Data Element Uniformity and Cross Se4ng Quality Measures

Data Element Uniformity and Cross Se4ng Quality Measures Stella Mandl, RN, Technical Advisor Tara McMullen, MPH, PhD(c), Analyst Anita Yuskauskas, PhD, Technical Director

Data Assessment Elements Goal When we keep in mind the ulamate goal of and step back to look at the big picture of what s been done to prepare, it becomes clearer where the work converges; how much of the work is connected and has already been done to achieve Achieving Uniformity to Facilitate Effec6ve Communica6on for Be:er Care of Individuals and Communi6es 2

CARE: Background 2000: Benefits Improvement & ProtecFon Act (BIPA) mandated standardized assessment items across the Medicare program, to supersede current items 2005: Deficit ReducFon Act (DRA) Mandated the use of standardized assessments across acute and post- acute sejngs Established Post- Acute Care Payment Reform DemonstraAon (PAC- PRD) which included a component tesang the reliability of the standardized items when used in each Medicare sejng 2006: Post- Acute Care Payment Reform DemonstraFon requirement: Data to meet federal HIT interoperability standards 3

CARE: Concepts Guiding Principles and Goals: Assessment Data is: Standardized Reusable InformaAve Communicates in the same informaaon across sejngs Ensures data transferability forward and backward allowing for interoperability StandardizaFon: Reduces provider burden Increases reliability and validity Offers meaningful applicaaon to providers Facilitates paaent centered care, care coordinaaon, improved outcomes, and efficiency Fosters seamless care transiaons Evaluates outcomes for paaents that traverse sejngs Allows for measures to follow the paaent Assesses quality across sejngs, and Inform payment modeling 4

Current State Data, Document and Transmission: A value stream for convergence PaAent and Resident Assessments uniform only at the provider- type level CommunicaAon not standardized Care CommunicaAon: Gap Measures lack harmonizaaon Providers double document/triple document Assessment Data not interoperable Data elements don t map exactly across sejngs Reliance on cross walks Quality measures only measure quality in one sejng 5

Building the Future State Assessment Instrument/Data Sets use uniform and standardized items Measures are harmonized at the Data Element level Providers/vendors have public access to standards Data Elements are easily available with naaonal standards to support PAC health informaaon technology (IT) and care communicaaon Transfer of Care Documents are able to incorporate uniform Data Elements used in PAC sejngs, if desired Measures can evaluate quality across sejngs 6

Keeping in Mind, the Ideal State FaciliAes are able to transmit electronic and interoperable Documents and Data Elements Provides convergence in language/terminology Data Elements used are clinically relevant Care is coordinated using meaningful informafon that is spoken and understood by all Measures can evaluate quality across se4ngs and evaluate intermisent and long term outcomes Measures follow the person Incorporates needs beyond healthcare system 7

Ideal State: Data Elements The Ideal Document and Data Elements would: Stop the push and pull of compeang documentaaon needs Be naturally occurring in paaent care documentaaon Able to serve mulaple purposes Create a common spoken and IT language Allow for reusable data E- specified using Federally accepted standards Allow for Interoperability Facilitate care coordinaaon through standardized communicaaon Be usable across the conanuum of care, and beyond the healthcare system Meet these requirements: Reflect natural Create useful informaaon for paaent care communicaaon and transfers of care Supply quality related informaaon Be available for payment methodology 8

As Is Transi6on To Be Nursing Homes MDS LTCHS LTCH CARE Data Set As Is: MulFple IncompaFble Data Sources InpaAent Rehab FaciliAes IRF- PAI Home Health Agencies OASIS Hospitals No Standard Data Set Physicians No Standard Data Set OutpaAent SeJngs No Standard Data Set GOAL: Uniform Data Elements Across Providers Standardized NaAonally Veded To Be: Uniform Assessment Data Elements Enable Use/re- use of Data Exchange PaFent- Centered Health Info Promote High Quality Care Support Care TransiFons Reduce Burden Expand QM AutomaFon Support Survey & CerFficaFon Process Generate CMS Payment 9

Future and Ideal States: Use of Data Elements Care Settings InpaFent RehabilitaFon FaciliFes Long term Care Hospitals Skilled Nursing FaciliFes Home Health Agencies Hospitals Hospice Physicians Community: LTSS/HCBS Data library of standardized elements SeJngs can pull from standardized inventory for data elements needed for assessments and/ or measures Data elements serve mulaple purposes, specifically a clinical purpose Use of standardized data elements in any sejng, for mulaple purposes especified 10

11 Data Element Library Concept Standardized data derived from CMS LTPAC PaFent Assessment Instruments, Clinical Quality Measures (CQMs), and other data requirements CMS Data Sets NH: MDS HHA: OASIS IRF: IRF:PAI LTCH: CARE Data Set HOSPICE Item Set (not assessment based now) Standardized metadata, pafent data, unique idenffiers (QuesFons, Responses and Data), clinical vocabularies and exchange standards mappings Data Element Library Data Consumers Care Planning CQM Reporting Payment (CMS /Stats) Program Integrity and Reg Compliance Research ecqm ReporFng: QDM Payment Survey and Certification CARE Data sets validated and applied by each Data Consumer Patient Transfers Other Data Users

Data Element Library & Oversight Data Element Library 12

CMS Quality ReporFng and Performance Programs Hospital Quality Physician Quality ReporFng Post Acute Care Payment Model ReporFng PopulaFon Quality ReporFng Medicare and Medicaid EHR IncenFve Program PPS- Exempt Cancer Hospitals InpaFent Psychiatric FaciliFes InpaFent Quality ReporFng Medicare and Medicaid EHR IncenFve Program Physician Quality ReporFng System (PQRS) erx quality reporfng InpaFent RehabilitaFon Facility Nursing Home Compare Measures LTCH Quality ReporFng Hospice Quality ReporFng Medicare Shared Savings Program Hospital Value- based Purchasing Physician Feedback/Value- based Modifier* ESRD QIP Medicaid Adult Quality ReporFng* CHIPRA Quality ReporFng* Health Insurance Exchange Quality ReporFng* Medicare Part C* Medicare Part D* HAC payment reducfon program Home Health Quality ReporFng Readmission reducfon program OutpaFent Quality ReporFng Ambulatory Surgical Centers PAC Assessment Data 13

CMS Vision for Quality Measurement Align measures with the National Quality Strategy and Six Measure Domains Implement measures that fill critical gaps within the six domains Develop parsimonious sets of measures - core sets of measures Remove measures that are no longer appropriate (e.g., topped out) Align measures with external stakeholders, including private payers and boards and specialty societies Continuously improve quality measurement over time Align measures across CMS programs whenever and wherever possible 14

Alignment: NQF #0678: Percent of Residents or PaFents with Pressure Ulcers that are New or Worsened Originally implemented in the skilled nursing facility sejng Expanded to Long Term Care Hospitals and InpaFent RehabilitaFon FaciliAes Goal of expansion: harmonizafon of priority HAC Skilled nursing facility data suggests validity and reliability of this quality measure Overall feedback regarding this measure has been posifve Further review, analysis and modificaaons are needed CMS and RTI has integrated feedback from interviews, environmental scan and TEP to inform modificaaons to this measure 15

CMS Framework for Measurement Care Coordination Clinical Quality of Care Care type (preventive, acute, post-acute, chronic) Conditions Subpopulations Person- and Caregiver- Centered Experience and Outcomes Patient experience Caregiver experience Preference- and goaloriented care Patient and family activation Infrastructure and processes for care coordination Impact of care coordination FuncFon Safety All-cause harm HACs HAIs Unnecessary care Medication safety Population/ Community Health Health Behaviors Access Physical and Social environment Health Status Efficiency and Cost Reduction Cost Efficiency Appropriateness Measures should be patientcentered and outcome-oriented whenever possible Measure concepts in each of the six domains that are common across providers and settings can form a core set of measures 16

Improving Medicare Post- Acute Care TransformaFon (IMPACT) Act of 2014 Requires Standardized PaAent Assessment Data that will enable Medicare to: 1. Compare quality across PAC sejngs 2. Improve hospital and PAC discharge planning 3. Use this informaaon to reform PAC payments (via site neutral or bundled payments or some other reform) while ensuring conanued beneficiary access to the most appropriate sejng of care. PaAent Assessment Data Requirement for InpaFent Hospitals (medical condiaon, funcaonal status, cogniave funcaon, living situaaon, access to care at home, and any other indicators necessary for assessing paaent need)

FuncFonal Status FuncAon is a measurement area that touches on all 6 PrioriAes. FuncAonal status is relevant to all sejngs: High priority to consumers Specialized area of care provided by post- acute care providers, including IRFs, LTCHs, SNFs, and HHAs Long term outcomes link to funcaon FuncAonal Status data are collected by post acute care providers for payment and quality monitoring: IRFs (payment), SNFs (payment), LTCHs (risk adjustor for quality) and HHAs (payment and quality). However, funcaonal status data are currently sejng- specific and are not easily compared. 18

Standardizing FuncFon Acute HCBS Post Acute 19

Measures in Development IRF Functional Outcome Measure: Change in self- care score for medical rehabilitation patients. IRF Functional Outcome Measure: Change in mobility score for medical rehabilitation patients. IRF Functional Outcome Measure: Discharge mobility score for medical rehabilitation patients. IRF Functional Outcome Measure: Discharge self- care score for medical rehabilitation patients. Percent of LTCH patients with an admission and discharge functional assessment and a care plan that addresses function. LTCH Functional Outcome Measure: Change in mobility among patients requiring ventilator support. 20

FuncFonal Status Quality Measures Data collecaon using the CARE Item Set occurred as part of the Post Acute Care Payment Reform DemonstraAon and included 206 acute and PAC providers hdp://www.cms.gov/medicare/quality- IniAaAves- PaAent- Assessment- Instruments/Post- Acute- Care- Quality- IniAaAves/ CARE- Item- Set- and- B- CARE.html 21

CMS Library Concept & CARE CMS Assessment Data Element Library HCBS CARE OASIS- C IRF- PAI MDS 3.0 LTCH CARE Data Set CARE

CMS Vision for Quality Measurement Align measures with the National Quality Strategy and Six Measure Domains Implement measures that fill critical gaps within the six domains Develop parsimonious sets of measures - core sets of measures Remove measures that are no longer appropriate (e.g., topped out) Align measures with external stakeholders, including private payers and boards and specialty societies Continuously improve quality measurement over time Align measures across CMS programs whenever and wherever possible 23

CMS Vision for MU

TEFT Grant Program Addresses the Vision Four Components of TEFT Test an experience of care survey Test a set of data elements from the functional domain in the Continuity Assessment Record & Evaluation (CARE) Demonstrate personal health records with guidance from the Department of Defense (DoD) Identify, evaluate and harmonize standards for electronic long term services and supports (e-ltss) records in conjunction with the Office of National Coordinator s (ONC) Standards and Interoperability (S&I) Framework

Expansion of CARE to CB- LTSS Goals for expanding CARE items to CB- LTSS: Standardizes assessment concepts across populations and settings of care Supports person centered care through transitions Facilitates quality monitoring across providers and settings Leverages existing standards developed for the interoperable exchange of CARE items, specifically function Achieves other administrative benefits such as Aligns with Balancing Incentive Program (BIP) requirements Reduces costs to develop assessment tools Reduces data collection burden Increases ability to report data to CMS Supports bundled payment initiatives