1. 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

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

3. Ensuring Quality of Care for Everyone’s Mom & Dad

4. 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!

5. 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.

6. 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?

7. 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.

8. 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)

9. How do data items fit within measure development?

10. 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)?

11. 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
Why are these measures useful to you?

12. 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
Why are these measures useful to you?

13. 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?

14. 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 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

15. 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?

16. 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?

17. 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?

18. 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

19. 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

20. 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

21. 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?

22. 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.

23. 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 to:
Payment Determination Affected
Data Collection Period
Data Submission Deadline
FY2018
10/1/16-12/31/16
5/15/17

24. 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

25. 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?

26. 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. For example, draft specifications for the SNF Functional Status Quality Measures comment period is 10/7/16 – 11/4/16. 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?

27. QUESTIONS?

28. THANK YOU!
Contact: