1. Quality Indicators/ Quality Measures Presented for the DOH by Catharine B. Petko, RN BSN Myers and Stauffer LC January 10, 2008

2. 2 Breaking News RAI Manual Update 1/08 –www.cms.hhs.gov/NursingHomeQualityInits/Down loads/MDS20Update200801.pdfwww.cms.hhs.gov/NursingHomeQualityInits/Down loads/MDS20Update200801.pdf MDS 3.0 to be implemented 10/1/09 –Timeline: www.cms.hhs.gov/NursingHomeQualityInits/Down loads/MDS30Timeline.pdf www.cms.hhs.gov/NursingHomeQualityInits/Down loads/MDS30Timeline.pdf –Teleconference on January 24, 2008: Register at http://registration.intercall.com/go/cms2 http://registration.intercall.com/go/cms2 Draft version MDS 3.0 not yet available

3. 3 www.qtso.com/mdsdownload.html

4. 4 History 1999: CMS implemented QI reporting system with 32 measures. Developed by CHSRA at University of Wisconsin 2002: CMS created a set of 6 chronic care and 4 post acute care Quality Measures for release on Nursing Home Compare 2005: CMS replaced old QI system with new QM/QI system which included all QMs and any QIs not replaced by QMs

5. 5 Domains 1. Accidents 2. Behavioral/ Emo- tional Patterns 3. Clinical Management 4. Cognitive Patterns 5. Elimination/ Incontinence 6. Infection Control 7. Nutrition/Eating 8. Pain Management 9. Physical Functioning 10. Psychotropic Drug Use 11. Quality of Life 12. Skin Care 13. Post-Acute Care Measures

6. 6 QM/QI Report

7. 7 Purposes of QM/QI Report A tool for surveyors and facility staff to use Provides summary information Highlights potential quality of care problems –Enable facility to identify possible areas for further emphasis in quality improvement –Highlight areas for investigation during the survey process

8. 8 Definitions Numerator (Num): The number of residents who actually triggered a QM/QI. They “have” the QM/QI. Denominator (Denom): The number of residents who could have the QM/QI. Observed Percent: Num/Denom x 100 (number who had QM/QI divided by number who could have QM/QI times 100)

9. 9 Definitions Adjusted Percent (for QIs 5.2, 8.1, 9.3, 13.1 and 13.3 only): A risk- adjusted percentage calculated by applying a mathematical model that takes other health characteristics of the resident (covariates) and the national percent for the measure into account to adjust the observed percent for the facility.

10. 10 Definitions Comparison Groups –Based upon QM/QI calculations that are performed for every facility in the state and in the nation –Performed on a monthly basis –Simple average of the observed percentages (or adjusted percentages for risk-adjusted measures) across all facilities in the state/nation –Allows comparison

11. 11 Definitions State percentile: A facility’s state rank, expressed as a percentage, on a given QM/QI. –For QM/QIs that are not risk adjusted, rank based on Observed percentage –For QM/QIs that are risk adjusted, rankings are based on Adjusted percentage. –Example: If facility's state percentile is 85, it means that 85% of the NFs in the state had a QM/QI score that was less or equal to the facility’s score

12. 12 Definitions Flagging: Asterisk (*) is placed after the State percentile if this number is 90 or above, or it is a Sentinel event (5.4, 7.3, 12.2) –Facility’s performance on this particular QM/QI has crossed a critical value or investigative threshold, and it is a concern for quality of care –Will be primary area of review for both facility and surveyors

13. 13 Definitions Prevalence: The type of QM/QI that is based upon a single assessment (rather than on change across a pair of assessments). Most QMs/QIs are prevalence measures. –1.2 Prevalence of falls –11.1 Residents who were physically restrained

14. 14 Definitions Incidence: The type of QM/QI that provides a description of what new conditions have developed over the course of two assessments. –Resident excluded from QI if doesn’t have current and prior assessment –May have special exclusion criteria –1.1 Incidence of new fractures –2.1 Residents who have become more depressed or anxious

15. 15 Definitions Risk groups: Subgroups of residents that are based upon the likelihood that a resident will trigger a QM/QI. –Low risk: less likely to trigger –High risk: more likely to trigger Sentinel health events: QM/QI that should occur very infrequently, if at all –5.4 Prevalence of fecal impaction –7.3 Prevalence of dehydration –12.2 Prevalence of Pressure Ulcers in a low risk population

16. 16 Assessments Used – Chronic Care Target Assessment: The resident’s most recent assessment within the time period selected for the QI Report. Prior Assessment: An assessment completed between 46 and 165 days before the Target assessment. Most Recent Full Assessment (for Carry Forward): If the Target assessment is a quarterly, some needed items may be missing so the data is “carried forward” from the Most Recent Full Assessment.

17. 17 Assessments Used - PAC Target Assessment: The resident’s 14 day SNF PPS assessment Prior Assessment: The resident’s 5 day SNF PPS assessment Most Recent Full Assessment (for Carry Forward): PPS assessment may be missing some needed items, so the data is “carried forward” from the Admission assessment.

18. 18 Assessments Used Chronic Care QIs –OBRA assessments only (AA8a = 1-5, 10) –Admission assessments used only for Incidence QIs as Prior assessment Post Acute Care QIs –PPS assessments only (AA8b = 1, 7) –Admission assessment used only for 13.1 Delirium risk adjustment

19. 19 1.2 Prevalence of falls Numerator: Residents who had falls within the past 30 days (J4a is checked) Denominator: All residents with a valid target assessment (AA8a = 2-5, 10)

20. 20 2.2 Prevalence of behavior symptoms affecting others Numerator: Resident with behavioral symptoms affecting others on target assessment: –Verbally abusive (E4bA >0) OR –Physically abusive (E4cA >0) OR –Socially inappropriate/ disruptive behavior (E4dA >0) Denominator: All residents with a valid target assessment Calculated three ways: Overall, High risk, Low Risk

21. 21 2.2 Prevalence of behavior symptoms affecting others (2) High risk for behavior symptoms: –Cognitive impairment (Short term memory problems [B2a = 1] AND Decision Making impairment [B4>0])OR –Psychotic disorders (I3a-e = 295.**, 297**, 298.** or I1gg Schizophrenia is checked)OR –Manic depression/bipolar disease (I1a-e = 296.** or I1ff is checked)

22. 22 2.2 Prevalence of behavior symptoms affecting others (3) Overall: Numerator = 16; Denominator = 106. Observed Percent = 15.1%. High risk: Numerator = 15; Denominator = 86. Observed Percent = 17.4% Low risk: Numerator = 1; Denominator = 20. Observed Percent = 5.0%

23. 23 2.3 Prevalence of symptoms of depression without antidepressant therapy Numerator: Residents with symptoms of depression AND no antidepressant therapy (O4c = 0) on the target assessment Denominator: All residents with a valid target assessment

24. 24 2.3 Prevalence of symptoms of depression without antidepressant therapy (2) Depressed if has a Sad Mood (E2 >0) and two symptoms of functional depression (only one from a group) 1. E1a >0 2. E1n, E1o, E1p or E4eA >0 3. E1j >0, E1d = 1, or N1a+N1b+N1c <=1 with B1 = 0 4. E1g >0 5. K3a = 1

25. 25 3.1 Use of 9 or more different medications Numerator: Residents who receive 9 or more different medications on the target assessment (O1 >=9) Denominator: All residents with a valid target assessment

26. 26 5.1# Low-risk residents who lose control of their bowels or bladder Numerator: Residents who were frequently or fully incontinent on the target assessment (H1a or H1b = 3 or 4) Denominator: Residents with a valid target assessment and not qualifying as high risk –High risk residents are excluded from denominator: Severe cognitive impairment (B4 = 3 and B2a = 1) OR Totally dependent in mobility ADLs (G1aA, G1bA and G1eA all 4 or 8) Exclude from Low-risk group if Comatose (B1=1), had a catheter or ostomy (H3d or H3i checked) (# = Included on NH Compare)

27. 27 5.3 Prevalence of occasional or frequent bladder or bowel incontinence without a toileting plan Numerator: Residents with no scheduled toileting plan and no bladder training program (neither H3a nor H3b is checked) AND the resident is incontinent (H1a OR H1b = 2 or 3) Denominator: Residents with frequent or occasional incontinence of bowel or bladder (H1a OR H1b = 2 or 3)

28. 28 5.4 Prevalence of fecal impaction Numerator: Residents with fecal impaction (H2d = checked) on the most recent assessment Denominator: All residents with a valid target assessment Sentinel event

29. 29 6.1# Residents with a urinary tract infection Numerator: Residents with urinary tract infection on target assessment (I2j = checked) Denominator: All residents with a valid target assessment

30. 30 7.1# Residents who lose too much weight Numerator: Residents who have experienced weight loss (K3a = 1) of 5% or more in last 30 days or 10% or more in last 6 months Denominator: All residents with a valid target assessment Exclude: Residents receiving hospice care (P1ao = checked)

31. 31 7.2 Prevalence of tube feeding 7.3 Prevalence of dehydration Prevalence of tube feeding –Numerator: Residents with tube feeding (K5b = checked) on latest assessment –Denominator: All residents with valid target assessment Prevalence of dehydration –Numerator: Residents with dehydration (J1c = checked or I3a-e = 276.5) on latest assessment –Denominator: All residents with valid target assessment –Sentinel event

32. 32 6.1# Residents who have moderate to severe pain Numerator: Residents with moderate pain at least daily (J2a = 2 AND J2b = 2) or horrible/excruciating pain at any frequency (J2b = 3) on the target assessment Numerator: All residents with a valid target assessment Adjusted percentage: Adjusted by Daily Decision-making (B4)

33. 33 9.2# Residents who spend most of their time in a bed or in a chair Numerator: Residents who are bedfast (G6a = checked) on target assessment Denominator: All residents with a valid target assessment Exclude: Comatose (B1 = 1)

34. 34 10.1 Prevalence of antipsychotic use in the absence of psychotic or related conditions Numerator: Residents receiving anti- psychotics (O4a >=1) on target assessment Denominator: All residents with a valid target assessment except those with psychotic or related conditions –Exclusions: I3a-e = 295.**, 297.**, 298.**, 307.23, 333.4; I1gg or J1i = checked

35. 35 10.1 Prevalence of antipsychotic use in the absence of psychotic or related conditions(2) High risk: Cognitive impairment (B2a=1 and B4>0) AND Behavior problems (E4bA, E4cA or E4dA >0) QM/QI Observed percent calculation (Num/Dem x 100): –Overall: Denominator includes everyone except those excluded for psychotic conditions –High risk: Denominator includes all residents identified as high risk except those excluded for psychotic conditions –Low risk: Denominator includes all residents who are not high risk except those excluded for psychotic conditions

36. 36 10.2 Prevalence of antianxiety/hypnotic use 10.3 Prevalence of hypnotic use more than two times in last week Prevalence of antianxiety/hypnotic use –Numerator: Residents who received antianxiety or hypnotics (O4b or O4c >0) on target assessment –Denominator: All residents with a valid target assessment except those with psychotic conditions (I3a-e = 295.**, 297.**, 298.**, 307.23, 333.4; I1gg or J1i = checked) Prevalence of hypnotic use more than two times in last week –Numerator: Residents who received hypnotics more than two times in last week (O4d >2) on target ass’t –Denominator: All residents with a valid target assessment

37. 37 11.1# Residents who were physically restrained Numerator: Residents who were physically restrained daily (P4c, P4d or P4e = 2) on target assessment Denominator: All residents with a valid target assessment.

38. 38 11.2 Prevalence of little or no activity Numerator: Residents with little or no activity (N2 >1) on the target assessment Denominator: All residents with a valid target assessment Exclusions: Comatose (B1 = 1)

39. 39 12.1# High-risk residents with pressure ulcers Numerator: Residents with pressure ulcers on target assessment (M2a >0 or I3a-e = 707.0*) who are defined as high risk Denominator: All residents with a valid target assessment and one of high risk criteria: –G1aA or G1bA = 3, 4 or 8OR –B1 = 1OR –I3a-e = 260, 261, 262, 263.0, 263.1, 263.2, 263.8 or 263.9

40. 40 12.2# Low-risk residents with pressure ulcers Numerator: Residents with pressure ulcers on target assessment (M2a >0 or I3a-e = 707.0*) who are defined as low risk Denominator: All residents with a valid target assessment who are defined as low risk (do not qualify as high risk in 12.1) Sentinel event

41. 41 PAC 13.1# Short-stay residents with delirium Numerator: Residents with SNF PPS 14- day assessment with at least one symptom of delirium (any B5a-f = 2) Denominator: All residents with valid SNF PPS 14-day assessment (AA8b = 7) Exclusions: B1 = 1; J5c or P1ao = checked Adjusted percent: Residential history (AB5a-f)

42. 42 PAC 13.2# Short-stay residents who had moderate to severe pain Numerator: On 14-day assessment, resident had moderate pain daily (J2a = 2 and J2b = 2) OR horrible/excruciating pain at any frequency (J2b = 3) Denominator: All patients with valid SNF PPS 14-day assessment (AA8b = 7)

43. 43 1.1 Incidence of new fractures Numerator: Residents with new fractures on target assessment (J4c or J4d is checked on the target assessment but not on the prior assessment) Denominator: All residents with valid target and prior assessments who did not have fractures on the prior assessment.

44. 44 2.1# Residents who have become more depressed or anxious Numerator: Residents whose Mood Scale scores are greater on target assessment than on the prior assessment. Denominator: All residents with a valid target assessment and a valid prior assessment Exclusions: B1 = 1

45. 45 2.1# Residents who have become more depressed or anxious (2) Mood Scale: Range 0 – 8 (one from each line) 1.Verbal Distress (E1a, E1c, E1e, E1f, E1g or E1h >0) 2.Crying, tearfulness (E1m >0) 3.Motor agitation (E1n >0) 4.Leaves food uneaten (K4c = checked). Response carried forward if target assessment is a quarterly. 5.Health complaints (E1h >0) 6.Repetitive verbalizations (E1a, E1c or E1g >0) 7.Negative statements (E1a, E1e, or E1f >0) 8.Mood symptoms not easily altered (E2 = 2)

46. 46 4.1 Incidence of cognitive impairment Numerator: Residents who were cognitively impaired on the target assessment and were not cognitively impaired on the prior assessment Denominator: Residents with valid target and prior assessments who were not cognitively impaired on the prior assessment Cognitively Impaired: B4 >0 AND B2a = 1

47. 47 5.2# Residents who have a catheter inserted and left in their bladder Numerator: Residents with indwelling catheters on target assessment (H3d = checked) Denominator: All residents with a valid target assessment Have Adjusted Percent calculated as well as Observed Percent –If had bowel incontinence on prior assessment (H1a = 4) –If had pressure ulcers on prior assessment (M2a = 3 or 4)

48. 48 9.1# Residents whose need for help with daily activities has increased Numerator: Resident with worsening in Late- loss ADL self performance at target relative to prior assessment –Two one-point increases in G1aA, G1bA, G1hA or G1iA between prior and targetOR –One two-point increase in same items Denominator: All resident with a valid target and prior assessment. Exclusions: –All late loss ADLs on prior assessment are 4 or 8 –B1 = 1 or J5c or P1ao are checked

49. 49 9.3# Residents whose ability to move in and around their room got worse Numerator: Residents whose value for locomotion self performance is greater at target relative to prior assessment (G1eA > on target than prior) All residents with valid target and prior assessments Exclusions: –G1eA on prior assessment is 4 or 8 –B1 = 1 or J5c or P1ao are checked

50. 50 9.4 Incidence of decline in ROM Numerator: Residents with increases in functional limitation in ROM between prior and target assessments (sum of G4A responses greater on target assessment than on prior) Denominator: All residents with valid prior and target assessments Exclusion: Residents with maximal loss of ROM on prior assessment (sum of G4A = 12)

51. 51 PAC 13.3# Short-stay residents with pressure ulcers Numerator: Short stays residents who have one of the following: –No pressure ulcer on 5 day assessment (M2a = 0) and M2a = 1-4 on 14 day OR –M2a = 1-4 on 5 day assessment and is the same or higher on 14 day (worsened or failed to improve) Denominator: All residents with valid 5 and 14 day assessments Adjusted percent: M3, G1aA, H1a, I1a, I1j, Low Body Mass

52. 52 QM/QI Reports on NH Compare 15 QM/QIs from facility QM/QI Report; identical logic used Result differences caused by: –Timing: NHC run once a quarter while MDS QM/QI system updated weekly –Selection periods: NHC requires target assessment be within last 3 months for chronic care and last 6 months for PAC. NF may customize selection period. –Risk adjustment: Calculations slightly different due to use of national averages and timing. –Minimum sample size: Denominator for chronic care must be 30 residents, and 20 for PAC to be reported

53. 53 Vaccination QMs on NHC Four vaccination QMs are calculated: –Chronic Care influenzal and pneumococcal QMs –PAC influenza and pneumococcal QMs QM User’s Manual Supplement: www.cms.hhs.gov/NursingHomeQuality Inits/downloads/NHQIVaccinationSuppl ement.pdf www.cms.hhs.gov/NursingHomeQuality Inits/downloads/NHQIVaccinationSuppl ement.pdf

54. 54 Percent of eligible and willing residents vaccinated for the influenza season, October 1 through March 31 Numerator: Residents in the influenza vaccination sample who received the influenza vaccine during the most recently completed influenza season (10/1 through 3/31) as indicated on the selected target MDS record (W2a = 1 or W2b = 2) Denominator: Residents in the influenza vaccination sample with a valid MDS target record in the Influenza Vaccination Reporting Period (10/1 through 6/30) Exclusions: W2b = 1, 3, 4 or 6. “—” in W2a or W2b does not exclude resident

55. 55 Chronic Care Influenza Sample Residents in the facility during the most recently completed influenza season (10/1 – 3/31) who –Has non-PPS OBRA assessment (AA8a = 1-5 or 10 and AA8b = blank) with A3a during the influenza seasonOR –Has Discharge (AA8a = 6-8) during the influenza season, has non-PPS OBRA assessment (AA8a = 1-5 or 10 and AA8b = blank) with A3a before 10/1 AND R4 minus A3a is 100 days or lessOR –Has a short non-PPS stay ending with D/08, and either AB1 or R4 is within the influenza season or R4 is within 13 days of the end of the season

56. 56 Chronic Care Influenza MDS Target Record Definition Use the most recent record (latest ARD or R4) in the 10/1 through 6/30 reporting period May be any type of record except a state- specific record (AA8b=6) or a Reentry (AA8a=9) –OBRA assessment records (AA8a = 1-5, 10) with ARD in the reporting periodOR –SNF PPS assessment records (AA8b = 1-5, 7, 8) with ARD in the reporting periodOR –Discharge records (AA8a = 6-8) with R4 in the reporting period

57. 57 Chronic Care Influenza QM Facility Exclusion Resident sample size is too small (<30) Must have minimum number of non-PPS long term Chronic Care stays in the facility (more than 29 non-PPS quarterly assessments [AA8a = 05] for the entire facility for the year ending 3/31)

58. 58 PAC Influenza Sample Definition Includes residents in the facility during the most recently completed influenza season (10/1-3/31) who had a PPS assessment in effect during any part of the season –Has a PPS assessment (AA8b = 1-5, 7, 8) with ARD during the influenza season OR –Has a PPS assessment before the season with a discharge (AA8a = 6-8) with R4 during the influenza season AND R4 minus PPS ARD is 45 days or less

59. 59 PAC Influenza Target Record and Facility Exclusion Target Record Definition: identical to Chronic Care (OBRA, PPS or Discharge during the 10/1 – 6/30 reporting period) Facility Exclusion: –PAC influenza resident sample size is too small (less than 20) –No 5-day PPS assessments (AA8b = 1) for the entire NF for the year ending 3/31

60. 60 Percent of eligible and willing residents with an up-to-date pneumococcal vaccination Numerator: Residents in the pneumococcal vaccination sample who have an up-to-date pneumococcal vaccination (W3a = 1) within the 6-month target period as indicated on the selected MDS target record Denominator: Residents in the pneumococcal vaccination sample with a valid MDS target record within the 6-month target period Exclusions: W3b = 1 or 2 “—” in W3a or W3b does not exclude resident

61. 61 Chronic Care Pneumococcal Sample Has non-PPS OBRA assessment (AA8a = 1-5 or 10 and AA8b = blank) with A3a during the selected 6-month target periodOR Has Discharge (AA8a = 6-8) during the selected 6-month target period, has non-PPS OBRA assessment (AA8a = 1-5 or 10 and AA8b = blank) with A3a before the selected 6-month target period AND R4 minus A3a is 100 days or lessOR Has a short non-PPS stay with no assessments ending with D/08 with R4 within the selected 6-month target period

62. 62 Chronic Care Pneumococcal MDS Target Record Definition Use the most recent record (latest ARD or R4) during the 6-month target period –OBRA assessment records (AA8a = 1-5, 10) with ARD in the target periodOR –SNF PPS assessment records (AA8b = 1-5, 7, 8) with ARD in the target periodOR –Discharge records (AA8a = 6-8) with R4 in the target period

63. 63 Chronic Care Pneumococcal QM Facility Exclusion Resident sample size is too small (less than 30) NF had less than 30 non-PPS quarterly assessments (AA8a = 5) for the entire facility for the year ending with the last day of the selected 6-month target period.

64. 64 PAC Pneumococcal Sample Definition Includes residents in the facility during the 6-month target period who had a PPS assessment in effect during any part of the target period –Has a PPS assessment (AA8b = 1-5, 7, 8) with ARD during the 6-month target period OR –Has a PPS assessment before the target period with a discharge (AA8a = 6-8) with R4 during 6-month target period AND R4 minus PPS ARD is 45 days or less

65. 65 PAC Pneumococcal MDS Target Record Definition and Facility Exclusion Target Records: Identical to Chronic Care (OBRA, PPS or Discharge) Facility Exclusion –PAC pneumococcal resident sample is too small (less than 20) –No 5-day PPS assessments (AA8b = 1) for the entire facility for the year ending with the last day of the 6-month target period

66. 66 Q & As Next teleconference: April 10, 2008 Topic: Restorative Nursing??? Any other ideas??? Send them to qa-mds@state.pa.us qa-mds@state.pa.us