Quality Improvement Using the Quality Indicators Reducing Hospitalization Rates

1. Quality ImprovementUsing the Quality IndicatorsReducing Hospitalization Rates Keith Rapp MD, CMD Keith.Rapp@gaa-ltc.com Mary Pat Rapp PhD, RN Mprapp75@aol.com Geriatric Associates of America, PA

2. Objectives • Describe Quality Indicators [QI] and Quality Measures [QM] • Describe Medical Director / provider roles in impacting QMs • Discuss avoidability of hospitalizations from nursing facilities • Discuss tools to assist in reducing avoidable hospitalizations

3. Quality Measures • 1990: Development of 24 QIs based on MDS 2.0 by the Center for Health Services Research Association [CHSRA] • 2002: Nursing Home Compare www.medicare.gov • Quality Measures • 2005: CMS merged QIs & QMs • Some risk adjustment • Not a static process • Continuing refinement by the National Quality Forum

4. Short-Stay Measures • Influenza Vaccination During the Flu Season (October 1 thru March 31) • Assessed and Given Pneumococcal Vaccination (Looks back 5 years) • Delirium (Looks back 7 days) • Moderate to Severe Pain (Looks back 7 days) • Pressure Sores (Looks back 7 days)

5. Quality Measures – Chronic Care.. • Need for help with daily activities has increased • Moderate to severe pain • Pressure Ulcers (high and low risk) • Physical restraints • Incontinence and Catheters • Low risk residents who lost control of bladder or bowel • Percent with indwelling bladder catheter • Residents who spend most of their time in bed

6. ..Quality Measures – Chronic Care • Decline in ability to move in and around their room • Urinary tract infection • Worsening anxiety or depression • Weight loss

7. Reporting of Measures • Measures with small denominators are not posted on NH Compare • Post-Acute Measures with less than 20 in denominator • Chronic Measures with less than 30 in the denominator

11. Geriatric Associates [GAA] Quality Model Pilot Started June 2002 Physician/Nurse Practitioner Collaboration on Medical Direction

12. GAA Quality Model • NP in facility 5 days per week • 25% NP time is contracted to facility • 75% of NP time spent seeing GAA pts • Physician weekly or more visits • Physician is Medical Director of facility

13. Quality Model Work • Daily stand up rounds with NF team • Quality Assurance committee participation • Mentoring and education for staff • Available for assessment of all residents • Available for “special projects” • Use of resident level summaries to improve QM / QIs

14. Facility/Community Advantages • Masters trained nurse in the facility 5 days/week • Increased level of communication • Increased facility census • More resources at the facility level • Increased ability to care for higher acuity patients = discharging hospital physicians with a higher comfort level • Lower hospitalization rates • (keep the backdoor closed) • Improved and increase in relationships with discharging Physicians and facilities • Enhanced tracking of referral resources

15. Medication ReductionPilot Outcomes • 2 units with BID dosing • Over 1,500 less pills/day dispensed • Improvement of other associated QA/QMs Percent on 9 or more medications

16. Liability Outcomes

17. GAA Quality Model Outcomes at 14 Facilities Benchmarking Provider Care

18. ALL GAA Quality Models HOUSTON/CENTRAL TEXAS 9 + MEDS Privileged and Confidential - Proprietary Information

19. ALL GAA Quality Models HOUSTON/CENTRAL TEXAS COGNITIVE IMPAIRMENT Privileged and Confidential - Proprietary Information

20. ALL GAA Quality Models HOUSTON/CENTRAL TEXAS NO TOILET PLAN Privileged and Confidential - Proprietary Information

21. ALL GAA Quality Models HOUSTON/CENTRAL TEXAS CATHETERS Privileged and Confidential - Proprietary Information

22. ALL GAA Quality Models HOUSTON/CENTRAL TEXAS UTI Privileged and Confidential - Proprietary Information

23. ALL GAA Quality Models HOUSTON/CENTRAL TEXAS TUBE FEEDING Privileged and Confidential - Proprietary Information

24. ALL GAA Quality Models HOUSTON/CENTRAL TEXAS Range Of Motion Privileged and Confidential - Proprietary Information

25. ALL GAA Quality Models HOUSTON/CENTRAL TEXAS NO ACTIVITY Privileged and Confidential - Proprietary Information

26. ALL GAA Quality Models HOUSTON/CENTRAL TEXAS Pressure Ulcer High Risk Privileged and Confidential - Proprietary Information

27. ALL GAA Quality Models HOUSTON/CENTRAL TEXAS Pressure Ulcer Low Risk Privileged and Confidential - Proprietary Information

28. ALL GAA Quality Models HOUSTON/CENTRAL TEXAS ANTIPSYCHOTICS Low Risk Privileged and Confidential - Proprietary Information

29. ALL GAA Quality Models HOUSTON/CENTRAL TEXAS ANTIANXIETY Privileged and Confidential - Proprietary Information

30. ALL GAA Quality Models HOUSTON/CENTRAL TEXAS BLADDER Low Risk Privileged and Confidential - Proprietary Information

31. ALL GAA Quality Models HOUSTON/CENTRAL TEXAS RESTRAINTS Privileged and Confidential - Proprietary Information

32. Management Pearls • Include MDS Coordinator in QA Committee • Focus on residents that have upcoming MDSs • Use resident level summary • Provider documentation • Root Cause analysis of QM issues • Understand MDS questions for indicators • Obtain user manual for QMs • Understand exclusions • Prioritize focus • One to Three action areas per month is reasonable • Responsibility needs to be assigned • Follow up on action items in QA meeting • Sentinel events (dehydration, impaction, low risk PU) • Indicators in 90 + percentile

33. Reference resources • http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/NHQIQMUsersManual.pdf • http://www.cms.hhs.gov/NursingHomeQualityInits/10_NHQIQualityMeasures.asp • Google “Quality Measures Nursing Homes”

34. Improving Nursing Facility Care byReducing Avoidable Acute Care Hospitalizations Used with permission Joseph G. Ouslander, M.D. Director, Boca Institute for Quality Aging Boca Raton Community Hospital Mary Perloe, MS,GNP-BC Project Coordinator Georgia Medical Care Foundation 34

35. Background • 40% of 100 admissions to 8 LA nursing homes rated as inappropriate1 • 68% of 200 admissions to 20 Georgia nursing homes rated as potentially avoidable2 1Saliba et al, J Amer Geriatr Soc, 2000 2CMS Special Study, 2008

36. Background Common Disruptive for the resident and family Fraught with many complications deconditioning, delirium, incontinence/catheter use, pressure ulcers, polypharmacy Costly Sometimes an inappropriate and avoidable use of the emergency room and acute hospital Hospitalization of Nursing Home Residents 36

37. Background Reducing avoidable hospitalizations represents an opportunity to improve care and reduce costs Some of the costs avoided can be reinvested in the infrastructure for nursing homes to provide high quality care 37

38. Percent of Potentially Avoidable Hospitalizations Georgia Medical Foundation N = 105 38

39. Expert OpinionAvoiding Hospitalizations The same benefits can often be achieved at a lower level of care One physician visit may avoid the transfer Better quality of care may prevent or decrease the severity of acute change Better advance care planning is necessary The resident’s overall condition may limit the ability to benefit from the transfer Provider Resources Physician or NP/PA present in facility at least 3 days per week Exam by physician or NP/PA within 24 hours Availability of lab tests within 3 hours Intravenous therapy 39

40. Facility Assessment Appropriate reporting mechanisms to ensure that changes of condition are reported appropriately to the right person Ability to start treatment, e.g., antibiotics, pain medication in a few hours Ability to start intravenous or clysis therapy for hydration within 2 hours of the order Sufficient nursing staff coverage to oversee appropriate monitoring over 24 hours Sufficient nursing staffing to ensure daily assessment until the acute behavioral change has resolved or stabilized Sufficient nursing staffing to recognize and report possible complications of treatment within 24 hours of their identification AMDA CPG Recognition of Change in Condition 40

41. A Tool Kit to Improve Nursing Home Care by Reducing Avoidable Acute Care Transfers and Hospitalizations Developed based on the data collected, and Expert Panel ratings of importance and feasibility Communication Tools Care Paths Advance Care Planning Tools http://www.qualitynet.org/dcs/ContentServer?cid=1181668673046&pagename=Medqic%2FContent%2FParentShellTemplate&parentName=Topic&c=MQParents 41

42. Communication Tools Keeping it Simple 42

43. Communication Tools *Situation, Background, Assessment, Recommendation 43

44. Recognize a Change in Condition No? TELL A NURSE Yes? Adapted from Boockvar, Kenneth et all, JAGS 48: 1086-1091,2000. Seemed like himself/herself Talked the same Overall function the same Participated in usual activities Ate the same amount N Drank the same amount Weak Agitated or nervous Tired or drowsy Confused Help with dressing, toileting, transfers 44

45. Associated with Hospitalizations • Boockvar KS, Lachs, MS [2003] JAGS, 51:1111- 1115. • Symptoms predict illness about 50% of the time. • Likelihood ratios show there is a moderate increase in the likelihood of disease. • However, if the signs are absent, you can be 90% positive the person is not ill. 45

46. Change in Condition Immediate Notification Any symptom, sign or apparent discomfort that is: Sudden in onset A marked change (i.e. more severe) in relation to usual symptoms and signs Unrelieved by measures already prescribed Sources: AMDA Clinical Practice Guideline – Acute Changes in Condition in the Long-Term Care Setting 2003. Ouslander, J, Osterweil, D, Morley, J. Medical Care in the Nursing Home. McGraw-Hill, 1996 46

47. Care Card Conditions that usually warrant transfer to the hospital: Acute abdominal pain with vomiting Chest pain not due to stomach pain, musculoskeletal pain, and not relieved with antacids or nitroglycerin Fall with pain and signs of fracture Hypertension with systolic BP over 230 mmHg and chest pain or signs of stroke Vomiting blood and low blood pressure and tachycardia Respiratory distress with rate over 28 and not relieved with oxygen, nebulizers, or suctioning 47

48. Care Card: Recognizing Pulmonary Signs and Symptoms • Labored breathing / shortness of breath • New or worsened cough • New or increased sputum production • New or increased findings on lung exam • Rhonchi: sputum • Wheezes: restricted airway • Crackles: fluid • Chest pain with inspiration or coughing 48 http://www.qualitynet.org/dcs/ContentServer?cid=1211554364427&pagename=Medqic%2FMQTools%2FToolTemplate&c=MQTools

49. Teaching MomentsCommon causes of dyspnea • Lungs • Asthma • Chronic obstructive pulmonary disease • Infection • Viral [influenza] • Bacterial • Pulmonary embolism • Heart • Congestive heart failure • Atrial fibrillation • Myocardial infarction 49

50. Communication *Suspect sepsis if there are two or more signs from red bolded parameters Physician/NP/PA Notification • Resident unable to eat and drink • Temp over 102ºF (38.9ºC) or less than 96.8ºF (36ºC) • Apical heart rate more than 100 • Respiratory rate > 30/min • BP less than 90 systolic • Oxygen saturation less than 90% Call urgently • Diabetes mellitus • Finger stick glucose • Less than 70 or more than 400 Consider hospital transfer • Results of chest radiograph show an infiltrate or pneumonia • Critical values in blood count or metabolic panel • WBC over 12, 000 or less than 4000 50