Nursing Home Quality Measures: What Advocates Need to Know Prepared for National Consumer Voice Annual Conference November 3, 2016 11:00am – 12:30pm Beverley Laubert Ohio State Long-Term Care Ombudsman Karen Reilly, ScD Director, Quality Measurement and Health Policy Program

Disclosure Acknowledge RTI’s CMS contract, Development and Implementation of Symptom Management Measures, HHSM-500-2013-130151 Presentation is for Consumer Voice information purposes and not intended to be a statement of official federal CMS policy.

Ensuring Quality of Care for Everyone’s Mom & Dad

Session overview What is a quality measure and how are they used? Nursing Home Compare quality measures The IMPACT Act of 2014 and the Skilled Nursing Facility Quality Reporting Program—why?—what measures? Partnering in quality of care Your input is needed during the session!

What is a quality measure? Quality measures are tools that help us assess and quantify organizational structure and/or healthcare processes, outcomes, and patient perceptions against scientifically sound standards. All elements associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. Health care quality goals include: effective, safe, efficient, patient-centered, equitable, and timely care. A measure should be reliable, valid, actionable, useable, and important/relevant.

Why do we have quality measures? There is a great demand today for accurate and useful information on health care quality that can help inform the decision-making of consumers, employers, physicians and other clinicians, and policymakers. Issues such as patient (resident) perception and satisfaction are becoming increasingly important. Quality of care is becoming ever more closely linked with payment. Other reasons for having quality measures?

How are quality measures being used? Public reporting Used by consumers, advocates, providers, policymakers, and researchers Internal quality improvement to improve resident outcomes and experience of care Payment How do you use quality measures? Selection of a home – one piece of the decision, use the data to individualize the choice. Example – high pressure sores: If mom is ambulatory and repositions herself in bed independently but has had back problems, pressure sores might not be as important as a measure like treatment of pain. Monitoring care – data changes so it’s helpful to check back, especially after a change in nursing leadership or administrator; such leadership changes can lead to better care but they could also lead to a decline in care. Being an active part of the care team – Ask questions, know what the home’s goals are and provide feedback. If home’s goal is to reduce pressure sores, speak up when you notice Mom is left in her chair for long periods of time and doesn’t reposition herself. Expect excellence – Think about what excellence means to you and look at the data to see if the home is living up to your expectations.

How are quality measures developed? Reflects an idea or theory containing various elements Is a fraction‒ May incorporate exclusion criteria/risk adjustment to improve accuracy Exclude records with missing data Pressure Ulcer measure adjustments for bowel incontinence, for example Antipsychotic measure excludes schizophrenia, for example Assessed with tools or instruments (e.g.,MDS) Comprised of data elements (e.g., M0800)

How do data items fit within measure development?

How do data items and quality measures fit together? Concept/Idea: What are we interested in measuring (e.g., skin integrity)? Data Items: What pieces of information can we collect to measure our concept (e.g., M0800 new or worsening Stage II-IV pressure ulcers)? Response Options/Scales: What ways can we respond (e.g., a number greater than zero)? Quality Measure: How can we assemble the pieces of information to rigorously measure our idea (e.g., Percent of High-Risk Residents with Pressure Ulcers)? Assessment Instrument: What is the tool used to collect all of the information we can use to develop quality measures (e.g., MDS)?

Quality measures reported on Nursing Home Compare for Short-Stay Residents Short-Stay Quality Measures Percentage of Short-stay Residents Who Made Improvements in Function (new April 2016) Percentage of Short-Stay Residents Who Were re-hospitalized after a Nursing Home Admission (claims-based) (new April 2016) Percentage of Short-Stay Residents Who Have Had an Outpatient Emergency Department Visit (claims-based) (new April 2016) Percentage of Short-Stay Residents Who Were Successfully Discharged to the Community (claims-based) (new April 2016) Percent of Short-Stay Residents Who Self-Report Moderate to Severe Pain Percent of Short-Stay Residents with Pressure Ulcers that are New or Worsened Percent of Short-Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine Percent of Short-Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine Percent of Short-Stay Residents Who Newly Received an Antipsychotic Medication https://www.medicare.gov/NursingHomeCompare/About/Short-Stay-Residents.html Why are these measures useful to you?

Quality measures reported on Nursing Home Compare for Long-Stay Residents Long-Stay Quality Measures Percent of Long-Stay Residents Experiencing One or More Falls with Major Injury Percent of Long-Stay Residents with a Urinary Tract Infection Percent of Long-Stay Residents who Self-Report Moderate to Severe Pain Percent of Long-Stay High-Risk Residents with Pressure Ulcers Percent of Long-Stay Low-Risk Residents Who Lose Control of Their Bowels or Bladder Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder Percent of Long-Stay Residents Who Were Physically Restrained Percentage of Long-Stay Residents Whose Ability to Move Independently Worsened (new April 2016) Percent of Long-Stay Residents Whose Need for Help with Activities of Daily Living Has Increased Percent of Long-Stay Residents Who Lose Too Much Weight Percent of Long-Stay Residents Who Have Depressive Symptoms Percent of Long-Stay Residents Who Receive Antianxiety or Hypnotic Medication (new April 2016) Percent of Long-Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine Percent of Long-Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine Percent of Long-Stay Residents Who Received An Antipsychotic Medication https://www.medicare.gov/NursingHomeCompare/About/Long-Stay-Residents.html Why are these measures useful to you?

New quality measures on Nursing Home Compare Six new quality measures added to nursing Home Compare in April 2016 All but one included in the calculation of Nursing Home Five-Star quality ratings Three of these six new quality measures are based on Medicare-claims data submitted by hospitals, which is significant because this is the first time CMS is including quality measures that are not based solely on data that are self-reported by nursing homes. These three include the rate of re-hospitalization, emergency room use, and community discharge among nursing home residents. The six new measures include: Percentage of short-stay residents who were successfully discharged to the community (claims-based) Percentage of short-stay residents who have had an outpatient emergency department visit (claims-based) Percentage of short-stay residents who were re-hospitalized after a nursing home admission (claims-based) Percentage of short-stay residents who made improvements in function (MDS-based) Percentage of long-stay residents whose ability to move independently worsened (MDS-based) Percentage of long-stay residents who received an antianxiety or hypnotic medication (MDS-based) (not used in Five-Star quality rating) Which are these measures are most useful to you? How do you use any of these new measures? https://www.medicare.gov/nursinghomecompare/search.html

Five Star Quality Rating System The Five-Star Quality Rating System (created by CMS in 2008) is a tool to help consumers select and compare skilled nursing care centers Health Care Surveys (both standard and complaint) number, scope, and severity of deficiencies identified during the three most recent annual inspection surveys, as well as substantiated findings from the most recent 36 months of complaint investigations. All deficiency findings are weighted by scope and severity Quality Measures Nine long stay measures and seven short stay measures Five new measures implemented between July 2016 and January 2017. In July 2016, they will have 50% the weight of the current measures. In January 2017, they will have the same weight as the current measures Percent e of short-stay residents who were successfully discharged to the community (claims-based) Percentage of short-stay residents who have had an outpatient emergency department visit(claims-based) Percentage of short-stay residents who were re-hospitalized after a nursing home admission(claims-based) Percentage of short-stay residents who made improvements in function (MDS-based) Percentage of long-stay residents whose ability to move independently worsened (MDS-based) Staffing Registered nurse (RN) hours per resident day Total staffing hours (RN+ licensed practical nurse (LPN) + nurse aide hours) per resident day from the CMS Certification and Survey Provider Enhanced Reports (CASPER) system, and are case-mix adjusted based on distribution RUG-III MDS

PBJ System Electronic Staffing Data Submission Payroll-Based Journal (PBJ) System Report hours paid (except for paid time off) Applies to direct care staff who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being Includes therapy (as per resident or ‘absolute terms’) Primary role (may change during shift) Data reported should be auditable Questions or issues related to PBJ System?

Participant input What additional measures would you like to see developed/reported? Are there additional ways these measures can be used to drive provider quality improvement? Have you used NHC measures to make decisions? Is the information helpful? What makes a good measure? What are the strengths of the system described? What quality measure information is most useful? Most useful items? Most useful measures? What are the caution flags?

Why are quality measures updated? Revisions lead to better quality measurement Increased precision in measuring concept Reflect changes in clinical practice Measure may become insensitive to capture quality differences across providers Adding/deleting quality measures from standard reporting alleviates provider reporting burden Questions or issues needing attention?

Policy history—new era with IMPACT Act of 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 is a Bipartisan bill passed on September 18, 2014 and signed into law by President Obama on October 6, 2014. Requires standardized patient assessment data across post-acute care (PAC) settings that will enable: Quality care and improved outcomes Data element uniformity Comparison of quality and data across post acute care settings Improved, person-centered, goal-driven discharge planning Exchangeability of data Coordinated care https://www.govtrack.us/congress/bills/113/hr4994

Purpose of the IMPACT Act of 2014 Improvement of Medicare beneficiary outcomes Provider access to longitudinal information to facilitate coordinated care Enable comparable data and quality across PAC settings Improve hospital discharge planning Research to enable payment models based on patient characteristics Why the attention on Post-Acute Care? Escalating costs associated with PAC Lack of data standards/interoperability across PAC settings Goal of establishing payment rates according to the individual characteristics of the patient, not the care setting

IMPACT Act Quality Domains Incidence of major falls Skin integrity and changes in skin integrity Functional status, cognitive function, and changes in function and cognitive function Medication reconciliation Communicating the existence of and providing for the transfer of health information and care preferences

IMPACT Act Resource Use and Other Measures Resource use and other measures will be specified for reporting, which may include standardized assessment data in addition to claims data Resource use and other measure domains include: Total estimated Medicare spending per beneficiary Discharge to community All-condition risk-adjusted potentially preventable hospital readmission rates Questions or input regarding the IMPACT Act measures?

Skilled Nursing Facility Quality Reporting Program In response to the reporting requirements under the IMPACT Act, CMS established the SNF Quality Reporting Program (QRP) and its quality reporting requirements in the FY 2016 SNF Prospective Payment System (PPS) final rule. Per the statute, SNFs that do not submit the required quality measures data may receive a two percentage point reduction to their annual payment update (APU) for the applicable payment year. The program is effective October 1, 2016 SNFs currently submit MDS 3.0 data to CMS through the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. The October 1, 2016 implementation of the SNF QRP will not change the process of MDS 3.0 data submission through QIES. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-IMPACT-Act-2014.html

SNF QRP roll out FY 2018 payment determination will be based on one quarter of data (10/1/16 to 12/31/16) In the FY 2016 SNF PPS final rule, 3 quality measures affecting FY 2018 payment determination were finalized for adoption into the SNF QRP Three claims based measures are added to the list in FY 2017 rule but it does not impact SNF data submission. Questions may be submitted by email to: SNFQualityQuestions@cms.hhs.gov Payment Determination Affected Data Collection Period Data Submission Deadline FY2018 10/1/16-12/31/16 5/15/17

SNF QRP quality measures All 3 quality measures use assessment data from the MDS 3.0 Application of Percent of Residents Experiencing One of More Falls with Major Injury (Long Stay) (NQF #0674) Reports the percentage of resident Medicare Part A stays where one or more falls with major injury (defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma) occurred during the SNF stay Percent of Patients or Residents with Pressure Ulcers that are New or Worsened (NQF #0678) This QM is adopted as a cross-setting measure to meet the requirements of the IMPACT Act of 2014 addressing the domain of skin integrity and changes in skin integrity This measure is intended to encourage PAC providers to prevent pressure ulcer development or worsening, and to closely monitor and appropriately treat existing pressure ulcers Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF #2631) CMS has adopted this measure to satisfy the IMPACT Act requirements for CMS to specify QMs and PAC providers to report standardized data regarding functional status, cognitive function, and changes in function and cognitive function. Section GG – self-care and mobility items added to MDS in order to calculate this quality measure https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/SNF-QRP-Measure-Specifications_August-2015R.pdf

Coming back to…how are quality measures used? Public reporting Used by consumers, advocates, providers, policymakers, and researchers Internal quality improvement to improve resident outcomes and experience of care Payment Need for accuracy of the MDS! How do you use quality measures?

Partnering in Quality of Care State Long-Term Care Ombudsman Participate in a Technical Expert Panel (TEP)—As part of its measure development process, a groups of stakeholders and experts who contribute input to the measure contractors during measure development. Priority that a consumer representative be on the TEP. You can nominate yourself or other individual for consideration on a TEP. Comment on a CMS quality measure—The public comment period provides an opportunity for the widest array of interested parties to provide input on the measures under development and can provide critical suggestions not previously considered by the measure developer or the TEP. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/CallforPublicComment.html. For example, draft specifications for the SNF Functional Status Quality Measures comment period is 10/7/16 – 11/4/16. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/CallforPublicComment.html. Summary report to be posted on CMS web site. Attend an Open Door Forum (ODF) & Special Open Door Forums (SODFs)—an opportunity for live dialogue between CMS and the stakeholder community at large. These are intended for all stakeholders who interact with CMS or work with consumers who rely on services that CMS provides Participate in National Provider Calls—educational conference calls conducted for the Medicare provider and supplier community that educate and inform participants about new policies and/or changes to the Medicare program. How would you like to become involved? What are the most important issues for you to have input on?

QUESTIONS?

THANK YOU! Contact: kreilly@rti.org BLaubert@age.ohio.gov