Quality Indicator Report: Chronic Quality Measures

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

2. Facility Quality Measure/Indicator Report 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

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

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

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;

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

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

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

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

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

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

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

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

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

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%)

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

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

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

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

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

24. Fourteen Chronic Care QMs:Time Frames

25. Time Frames Time frame for each of the 13 Chronic Care QMs: • 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)

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)

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

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) • Percent of low-risk residents who lose control of the bowels or bladder (looks back 14 days)

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)

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

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

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

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

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

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

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

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

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

40. Avoiding Assessment Errors (cont.) 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 contactPatient 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