Quality Measure Focus: Incontinence Keith Chartier, MPH Clinical Project Manager Elaine Nelson, RN, RAC-CT Clinical Project Manager (HSAG) August 25, 2015 Objectives 2 1
How Would It Make You Feel? Embarrassed Isolated Loss of dignity Quality of life How else? 3 Change Package Concepts Strategy 3 (p. 14): Connect With Residents Treat residents as they want to be treated; your facility is their home. Foster relationships with families. Source: http://qioprogram.org/system/files_force/resources/documents/nh_chan gepackage_032615_final_508_2.pdf?download=1 4 2
Incontinence: A National Issue 5 Incontinence: A National Issue Nursing home residents not in complete control of urinary bladder function or bowel movement during 14 days prior to interview. Long-stay residents: 75.8 percent Source: Gorina Y, Schappert S, Bercovitz A, et al. Prevalence of incontinence among older Americans. National Center for Health Statistics. Vital Health Stat 3(36). 2014. http://www.cdc.gov/nchs/data/series/sr_03/sr03_036.pdf 6 3
State-by-State Quality Measure Average *data for rolling six months ending May 31, 2015 National Average: 45.95% Source: Centers for Medicare & Medicaid Services (CMS) Quality Innovation Network (QIN) National Coordinating Center (NCC) 7 Top Three Contributors to Composite Score* *Based on 2014 full-year data Source: CMS QIN NCC 8 4
Resident Burden of Incontinence Shame and embarrassment General health and quality of life Emotional well-being Loss of social functioning/interaction Fewer opportunities for personal growth and enjoyment 9 Financial Burden of Incontinence $19.5 billion in 2000 $14.2 billion among community residents $5.3 billion among institutional residents $4,110 per person with fecal incontinence 50 75 percent of cost attributed to resources for management or routine care Absorbent pads Protection Laundry 10 5
Nursing Home Burden of Incontinence Infections Pressure ulcers Other health complications from poor health hygiene Falls Lack of mobility Low satisfaction Poor quality measure score 11 Nursing Home Burden of Incontinence (cont.) Incontinence care is seen as Most onerous and difficult part of the job Time consuming, if done properly 12 Source: Schnelle J. Incontinence. In Comprehensive Clinical Psychology. Pergamon, NY. 1998; 433-454 6
About the Quality Measure Quality Measure Description Percent of Long-Stay, Low-Risk Residents Who Lose Control of Their Bowel or Bladder Minimum Data Set (MDS) 3.0 measure reports the percentage of long-stay residents who frequently lose control of their bowel or bladder. Source: RTI International. MDS 3.0 quality measures user's manual. v8.0. Baltimore (MD): CMS; 2013 Apr 15. 80 p. http://www.qualitymeasures.ahrq.gov/content.aspx?id=38346 14 7
Rationale for Quality Measure Not a normal sign of aging Can often be successfully treated May be caused by Physical and medical conditions Reactions to medication Diet and fluid intake Distance from toilet 15 Rationale for Quality Measure (cont.) Individualized programs should focus on evaluation of residents to identify Potential causes Early intervention Care planning Education Increasing continence can help the well-being of the resident by restoring dignity and social interaction. 16 8
Quality Measure Specifications Numerator A resident will trigger if the most recent MDS 3.0 indicates frequently or always incontinent of bladder or bowel. Denominator All long-stay residents with a selected target assessment, except those with exclusions. 17 Quality Measure Specifications (cont.) Who is excluded? Totally dependent in bed mobility self performance Totally dependent in transfer Totally dependent in locomotion on unit self performance Severe cognitive impairment on targeted assessment 18 9
Become a Detective http://www.cms.gov/medicare/provid er-enrollment-and- Certification/QAPI/Downloads/QAPIAt aglance.pdf 20 10
Quality Assurance + Performance Improvement 21 When a Resident Triggers Determine percent of low-risk residents with loss of bowel or bladder. Review MDS 3.0 Resident Level Quality Measure Report. Audit charts for residents who flag. Start a small performance improvement project. How can we affect this number? Do any issues come to mind? 22 11
Composite Score Calculator http://www.hsag.com/compositescore 23 Composite Score Calculator (cont.) 24 12
Resident Level Report 25 Five Whys Technique 26 13
Change Package Concepts 3.a.3: List resident choice and preference. 3.a.4: Develop communication strategy for staff to observe and share resident information. 3.a.8: Learn from family. 27 Do You Know How many of your residents are continent upon admission? How many of your residents become incontinent after admission? How many days it takes for your continent residents to become incontinent? 28 14
Possible Reversible Factors What resident conditions may be contributing to incontinence? Delirium, depression, urinary tract infection, excess caffeine, etc. What environmental conditions may be contributing to incontinence? Mobility, toilet access, restrictive clothing, etc. What medications may be contributing to incontinence? 29 Types of Urinary Incontinence Stress incontinence Caused by increased compression during exercise, coughing, or sneezing Urge incontinence Caused by sudden, involuntary bladder contraction Source: Types of Urinary Incontinence. WebMD. August 23, 2015. Accessed August 19, 2015. http://www.webmd.com/urinary-incontinence-oab/types-of-urinaryincontinence 30 15
Types of Urinary Incontinence Mixed incontinence Stress and urge incontinence Overflow incontinence Not able to empty bladder appropriately 31 Bladder Incontinence Causes Age-related changes in urinary tract Urinary tract infection Other conditions Diabetes Cancer Stroke Cognitive impairment Mobility impairment Source: Gorina Y, Schappert S, Bercovitz A, et al. Prevalence of incontinence among older Americans. National Center for Health Statistics. Vital Health Stat 3(36). 2014. 32 16
Bowel Incontinence Risk Factors Chronic diarrhea Inadequate fiber and water intake Chronic constipation Diabetes Stroke Psychiatric conditions Cognitive impairment Mobility impairment 33 Current Approaches to Care Planning Bladder retraining Prompted voiding Pads/briefs Habit training Scheduled toileting Catheter Pelvic muscle rehabilitation 34 17
Incontinence Management Training Module (cont.) Step 1: Conduct a basic resident evaluation. Step 2: Assess resident responsiveness to prompted voiding. http://www.mc.vanderbilt.edu/root/vumc. php?site=cqa&doc=43434 35 Incontinence Management Training Module (cont.) Step 3: Implement time-saving strategies to maintain program. Step 4: Conduct periodic control checks to maintain quality. 36 18
Other Resources AMDA Clinical Corner: Incontinence http://www.amda.com/tools/clinical/urinaryincontinence.cfm Bowel & Bladder Incontinence Toolkit http://mpqhf.com/qio/wpcontent/uploads/2015/08/bowel_bladder_elimination_toolkit.pdf Medline University Incontinence Webinars https://www.medlineuniversity.com/desktopshell.aspx?tabid=62&goto=browse&brows e=keyword&keyoption=both&clinical=both&local=all&bycost=0&contenttypes=1&keyw ord=incontinence AANAC Section H: Bowel and Bladder Coding http://www.aanac.org/docs/mds-3.0-rai-users-manual/11123_mds_3-0_chapter_3_-_section_h_v1-12.pdf?sfvrsn=6 37 Peer Coach Insight Nancy Wilson Administrator Sun Health La Loma Litchfield Park, AZ Phyllis Brown Director of Nursing Mission Palms of Mesa Mesa, AZ 38 19
Thank You! Keith Chartier 602.801.6906 kchartier@hsag.com Elaine Nelson 602.801.6933 enelson@hsag.com CMS Disclaimer This material was prepared by, Inc., the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, 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. QN-11SOW-C.2-08212015-01 20