Learning Objectives 4/19/2016. The Five-Star Ratings Have Changed IMPROVING YOUR CMS FIVE-STAR QUALITY RATING KAY HASHAGEN, PT, MBA, RAC-CT

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1 IMPROVING YOUR CMS FIVE-STAR QUALITY RATING KAY HASHAGEN, PT, MBA, RAC-CT Learning Objectives How to analyze the current Star Rating in each area Evaluate current operations to determine the most critical target opportunities for change Understand critical training opportunities to make changes in the Star Rating Set targets for improvement in the 5 Star Rating that can be accomplished within one year Identify tools and technology to assist with monitoring and improving the 5 Star Rating The Five-Star Ratings Have Changed Expansion of the Five-Star Ratings is part of The Improving Medicare Post-Acute Care Transformation Act of 2014 or IMPACT ACT of 2014 CMS wants to encourage higher standards The threshold to achieve a high score has been raised This makes it harder to achieve high scores 1

2 Reason to Improve Rating Five-Star Ratings are posted on the Nursing Home Compare website Consumers and healthcare partners use this site to make decisions If your Star Rating drops because CMS raised the bar on how they now measure the ratings this could give the impression that your care delivery has dropped! Reason to Improve Rating Five-Star Ratings are being used for Value Based Purchasing decisions The Comprehensive Care for Joint Replacement (CJR) initiative plans to use the Five-Star Quality Rating Only facilities that have 3 or higher Star Rating (in seven of the previous 12 months) will be eligible for inclusion in the 3 day inpatient stay waiver program This will cause hardship for those facilities who fall in the lower portion of the star distribution. Implications of a Low Star Rating In the limited sample of 67 test locations for the CJR, a recent analysis of CMS data by Modern Healthcare estimates one in three SNF under CJR initiative testing will be shut out from a waiver due to their Star Rating! In some test areas, up to 80% of facilities would be barred from the waiver due to their low star rating. The three-day waiver for SNF won t go into effect until the 2 nd year of the model The time to focus on your Star Rating is NOW! Don t get caught at the bottom of the curve 2

3 IMPACT ACT CHANGES The changes made to the Five-Star and Quality Measure ratings in February 2015 resulted in changes in ratings for many facilities. Underlying quality data may not have changed BUT, nearly 1/3 of SNFs saw a drop in their scores! 28% dropped by 1 Star 3% dropped by 2 Stars 1,200 facilities lost their Five-Star Rating Source: Nursing Home Quality Scores Drop in New Federal Ratings, Pete Eisler and Christopher Schnaars, USA TODAY, February 20, 2015 The Starting Point: Know Where You Are The 3 focus areas that make up the Five-Star Quality Rating Health Inspections Rating + Staffing Rating + Quality Measures Rating = OVERALL FACILITY RATING Calculating the Overall Rating 3

4 Health Inspections Rating This rating is based on the number, scope and severity of deficiencies identified during The 3 most recent annual inspection surveys Substantiated findings from the most recent 36 months of complaint investigations The number of revisits required to ensure that deficiencies identified have been corrected All deficiency findings are weighted by scope and severity Staffing Assessment CMS found a direct correlation between Direct Care Nursing Staffing ratios and Quality of Care Staffing Information is currently collected on the 671 and 672 forms at the annual survey Payroll Based Journal (PBJ) becomes mandatory July 2016 Quality Measures Rating Based on MDS data from the 3 most recent quarters from which data is available. 18 Quality measures are in the MDS 11 have been used in the calculation of the Five-Star Rating in the past There are 6 new QM beginning April are to be calculated from claims data 3 will be from MDS 3.0 data 4

5 Your Facility Rating Each facility Five-Star Rating is based on many factors: Individual facility performance related to inspections, staffing, and quality measures Comparison to State and National standards Reasons for Change in Rating New Data for Your Facility A new health inspection survey Data may change due to aging of complaint deficiencies Staffing data will be submitted quarterly Quality Measure data are also updated quarterly Changes in Data for Other Facilities New health inspection survey New complaint information How do you change your rating? Know the specifics in your facility that drive the scores AND Know the external ranking 5

6 How to Access CMS Data Table of Data Choices 6

7 Open the Provider Info Tab Filter the columns Sort according to Location to your facility Size of your facility State information Compare Star Ratings Compare Staffing Models Deficiencies ETC. This information can provide you with best practice statistics and awareness of the environment Target Areas for Change: Health Inspections and Survey The Health Inspection Rating is the starting point for the Overall Star Rating, so this is where most want to begin to make changes Don t spend time agonizing over the past It takes a minimum of 3 years to overcome one bad survey BUT Understand how the ratings are determined Health Inspection Cut Points The quality ratings on the health inspection domain are based on the relative performance of facilities within a state. The top 10 percent (lowest 10 percent in terms of health inspection deficiency score) in each state receive a five-star rating. The middle 70 percent of facilities receive a rating of two, three, or four stars, with an equal number (approximately percent) in each rating category. The bottom 20 percent receive a one-star rating. 7

8 Cut Point Levels for Pennsylvania # Facilities 1 Star 2 Stars 3 Stars 4 Stars 5 Stars 699 >61.33 <61.33->36.00 <36.00-> < >7.33 <7.33 Note: A higher score indicates a worse performance on health inspections. The cut points are based on facility health inspection scores and are set separately for each state to achieve this distribution: 5 Stars: <10 th percentile 4 Stars: >10 th percentile and < rd percentile 3 Stars: >33.33 rd percentile and <56.66 th percentile 2 Stars: >56.66 th percentile and <80 th percentile 1 Star: >80 th percentile Each facility s Star Rating is relative to the other facilities in the state! Health Inspection Scores There are points for different types of deficiencies A, B, C = 0 points D = 4 points E = 8 points F = 16 points G = 20 points H = 35 points I = 45 points J = 50 points K = 100 points L = 150 points Based on cut point levels for the state, you can see where you fall based on the total point score that you currently have. Target Areas for Change: Staffing In % received 4 or 5 star ratings in staffing; by 2014 it had increased to 54%. The self reporting accuracy was being questioned! Medicare Star Ratings Allow Nursing Homes to Game the System A New York Times article published in October 2014 caught the attention of CMS! 8

9 Target Areas for Change: Staffing Although the current procedure for submitting staffing data through the use of 671/672 forms will continue Section 6106 of the Affordable Care Act now requires SNFs to electronically submit staffing data Mandatory submission begins July 1, 2016 through the use of the new Payroll Based Journal (PBJ) PBJ Date Range and Submission Deadlines WHY PBJ? PBJ was designed to bring Consistency Transparency Validation of staffing information 9

10 PBJ: What information is required? Employee Tenure Requires Hire date Job Title Code Pay Type Code Termination Date Direct Care Hours Worked Including agency and contractor data This information is required daily Census Data Submitted at the end of every month PBJ Questions? Do you have access? Go to to register Request a CMS Net User ID Decide you in your facility will have access Who is considered Direct Care? This is a change from the 671/672 data Review CMS definitions Follow the list of CMS Job Code Titles How will you collect this information? Use payroll information for internal staff Need procedure to get hours from external contractors More PBJ Questions? Once you collect payroll hours and external hours, who will enter this information? What will the information be entered into? How often will data entry occur? Who will check data to insure that it is entered properly according to the rules? How many hours per week/month will this take? Who will be responsible to submit the data? AND Can you handle this In-house or Do you need to Out-source? 10

11 Target Areas for Change: Quality Measures Most of the Quality Measures come from data manually entered into the MDS 3.0 Quality Measures are designed to describe the quality of care in each facility Some of the values are risk adjusted For each measure, points are assigned based on facility performance All QM have equal weight. Total possible scores range between points. Star Cut-points are assigned; more points higher Star rating Star Cut-Points for Quality Measures 11 Quality Measures from Past Rating % of Long Stay Whose ADL Need Has Increased % of Long Stay Reporting Moderate to Severe Pain % of High Risk Long Stay with Pressure Ulcers % of Long Stay with Catheter Inserted and Left In Bladder % of Long Stay with Urinary Tract Infections % of Long Stay Who Were Physically Restrained % of Long Stay with One or > Falls with Injury % of Long Stay Receiving Antipsychotic Meds % of Short Stay Reporting Moderate to Severe Pain % of Short Stay With New or Worsened Pressure Ulcers % of Short Stay with New Antipsychotic Meds 11

12 QM Focus Area: Psychotropic Meds The addition of the 2 new QM that track antipsychotic medications, as of February 2015, had a significant impact on the QM Star Rating Nearly 20% of all SNF scored the lowest possible score on this measure! CMS scored these QM on a curve, giving one star to homes that ranked in the bottom fifth Facilities were docked for using drugs on residents unless they were indicated for specific conditions, such as schizophrenia, Huntington s Disease or Tourette s Syndrome. New QM included in the Five-Star Rating Beginning July capture outcomes for the Short-Stay Medicare Beneficiary and 2 are for the Long-Stay recipient Benefits of these new measures include: Increase the number of short-stay measures Cover important domains not covered by other measures Claims-based measures may be more accurate than MDS-based measures New QM included in the Five-Star Rating Beginning July 2016 The 3 claims based QM are: 30-day all-cause readmissions 100-day community discharge without readmission 30-day outpatient emergency department visits These are measured for Medicare fee-forservice claims only These are risk adjusted using items from 12 months of data and updated twice annually 12

13 New QM included in the Five-Star Rating Beginning July 2016 The new QM that come from the MDS are: Short-stay residents who made improvement in function between the 5-Day and Discharge Assessment Uses mid-loss ADL such as transfers, locomotion on the unit and walking in corridor Long-stay residents whose ability to move independently has worsened Long-stay resident who received anti-anxiety or hypnotic medications* *this measure will not be included in 5 Star Ratings Moving Forward: Health Inspections Be survey ready all the time Educate staff on areas where deficiencies occurred in the past Fix any deficiencies that occurred previously Prepare for follow up inspections timely Know what the surveyors are looking for Make sure that you are diligent in the details so that future surveys are spot on Moving Forward: Health Inspections Use your QAPI program Is your process up and running? Use QAPI to support any deficiencies that you had in the past Figure out if there is a hole in your current process Consider Mock Surveys from an external source You don t know what you don t know! Implement audits between disciplines to identify errors It s hard to see your own mistakes; easy for others to spot 13

14 Moving forward: Health Inspections Analytics comes to the SNF arena! Predictive analytics is the practice of extracting information from existing data sets in order to determine patterns and predict future outcomes and trends. Data Analytics is the science of examining raw data with the purpose of drawing conclusions about that information. Using Analytics with Five-Star There are systems that help you to do this Vendors have new products for purchase that analyze and provide recommendations Consultants support this on an individual basis You can use the publicly available survey information Apply what if functions to see how points would change Manipulate current data to see changes Moving Forward: Staffing PBJ will require daily tracking of direct care hours compared against census Decision choices for data entry Approach 1: enter data using CMS QIES manual entry Requires staff hours entered daily; census on the last day of each month CMS only allows 2 users per Provider Number There is a time out on the system There is no access to the internet to copy and paste info Approach 2: Build an Internal Electronic Solution using XML files to upload into the CMS QIES Approach 3: Leverage an External Solution Offering NEW Vendor offerings available since PBJ development! 14

15 Changes related to staffing The star rating opportunities changed with the recalibration of the point allocations effective February 2015 PBJ imposes challenges based on data entry requirements The volume of accurate data will demonstrate more significant trends in staffing patterns The transparency of the data will be evident The impact of insufficient staffing will be felt in the Star Rating! Expect new QM related to staff turnover, retention, types of staffing and levels of different types of staffing all related to PBJ! Staffing Points and Rating Focus on Daily Staffing Levels Benchmark staffing levels against budget and Five Star Quality Rating Evaluate staffing requirements every shift Gain visibility into staffing Adjust staff as needed Correlate labor staffed to needs based on estimated future census Understand all the rules around PBJ to make sure that you enter and submit correctly Consider using software programs to analyze appropriate staffing 15

16 Internal Focus on Quality Measures Accuracy of MDS is the #1 reason for low QM 1. Implement steps to eradicate ERRORS 2. Educate staff on proper coding 3. Search for documentation errors 4. Make sure you Compliance Program supports this initiative! 5. Incorporate QAPI projects to improve areas of concern and measure to see how focused effort pays off External Focus on Quality Measures Accuracy of MDS is the #1 reason for low QM 1. Review the MDS Focused Survey 2. Schedule a Mock MDS Focused Survey 3. Solicit external support for assistance with audits and educational training Prepare for the new MDS based QM First become familiar with them Review coding conventions for the MDS items emphasized in the new QMs Educate your staff The devil is in the details watch for the new Technical User s Manual from CMS 16

17 Prepare for the New Claims Based QM Review the data sets and systems in place for the completion of the UB04 Are the right ICD-10 codes listed and properly prioritized? Are the dates correct? Risk adjustment items come from ICD codes indicating primary diagnosis and LOS in the hospital, and MDS items associated with readmission rates. Improving Your Quality Measures Analytics can also assist for QM! Compare current rating to national cut-points to see how many points are needed to get to the next-higher star rating. Apply the what if functionality to see how making changes to the QM percentages change the rating Explore resources such as LeadingAge Snip from LeadingAge Five Star Analysis 17

18 Ready Set Go Ready: Take time to figure out where you are now Lay out positives to expound on Identify areas to improve Ready Set Go Set: Decide on the PBJ system you are going to use Pick top areas for opportunity to enhance training and minimize errors related to past deficiencies and missed cut points Analyze whether external support is affordable for your facility to achieve/maintain the Star Rating that you want Ready Set GO Train Audit Utilize QAPI Secure relationships Monitor 18

19 Thank you! Contact Information 19