1. THE FINAL RULE, VALUE BASED PURCHASING, AND OTHER HOT TOPICS BHS Clinical Services Group September 2015

2. OBJECTIVES  Familiarize and/or re-familiarize your understanding of the multitude of regulatory and payment changes occurring across the healthcare continuum  Identify the steps each community can implement to be best prepared for the transformation  Attain the top 10 th percentile of quality utilizing Competency Based Training

3. In the past 6 months you’ve learned:  Cuts to Medicare Payment rates by 2% is coming (PAMA & VBP)  Hips & knees bundles will be controlled by the hospitals (CMS Bundles)  MDS Focused Surveys started for validating MDS accuracy  Dementia Care Focused surveys have started  CMS is adding new 5 Star quality measures in 2016 (IMPACT)  Changes to the MDS effective October 1, 2016 (IMPACT)  Payroll data must be submitted to CMS (PBJ)  Changes ICD-9 coding to ICD 10 (ICD-10)  Revised SNF requirements of participation regulations (ROP)  Hospitals are asking if you are using Interact to reduce re- hospitalizations

4. HHS PAYMENT REFORM  HHS announced targets to increase the number of payments that are linked to quality outcomes by 2018  “We are setting clear goals – and establishing a clear timeline --for moving from volume to value in Medicare payments”  “Our first goal is for 30% of all Medicare provider payments to be in alternative payment models that are tied to how well providers care for their patients, instead of how much care they provide – and to do it by 2016. Our goal would then be to get to 50% by 2018”  “Our second goal is for virtually all Medicare fee-for-service payments to be tied to quality and value; at least 85% in 2016 and 90% in 2018” HHS Secretary Burwell Jan 26, 2015 - David Gifford, MD, MPH, American Health Care Association

5. THE PROPOSED FINAL RULE Comprehensive person-centered care planning §483.21  Require proposed baseline care plan be completed within 48 hours of a resident’s admission.  Increased coordination and updating to PASARR  Mandatory members of IDT – add NA with responsibility for the resident, appropriate member of the food and nutrition services staff, social worker.

6. THE PROPOSED FINAL RULE  Facility Assessment – Annually  Determine resources needed to “care for its residents competently both day to day operations and emergencies”  Resident capacity and number of residents / Care required by the resident population  Staff education and competencies required  Determining staffing requirements  Emergency Preparedness planning  Physical environment needs for the population  Ethnic, cultural, religious factors (r/t food and activities)  Services provided (e.g. rehab, respiratory care)  HIM needs  QAPI development

7. THE PROPOSED FINAL RULE  Physician Credentialing  MD/NP/PA present prior to sending a resident to the ED or hospital unless emergent  Lab results must go to the exact person who ordered it  Social Worker FT basis;  Asking if other gerontology degrees would work in place of a SW  Activity Director qualifications  Sufficient Staff with competencies  Respiratory Therapist

8. THE PROPOSED FINAL RULE  Behavioral Health  Competencies:  Propose to require that staff must have the appropriate competencies and skills to provide behavioral health care and services, which include caring for residents with mental and psychosocial illnesses and implementing non-pharmacological interventions. “Trauma Informed” staff  Extending decreasing ALL psychotropic drug use (even include opioids, “and any other drug that result in effects similar to the drugs listed above (anti-psychotic, anti-depressant, anti-anxiety, hypnotic…)

9. THE PROPOSED FINAL RULE (COMMENTS DUE WITH EXTENDED DEADLINE TO OCTOBER 14, 2015  Infection Prevention and Control Program (PICP)  Infection Prevention and Controls Officer(s) (IPCO).  Specialized training (undefined)  Major responsibility of the individual assigned  Ethics  QAPI within 1 year after the date on which the regulations are promulgated  And much more…!

10. PAYMENT AND QUALITY  Protecting Access to Medicare Act  PAMA  Improving Medicare Post-Acute Care Transformation  IMPACT  Value Based Purchasing  VBP  Payroll Based Journal  PBJ

11. Top 10% in Quality of Care and Life Measures Excellent patient experience + Excellent Care = The Right Reimbursement Link to Proposed Final Rule: http://www.gpo.gov/fdsys/pkg/FR-2015-07-16/pdf/2015-17207.pdf

12. Protecting access to Medicare act (PAMA) of 2014 links SNF rehospitalization to SNF Medicare Part A payments  Uses a with-hold approach  2% “mathematical” withhold of SNF Part A payments  50-70% of the withhold is used to create an incentive pool  SNFs can earn back their 2% withhold based on their rehospitalization performance score;  Rehospitalization score is a combination of level of achievement and improvement, which ever is better  First adjustment to a SNF’s payment will be in Oct 2018 based on performance likely starting in early to mid 2016 David Gifford, MD, MPH, American Health Care Association

13. PAC REFORM “IMPACT ACT OF 2014” Legislation has five parts : 1. Incorporate standardized clinical assessments 2. Public reporting of common quality measures 3. Provide quality measures to consumers when transitioning to a PAC provider 4. Interoperability of information at transfer 5. HHS and MedPAC to conduct several studies

14. “IMPACT ACT OF 2014” - PART 1  Incorporate standardized assessment(s) (e.g. CARE tool) into existing assessment tools across all PAC providers (LTCH, IRF, SNF, & HH) for  Pressure ulcers  Functional status  Cognitive status  Others as directed by Secretary  Collect standard data at admission and discharge  Fully Implement by Oct 2018

15. “IMPACT ACT OF 2014” PART 2  Publicly report quality measures across PAC settings  Rehospitalizations  Discharge to community  Pressure ulcers  Medication reconciliation  Incidence of major falls  Functional Status  Patient preferences  Efficiency measure(s): Avg Total Medicare Spend per Beneficiary  Plus any other measures Secretary wants  Measures to be approved by National Quality Forum (NQF) Red Txt specified by CMS in 2016 Proposed rules for SNF, IRF & LTCH

16. ESTIMATED TIMELINE FOR SNF VBP IMPLEMENTATION 16 Oct 2018 Withhold Starts Post withhold in Proposed Rule Collect Data July 2016 Measurement Period Analyze Data Oct 2016 Oct 2017 Oct 2019 Oct 2015 SNF comments

17. SNF NATIONAL REHOSPITALIZATION RATES At risk for full 2% penalty Likely to receive 2% back

18. WHERE DO WE FOCUS? All Policies involve re-hospitalizations:  HRRP program financially penalizes hospitals with high 30 day re- admission rates  ACOs & bundle payment models can only financially work by lowering re-hospitalizations over 90 days  SNF VBP Statute requires CMS to implements a 2% withhold of SNF Part A payments that can be returned based on your re- hospitalization rates  IMPACT act of 2014 requires CMS to measure and publicly report collection of PAC quality measures including re-hospitalization and Discharge to community  Re-hospitalization rates will be added to Five Star  Protecting Access to Medicare Act (PAMA) of 2014 – contains VBP section with re-hospitalization metrics. David Gifford, MD, MPH, American Health Care Association  Adverse Events, OIG 2014 – findings show AE’s increase re-hospitalizations

19. WHERE DO WE FOCUS?  Adverse Events  Medication Related 37%  Care Related37%  Infection Related27%  Contributing to Re-hospitalization and lengthened length of stay OIG Adverse Events in SNF Report; February 2014

20. WHERE DO WE FOCUS?  Re-hospitalizations  Discharge to the Community  Length of Stay  5 Star Rating  5 Star: QM’s  5 STAR Staffing  Survey Preparedness  Capacity & Competency Based Training (K-S-A)

21. WHERE DO WE FOCUS?  QM’s with Highest Impact on VBP:  Pain  Pressure Ulcer  Satisfaction  Falls with Major Injury  Re-hospitalization  Discharge to Community

22. FY 2016 PROPOSED RULE  Specifies three measures  New or worsening pressure ulcers  Based on MDS SNF short stay pressure ulcer measure  Falls with injury  Based on MDS SNF long stay falls measure  Functional assessment at admission and discharge with goals  Based on Section IV of CARE tool (self-care & Mobility)  Specify changes to MDS  Adds section GG for self-care & mobility items from CARE tool  Changes to Discharge Assessment  Adds falls and section GG CARE items  Requires discharge assessment at discharge from SNF Part A coverage

23. 5 STAR OVERALL SCORING METHODOLOGY Step 1: Initial star rating based on State ranking on your Survey Score Step 2: Add or subtract one Star based on Staffing component Subtract 1 star if staffing rating is 1 star Add 1 star if staffing is 4 or 5 stars & > Survey rating Step 3: Add or subtract 1 Star based on QM component Subtract 1 star if QM rating is 1 star Add 1 star if QM rating is 5 stars WHERE DO WE FOCUS?

24. Value Based Purchasing  5 Star management – no return of the 2% if a community is not at least a 3 Star Community  What can I control:  Can plan on Staffing point with focus  Can plan of QM’s with focus  What can be managed but not controlled:  Survey management not totally predictable  Must have low scope and severity deficiencies  Must pass the 1 st re-survey

25. KEY COMPONENTS OF A SUCCESSFUL TRANSITION  Nurse Transition Coordinator  Alignment with referral sources  Warm hand offs  Patient goal setting  Advanced Care Planning  Patient / care giver education  Medication Reconciliation at each transition  “Bed-side Care Conferences  On-going progress towards goal discussions  “Real” discharge planning  Appointment set up  Transportation  Socio-economical factors  Follow-up calls  Patient satisfaction interview process

26. KEY COMPONENTS FOR SUCCESSFUL TRANSITIONS  Cost of Care  By co-morbids?  Length of Stay (LOS)  St Catherine University possible grant  Importance of Partnering  Transparency  Shared Risk  Removing Barriers  Alignment with referral sources  Interoperability  Admission Criteria (Capacity)  Alignment of brands (e.g. type of dressings)  NURSE TRANSITIONS COORDINATOR

27. ADVANCE CARE PLANNING TO REDUCE RE-HOSPITALIZATIONS 5 Questions to Ask the Elderly based on Atul Gwande’s Book: “Being Mortal” 1. What is your understanding of where you are and of your illness? 2. What are your fears and worries for the future? 3. What are your goals and priorities? 4. What outcomes are unacceptable to you? What are you willing to sacrifice and not? 5. What would a good day look like? From Atul Gwande’s book: “Being Mortal” David Gifford, MN, MPH, AHCA/NCAL’s summary of “Being Mortal”

28. TARGET INDIVIDUALS AT HIGH RISK  Target individuals at high risk:  How can you determine who is at high risk for readmission?  Prior hospitalization in past 12 months is strong predictor  ICU stay  Long Hospital LOS (such as >10 days)  How many risk factors that are used in OnPoint-30 Measure does the resident have  Quick and simple approach is to add up the number of 33 risk adjusted variables a person has at admission to SNF  Use systems to prevent adverse events that lead to hospitalizations  Medication errors for medications that require monitoring  Falls (often related to orthostatic hypotension)  Infections David Gifford, MD, MPH, American Health Care Association

29. RISK ADJUSTMENT VARIABLES USED  Diagnoses  Anemia  Asthma  Diabetes Mellitus  Hx of Viral Hepatitis  Hx of Septicemia  Hx of Heart Failure  Hx of Internal bleeding  Services & treatments  Dialysis  Insulin prescribed  Ostomy care  Cancer Chemotherapy  Receiving Radiation Therapy  Continue to receive IV Medication  Continue to receive oxygen  Continued tracheostomy care  Demographic  Age >65  Male  Medicare as Primary Payor  Functional Status  Total Bowel Incontinence  Eating dependent  Needs 2 person assistance in ADLs  Cognitive Impairment (Dementia)  Prognosis  End Stage prognosis poor  Recently rehospitalized  Hx of Respiratory Failure  Receiving Hospice Care  Clinical Conditions  Daily pain  Pressure Ulcer Stage >2 (split into 4 variables)  Venous Arterial Ulcer  Diabetic Foot Ulcer

30. FACTORS ASSOCIATED WITH LOW REHOSPITALIZATIONS  Three strongest predictors from per JAMDA article: 1. Training provided to nursing staff on how to communicate effectively with physicians about a residents condition 2. Physicians who practice in this nursing home treat residents within the nursing home whenever possible, saving hospitalization as a last resort 3. Provided better information and support to nurses and aides surrounding end-of-life care 1 Young Y et al. Clinical and Nonclinical Factors Associated with potentially preventable hospitalizations among nursing home residents in NYS. JAMDA 2011;12:364-371.

31. COMPETENCY BASED TRAINING: KSA Knowledge Skill Attitude Educate Train Practice

32. CLINICAL CAPACITY Clinical Needs of the Center Competency Based Training Critical thinking via Simulation

33. RAISING CAPACITY OF THE CARE CENTER Assess Referral Source Needs Create Admission Criteria Assess Gap Between Admission Criteria and Current Skill Level

34. BUILDING CRITICAL THINKING Reduce HF Hospitalizations Educate Red Flag Warning Signs Train Practice Interventions Using Expected Scenarios Practice

35. DATA DRIVEN DECISIONS  Use INTERACT PROGRAM  Use all its components  Its all about implementation  FYI: MatrixCare is not updating Interact and will be using AMDA Clinical Practice Guidelines  Root cause analysis of each hospitalization  Start with the view point: 100% are preventable  Risk stratify each admission for re-hospitalization risk  Treat rehospitalizations as trigger to have end-of-life discussion  David Gifford, MD, MPH, AHCA/NCAL

36. DATA: CMS SNF RM VS POINTRIGHT PRO 30 POINTRIGHT PRO 30  MDS based  All payer  30 day window  During SNF stay only  All cause readmission  Observation included  Includes elective admits CMS SNF-RM  Part A claims only  Part A SNF FFS  30 day window  During & after SNF stay  All cause readmission  No observations  Excludes elective admits

37. DATA: AHCA DEVELOPED PAC MEASURES  PointRight Pro 30 Rehospitalization* (now available)  Discharge Back to the Community (now available)  Length of Stay(now available)  Improvement in Functional Status* (now available)**  Mobility (based on CARE tool)  Self-Care (based on CARE tool)  Customer Satisfaction***(now available)  Long Stay Hospitalization (Oct 2015)  Unintended Healthcare Outcomes(Mar 2016) *NQF endorsed measures **Requires use of CARE tool linked with MDS admission data ***Requires use of AHCA CoreQ satisfaction questionnaire

38. VALUE OF QUALITY AWARD  Silver & Gold recipients have better  Survey Scores and fewer deficiencies  Quality Measures  5 Star Ratings  Rehospitalization rates  Staff Retention & less turnover  Occupancy

39. ACTIONS  Know your capacity and competency  Re-evaluate your associate education/skill  Focus on re-hospitalization rates  Transitions of care  Interact 4.0  Root Cause Analysis  5 Star Program:  Focus on QM & Staffing in the 5 Star Program  Survey Management – tools within the 360  MUST pass re-survey  Focus on the upcoming new QM’s from IMPACT  Cost of Care  Don’t forget data integrity of MDS (Triple Check, MDS Audits, PointRight)  Keep up with the professional reading & be networked

40. APPENDIX

41. What is the CCJR Proposal? Comprehensive Care for Joint Replacement (CCJR) Proposed Rule The proposal would  Test 90 day bundled payments for lower extremity joint replacement (Hips & Knees)  Apply to FFS Medicare Beneficiaries only  Apply to hospitals in 75 Metropolitan Statistical Areas (MSAs)  Run for five years  Waives 3 day stay o Begin January 1, 2016 and end December 31, 2020

43. Payment & Pricing: Link to Quality  Hospitals must meet minimum threshold on 3 quality metrics to receive their bonus: 1. Hospital Level Risk Standardized Complication Rate (RSCR) for elective Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA) 2. Hospital Level 30 Day, All Cause Risk Standardized Readmission Rate (RSRR) Following THA or TKA 3. Satisfaction based on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS) Survey  Additional financial incentive to submit data on a patient- reported functional outcome measure

44. TIPS ON HOW TO SUCCEED IN CCJR  Collect data on your performance & share with hospitals  Rehospitalization rate during SNF stay & after SNF discharge  Discharge to community rate  LOS  Improved function  Satisfaction score  Improve your rates on the measures that count  Maintain 3 Star rating or higher