Understanding Quality and Accountability Supplemental Payment (QASP) (Psst… $90 Million dollars for Quality Care you are already doing!!) CAHF Annual Conference November 14, 2017 Mike Williams, Ensign Services Terry Sheets, Meritage Healthcare

What is the Quality and Accountability Supplemental Payment Program (QASP)? Pays a Supplemental Payment (not related to your MediCal rate Two Components: Incentive Award: Performance against state averages and 75th percentile of selected Quality Measures Improvement Award: Performance Improvement in your own operation vs. the prior year in selected Quality Measures

What is the Quality and Accountability Supplemental Payment Program (QASP)? Created as part of the requirements of AB 1629, the rate setting legislation Required that State develop a quality based reimbursement program Instituted in FY 2013-14, with initial performance period from July 2012-June 2013 Payments are made in April of the year following the performance periods Performance periods are always July 1 through the following June 30

How Does it Work? Earn Points (up to 100 points) Based on Specified Quality Measures Points are earned by meeting or exceeding The Statewide Average but less than the 75th percentile for the Performance period (more later on this) will earn ½ of available points for that QM The Statewide 75th percentile and above for the Performance period will earn full available points for that QM

How Does it Work? Points determine your potential award: Incentive Award (90% of the Pool) Improvement Award (10% of the Pool) Pool Amount is currently budgeted for $90,000,000 Program is budgeted through FY 2018-19 as part of the 5 year extension of AB 1629

How Does it Work? Points determine your potential award: All money is awarded, the fewer the qualifiers, the more they each earn Payment is on a per diem basis, based on your facility cost report The cost report used is the one for the rate setting for the FY when the award is paid. Awards paid in April of 2018 will be based on days reported in your 2015 cost report

What are the Timing Landmarks? Performance period is from July 1 through the following June 30. Measures you against all MediCal certified facilities in the state Baseline period for Improvement period, is July 1 through June 30 of the year prior to the Performance period, and measures your facility points earned against its prior year points earned

What are the Point Thresholds Again? Benchmark is the statewide average for each measure in the performance period Less than average—zero points At or above statewide average but less than 75th percentile—half points 75th and above—full points

What are the Quality Measures and Points What are the Quality Measures and Points? (These remain for 2017-18 period also!)

Point Allocations for Awards Points are totaled Three tiers Tier Less than Zero—facilities that were disqualified Tier 0—0 to 49.49 points Tier 1—50 to 66.66 points Tier 2—66.67 to 100 points Tier 2 per diem is set at 1.5 times higher than Tier 1 Payment based on per diem times annual Medi-Cal bed days from annual rate study used for the rate setting in the FY

Disqualifications Failure to comply with 3.2 hours per patient day (HPPD) during the performance period as identified in a CDPH audit An A or AA citation for an incident during the performance period Failure to have at least one fee-for-service day paid by Medi-Cal during the performance period (impacts facilities in COHS counties) No Medi-Cal bed days

New non-MDS measure for 2015-16 performance period Staffing retention of direct care staff, using OSHPD data from filed and audited cost reports Data for Performance period is from cost report for the FY in which the payment will be made Performance period that ended June 30, 2017, with payment in April 2018, is using data from your report filed for 2015. Can calculate your own number from your filed report, using “EMPL NRSG BEG” and “EMPL NRSG CONT”, and divide the second by the first. Last year of released data the Average was 73.566%, and the 75th percentile was 83.333%

New semi-MDS measure for 2016-17 performance period Re-Hospitalization Measure, Using MDS data, and then Risk-Adjusted Numerator: the number of admissions during the SNF stay that are sent back to any hospital (excluding emergency department only visits) for any reason as indicated on the Minimum Data Set (MDS) discharge assessment within 30 days of admission to the facility. This captures both inpatient and observation status admissions.

New semi-MDS measure for 2016-17 performance period Re-Hospitalization, Using MDS data, risk adjusted Denominator: all admissions from an acute hospital to the facility during the 12 month performance period as indicated on the admission MDS assessment (either 5 day or readmission/return SNF prospective payment system [PPS] or 14 day Omnibus Budget Reconciliation Act of 1987 [OBRA] assessment) regardless of payor status and type of hospitalization (inpatient or observation).

New semi-MDS measure for 2016-17 performance period Re-Hospitalization, Using MDS data, risk adjusted Actual Rehospitalization Rate: Calculated by dividing the number of SNF stays sent back to any acute care hospital within 30 days of admission to the facility by the number of admissions to the facility from acute hospitals over the 12 month performance period.

New semi-MDS measure for 2016-17 performance period Re-Hospitalization, Using MDS data, risk adjusted Risk-Adjusted Rehospitalization Rate: a facility’s expected rehospitalization rate was compared to the actual rehospitalization rate and that ratio was multiplied by the state average. (𝐴𝑐𝑡𝑢𝑎𝑙 𝑅𝑒ℎ𝑜𝑠𝑝𝑖𝑡𝑎𝑙𝑖𝑧𝑎𝑡𝑖𝑜𝑛/𝐸𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑅𝑒ℎ𝑜𝑠𝑝𝑖𝑡𝑎𝑙𝑖𝑧𝑎𝑡𝑖𝑜𝑛)×𝑆𝑡𝑎𝑡𝑒 𝐴𝑣𝑒𝑟𝑎𝑔𝑒=𝑅𝑖𝑠𝑘 𝐴𝑑𝑗𝑢𝑠𝑡𝑒𝑑 𝑅𝑎𝑡𝑒 The risk adjustment formula is a similar method used by CMS to calculate hospitals’ 30-day readmission rate reported on Hospital Compare. Also, this similar calculation method has been endorsed by NQF and is used to calculate the rehospitalization rate that CMS uses to assess payment penalties to hospitals. Risk-adjusted rates were not reported for facilities with less than 30 admissions in the denominator

New semi-MDS measure for 2016-17 performance period Re-Hospitalization, Using MDS data, risk adjusted This risk adjusted calculation is essentially the same as the Point Right Pro-30 that is available on TrendTracker, through AHCA. It is generally about 6 months behind, but at least gives an indication of where you are and how you are doing. This will be the first year that it is used, for the payments to be made in 2018, so we have no state average nor 75th percentile to compare with.

How are Improvement Payments Determined? 10% of total funding is for improvement QMs are compared for the performance year to the prior year Improvement scores are ranked Facilities in the top 20% are eligible for an improvement per diem based on Medi-Cal bed days Avg points improvement in the last 3 years has been 12-13 points to be in top 20%

DHCS and CDPH Websites http://www.dhcs.ca.gov/services/medi- cal/Pages/LTCAB1629QAP.aspx DHCS manages the payments, and calculations of results https://www.cdph.ca.gov/Programs/CHCQ/LCP/Page s/QASP.aspx CDPH manages the Quality measure selection, ongoing state averages, and point allocations

CDPH Quarterly and Aggregated QM’s (10-17-17)

CDPH Quarterly and Aggregated QM’s (10-17-17)

With the exception of Pressure Ulcers, all the QMs used for QASP are exactly the MDS 3.0 measures. These measures are described in the MDS 3.0 QM Users Manual v8 http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-User%E2%80%99s-Manual-V80.pdf

CA law requires Pressure Ulcer measures to be Facility Acquired and the CMS specifications were slightly modified to meet this requirement.  For the Long Stay pressure ulcer measure, the numerator criteria were modified in order to only capture those pressure ulcers that are new or worsening (e.g., pressure ulcers present on admission were excluded). The addition of these exclusionary criteria limits the evaluation of pressure ulcer incidence to those that were acquired at the facility. http://www.cdph.ca.gov/PROGRAMS/LNC/Pages/SNFQandAProg.aspx

If the QM has an exclusion, your expected rate and your adjusted rate may not be the same. In this case, it is the adjusted rate that is counted towards the point score for that QM.

All resident assessments are pulled for the performance year All resident assessments are pulled for the performance year. Changes to the assessment would have to be done and processed by the end of August to be in the pulled data.

MDS Data Connection to Quality Measures Is your data correct??

Use of Physical Restraints (Long Stay) Section P – Restraints and Alarms Alarms is new as of October 1, 2017 7 Day look back period Restraint Assessment criteria Easily and voluntarily removed Restrict freedom of movement Restrict access to own body Decision to code a device as a restraint depends on the effect it has on the resident

Definitions PHYSICAL RESTRAINTS Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident’s body that the individual cannot remove easily, which restricts freedom of movement or normal access to one’s body (State Operations Manual, Appendix PP).

Definitions “Remove easily” means that the manual method or physical or mechanical device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by the staff (e.g., side rails are put down or not climbed over, buckles are intentionally unbuckled, ties or knots are intentionally untied), considering the resident’s physical condition and ability to accomplish his or her objective (e.g., transfer to a chair, get to the bathroom in time). “Freedom of movement” means any change in place or position for the body or any part of the body that the person is physically able to control or access.

Use of Physical Restraints (Long Stay) Devices Bed rail Trunk or limb restraint Other Alarms Bed or chair alarm Floor mat Motion sensor Wander guard

Facility Acquired Pressure Ulcer Incidence (Long Stay) New or Worse Pressure Ulcers Stages 2, 3 or 4 M0800 – Worsening in PU Status since Prior Assessment Number of current PU not present on prior assessment Number of current PU that were a lesser stage on prior assessment

Facility Acquired Pressure Ulcer Incidence (Long Stay) Common Coding Errors Accurate head to toe assessments Accurate tracking of skin conditions, particularly PU Accurate staging of PU

Influenza Vaccination (Short Stay) O0250 – Influenza Vaccine Did the resident receive the influenza vaccine in this facility for this year’s influenza vaccination season? October 1st through March 31st Higher rate indicates better performance

Influenza Vaccination (Short Stay) QM – Percentage of residents who: Receive vaccine Offered and Refused Did not receive due to medical condition Common Coding Errors Knowledge of influenza vaccination season Remembering to carry over code to next season Lack of investigation as to administration outside of the facility Lack of documentation

Pneumonia Vaccination (Short Stay) O0300 – Pneumococcal Vaccine No specific look back period QM – Percentage of residents who: Receive vaccine Offered and Declined Did not receive due to medical condition Higher rate indicates better performance

Pneumonia Vaccination (Short Stay) Common Coding Errors Lack of investigation as to administration outside of the facility Lack of documentation

Urinary Tract Infection (Long Stay) I2300 - UTI in 30 day look back period UTI Criteria: It was determined that the resident had a UTI using evidence-based criteria such as McGeer, in the last 30 days, AND A physician documented UTI diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days.

Urinary Tract Infection (Long Stay) Common Coding Errors Not following McGeer’s Criteria Lack of evidence that diagnosis of UTI is supported by: Documentation of signs and symptoms Laboratory testing – culture tests

Loss of Bowel & Bladder Control (Long Stay) H0300 (Bladder) and/or H0400 (Bowel) 7 Day look back period Frequency of bladder incontinence Frequent (seven or more episodes of incontinence but had at least one continent void.) Always (had no continent episodes) Frequency of bowel incontinence Frequent (two or more episodes of incontinence but had at least one continent episode.) Always (had not continent episodes)

Loss of Bowel & Bladder Control (Long Stay) High risk conditions exclude MDS Comatose (B0100) Severe cognition (C0500 < 7) Totally dependent bed mobility (G0110A) Totally dependent transfer (G0110B) Totally dependent locomotion (G0110E) Catheter (H0100A) or Ostomy (H0100C)

Loss of Bowel & Bladder Control (Long Stay) Common Coding Errors Incorrect calculations as to episodes of incontinence per frequency definitions Lack of documentation as to toileting program

Self-Report of Moderate – Severe Pain (Short & Long Stay) Pain Interview (J0300-J0600) 5 day look back Criteria Daily pain (J0400) with At least one episode of moderate/severe pain, OR Horrible/excruciating pain (J0600) at any frequency

Self-Report of Moderate – Severe Pain (Short & Long Stay) Coding Challenges Subjective report by resident Interview skills of nurse Interview timing Drug seekers Resident interview not completed

Increased Need for Help in Activities of Daily Living (Long Stay) Section G0110 – Activities of Daily Living 7 Day look back period Late Loss ADLs A - Bed Mobility, B - Transfers, H - Eating, and I - Toileting Comparison to prior assessment

Increased Need for Help in Activities of Daily Living (Long Stay) Increased in 2 or more ADLs by one point Bed mobility 2/2 goes to a 3/2 Toileting 2/2 goes to a 3/2 Increase in one late loss ADL by two points Transfer 2/2 goes to a 4/3

Increased Need for Help in Activities of Daily Living (Long Stay) Common Coding Errors: Lack of knowledge by CNAs and nurses as to ADL task components Lack of knowledge by CNAs and nurses as to ADL assistance definitions Lack of documentation in look back period

Increased Need for Help in Activities of Daily Living (Long Stay) Exclusions: Comatose (B0100) Prognosis of life expectancy is less than 6 months (J1400) Hospice Care (O0100K) All 4 late loss are dependent on prior MDS Three late loss are dependent on prior MDS and 4th is extensive assist

30 Day SNF Rehospitalization MDS Entry Form A1600 Entry Date Within 30 Days Later…. Discharge Return Anticipated A2000 – Discharge Date A2100 – coded 03 – Acute Care Hospital Discharge Return Not Anticipated Community Discharge

MDS CODING IS CRITICAL MDS Coordinators should: Thoroughly review documentation of all sources Collaborate with DSDs to ensure CNAs and nurses understand ADL documentation Interview residents independently, at a good time of the day, and using interpreters if necessary. Work with licensed nurses and the Infection Preventionist to ensure McGeer’s criteria is followed and proper laboratory tests are obtained.

And, be rewarded for the quality care we give! What we do to measure ourselves, and continually improve quality outcomes And, be rewarded for the quality care we give!

Monthly MDS QM tool for Updates

Monthly MDS QM tool for updates   Q3 2016 Q4 2016 Q1 2017 Q2 2017 YTD AVERAGE 75th Percentile Statewide Average Pressure Ulcer Long Stay 5.50% 10.30% 9.10% 7.70% 8.15% 1.930% 5.700% Bowel And Bladder Long Stay 43.80% 60.70% 51.90% 59.10% 53.88% 34.783% 45.276% Restraints Long Stay 0.00% 0.000% 0.609% Flu Vaccine Short Stay 88.50% 97.045% 86.493% Pneumo Vaccine Short Stay 99.50% 100.00% 99.75% 97.701% UTI Long stay 3.30% 1.60% 2.05% 0.730% 2.563% Self Report of Mod/Severe Pain Long Stay 1.80% 5.00% 1.70% 4.243% Self Report of Mod/Severe Pain Short Stay 7.10% 19.70% 6.70% 1.596% 8.599% ADL Decline Long Stay 5.30% 8.50% 8.80% 6.08% 6.586% 10.919%

Monthly QASP Spreadsheet (sample) Facility Name Medi-Cal Bed Days for 2015 Pressure Ulcers: Long Stay Bowel and Bladder Physical Restraints: Long Stay Influenza Vaccination: Short Stay Pneumococcal Vaccination: Short Stay Rehospitalized after NH admission: Short Stay UTI Long Stay Self Report of Mod-Severe Pain Long Stay Self Report of Mod-Severe Pain Short Stay ADL Decline Staff Retention Number of Non-Compliant Days Total Points for the Facility 15/16 Total Points for the Facility 16/17 Variance AA/A Citations Incentive Payment Amount Improvement Payment COMBINED   28,054 5.20% 43.53% 0.00% 94.40% 95.95% 15.90% 1.65% 0.40% 10.45% 68.82% 34.375 55.556 21.181 $224,432.00 $49,094.50 $273,526.50 5.556 11.111 2.778 - 6,279 6.60% 42.08% 100.00% 17.00% 2.13% 7.75% 50.00% 46.875 52.778 5.903 $50,232.00 $0.00 POINTS CUT POINT TABLE 11.1110 5.55575 100.0000 50-74th 5.5555 2.7779 50.0000 75th+ 5.5558 QM'S 75th Percentile 1.930% 34.783% 0.000% 97.045% 97.701% 13.911% 0.730% 1.596% 6.586% 80.882% Statewide Average 5.700% 45.276% 0.609% 87.220% 86.493% 16.675% 2.563% 4.243% 8.599% 10.919% 71.930%

TMS Healthcare Consulting, Inc. 2009 Questions? TMS Healthcare Consulting, Inc. 2009