1. Quality Indicator Report: Chronic Quality Measures Susan duLaney RN CWCN Tara-Lynne Bixenman RN BSN 1

2. Facility Quality Measure/ Indicator Report 2 Example of what the report looks like:

3. Two Major Steps in Calculation The measures contained on the Quality Measure/Quality Indicator (QM/QI) Report are calculated in two major steps: ―Chronic care sample ―Post acute care sample 3

4. Report Contents and Indications This report shows each of the QM/QI, the facility percentage, and how the facility compares with other facilities in the State and the nation The QM/QI reports are not definite measures of quality of care but are “pointers” that indicate potential problem areas that need further review and investigation 4

5. Three Sections of the Report The report is divided into three distinct sections: –Domain/Measure Description –Facility Statistics –Comparison Group 5

6. 6 Chronic Care Quality Measures

7. Purposes of the Measures Nursing home quality measures have four intended purposes: –To give information about the care at nursing homes to help the consumer choose a nursing home for himself or others; –To give information to the consumer or family members about the care at nursing homes where the resident lives; 7

8. Purpose of the Measures (cont.) –To get the consumer to talk to nursing home staff about the quality of care; and –To provide data to the nursing home to help them with their quality improvement efforts 8

9. Types of Chronic Care Residents Chronic care refers to the types of residents who enter a nursing facility typically because they no longer are able to care for themselves at home These residents tend to remain in the nursing facility anywhere from several months to several years 9

10. Function of the Chronic Care Quality Measures Chronic Care Quality Measures (QM/QI) are calculated based upon data from any residents with a full or quarterly Minimum Data Set (MDS) in the target assessment period; this allows for comparison over two quarters These measures offer a snapshot of the facility at a point in time and allow for comparison to other facilities 10

11. Incidence Measures Incidence Measures are conditions that have developed over the course of two assessments (a comparison of two assessments) –The data is collected from the most recent MDS and the MDS completed immediately prior to the most recent assessment 11

12. Prevalence Measures Prevalence Measures are based upon a single assessment. This type of measure provides information about a specific point in time. 12

13. 13 QM/QI Report: Definitions

14. Numerator Numerator: The number of facility residents who actually triggered for a Quality Measure/Quality Indicator (QM/QI) –These are residents who are included in the QM/QI calculation after the exclusions are applied 14

15. Denominator Denominator: This entry defines whether a resident has the necessary records available to be a candidate for the QM –The resident will be included in the denominator for the QM rate in the facility 15

16. Exclusions Exclusions: This entry provides clinical conditions and missing data conditions that would preclude a resident from consideration for the QM. –An excluded resident is excluded from both the numerator and denominator of the QM rate for the facility 16

17. Exclusions (cont.) –All Chronic Care QMs have specific exclusions unique to that measure. 17

18. Facility Observed Percent Facility Observed Percent: –The percentage is determined by calculating the number of residents that have each characteristic with the total number of residents This is calculated by dividing the numerator by the denominator (example: 3/86 = 0.0348 x 100 = 03.4%) 18

19. Covariates/Risk Adjustment Covariates/Risk Adjustment: This entry defines the calculation logic for covariates – Covariates always have a prevalence value of 1 if the condition is present and a value of 0 if the condition is not present Only three Chronic Care QM/QI have covariates – 5.2 Residents who have/had a catheter inserted and left in the bladder – 8.1 Residents who have moderate to severe pain – 9.3 Residents whose ability to move in and around their room decreased 19

20. State/National Averages State/National Averages: A facility with a high percentile ranking means that the nursing facility has a higher percentage of residents with the presence of the QI than the comparison group 20

21. State Percentile State percentile: A facility’s ranking among other facilities in the State, expressed as a percentage –i.e., If a facility is 85%, it means that 85% of the facilities in the State had a QM/QI less than or equal to the facility’s score. Review any QM where the State Percentile is ranked at 75% or higher 21

22. Thresholds Thresholds: Set points for QM/QI at which the likelihood of a problem is sufficient to warrant emphasis or at least an investigation by the facility or the survey team Measures that exceed these threshold are “flagged” with an asterisk on the report 22

23. Sentinel Events Sentinel Events: –There are three QMs that qualify 5.4 Prevalence of fecal impaction 7.3 Prevalence of dehydration 12.2 Low-risk residents with pressures 23

24. 24 Fourteen Chronic Care QMs: Time Frames

25. Time Frames Time frame for each of the 13 Chronic Care QMs: 1.Percent of long-stay residents given the influenza vaccine (between October 1 and March 31) 2. Percent of long-stay residents given the pneumococcal vaccine (looks back 5 years) 3. Percent of residents whose need for help with activities of daily living (ADLs) has increased (looks back 7 days) 25

26. Time Frames (cont.) 4. Percent of residents who have moderate to severe pain (looks back 7 days) 5. Percent of high-risk residents who have pressure ulcers (looks back 7 days) 6. Percent of low-risk residents who have pressure ulcers (looks back 7 days) 26

27. Time Frames (cont.) 7. Percent of residents who spend most of their time in bed or in a chair (looks back 7 days) 8.Percent of residents whose ability to move about in and around in their room got worse (looks back 7 days) 27

28. Time Frames (cont.) 9. Percent of residents who were physically restrained (looks back 7 days) 10. Percent of residents who are more depressed or anxious (looks back 30 days) 11.Percent of low-risk residents who lose control of the bowels or bladder (looks back 14 days) 28

29. Time Frames (cont.) 12. Percent of residents with a urinary tract infection (looks back 30 days) 13. Percent of residents who lose too much weight (looks back 7 days) 14. Percentage of residents who have had a catheter inserted and left in their bladder (looks back 14 days) 29

30. 30 The Correlation of the MDS and the QM/QI Report

31. MDS Data Generate the Reports After the facility completes and transmits the MDS to the appropriate regulatory agency, the data is used to generate quality indicator reports It is essential that the MDS be coded accurately to reflect the nursing facility’s residents and the care provided to them 31

32. Handouts Refer to the handout package Appendix A Technical Specifications Using The Reports Report Specifics 32

33. Accidents The MDS items relating to fractures are: Hip fracture in the in the last 180 days [J4C] Other fractures in last 180 days [J4d]. –Only one of the above needs to be coded on the MDS to trigger the QM –It will be necessary to obtain adequate medical records from previous health care facilities 33

34. Accidents (cont.) Numerator: Residents with new fractures who have J4c orJ4d [t-1] checked on a target assessment and not checked on a prior assessment Denominator: All residents with a valid target assessment and a valid prior assessment who did not have fractures (J4c[t-1] or J4d[t-1]) is not checked 34

35. Accidents (cont.) The related MDS specifically relates to falls in the last 30 days [J4a] (refer to MDS handout page 2) The indicator considers the data from the current MDS assessment 35

36. Accidents (cont.) MDS item J4a is an exception to the 7-day assessment rule. It is important to count the actual days rather than considering just one month before the assessment reference date. If J4b (fell in 31-180 days) is checked, it will not influence this quality indicator 36

37. Physical Restraint Domain Refer to handout for Physical Restraints Reflects the percent of residents that were physically restrained during the 7 day assessment period 37

38. Avoiding Assessment Errors It is imperative that the MDS accurately reflect the resident and the care provided Using proper assessment techniques helps to minimize errors 38

39. Avoiding Assessment Errors (cont.) Understand exactly what the question is asking –Refer to the Resident Assessment Instrument (RAI) manual to determine how to code a correct response One incorrect code can affect the quality indicator and may indicate to regulatory surveyors the presence of a care problem that does not exist 39

40. Avoiding Assessment Errors (cont.) 40 Incorrect quality indicator scores may suggest to surveyors the presence of a care problem that does not exist and could penalize the facility in the following ways: – Result in Civil Money Penalties (CMP) – Loss of Medicare/Medicaid Funding Losing the Provider Number – Facility closure Resident Eviction Staff Unemployment

41. For assistance contact Patient Safety NH Team: Beth Hercher QI Specialist Direct: 901.273.2640 Fax: 901.761.3786 bhercher@qsource.org Tiresa Parker, R.N., C QI/Compliance Specialist tparker@qsource.org Tara-Lynne Bixenman RN QI Specialist Direct: 615.574.7210 Fax: 615.259.1291 tbixenman@qsource.org Laurie Gyscek, BSN Nursing Home Manager Direct: 615.574.7201 Fax: 615.259.1291 lgyscek@qsource.org Susan duLaney, RN, CWCN Wound Care Quality Specialist Direct: 615.574.7203 Fax: 615.259.1291 sdulaney@qsource.org x This presentation and related materials were developed by QSource, the Medicare Quality Improvement Organization for Tennessee, under contract with the Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health and Human Services. Contents to not necessarily reflect CMS policy. QSource-TN-PS-2009-34