McKesson Medical-Surgical Clinical Connection Webinar Series: Five Star Rating How to Improve Your Rating Through Data and Quality Processes

Transcription

1 McKesson Medical-Surgical Clinical Connection Webinar Series: Five Star Rating How to Improve Your Rating Through Data and Quality Processes January 11, 2017 Karolee Alexander, RN RAC-CT Director of Clinical & Reimbursement Consulting Pathway Health

2 Karolee Alexander, RN RAC-CT Pathway Health Director of Clinical & Reimbursement Consulting Speaker: Karolee Alexander, RN RAC-CT Karolee has more than 22 years of nursing leadership in long-term care, including 12 years as a director of nursing services for various facilities. She is a strong proponent of resident-centered care, establishing many programs and processes to bring about cultural changes to ensure quality care. Karolee has proven success with regulatory turn around, nurse management mentoring and interim director of nursing roles. She is also experienced with implementing clinical software systems. Karolee is a licensed, registered nurse and an AHIMA-approved ICD-10-CM/PCS Trainer. Slide 2 1/10/2017 (C) 2013 McKesson Medical-Surgical

3 5 Star Nursing Home Rating 3

4 Nursing Home Compare Each nursing home participating in Medicare and/or Medicare is a assigned an overall rating between one and five stars 5 Stars = Much above average* 1 Star = Much below average* * Compared to other nursing homes in the state 4

5 5 Star History Beginning December 18, Star rating were added to Nursing Home Compare. Purpose: To allow consumers to compare information about nursing homes Only nursing homes participating in Medicare and Medicaid programs appeared. Quality Measure domain calculated from 11 QMs.

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7 Five-Star Basics Two Primary Goals of the CMS 5 Star System Help consumers make meaningful distinctions among highperforming and low-performing nursing homes Help nursing homes identify areas for improvement Who is Looking At Your 5 Star Data? Existing families, staff, and residents. Families, physicians, social workers, discharge planners ACOs, Bundled Payment Providers, and Insurance Companies. Media Attorneys 7

8 Download and Learn wnloads/usersguide.pdf 8

9 Five-Star Components Health Inspections Rating Based on outcomes from State health inspections Number, scope, and severity of deficiencies during the most recent 36 months Standard and substantiated complaint surveys Staffing Rating Measures based on nursing home staffing levels RN hours PPD, RN + LPN + NA hours PPD Case mix adjusted Quality Measures Rating Overall Nursing Home Rating Measures based on resident-level quality measures (QMs) Use data from the MDS Use a portion of the publically reported QMs Composite Rating 5 step process 9

10 5 Steps to Overall 5 Star Rating 1 2 Start with the health inspection five-star rating. The overall rating cannot be more than five stars or less than one star. Add one star to Step 1 if staffing rating is four or five stars and greater than the health inspection rating Subtract one star if staffing is one star. 3 Add one star to Step 2 if quality measure rating is five stars. Subtract one star if quality measure rating is one star. 4 If the health inspection rating is one star, then the overall quality rating cannot be upgraded by more than one star based on the staffing and quality measures. 5 If the nursing home is a Special Focus Facility (SFF) that has not graduated, the maximum overall quality rating is three stars. 10

11 Data Updates The CASPER data, from CMS s health inspection database, contained on Nursing Home Compare is updated on a monthly basis and the MDS data is updated quarterly. there may be a lag time between the date of the inspection and the date that the inspection results are entered into CMS s database. Therefore, the data may not necessarily reflect the results from the last inspection completed. Each nursing home is also required by law to have the latest inspection results on hand for the public to review.

12 Health Inspections Rating 12

13 Health Inspection Ratings Strengths: Comprehensive Onsite visits by trained inspectors Federal quality checks Limitations: Variation among states Medicaid program differences

14 5 Steps to Overall 5 Star Rating 1 2 Start with the health inspection five-star rating. The overall rating cannot be more than five stars or less than one star. Add one star to Step 1 if staffing rating is four or five stars and greater than the health inspection rating Subtract one star if staffing is one star. 3 Add one star to Step 2 if quality measure rating is five stars. Subtract one star if quality measure rating is one star. 4 If the health inspection rating is one star, then the overall quality rating cannot be upgraded by more than one star based on the staffing and quality measures. 5 If the nursing home is a Special Focus Facility (SFF) that has not graduated, the maximum overall quality rating is three stars. 14

15 Health Inspections Score GOAL TO GET LOWEST NUMBER OF POINTS! Severity Isolated Scope Pattern Scope Widespread Scope Immediate jeopardy to resident health or safety * = 20 points if status of deficiency is past noncompliance () = Substandard Quality of Care (SQC) Actual harm that is not immediate jeopardy No actual harm with potential for more than minimal harm that is not immediate jeopardy No actual harm with potential for minimal harm J 50 points* (75 points) G 20 points D 4 points A 0 points K 100 points* (125 points) H 35 points (40 points) E 8 points B 0 points L 150 points* (175 points) I 45 point (50 points) F 16 points (20 points) C 0 points 15

16 Weights for Repeat Visits Revisit Number Noncompliance Points % of health inspection score 3 70% of health inspection score 4 85% of health inspection score 16

17 Health Inspections Health Inspection Score Weights Year 3 17% Year 2 33% Year 1 50% 17

18 Complaint Surveys Complaint inspections assigned to calendar year in which the survey occurred. Most recent 12 months preceding the current web site update = 1/2; months ago = 1/3, months ago = 1/6.

19 Complaint Survey Weights months 17% months 33% 12 months 50%

20 Weighted Deficiency Score Lower score = Fewer deficiencies and revisits More recent surveys are weighted more heavily than earlier surveys Most recent period Cycle 1 Previous period Cycle 2 Second prior survey Cycle 3 20

21 What Changes A Score? A new health inspection survey A complaint or MDS Focus Survey that results in one or more deficiency citations A 2 nd, 3 rd, or 4 th revisit Resolution of an Informal Dispute Resolution (IDR)resulting in changes to the severity and/or scope of deficiencies The aging of complaint deficiencies 21

22 Compare Within A State Top 10% 5 Stars Middle 70% 2, 3, or 4 Stars 23.33% each Bottom 20% 1 Star 22

23 Cut Points Re-calibrated every month Relatively constant distribution within the state Rating for a given facility is held constant until there is a change in the weighted health inspection score for that facility New health inspection Complaint investigation resulting in citations 2 nd, 3 rd, or 4 th re-visit Informal Dispute Resolutions (IDR) Aging complaint deficiencies Based on a calendar year 23

24 Strategies for Improvement Know the regulations and educate the staff Use the QAPI process Perform compliance reviews Focused and general Conduct root cause analysis for noncompliance Involve the staff who perform the process you are trying to improve Implement small scale improvements Roll out changes to the rest of the facility after you achieve the outcome you were trying to reach CELEBRATE!!

25 Staffing Rating 25

26 Staffing There is considerable evidence of a relationship between nursing home staffing levels and resident outcomes. The CMS Staffing Study found a clear association between nurse staffing ratios and nursing home quality of care, identifying specific ratios of staff to residents below which residents are substantially higher risk of quality problems. Kramer AM, Fish R. The Relationship Between Nurse Staffing Levels and the Quality of Nursing Home Care. Chapter 2 in Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report. Abt Associates, Inc., Winter

27 Steps to Overall 5 Star Rating 1 Start with the health inspection five-star rating. The overall rating cannot be more than five stars or less than one star. 2 3 Add one star to Step 1 if staffing rating is four or five stars and greater than the health inspection rating Subtract one star if staffing is one star. Add one star to Step 2 if quality measure rating is five stars. Subtract one star if quality measure rating is one star. 4 If the health inspection rating is one star, then the overall quality rating cannot be upgraded by more than one star based on the staffing and quality measures. 5 If the nursing home is a Special Focus Facility (SFF) that has not graduated, the maximum overall quality rating is three stars. 27

28 Staffing Rating Strengths: Overall staffing Adjusted for the population Limitations: Self-reported Snap-shot in time

29 Staffing Data Source Annual Survey CMS-671 Form RN Hours (F41, F39, and F40) RNs, DON, RNs with administrative responsibility LPN Hours (F42) LPNs/LVNs Nurse Aide Hours (F43, F44, and F45) CNAs, Aides in training, Medication aides/technicians Includes facility employees, organization (agency) contract employees, or an individual contract Does not include private duty hired by resident CMS-672 Form Resident Census (F78) 29

30 Calculations Reported Hours Data on Form 671 converted to FTEs HRD Calculated Hours per Resident Day calculated for each discipline/census/ 14 days Expected Hours Sum the nursing times from the STRIVE study connected to each RUGS-III category/census RUGS-III 53 group version STRIVE = Staff Time and Resource Intensity Verification Adjusted Hours National Average Hours as of April 2012 Total nursing staff RNs Adjusted Hours = Reported Hours/Expected Hour X National Average Hours 30

31 3 Different Sets of Staffing Hours Reported Hours Data on Forms 671 converted to FTEs HRD Calculated Hours per Resident Day calculated for each discipline/census/14 days 31

32 3 Different Sets of Staffing Hours Expected Hours Sum the nursing times from the STRIVE study connected to each RUGS-III category/census RUGS-III 53 group version STRIVE = Staff Time and Resource Intensity Verification 32

33 Staffing Cut Points and Rating 2016 Staffing levels must be at 4 Star level for RNS and 4 Star level for Total Nursing Staff to positively impact over-all facility star rating. RN Rating RN Hours Total Nursing Rating & Hours Total Nursing Rating & Hours Total Nursing Rating & Hours Total Nursing Rating & Hours Total Nursing Rating & Hours < >/= < star 1 star 2 stars 2 stars 3 stars star 2 stars 3 stars 3 stars 3 stars 2 stars 3 stars 3 stars 3 stars 4 stars 2 stars 3 stars 4 stars 4 stars 4 stars 5 >/= stars 3 stars 4 stars 4 stars 5 stars 33

34 Payroll Based Journal ( PBJ ) Section 6106 of the Affordable Care Act requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data. 42 CFR (u) When combined with census information, can be used to report: Staffing levels Employee turnover Employee tenure 34

35 Use of PBJ data Future steps will address activities such as how the data will be verified, how compliance will be enforced, and how the information will be publically reported (such as quality measures on the Nursing Home Compare website). Information about these future steps will be communicated over the next several months. Patient-Assessment- Instruments/NursingHomeQualityInits/Staffing- Data-Submission-PBJ.html

36 Strategies for Improvement Ensure that the CMS 671 form is completed accurately Forms/downloads/cms671.pdf New regulatory process for competency based staffing Focus on retention as well as recruitment Submit PBJ data routinely

37 Quality Measures Rating 37

38 5 Steps to Overall 5 Star Rating 1 Start with the health inspection five-star rating. The overall rating cannot be more than five stars or less than one star. 2 Add one star to Step 1 if staffing rating is four or five stars and greater than the health inspection rating Subtract one star if staffing is one star. 3 Add one star to Step 2 if Quality Measure rating is five stars. Subtract one star if Quality Measure rating is one star. 4 If the health inspection rating is one star, then the overall quality rating cannot be upgraded by more than one star based on the staffing and quality measures. 5 If the nursing home is a Special Focus Facility (SFF) that has not graduated, the maximum overall quality rating is three stars. 38

39 Quality Measures Rating Strengths: In-depth look National measures Limitations: Self-reported data Just a few aspects of care

40 STAR QMs QM Stay group Data Source % residents with increased dependence in ADLs Long MDS 3.0 % high risk residents with pressure ulcers Long MDS 3.0 % residents with indwelling catheter Long MDS 3.0 % residents with physical restraint Long MDS 3.0 % residents with UTI Long MDS 3.0 % residents with self report of moderate to severe pain Long MDS 3.0 % residents with one or more falls with serious injury Long MDS 3.0 % residents on antipsychotic medication Long MDS 3.0 % residents with new or worse pressure ulcer Short MDS 3.0 % residents with self-report of moderate to severe pain Short MDS 3.0 % residents newly on antipsychotic medication Short MDS 3.0

41 2016 QMs for 5 Star Five New for July 2016 % Residents whose ability to move Independently worsened % Residents whose had an outpatient emergency department visit within 30 days of SNF admission % Residents who were successfully discharged to the community within 30 day of SNF discharge % Residents who make improvements in function in Transfer, Locomotion and Walking Stay Group Long Short Short Short Data Source MDS Claims Claims MDS Plus new VBP Measure for Readmissions Short Claims No Changes to Existing 11

42 QM Rating Methodology Step 1: Assign 20, 40, 60, 80 or 100 points for each QM based on QM rate against a set of threshold cut-points points assigned based on comparison of facility to national distribution of the QM Some QM s assigned to quintiles 20 points for poorest performing quintile, 40, 60, 80 points for second, third and fourth quintiles Long stay: ADL worsening, pressure ulcers, catheter, UTI, pain, falls and Short stay: pain

43 Rating Methodology Long stay restraints Facilities achieving the best possible score get 100 points (about 60% of all facilities) Remaining facilities are divided into poorer performers = 20 points and better performers = 60 points Short stay pressure ulcer Facilities achieving the best possible score get 100 points (about 60% of all facilities) Remaining facilities are divided into three groups and receive 25, 50 or 75 points

44 Rating Methodology Long stay antipsychotics, mobility decline and Short stay functional improvement, short stay antipsychotics plus the three claims based measures Top 10% get 100 points Poorest performing 20% = 20 points Remaining facilities divided into three groups for 40, 60 and 80 points Claims based measure points based on Q thru Q2 of 2015 data

45 QM Scoring All 11 QMs have equal weight Points are assigned by various methods Quintiles (5 Groups) Long Stay ADL worsening, pressure ulcers, catheters, UTIs, pain, injurious falls Short Stay pain 0% = 100 Points Long Stay physical restraints > 0% sorted into 2 groups and assigned 20 or 60 points respectively Short Stay pressure ulcers > 0% sorted into 3 groups and assigned 25, 50, or 75 points respectively Antipsychotic Medications 45

46 Antipsychotic Med QM Scoring Long Stay 5 Groups Top 10% receive 100 points Bottom 20% receive 20 points Middle 70% divided into 3 groups and receive 40, 60, or 80 points respectively Short Stay 0% = 100 points Bottom 20% receive 20 points Remaining divided into 3 groups and receive 40, 60, or 80 points respectively 46

47 Rating Methodology Step 2: Add up points for all 16 QMs For July 2016 January 2017 Old 11 QMs 100% of points count New 5 QMs now also 100% points count Step 3: Compare aggregate score of 16 QMs against national threshold cut-points to assign stars

48 August 2016 Changes Using 4 quarters of data for calculations New QM s weigh 50% from July 2016 through December Shifted ADL thresholds that were state-specific to one set based on national thresholds Made changes to increase the inclusion of SNFs with small number of residents Lowered the minimum number of residents per measure from 25 to 20 For SNFs still with missing data on a QM; CMS first considers as many SNF residents as possible and then combines with state average to meet the minimum sample of 20

49 Changes in 5 Star Ratings July 2016

50 New Cut Points for July 2016 QM rating Point range July 2017 % Facilities in rating % % % % % Subtract 1 star from Overall Rating Add 1 star to Overall Rating Total possible points beginning July 2016 = Total possible points beginning January 2017 =

51 Strategies for Improvement Understand the details of included data for each quality measure Review MDS coding accuracy Review clinical systems that impact that aspect of care or resident outcome Observe care delivery Use CASPER Monthly Comparison report to see changes

52 Calculating the Overall Nursing Home Rating 52

53 Five-Star Components Health Inspections Rating Measures based on outcomes from State health inspections Number, scope, and severity of deficiencies during the most recent 36 months Standard and substantiated complaint surveys Staffing Rating Measures based on nursing home staffing levels RN hours PPD, RN + LPN + NA hours PPD Case mix adjusted Quality Measures Rating Measures based on resident-level quality measures (QMs) Use data from the MDS Use a portion of the publically reported QMs Overall Nursing Home Rating Composite Rating 5 step process 53

54 5 Steps to Overall 5 Star Rating Start with the health inspection five-star rating. Add one star to Step 1 if staffing rating is four or five stars and greater than the health inspection rating Subtract one star if staffing is one star. The overall rating cannot be more than five stars or less than one star. Add one star to Step 2 if quality measure rating is five stars. Subtract one star if quality measure rating is one star. The overall rating cannot be more than five stars or less than one star. 4 If the health inspection rating is one star, then the overall quality rating cannot be upgraded by more than one star based on the staffing and quality measures. 5 If the nursing home is a Special Focus Facility (SFF) that has not graduated, the maximum overall quality rating is three stars. 54

55 Change in Nursing Home Rating Because the overall rating is based on three individual components: Health Inspections Staffing Quality Measures a change in any one of the components can affect the overall rating. 55

56 What Might Change the Rating? New data New survey, complaint surveys, revisits, IDRs Timing of updates not standard Aging data Complaint surveys are assigned to a calendar year When it ages into a prior period, it receives less weight in the scoring process When previously unavailable RUG data becomes available, the staffing rating will be recalculated Quality Measure data quarterly updates Mid-month January, April, July, and October 56

57 Next Steps for You Know Your Data! Always pre-view your star ratings from CMS on QIES Accessed usually by MDS Coordinator Check Nursing Home Compare at least monthly Download Nursing Home Compare Five- Star Quality Rating System: Technical Users Guide from the cms.gov website 57

58 Next Steps for CMS Additional Quality/Performance Measures Re-hospitalizations Discharge back to community Staffing turnover and retention Other measures from IMPACT act Alternative methods for obtaining actual staffing PBJ Increased scrutiny of MDS 3.0 during surveys MDS Focused Surveys 58

59 Upcoming Rehospitalization QM Beginning in 2017 All cause, all condition Not for Medicare Advantage Not for primary cancer diagnosis or pregnancy Not for discharges AMA Not for hospital stay for fitting of prosthesis Not for Observation stay Admitted to SNF within 1 day of discharge from acute hospital Had Medicare for 12 months prior to hospital admission 59

60 Questions?

61 Thank You! Karolee Alexander, RN RAC-CT Director of Clinical and Reimbursement Consulting Pathway Health The information contained in this complimentary webinar. McKesson makes no representations or warranties about, and disclaims all responsibility for, the accuracy or suitability of any information in the webinar and related materials; all such content is provided on an as is basis. MCKESSON FURTHER DISCLAIMS ALL WARRANTIES REGARDING THE CONTENTS OF THESE MATERIALS AND ANY PRODUCTS OR SERVICES DISCUSSED THEREIN, INCLUDING WITHOUT LIMITATION ALL WARRANTIES OF TITLE, NON-INFRINGEMENT, MERCHANTABILITY, AND FITNESS FOR A PARTICULAR PURPOSE. The content of webinar and related materials should not be construed as legal advice and is intended solely for the use of a competent healthcare professional. Eligibility Requirements For Participating in a McKesson Webinar: This webinar is not open to the general public. Your participation in this webinar cannot be transferred or assigned to anyone for any reason. You do not have to be a current customer of, purchase products from, or be affiliated with, McKesson, in order to participate in the webinars. McKesson, in its sole discretion, may terminate this promotion at any time. Due to certain regulatory restrictions, this promotion cannot be offered to health care providers licensed in Vermont and/or to government employees.

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