The Quality Innovation Network -Quality Improvement Organization (QIN-QIO ) Program and the National Nursing Home

1. The Quality Innovation Network -Quality Improvement Organization (QIN-QIO) Program and the National Nursing Home Composite Score Joseph M. Bestic, NHA, BA Health Services Advisory Group, Inc. (HSAG)

2. Presentation Goals • Review quality measure outcomes from our current work. • Identify NH specific components of upcoming Centers for Medicare & Medicaid Services (CMS) initiatives • Learn about focus areas of the National Nursing Home Quality Care Collaborative (NNHQCC). • Understand how the National Nursing Home Composite Score is calculated from 13 existing quality measures. • Realize opportunities to improve your nursing home’s composite score.

3. Review of Quality Measure Outcomes

4. Phase-One Physical Restraints

5. Phase-One Pressure Ulcers

6. Phase-Two NHQCCNational Rates

7. Arizona—Where Are We?

8. Upcoming CMS NH Initiatives Aligns with the Nursing Home Action Plan of 2012 Identifies five approaches: • Enhance consumer engagement. • Strengthen survey processes, standards, and enforcement. • Promote quality improvement. • Create strategic approaches through partnerships. • Advance quality through innovation and demonstration. http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/2012-Nursing-Home-Action-Plan.pdf

9. Approach #1 Enhance Consumer Engagement: • Consumers are essential participants in ensuring the quality of care in any healthcare system. • Involving consumers, families, and others in healthcare decisions, as well as resident-centered care on an individual basis, will enhance the overall individual experience of care.

10. Approach #2 Strengthen Survey Processes, Standards, and Enforcement: • The adoption of a quality improvement methodology by NHs, especially those challenged to succeed, will improve internal system operations and lead to overall improvement as documented by lessening the rate of HACs and other measured outcomes. • Support the adoption and utilization of the Division of Nursing Homes’ Quality Assurance & Performance Improvement (QAPI) as the framework for NHs participating in the NNHQCC.

11. Approach #3 Promote Quality Improvement: • Work on consistent/permanent staff assignment, communications, leadership, regulatory compliance, clinical models, and quality-of-life indicators.

12. Approach #3 (cont’d) The QIN-QIO shall also have a targeted focus on: • Increasing mobility among long-stay residents/beneficiaries. • Decreasing unnecessary use of antipsychotics in dementia residents/beneficiaries. • Decreasing potentially avoidable hospitalizations (PAHs). • Decreasing healthcare-acquired infections (HAIs) and HACs.

13. Approach #4 Create Strategic Approaches through Partnerships: • Healthcare associations • The National Association of Directors of Nursing Administration in Long Term Care (NADONA) • American Medical Directors Association (AMDA) • University programs of gerontology • Colleges/universities of nursing • Community colleges or others training medical assistants • Accountable Care Organizations (ACOs)

14. Approach #5 Advance Quality through Innovation and Demonstration: • The goal is to foster healthcare transformation by finding new ways to pay for and deliver care that improves care and health while lowering costs.

15. Approach #5 (cont’d) • Recruit NH to participate in NNHQCCs I and II and seek to reduce HACs, improve resident care, and increase resident satisfaction. • Work to incorporate successful interventions into NHs, promote resident-centered care and clinical care focused on the needs of long-stay residents, and actively include residents in quality-improvement activities.

16. Upcoming Initiatives Two NNHQCCs: • NNHQCC I (April 1, 2015–September 30, 2016) • NNHQCC II (April 1, 2017–September 31, 2018) Progressive NH recruitment by the QIN-QIO: • 35% (50) of Arizona NHs recruited by March 31, 2015 • 75% (107) of Arizona NHs recruited by March 31, 2017 • Includes a minimum of 6 one-star and 4 five-star NHs

17. Upcoming Initiatives (cont’d) • NHs enrolling in the NNHQCC I and II will be asked to sign a Participation Agreement by the QIN-QIO • Authorized signatures include: chief executive officer, the chief operating officer, the administrator, or the owner. • NHs that do not participate in either NNHQCC I or II will be listed on a Decision Not to Participate document, which will be submitted to CMS.

18. Upcoming Initiatives (cont’d) NNHQCC topics include, but are not limited to: • Staff stability and consistent/permanent staff assignment. • Antipsychotic medication reduction. • Increasing mobility among long-stay residents. • Urinary tract infections. • High-risk pressure ulcers. • Physical restraints.

19. Upcoming Initiatives (cont’d) • Ensuring an “injury and violence free living” environment as noted in the National Prevention Strategy. • Other areas that NHs may choose to work on include: • Team building, finance, and/or leadership. • Methicillin-resistant Staphylococcus aureus and Clostridium difficile • Vaccinations (pneumonia and influenza).

20. Upcoming Initiatives (cont’d) Peer Coaches (NH staff): • NHs identified as high-performers (top 10 percent of the National Nursing Home Composite Quality Measure Rate provided by CMS) may recommend peer-coaches to the QIN-QIO. • Peer-coaches will assist those NHs in the NNHQCC that need further support and guidance. • The QIN-QIO shall provide training to peer-coaches in the following areas: coaching, quality-improvement methodology, CASPER data, and adult learning techniques.

21. Upcoming Initiatives (cont’d) Peer coaches (resident/beneficiary or family member): • Recruit at least one resident/beneficiary or family member per participating area, state or territory to be peer-coaches. • Include residents/beneficiaries and/or family members in at least two quality improvement activities initiated or performed by the QIN-QIO. • Encourage NHs to include residents and family members in quality improvement activities.

22. Desired Outcomes • Work with NNHQCC facilities to attain a score of six or better on the Nursing Home Quality Composite Measure Score by 2019. • Improve the rate of mobility among long-stay nursing home residents (goal TBD). • Reduce antipsychotic medication use (goal TBD). • Maintain/Update the Quality Assessment-Performance Improvement (QAPI) Self Assessment Tool. • All NNHQCC I and I NHs

23. The Nursing Home Composite Score Measure

24. NH Composite Score Measure The composite quality measure comprises 13 National Quality Forum (NQF)-endorsed, long-stay quality measures: • % of residents with one or more falls with major injury • % of residents with a urinary tract infection • % of residents who self-report moderate to severe pain • % of high-risk residents with pressure ulcers • % of low-risk residents with loss of bowels or bladder • % of residents with catheter inserted or left in bladder • % of residents physically restrained

25. NH Composite Score Measure (cont’d) • % of residents whose need for help with activities of daily living has increased • % of residents who lose too much weight • % of residents who have depressive symptoms • % of residents who received antipsychotic medications • % of residents assessed and appropriately given flu vaccines** • % of residents assessed and appropriately given pneumonia vaccines** **The direction of the two vaccination measures are reversed because they are directionally opposite of the other measures. This is accomplished by subtracting the numerator from the denominator to obtain a “new” numerator. By keeping all measure directions consistent, interpretation of the composite score can be kept as: “the lower, the better.”

26. NH Composite Score Measure (cont’d) • The composite score is calculated using a methodology based on the opportunity model. • Numerator represents the number of times an opportunity was missed. • Denominator represents the number of opportunities to provide or reflect high quality care.

27. NH Composite Score Example Subtotals: 81 1,116

28. NH Composite Score Example (cont’d) Percent of residents assessed and appropriately given flu vaccines** Numerator: 125 Denominator: 132 Adjusted Numerator (missed opportunities): 7 Percent of residents assessed and appropriately given pneumonia vaccines** Numerator: 125 Denominator: 132 Adjusted Numerator (missed opportunities): 7 **Obtained via Facility and Resident Quality Measure Preview Reports, available in the facility’s shared folders on CMS’ QIES website.

29. NH Composite Score Example (cont’d) Subtotals: 81 1,116 Residents assessed and given flu vaccines: 7 132 Residents assessed and given pneumonia vaccines 7 132 Total: 95 / 1,380 = 0.0688 * 100 = 6.88 NH Composite Score

30. National Rates

31. National Distribution of Composite Scores

32. Arizona—Where Are We?

33. NH Composite Score Improvement Thoughts • Implement QAPI to improve and sustain systems. • Review CMS MDS 3.0 CASPER reports regularly. • Review the CMS Facility and Resident Quality Measure Preview Reports when available. • Educate staff members on clinical care processes.

34. Questions?

35. Contact Information Joe Bestic, NHA, BA Director, Nursing Home jbestic@hsag.com 602.801.6930

36. Join Us All providers, stakeholders, and Medicare beneficiaries with the will to improve healthcare are invited to be part of these improvement initiatives.

37. We convene providers, practitioners, and patients to build and share knowledge, spread best practices, and achieve rapid, wide-scale improvements in patient care; increases in population health; and decreases in health care costs for all Americans. www.hsag.com This material was prepared by Health Services Advisory Group, Inc., the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. AZ-10SOW-7.2-052814-01