1. The Future and Direction of Quality in Post Acute Care “Everyone’s talking….” Cheryl Phillips, M.D. SVP Public Policy and Advocacy LeadingAge

2. Who Drives Quality Measures in PA/LTC? – CMS – Legislation – Consumers – State Medicaid Offices – NQF – NCQA – Joint Commission Quality Car

3. MULTIPLE FORCES ARE DRIVING CHANGE in Long Term Care

4. High Level Look at Some of These Forces New payers, new players, new rules Payment for quality – AKA Value-based purchasing Restricted networks New “partners” – ACOs, bundled payments, “non-traditional” health care providers Proposed payment changes Big shifts in consumer expectations

5. “Better, Smarter, Healthier Care” Shared Savings Models Bundled Payments Quality Incentives Penalties Value-based Payment for PA/LTC

6. Current Measures CMS NH/HH Compare QMs Survey Findings Managed Care, ACOs and Bundled models – including measures of utilization and service Length of stay 24/7 admission availability Utilization of Interact tool to reduce hospital admissions WIDE variety of state-level VBP measures Potential……NQF PA/LTC measure set Soon to be…….IMPACT measures

7. MEASURES OUT FOR PUBLIC COMMENT NOW…

8. A Step by Step Guide to Building a Quality Assurance and Performance Improvement (QAPI) Program in Your Nursing Home

9. Quality Measurement: Our New Currency

10. What Will Change? CMS 5-Star Quality Rating

11. NH Five-Star Quality Measures Long-stay residents – % whose need for help with ADLs has increased – % of high risk residents with pressure ulcers – % of residents who have/had a catheter placed and left in their bladder – %of residents who were physically restrained – % of residents with a UTI – % of residents who self-report mod to severe pain – % of residents experiencing one or more falls with major injury – % of residents who received an antipsychotic medication Short-stay residents – % of residents with pressure ulcers that are new or worsened – % of residents who self-report mod to severe pain – % of residents who newly received an antipsychotic med

12. Longer-Term Potential Further Improvements to NH Compare (per CMS) Dynamic consumer testing Interactiveness: Make the website more interactive to refine search Staffing Data: Collect staffing data based on payroll sources, submitted quarterly Quality Measures: Add new quality measures (hospitalization measure…others?)

13. Longer-Term Potential Further Improvements to NH Compare NH Characteristics + Capabilities: Add additional information about nursing homes –Private rooms –Languages spoken –Availability of specialty units (rehab, ventilator support…) Satisfaction Surveys: Study potential reporting of satisfaction survey results – residents, families, staff

14. HR 4303: Protecting Access to Medicare Act of 2014 (PAMA) All-cause, all-condition hospital readmission SNF measure by 10/1/15 Risk-adjusted potentially preventable hospital readmissions for SNF by 10/1/16 Quarterly feedback to SNFs Public reporting on NH Compare Establish a SNF VBP program with incentive/penalty payments to SNF

15. IMPACT Act Improving Medicare Post-Acute Care Transformation – “IMPACT” Legislation introduced in June, H.R. 4994/S. 2553 Bipartisan, bicameral interest and support Passed House and Senate week of Sept. 15… now Law In addition to new reporting requirements – sets the path for new models of post-acute payment

16. Stated Goals of IMPACT Compare quality across post-acute settings (hospitals originally included, but were exempted in final bill) Improve hospital and PAC discharge planning Use information to reform PAC payments (???site neutral) Public reporting

17. A Side Word on Site-Neutral (the point where true site-neutral occurs)

18. IMPACT Required Standardization PAC providers must report: – Standardized resident assessment data – Data on quality measures – Data on resource use and other measures PAC assessment instruments must be modified to: – Enable the submission of standardized data – Compare data across all applicable providers – ??? How this will align with current assessment requirements

19. IMPACT Quality Measures Functional status and changes Cognitive function and changes Skin Integrity Special services, treatments, etc (resource use) Medical conditions and co-morbidities Other impairments Medication reconciliation* Major falls* Patient preferences* * CMS is currently behind in development of standardized reporting measure

20. IMPACT Resource Use Measure May include standardized assessment data in addition to claims data Total est. Medicare spending per beneficiary (will involve contractor to collect and report) Discharge to community All-condition, risk-adjusted potentially preventable hospital readmission rates

21. Resources for PAMA and IMPACT Protecting Access to Medicare Act of 2014 (PAMA) signed 4/1/14: – https://www.govtrack.us/congress/bills/113/hr4302/text/ enr#link+11_215&nearest=H80C0CE9753E241C2B84F9141 D931FA6F https://www.govtrack.us/congress/bills/113/hr4302/text/ enr#link+11_215&nearest=H80C0CE9753E241C2B84F9141 D931FA6F Improving Medicare Post-acute Care Transitions (IMPACT) Act of 2014, signed 10/6/14 – https://www.govtrack.us/congress/bills/113/hr4994 https://www.govtrack.us/congress/bills/113/hr4994

22. Aligning what CMS and Payors Will be Looking For Resource utilization (cost of care) Adverse Events (falls, pressure wounds, etc) Readmissions Length of Stay Return to home/community Timeliness of service Patient experience of care

23. What do we do??

24. Working Together to Improve Care, Communication, and Continuity for our Residents https://interact2.net/

25. http://go.cms.gov/Nhqapihttp://go.cms.gov/Nhqapi.

27. 3,805 Consumers 3,673 Nursing Home Staff Members 53 State-based LANEs

30. Assisted Living, Residential Care and Home Care/Personal Care Services Regional quality problems in Residential Care/AL No federal quality regulatory system now or likely in the future MULTIPLE states are looking at a variety of quality measures and oversight strategies Quality strategies for nursing homes and home health can be applied to assisted living

32. What does it mean to create a culture of safety? How can I use these quality tools and measures to make that happen?

33. Shift in thinking… Goal is to create an environment of efficient, high quality, person-centered care across PA/LTC Need to move to a “culture of safety” Need to understand “systems” within PA/LTC and how to transform care BEFORE we penalize Need to make the investment in workforce (training and resources)

34. Questions, Discussion and Case Studies…..