F-6. Pay for Performance. Are You Ready? October 10, 2007

1. F-6. Pay for Performance. Are You Ready?October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter, & Company, P.C., Beaverton, Oregon 1-800-547-3159 1

2. Long Term Care Culture Changes • 1990 – OBRA, MDS assessment tool, emphasis on social model as well as clinical assessment • 1998 – PPS, Medicare skilled service payments based on acuity, clinical assessment 2

3. 2006 And On • Value based purchasing for Medicare (& Medicaid) services, Pay for Performance model introduced, health care service payments based on quality and efficiency (cost) 3

4. Research • Evidence-based studies • It is about outcomes • It is about cost • It is about how the two meet for quality of care 4

5. Secretary Leavitt Reports to Congress • Improvement has occurred on clinical quality measures • Need for more improvement to succeed in promoting broader, more rapid improvement that results in high levels of quality for Medicare beneficiaries and efficient use of Medicare resources 5

6. FOUR STRATEGIES:If Adopted by Providers Can Lead To High Performance • Measurement & reporting of quality • Adoption & use of health information technology (“more computerized records”) • Redesign of care processes (“treatment protocols, screenings, disease management, follow up, etc.) • Change in organizational culture & management 6

7. CMSs Quality Improvement Roadmap • Work through partnerships: HHS, other Fed & state agencies, health professionals, etc. • Publish quality measures & info to beneficiary, purchaser, professional, provider, others • Pay to support providers in doing the right thing; improving quality, avoiding unnecessary costs, promoting competition to improve quality 7

8. Improvement Map (cont) • Assist practitioners & providers in taking the necessary steps to make care more effective & less costly, incl. use of electronic health systems • CMS will become active partner in creating & using evidence of healthcare technologies to bring innovations to pts more rapidly, & help Drs. & pts use txs Feds pay more effectively 8

9. CMSs Goals • Through quality improvement initiatives • Will modernize Medicare through pay for performance and • Competitive bidding programs 9

10. Pay for Performance (P4P) • Value based purchasing • Quality based purchasing • Performance based health care service purchasing 10

11. How does cost of care combine with positive outcomes? • Through payment methods (i.e. pay for performance) & other incentives to obtain patient focused high quality care at the most reasonable cost 11

12. CMS believes that States are interested in… • Ways to improve quality of care in flexible programs that control costs & provide value for dollars spent and that • Payments are directed toward care that will improve health status of citizens 12

13. Pay for Performance is one method of value based, quality based purchasing • Incentive payments will be made to facilities who meet certain criteria based on quality measures from several sources 13

14. How is this Pilot Program Funded? • The pilot requires budget neutrality or cost effectiveness (“savings”) • Funding will come from reduced avoidable hospitalizations 14

15. Performance Measures/Quality Measures • Critical to the process of assessing improvements in quality & providing info to consumers • Nursing Homes were one of the first health care providers to be required to implement/use quality measures 15

16. Who Is Involved in Pay for Performance? • Hospitals • Physician office practices/Ambulatory care • Home Health • Nursing Homes • Medicare B: PT & OT • Dialysis providers • And more 16

17. CMS Describes the QIO Program • Substantial contribution to efficiency of resource use in Medicare • Program will increase focus in areas where their costs can be substantially offset by quality improvements that increase efficiency 17

18. QIO Program Contracting for Projects to Develop Evidence Base for Improving Quality & Efficiency • Preventing hospital admission for patients in nursing homes • Improving transitions of care for patients moving across settings • Measuring & improving palliative & hospice care • Improving quality & efficiency of care for pts w/multiple chronic illnesses 18

19. QIO Nursing Home Campaign Will Assess These Measurable Goals • Reducing high risk pressure ulcers • Reducing use of daily restraints • Improving pain management in long term & short term, post acute residents • Establishing individual targets for improving quality • Assessing res & family satisfaction w/quality of care 19

20. Nursing Home Campaign (cont) • Increasing staff retention • Improving consistent assignment of nursing home staff, so res regularly receive care from same care givers • THE ABOVE MEASURES ARE IN ADDITION TO THE QIO PROGRAM AS IT HAS BEEN IN THE PAST 20

21. QIO Scope of Work Measures (subtasks) • Clinical Measures: Restraints, Pressure Ulcers, Pain, Depressive Symptoms • Non-clinical Measures: Staff retention, Resident satisfaction, Staff turnover, Target-setting on clinical measures, Process changes on clinical measures 21

22. Other Pay for Performance Programs • Improvement in patients with certain chronic diseases • Pt & OT therapy outcomes for Med B • Certain hospital clinical conditions • Post acute payment reform demonstration • Medicaid P4P 22

23. Post Acute Payment (PAC) Reform Demonstration • Scheduled to start in April 2008 • Diagnoses or diagnostic conditions specified by Secretary Leavitt would require a comprehensive assessment at hospital discharge to help determine appropriate post acute care placement 23

24. Post Acute Care Demonstration (cont) • The Post Acute Care placement based on pt needs & pt clinical characteristics • Data on fixed & variable costs for each pt & on care outcomes would be gathered • Standardized assessment instrument to measure functional status & other factors during tx & at discharge across PAC settings 24

25. NURSING HOMES: Pay for Performance • Quality Measures from MDS • Sec W (immunizations) • Surveys • Staffing levels • Avoidable hospitalizations 25

26. Recommended Measures by Abt Associates Inc. (demonstration design) • Nursing home staffing • Rate of potentially avoidable hospitalizations • MDS-based resident outcome measures • Outcomes from state survey inspections 26

27. How will Performance be measured for Nursing Homes? • Answers to the MDS including: • Subset of MDS driven quality measure (nursing home compare) • Resident immunization rates (Sec W) • Outcomes from surveys • Staffing levels (licensed and certified nursing assistant hrs per res day) & rewards for high staff retention &/or low turnover 27

28. Performance Measures for Nursing Homes (cont) • Potentially avoidable hospitalizations, both long and short stay 28

29. Avoidable Hospitalizations; Short Stay Residents • Potentially avoidable hospitalizations: short stay residents, % of short stay res with a hospitalization w/in 30 days of admit or 7 days of discharge if length of stay is less than 23 days for a potentially avoidable hospitalization • Source of info: Medical record 29

30. Potential Problems to Consider • Could be “bad outcome gaming”; not sending someone to hospital • Need to consider patient request to go to hospital • How do we deal with families that insist on transfer? • Need to consider code status 30

31. Who Is Reviewing Record? • What is the criteria for determining that a hospitalization was potentially avoidable? • What does documentation say? • Nurses notes • Physician notes • Lab reports • Assessments • Etc. 31

32. Avoidable Hospitalization: Long Stay Resident • Source of information: Medical Record 32

33. Recommended Risk Adjustment for Potentially Avoidable Hospitalizations • Age • ADL score • Bedfast • Cognitive Performance Scale • Congestive Heart Failure • Do Not Resuscitate • Dysphagia 33

34. Risk Adjustment (cont) • Feeding tube present • Hypertension with complications • Renal failure • Requires assistance to eat • Respiratory disease 34

35. DISCUSSION 35

36. Specific MDS questions that are calculated • ADL decline • Pain • Physical restraints • Urinary Tract Infections • Pressure sores, high risk, low risk • Worsening of depression or anxiety • Bedfast 36

37. Specific MDS info (cont) • Indwelling catheter • Incontinence, low risk • Mobility decline (locomotion, self performance) • Weight loss • Delirium and/or pain on post acute residents • Section W 37

38. Other Measures/Survey Focus Issues • Process measures • Resident satisfaction • Quality of life measures • New measures will be added as new data becomes available 38

39. Possible Process Issues • Treatments, timing, protocols for wound care • Treatment, timing, results for pain management • Decisions, interventions for acute symptoms • Incident, complaint management • Care plans, follow up 39

40. Per CMS, Information Re: Nursing Home Process Issues Will Come From: • Survey • QIO interaction/feedback 40

41. Possible Post Acute Care Process for Nursing Homes • How quickly did RN assess and intervene • Was care plan implemented appropriately • Were current orders carried out • Was physician notified and new orders received and implemented • Was documentation appropriate • Were skilled services performed within the facility (i.e. O2, lab work, IVs, wound tx, etc.) 41

42. Resident Satisfaction/Survey • Interviews with resident • Interviews with family • Interviews with significant other • Interviews with legal representative 42

43. Quality of Life • Individualized activities • Resident specific activity preferences • Consistent direct care giver • Food preferences • What is most important to this specific resident? • Cognitively impaired/specific issues 43

44. Guide to Quality Measures • There is a compendium of all of the current quality measure throughout all health care delivery systems 44

45. General Categories: Compendium of Quality Measures • Access/children • Acute Myocardial Infarction: ASA given, Ace inhibitor given, Smoking cessation info, beta blockers ordered, thrombolytic agent w/in 30 mins of hosp arrival, time to pericutaneous coronary intervention is 120 mins or less, death w/in 30 days • Ambulatory care: hospitalization rate for all conditions, acute & chronic, children 45

46. Compendium (cont.) • Asthma: meds in ER & disch. w/steroids, medical record management, pharmacologic therapy management, hospital readmit rate • Osteoarthritis: diagnoses, pain management (incl. risk factors), exercise education • Hospital discharge process • Children with special needs • % of pts who return to ER w/in 7 days 46

47. Compendium (cont) • Coronary artery disease: artery graft pts who have bypass surgery, % of pts w/prior MI who were prescribed beta blockers, % pf pts who had lipid profile, % of pts on lipid lowering meds, cholesterol levels post cardiac event, % of pts w/diabetes &/or vascular disease & on ASA 47

48. Compendium (cont.) • Dental • Depression: screening, med management, length of tx, follow up, suicide risk, & other • Diabetes: lab work & results incl. lipid management, blood pressure management, retinol exams, foot exams, neuropathy monitoring, ASA therapy, pt management, smoking cessation, flu vaccine, hosp admits, amputations 48

49. Compendium (cont) • Efficiency: (chronic conditions, diabetes, cardiac condition, asthma, COPD, uncomplicated hypertension, ER discharge instructions) • End Stage Renal Disease: dialysis manage-ment, fistula issues, catheters, pts w/grafts, lab work & management, survival rate 49

50. Compendium (cont.) • Heart failure: detailed discharge instructions from hospital stay, left ventricular function assessment, med management, smoking cessation info, weight recorded, mortality w/in 30 days • HIV/AIDS: med mngmt, pt mngmnt, lab work, screenings, vaccinations, other 50