1. 1/22/2016 Better Health. Better Care. Lower Costs

2. QIO Program Restructures New multistate, five-year contract began Aug 1, 2014 Quality Innovation Network-Quality Improvement Organization (QIN-QIO) awarded 14 QIN-QIOs nationwide tasked to advance national quality improvement activities atom Alliance

3. QIO Program Restructures (cont.)

4. atom Alliance Partners Multistate alliance for powerful change composed of three nonprofit, healthcare quality improvement consulting companies

5. Meet the atom Alliance Nursing Home Team Welcome from atom Alliance 5

6. Disclaimer This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. It may contain references or links to statutes, regulations or other policy materials. The information is only intended to be a general summary and is not intended to take the place of either the written law or regulations. We encourage you to review the specific statutes, regulations and other interpretive materials for full, accurate information.

7. Powerful and Exciting Changes 7 For the first time in more than 40 years, a new pathway to better patient care has been strategically charted to include healthcare providers, partners and patients coming together in unprecedented numbers, working together to achieve unprecedented outcomes. Better health of our citizens Better healthcare through improved clinical interventions and processes Lower healthcare costs for everybody

8. Proposed Reform of Requirements for Long-Term Care Facilities Requirements for Long-Term Care (LTC) Facilities are the health and safety standards that LTC facilities must meet to participate in Medicare or Medicaid Programs Current requirements: found at 42 CFR 483 Subpart B have not been comprehensively updated since 1991

9. Proposed Reform of Requirements for Long-Term Care Facilities (cont.) Proposed revisions: reflect advances in the theory and practice of service delivery and safety implement sections of the Affordable Care Act (ACA) Proposed rule includes a crosswalk to help readers find where existing provisions have been incorporated.

10. Themes of the Rule 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

11. Person-Centered Care Residents and Representatives: Informed, Involved and In Control Existing protections maintained Choices Care and Discharge Planning

12. Quality Quality of Care and Quality of Life Additional special care issues: restraints, pain management, bowel incontinence, dialysis services and trauma-informed care Quality Assurance and Performance Improvement — based on the pilot Resources available — http://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/QAPI/nhqapi.html

13. 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

14. Align with Current HHS Initiatives Advancing cross-cutting priorities Reducing unnecessary hospital readmissions Reducing the incidences of healthcare acquired infections (HAIs) Improving behavioral healthcare Safeguarding nursing home residents from the use of unnecessary psychotropic (antipsychotic) medications

15. Comprehensive Review and Modernization Bringing it into the 21 st Century Reorganized and updated Consistent with current health and safety knowledge; revised care and discharge planning requirements Current infection control standards, including antibiotic stewardship Updated special care issues like pain management and dialysis Allows professionals to perform to their full scope of practice where possible

16. Implementation of Legislation It’s the law Section 6102(b) of Affordable Care Act, compliance and ethics program Section 6102(c) of ACA, quality assurance and performance improvement program (QAPI) Section 6703(b)(3) of the ACA (Section 1150B of the Act), requirements for reporting to law enforcement suspicion of crimes

17. It’s the law Section 6121 of ACA, dementia and abuse training Section 2 of the IMPACT Act (adds 1899B to the Act), discharge planning requirements for Skilled Nursing Facilities (SNFs) Implementation of Legislation (cont.)

18. CMS announces new bundled payment initiative for Medicare providers A new initiative under the Affordable Care Act will provide bundled payments to healthcare providers — including post- acute facilities — to improve the coordination of care of Medicare beneficiaries when they are discharged from the hospital

19. Bundled Payments The Bundled Payments initiative is being overseen by the Centers for Medicare & Medicaid Services' new Center for Medicare and Medicaid Innovation. The initiative “will align payments for services delivered across an episode of care, such as heart bypass or hip replacement, rather than paying for services separately,” according to CMS officials. The program incentivizes providers to improve the quality of care and save Medicare dollars, they added.

20. Bundled Payments The Innovation Center has developed four models for the Bundled Payment program. According to the Innovation Center, providers must decide whether to define the episode of care as the acute care hospital stay only (Model 1), the acute care hospital stay plus post-acute care associated with the stay (Model 2), or just the post-acute care, beginning with the initiation of post-acute care services after discharge from an acute inpatient stay (Model 3). There is also a fourth model that encompasses all services. Providers need to issue a letter of intent by Sept. 22 for Model 1 and by Nov. 4 for Models 2-4.

21. Nursing Home Value-Based Purchasing CMS will assess the performance of participating nursing homes based on selected quality measures. CMS will then make incentive payment awards to those nursing homes that perform the best or improve the most in terms of quality

22. Nursing Home Quality Reporting Quality Reporting On September 18, 2014, Congress passed the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act). The Act requires the submission of standardized data by Long-Term Care Hospitals (LTCHs), Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs) and Inpatient Rehabilitation Facilities (IRFs). The IMPACT Act establishes a quality reporting program (QRP) for SNFs.

23. Nursing Home 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.

24. Nursing Home Quality Reporting The Act further requires that CMS develop and implement quality measures from five quality measure domains using standardized assessment data. In addition, the Act requires the development and reporting of measures pertaining to resource use, hospitalization, and discharge to the community.

25. Nursing Home Quality Reporting Through the use of standardized quality measures and standardized data, the intent of the Act, among other obligations, is to enable interoperability and access to longitudinal information for such providers to facilitate coordinated care, improved outcomes, and overall quality comparisons.

26. 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.

27. CMS Quality Strategy Affordable Care: Reduce the cost of quality healthcare for individuals, families, employers, and government

28. CMS Quality Strategy & The IMPACT Act The IMPACT Act supports these three aims while upholding the CMS Quality Strategy’s goals, which are: 1. Making care safer by reducing harm caused in the delivery of care. 2. Ensuring that each person and family is engaged as partners in their care. 3. Promoting effective communication and coordination of care. models.

29. CMS Quality Strategy & The IMPACT Act 4. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease. 5. Working with communities to promote wide use of best practices to enable healthy living. 6. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new healthcare delivery

30. SNF QRP 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://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/Post-Acute-Care-Quality-Initiatives/PAC-Quality-Initiatives.html Information on the IMPACT Act of 2014 can be found at: http://www.gpo.gov/fdsys/pkg/BILLS-113hr4994enr/pdf/BILLS-113hr4994enr.pdf https://www.govtrack.us/congress/bills/113/hr4994 For SNF Quality Reporting Program comments or questions: SNFQualityQuestions@cms.hhs.gov

31. 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. About 14% 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.

32. Skilled Nursing Facilities Could Face Readmission Penalties HHS’s proposal reduces payments by up to 3% 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.

33. 30 Day Readmissions If facilities faced rehospitalization penalties, they would be more inclined to ensure that patients were physically ready, to see that their families were adequately educated (e.g., about medication management, advance directives, and hospice care), and to partner with high-quality community services to avoid readmission to the hospital,” says the report regarding last year’s recommendation to reduce skilled nursing facility payments for high readmission rates.

34. 30 Day Readmissions For the 2013 report, MedPAC staff worked with a contractor to develop a risk-adjusted measure of rehospitalization during the 30-day window following discharge from a skilled nursing facility. The method considered patients’ comorbidities, ability to perform activities of daily living, whether the patient and a surgical procedure during a prior hospital stay, and the number of times the physicians’ order Discharges from skilled nursing facilities, excluding direct hospitalizations and deaths, were to long-term nursing home care 31% of the time, to home health care services 45% of the time, and back to the community with no services, or some other type of care such as hospice, 24% of the time.

35. 30 Day Readmissions Beginning in 2018, the HHS budget also proposes implementing a bundled payment system for post- acute care providers, including skilled nursing facilities, home health providers, and inpatient rehab facilities. Rates would be based on patient characteristics and other factors producing a permanent and total cumulative adjustment of rates, bringing them down 2.85% by 2020 and resulting in an estimated $8.2 billion in savings over 10 years.

36. ……AND…… Pay-Roll Based Journal New Regulation for Infection Control Program Dementia-Focused Survey Antibiotic Stewardship NHSN Reporting Staff Stability Changes to the Five Star Rating Systems Changes to the MDS 3.0 And the list goes on…….

37. Overwhelmed????

38. Trying to Get It All Done?

39. Some Tools and Resources To Help Information & Quality Healthcare/Atom Alliance Leading & Sustaining Systemic Change Collaborative NHSN/C-Diff Cohort Care Coordination Communities atomalliance.org Quality Assurance & Performance Improvement (QAPI) Tools and Resources TEAMSTEPPS

40. Affordable Care Act requires CMS to establish QAPI standards Nursing homes are mandated to utilize QAPI strategy QAPI: A Transformative Approach to Quality in Nursing Homes 40

41. QAPI: QA + PI 41

42. Using Data: Nursing Home Composite Score Comprised of 13 long-stay quality measures Calculated as (sum of numerators/sum of denominators) x 100 Since the two vaccination measures are directionally opposite (i.e., higher rate represents better performance), composite numerator for these two measures is (denominator-numerator). Interpreted as lower = better Calculated based on the “opportunity model” concept

43. Composite Score Calculation Based on the “opportunity model” concept—numerators and denominators are summed across all 13 quality measures to determine the composite numerator and denominator Composite numerator divided by the composite denominator and multiplied by 100 results in the composite score

44. Vaccine Measures Since the two vaccination measures are directionally opposite (i.e., higher rate represents better performance), the composite numerator for these two measures is denominator minus numerator. Interpreted as lower missed opportunities = better

45. Example 1: Missed Opportunities vs. Composite Score While this facility seems to be performing well on most measures, use of antipsychotic medications burdens overall composite score.

46. Example 2: Missed Opportunities vs. Composite Score This facility has several opportunities for improvement; focusing on incon (incontinence) and ADL (ADL decline) measures may improve the overall composite score.

47. Key Recommendations Include middle- and upper-level managers directly in the organizational and practice change initiatives. Create strategies to introduce changes that engage staff at all levels, across departments and shifts, reaching most staff in the facility. Design changes with active, ongoing input from staff who will be involved in work process changes. Ensure active engagement of unit nurses and department heads in planning and supporting educational programs and practice changes involving frontline staff.

48. Cont. Explore and address the organizational influences on planned practice changes. Acknowledge and address organizational, as well as clinical, barriers to clinical practice change. Support the development of problem-solving skills among staff involved in practice or organizational changes. Create accountability systems that will provide timely and effective feedback about the changes. Be sure roles of participating staff are clear and consistent with the goals of the organization

49. Survival Tips Person-Centered Care and Culture Change Models Effective Leadership Developing Teams Developing Staff Preparation Activities and Conducting Organizational Assessments Sustaining Change and Developing Accountability Systems

50. Quality Advisor Contact Information Mae McDaniel, RN, RAC-CT, C-NE, DNS-CT Information & Quality Healthcare Quality Improvement Advisor Mae.mcdaniel@area-g.hcqis.org 1-601-957-1575 ext. 221 This material was prepared by the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama under a contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services. Content does not necessarily reflect CMS policy. 15.ASC2.08.048