Admissions and Readmissions from Post-Acute Care Facilities Regional Learning & Action Network Meetings 2017

Acronyms DE – Data element HHAs – Home health agencies IMPACT Act – Improving Medicare Post-Acute Care Transformation Act of 2014 IRFs – Inpatient rehabilitation facilities IRF-PAI – IRF-Patient Assessment Instrument LTCHs – Long-term care hospitals

Acronyms (cont.) LCDS – LTCH CARE Data Set MDS – Minimum Data Set OASIS – Outcome and Assessment Information Set PAC – Post -acute care PAC-PRD – Post-Acute Care Payment Reform Demonstration QRP-quality reporting program SNFs – Skilled nursing facilities TEP – Technical Expert Panel

Why are we discussing this now? Improved QUALITY OF CARE for our residents Impact ACT Failure to Report Assessment Data Penalties Coordination of Care Readmission Penalties (2018)

CMS Overall Quality Strategy Affordable Care: Reduce the cost of quality healthcare for individuals families, employers, and government Background The demonstration will be open to free-standing and hospital-based facilities and will include beneficiaries who are on a Part A stay as well as those with Part B coverage only. The demonstration will be conducted in 3 states: Arizona, New York and Wisconsin. Each year of the demonstration, CMS will assess each participating nursing home’s quality performance based on four domains: staffing, appropriate hospitalizations, minimum data set (MDS) outcomes, and survey deficiencies. CMS will award points to each nursing home based on how they perform on the measures within each of the domains. These points will be summed to produce an overall quality score. For each State, nursing homes with scores in the top 20 percent and homes that are in the top 20 percent in terms of improvement in their scores will be eligible for a share of that State’s savings pool. Initiative Details A payment pool will be determined each year for each State based on Medicare savings that result from reductions in the growth of Medicare expenditures, primarily from reductions in hospitalizations. We anticipate that higher quality of care will result in fewer avoidable hospitalizations, resulting in decreases in Medicare-paid hospitalizations and subsequent skilled nursing home stays. The demonstration began July 1, 2009. The number of participating nursing homes in each State is as follows: Arizona - 41 homes; New York - 79 homes; Wisconsin - 62 homes.

IMPACT ACT This important legislation requires that patient assessment data used in post-acute care settings be standardized to improve quality of care. Post Acute Care Providers(PAC): Skilled Nursing Facilities Home Health Agencies Inpatient Rehabilitation Facilities Long-Term Care Hospitals

IMPACT ACT (cont.) The Act also supports the interoperable exchange of assessment data across post-acute care settings and other providers to facilitate coordinated care and improved beneficiary outcomes. Patrick Conway: http://bit.ly/2gP6ekE

Mississippi 30 day Readmission by Facility Type (1st quarter 2017)

Themes of the New Rules for Healthcare Person-Centered Care Residents and Representatives: Informed, Involved and In Control Quality Quality of Care and Quality of Life Facility Assessment, Competency-Based Approach Facilities need to know themselves, their staff and their residents

Person-Centered Care Residents and Representatives: Informed, Involved and In Control Existing protections maintained Choices (treatment preferences of patients) Care and Discharge Planning (goals of care of the patients) Definition of Person Centered Care Choices: Residents rights ., participate in Care planning, identify individuals, request meetings, request revisions of Plan of Care. Right to sign care plan. Evidence of care giverfs, SSA, etc. Care planning: Comprehensive Person Centerd Care Planning Improving resident satisfactin and safety. Example: documentation if a resident is not involved in the IDT C.N.A. , dietary, social worker to be included Dietary and uplanned weight loss…social workers significant role ..w/familes. Qualiticaton for SW: must have a bacholr degree or HS field Goals of care , desired outcomes. Sect 2 Impact Act: residnets be informed. Asst residents Residnets needs and rights to make choices.

Facility Assessment and Competency-Based Approach Facilities need to know themselves, their staff and their residents. Not a one-size fits all approach Accounts for and allows for diversity in populations and facilities Focuses on each resident achieving their highest practical physical, mental and psychosocial well-being Facilites need to know themselves, staff and residents. Individualized assessment. Population varies between faciliitles, example high post acute, or high alzhermier/dementa, or yuounger population Know acuity and range of diagnosis…this data should be used e.g. staffing. Competency based staffing: facility responsibilities, respect resdidnets choice Nursing ; sufficient nursing staff. Food and nutrial services, staffing mus mueet needs. 5 year window for existing professionals to meet new requirements. Activities director: support mental and pyshco social

Quality Reporting Quality Reporting The IMPACT Act of 2014 requires the Secretary to implement specified clinical assessment domains using standardized (uniform) data elements to be nested within the assessment instruments currently required for submission by LTCH, IRF, SNF, and HHA providers. Background The demonstration will be open to free-standing and hospital-based facilities and will include beneficiaries who are on a Part A stay as well as those with Part B coverage only. The demonstration will be conducted in 3 states: Arizona, New York and Wisconsin. Each year of the demonstration, CMS will assess each participating nursing home’s quality performance based on four domains: staffing, appropriate hospitalizations, minimum data set (MDS) outcomes, and survey deficiencies. CMS will award points to each nursing home based on how they perform on the measures within each of the domains. These points will be summed to produce an overall quality score. For each State, nursing homes with scores in the top 20 percent and homes that are in the top 20 percent in terms of improvement in their scores will be eligible for a share of that State’s savings pool. Initiative Details A payment pool will be determined each year for each State based on Medicare savings that result from reductions in the growth of Medicare expenditures, primarily from reductions in hospitalizations. We anticipate that higher quality of care will result in fewer avoidable hospitalizations, resulting in decreases in Medicare-paid hospitalizations and subsequent skilled nursing home stays. The demonstration began July 1, 2009. The number of participating nursing homes in each State is as follows: Arizona - 41 homes; New York - 79 homes; Wisconsin - 62 homes.

Requirement for Reporting Assessment Data Beginning no later than Oct.1, 2018 the Secretary shall require PAC providers to submit to the Secretary, under the applicable reporting provisions and through the use of Post Acute Care assessment instruments, the standardized patient assessment data.

Standardized Patient Assessment Data Functional status, such as mobility and self care at admission to a PAC provider and before discharge from a PAC provider Cognitive function, such as ability to express ideas and to understand, mental status, such as depression and dementia Special services, treatments, and interventions, such as need for ventilator use, dialysis, chemotherapy, central line placement and total parenteral nutrition.

Standardized Patient Assessment Data (cont.) Medical conditions and co-morbidities, such as diabetes congestive heart failure, and pressure ulcer. Impairments, such as incontinence and an impaired ability to hear see, or swallow.

Standardized Patient Assessment Data (cont.) Skin integrity and changes in skin integrity Medication reconciliation Incidence of major falls Communicating and providing for the transfer of health information and care preferences of an individual when the individual transitions

Penalties for Failure to Report Beginning fiscal year (FY) 2018 and each subsequent rate year, the Secretary shall reduce payment rates during such FY by 2 percentage points for any SNF that does not comply with data submission requirements for such a FY. Background The demonstration will be open to free-standing and hospital-based facilities and will include beneficiaries who are on a Part A stay as well as those with Part B coverage only. The demonstration will be conducted in 3 states: Arizona, New York and Wisconsin. Each year of the demonstration, CMS will assess each participating nursing home’s quality performance based on four domains: staffing, appropriate hospitalizations, minimum data set (MDS) outcomes, and survey deficiencies. CMS will award points to each nursing home based on how they perform on the measures within each of the domains. These points will be summed to produce an overall quality score. For each State, nursing homes with scores in the top 20 percent and homes that are in the top 20 percent in terms of improvement in their scores will be eligible for a share of that State’s savings pool. Initiative Details A payment pool will be determined each year for each State based on Medicare savings that result from reductions in the growth of Medicare expenditures, primarily from reductions in hospitalizations. We anticipate that higher quality of care will result in fewer avoidable hospitalizations, resulting in decreases in Medicare-paid hospitalizations and subsequent skilled nursing home stays. The demonstration began July 1, 2009. The number of participating nursing homes in each State is as follows: Arizona - 41 homes; New York - 79 homes; Wisconsin - 62 homes.

CMS Quality Strategy & The IMPACT Act The IMPACT Act supports these aims while upholding the CMS Quality Strategy’s goals, which are: Making care safer by reducing harm caused in the delivery of care. Ensuring that each person and family is engaged as partners in their care. Promoting effective communication and coordination of care models. Background The demonstration will be open to free-standing and hospital-based facilities and will include beneficiaries who are on a Part A stay as well as those with Part B coverage only. The demonstration will be conducted in 3 states: Arizona, New York and Wisconsin. Each year of the demonstration, CMS will assess each participating nursing home’s quality performance based on four domains: staffing, appropriate hospitalizations, minimum data set (MDS) outcomes, and survey deficiencies. CMS will award points to each nursing home based on how they perform on the measures within each of the domains. These points will be summed to produce an overall quality score. For each State, nursing homes with scores in the top 20 percent and homes that are in the top 20 percent in terms of improvement in their scores will be eligible for a share of that State’s savings pool. Initiative Details A payment pool will be determined each year for each State based on Medicare savings that result from reductions in the growth of Medicare expenditures, primarily from reductions in hospitalizations. We anticipate that higher quality of care will result in fewer avoidable hospitalizations, resulting in decreases in Medicare-paid hospitalizations and subsequent skilled nursing home stays. The demonstration began July 1, 2009. The number of participating nursing homes in each State is as follows: Arizona - 41 homes; New York - 79 homes; Wisconsin - 62 homes.

CMS Quality Strategy & The IMPACT Act (cont.) Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease. Working with communities to promote wide use of best practices to enable healthy living. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new healthcare delivery Background The demonstration will be open to free-standing and hospital-based facilities and will include beneficiaries who are on a Part A stay as well as those with Part B coverage only. The demonstration will be conducted in 3 states: Arizona, New York and Wisconsin. Each year of the demonstration, CMS will assess each participating nursing home’s quality performance based on four domains: staffing, appropriate hospitalizations, minimum data set (MDS) outcomes, and survey deficiencies. CMS will award points to each nursing home based on how they perform on the measures within each of the domains. These points will be summed to produce an overall quality score. For each State, nursing homes with scores in the top 20 percent and homes that are in the top 20 percent in terms of improvement in their scores will be eligible for a share of that State’s savings pool. Initiative Details A payment pool will be determined each year for each State based on Medicare savings that result from reductions in the growth of Medicare expenditures, primarily from reductions in hospitalizations. We anticipate that higher quality of care will result in fewer avoidable hospitalizations, resulting in decreases in Medicare-paid hospitalizations and subsequent skilled nursing home stays. The demonstration began July 1, 2009. The number of participating nursing homes in each State is as follows: Arizona - 41 homes; New York - 79 homes; Wisconsin - 62 homes.

Quality Report Program Additional Resources Please also visit the CMS Post-Acute Care Quality Initiative website for more information related to cross setting quality measures and quality initiatives: http://go.cms.gov/2werYwb Information on the IMPACT Act of 2014 can be found at: http://bit.ly/1zdNnAP http://bit.ly/2xiJ9S7 For SNF Quality Reporting Program comments or questions: SNFQualityQuestions@cms.hhs.gov Background The demonstration will be open to free-standing and hospital-based facilities and will include beneficiaries who are on a Part A stay as well as those with Part B coverage only. The demonstration will be conducted in 3 states: Arizona, New York and Wisconsin. Each year of the demonstration, CMS will assess each participating nursing home’s quality performance based on four domains: staffing, appropriate hospitalizations, minimum data set (MDS) outcomes, and survey deficiencies. CMS will award points to each nursing home based on how they perform on the measures within each of the domains. These points will be summed to produce an overall quality score. For each State, nursing homes with scores in the top 20 percent and homes that are in the top 20 percent in terms of improvement in their scores will be eligible for a share of that State’s savings pool. Initiative Details A payment pool will be determined each year for each State based on Medicare savings that result from reductions in the growth of Medicare expenditures, primarily from reductions in hospitalizations. We anticipate that higher quality of care will result in fewer avoidable hospitalizations, resulting in decreases in Medicare-paid hospitalizations and subsequent skilled nursing home stays. The demonstration began July 1, 2009. The number of participating nursing homes in each State is as follows: Arizona - 41 homes; New York - 79 homes; Wisconsin - 62 homes.

Skilled Nursing Facilities Could Face Readmission Penalties Skilled nursing facilities could soon share responsibility—and accompanying penalties—with hospitals for avoidable readmissions, as the Department of Health and Human Services (HHS) included the Medicare Payment Advisory Commission’s (MedPAC) recommendation to Congress in its fiscal year 2014 budget proposal.

Skilled Nursing Facilities Could Face Readmission Penalties (cont.) About 14 percent of Medicare patients discharged from hospitals to skilled nursing facilities are re-hospitalized for conditions that potentially could have been avoided, according to MedPAC analysis.

Skilled Nursing Facilities Could Face Readmission Penalties (cont.) HHS’s proposal reduces payments by up to 3 percent for skilled nursing facilities with high rates of care-sensitive, preventable hospital readmissions beginning in 2017 in a bid to promote high quality care and potentially save $2.2 billion over 10 years. The Affordable Care Act places emphasis on hospitals and their ability to provide quality care while achieving cost savings for Medicare and reducing preventable hospital readmissions, but the skilled nursing industry has “considerable opportunities” to improve the care they provide and arrangements made for post-discharge care, MedPAC said in its Congressional report.

30 Day Readmissions If facilities faced rehospitalization penalties, they would be more inclined to Ensure that residents were physically ready, Assure that their residents families were adequately educated (e.g., about medication management, advance directives, and hospice care), Partner with high-quality community services to avoid readmission to the hospital

Intervention: INTERACT INTERACT® is an acronym for “Interventions to Reduce Acute Care Transfers.” A quality improvement program designed to improve the identification, evaluation, and communication about changes in resident status. Was first designed in a project supported by the Centers for Medicare and Medicaid Services (CMS). Now, many post-acute providers across the U.S. are using INTERACT®. http://www.pathway-interact.com/

Intervention: INTERACT Aids in the early identification of a resident change of status Guides staff through a comprehensive resident assessment when a change has been identified Improves documentation around resident change in condition Enhances communication with other health care providers about a resident change of status

What are the INTERACT® Tools? There are four basic types of tools: Quality Improvement tools  Communication tools Decision Support tools Advance Care Planning tools

RARE- Reducing Avoidable Readmissions Effectively 5 Key Areas Known to Reduce Avoidable Readmissions Comprehensive discharge planning » resources Medication management » resources Patient and family engagement » resources Transition care support » resources Transition communications » resources Patient-provider communication/health literacy http://www.rarereadmissions.org/

Ways to Improve Transitions From the Hospital to Post Acute Care

Learn More Library of resources: websites, videos, podcasts, tools Quality improvement news and blogs Latest CMS and partner updates www.atomAlliance.org

Join the community coalition near you and serve on the Readmission Reduction workgroup Contact Information Mary Helen Conner, PhD, MPH, BSN, RN, MCHES Mary.conner@area-g.hcqis.org Quality Improvement Advisor 1-601-957-1575 ext. 219