the following conditions: – Resident totally dependent during locomotion on prior

assessment (G0110E1 = [4, 7, or 8])

– Missing data on locomotion on target or prior assessment (G0110E1 = [-]).

– Prior assessment is a discharge with or without return anticipated (A0310F = [10, 11])

– No prior assessment is available to assess prior function

– Target assessment is an admission assessment (A0310A = [01]), a PPS 5-day (A0310B = [01]), or the first assessment after an admission (A0310E = [01]), or A0310B = [06]

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Residents Whose Ability to Move Independently Has Worsened6

Covariates (Handout p.13)

From the prior assessment:

• Eating (self-performance): Needs help (G0110H1)

• Eating (self-performance): Dependence (G0110H1)

• Toileting (self-performance): Needs help (G0110I1)

• Toileting (self-performance): Dependence (G0110I1)

• Transfer (self-performance): Needs help (G0110B1)

• Transfer (self-performance): Dependence (G0110B1)

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Residents Whose Ability to Move Independently Has Worsened7

Covariates (Handout p.13)(Con’t) • Walking in corridor (self-performance): Independence (G0110D1)

• Walking in corridor (self-performance): Needs some help (G0110D1)

• Walking in corridor (self-performance): Needs more help (G0110D1)

• Severe cognitive impairment (C0500, C0700, and C1000)

• Linear age (A0900)

• Gender (A0800)

• Positive vision change score calculated from prior assessment to latest assessment with non-missing value after prior assessment (B1000)

• No oxygen use on prior assessment (O0100C2 = [0]) and oxygen use on latest assessment with non-missing value after prior assessment (O0100C2 = [1])

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Residents Who Receive Antianxiety/Hypnotic Medication1

Captures long stay residents receiving an antianxiety and/or hypnotic medication. It excludes residents who are receiving hospice care or have a life expectancy of less than 6 months

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Residents Who Receive Antianxiety/Hypnotic Medication2

Numerator

• Long-stay residents with a selected target assessment

where any of the following conditions are true:

– For assessments with target dates on or before 03/31/2012:

– Antianxiety medications received (N0400B = [1]), or

– Hypnotic medications received (N0400D = [1]).

– For assessments with target dates on or after 04/01/2012:

– Antianxiety medications received (N0410B = [1, 2, 3, 4, 5, 6,

7]), or

– Hypnotic medications received (N0410D = [1, 2, 3, 4, 5, 6,

7]).

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Residents Who Receive Antianxiety/Hypnotic Medication3

Denominator

• Long-stay residents with a selected target assessment,

except those with exclusions (see next slide

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Residents Who Receive Antianxiety/Hypnotic Medication4

Exclusions

• The resident did not qualify for the numerator and any of the following is true:

– For assessments with target dates on or before 03/31/2012: (N0400B = [-] or N0400D = [-])

– For assessments with target dates on or after 04/01/2012: (N0410B = [-] or N0410D = [-])

– Any of the following related conditions are present on the target assessment (unless otherwise indicated):

– Life expectancy of less than 6 months (J1400 = [1])

– Hospice care while a resident (O0100K2 = [1])

Improving and Maintaining QM scores

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Poor QM Score Contributors

• Staff don’t understand the QM scores

• Lack of PIPs for poor performing QMs

• Not all shifts are included in CQI

• Lack of coordination across the care continuum

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Poll Question #2

How would you rate your facility’s Quality Measure management system?

a) Fair

b) Average

c) Good

d) Excellent

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Tips to Improved Scores

• Manage QMs PROACTIVELY rather than Retrospectively

• Download and review QM scores Monthly

• Review scores as a team

• Sample audit resident charts

• Evaluate and enhance Transitions of Care Program

• Understand the Reimbursement Implications

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Tips to Improved MDS Accuracy

• Ensure accuracy of MDS assessments

• Shore up documentation

• Utilize the entire care team

• Code with integrity

QUESTIONS

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Resources

MDS 3.0 Quality Measures User’s Manual v10

• https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-Users-

Manual-V10.pdf

CMS Five-Star Quality Rating System website

• https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/fsqrs.html

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Resources

Claims-based QM Technical Specifications Manual

• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/New-Measures-Technical-Specifications-DRAFT-04-05-16-.pdf

Claims-based QM Technical Specifications Appendices • https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/CertificationandComplianc/Downloads/APPENDIX-New-Claims-based-measuresTechnical-Specifications-04-05-16.pdf

SNF PPS Proposed Rule • https://www.gpo.gov/fdsys/pkg/FR-2016-04-25/pdf/2016-09399.pdf

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Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program • https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP-Proposed-Rule-ODF-Presentation.pptx