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Thank You for Joining! New England Nursing Home Quality Care Collaborative Massachusetts Learning & Sharing Webinar: QAPI Data Techniques August 25, 2015 Call-In Number: 855-309-6568 Access Code: 7523186 This material was prepared by New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement Organization for New England, 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. CMSMA_C2_201507_0147

Brockton Health Center Brookside Rehabilitation Cape Regency Rehabilitation & Health Care Center Epoch of Brewster Epoch of Norton Hathaway Manor Extended Care Facility Healthbridge Jewish Healthcare Center Kindred Great Barrington laurel lake Life Care Center Of Acton Life Care Center Of Merrimack Valley Life Care Centers of America Northeast Division Marquis Health Services WELCOME NENHQCC Participants! Newton Wellesley Center For Alzheimer's Care Northwood Rehab Penacook Place Queene Anne Nursing Home Royal Braintree Royal Cape Cod Nursing & Rehabilitation Center Royal Falmouth Royal Health Group Royal of Fairhaven Royal Taber Street Nursing & Rehab St. Joseph Rehabilitation & Nursing Center Stonehedge Rehabilitation & Skilled Care Center The Royal Megansett The TCU at Signature Healthcare/Brockton Hospital Thomas Upham House Victoria Haven Nursing Facility 8/25/2015 2

Lori Nerbonne Lori Nerbonne, BSN, RN Senior Program Coordinator Healthcentric Advisors

Objectives Objectives Understand the nursing home quality measures and identify opportunities to improve your Five-Star Quality Rating Learn how to use data to monitor and evaluate QAPI program performance Use data as a tool to build relationships with hospitals, ACOs and other partners Hear from other participating nursing home teams on how they are using data to drive quality improvement. 8/25/2015 4

Navigating the Collaborative Learning Series 1 Path: Safe Transitions 5

Learning Period 3 Pre- Work Webinar Learning Module Action Period July Sept. 2015 Pre-Work Webinar Learning Module Action Period QAPI Pre-Work: click here View the NE-NHQCC: Transitions of Care Webinar (July 9, 2015) Click here Click here to view all Learning Modules Module 6: End-of-Life Care Lesson 1 Lesson 2 Lesson 3 Lesson 4 Module 9: Getting a Seat at the Referral Table Coming Soon! Update goals on Charter as needed Start a PIP and share with your QIN-QIO state lead Track progress and celebrate achievements Contact your QIN-QIO state lead for assistance click here Continue onto the Next Learning Period 8/25/2015 6

Mark Your Calendars! Face to Face Learning & Sharing Days October 29, 2015 & December 3, 2015 Value-Based Purchasing Star Ratings Habilitation Therapy for Dementia Care Panel Discussions & Patient Stories 8/25/2015 7

Why is data important? QAPI regulations Five-Star Quality Ratings SNF Value-Based Payment Programs ACOs

New Focus on Quality and Value 8/25/2015 9

Measure clinical outcomes Drives quality improvement Monitor improvement Evaluate progress Marketing tool How is data used? 8/25/2015 10

Data tells a story. Informs about what you are doing well & what opportunities you have to improve Educates consumers about how your facility leaders and staff are performing Tells whether changes or improvements you make are working or not Demonstrates your commitment to quality and improving outcomes 8/25/2015 11

Using Data in To identify opportunities for Performance Improvement Projects How you will track your PIP progress What your end result is: are our changes working to get the results we want?

Sarah Dereniuk Sarah Dereniuk, MHA, NHA Program Administrator Healthcentric Advisors

Sharing Best Practices The QAPI Journey: Changing the way we use data D Youville Senior Care Andrea Rathbone, Administrator 8/25/2015 14

Data Sources Nursing Home Compare CASPER reports NE QIN-QIO Standard Analytic Report (SAR) NE QIN-QIO Readmission Report Facility logs or other data tracking systems

Nursing Home Compare 8/25/2015 16

13 Long-Stay Quality Measures % of residents with increased need for help with ADLs % of high risk residents with pressure ulcers (sores) % of residents who have/had a catheter inserted and left in their bladder % of residents who were physically restrained % of residents with a urinary tract infection % of residents who self-report moderate to severe pain % of residents experiencing one or more falls with major injury % of residents who received an antipsychotic medication % of l low-risk residents who lose control of their bowels or bladder % of residents who lose too much weight % of residents who have depressive symptoms % of residents assessed and given the seasonal influenza vaccine % of residents assessed and given the pneumococcal vaccine

5 Short-Stay Quality Measures Percent of residents with pressure ulcers (sores) that are new or worsened Percent of residents who self-report moderate to severe pain Percent of residents who newly received an antipsychotic medication Percentage of short-stay residents assessed and given the seasonal influenza vaccine Percentage of short-stay residents assessed and given the pneumococcal vaccine

Who uses Quality Measures Nursing Center Quality Team Surveyors Consumers Referral Sources Payors 8/25/2015 19

Calculating your Five-Star Rating Step 1: Start with the health inspections rating Step 2: Add 1 star if the staffing rating is 4 or 5 stars and greater than the health inspections rating. Subtract 1 star if the staffing rating is 1 star. Step 3: Add 1 star if the quality measures rating is 5 stars; subtract 1 star if the quality measures rating is 1 star.

CASPER Quality Measure Reports MDS 3.0 Facility Characteristics Report MDS 3.0 Facility Level Quality Measure Report MDS 3.0 Resident Level Quality Measure Report

Understanding Quality Measures to Identify Opportunities for Improvement Ratings for the Five-Star QM domain are calculated using the three most recent quarters for which data are available All of the QMs are given equal weight For each measure, 20 to 100 points are assigned based on facility performance 8/25/2015 22

QM Score Quality Measure Antipsychotic Medications (long-stay) # of QM Points is For QM Values Between And 100 0.00000000 0.08088236 80 0.08088237 0.14285715 60 0.14285716 0.19642856 40 0.19642857 0.26775956 20 0.26775957 1.00000000 Source: Five-Star Quality Rating System: Technical User s Guide Feb 2015, Table A3

Calculating your QM Rating Source: Five-Star Quality Rating System: Technical User s Guide Feb 2015

Monitor and Evaluate Performance 8/25/2015 25

Standard Analytic Report (SAR)

Resident & Family Satisfaction Data 8/25/2015 27

Now What? Start a Performance Improvement Plan (PIP) Use the Change Package: Evidence-based strategies Change concepts Actionable items 8/25/2015 28

Change Package Successful practices of high performing nursing homes. Evidence-based strategies Change concepts Actionable items Download the Change Package: http://www.healthcarefornewengland.org/wp-content/uploads/qapi-packet_042915.pdf

For More Information Download the QAPI Program Packet: http://www.healthcarefornewengland.org/wp-content/uploads/qapi-packet_042915.pdf Included in the Packet: Charter and Sample PIP and Sample Notebook Sections

Questions? 8/25/2015 31

Leadership in Dementia Care: OASIS Curriculum Boot Camps/Booster Sessions Full Day Train-the-Trainer Boot Camp sessions on Sept 15th or Sept 16 th Half Day Booster sessions on Oct 21st or Oct 28 th Contact Mass Senior Care: ddesimone@maseniorcare.org

Contact http://www.healthcarefornewengland.org Sarah Dereniuk, MHA, NHA Massachusetts NE NHQCC Program Administrator 1-877-904-0057 X3304 sdereniuk@healthcentricadvisors.org Lori Nerbonne, BSN, RN Massachusetts NE NHQCC Senior Program Coordinator 1-877-904-0057 X3302 lnerbonne@healthcentricadvisors.org Ashley Harris Massachusetts NE NHQCC Program Assistant 1-877-904-0057 X3305 aharris@healthcentricadvisors.org 8/25/2015 33

Resources Downloads: Nursing Home QM Manual: http://www.healthcarefornewengland.org/wp-content/uploads/qm-manualv1-4_042815.pdf Five Star Rating Technical User s Guide: http://www.cms.gov/medicare/provider-enrollment-and- Certification/CertificationandComplianc/downloads/usersguide.pdf RAI User s Manual: http://www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/NursingHomeQualityInits/MDS30RAIManual.html CASPER MDS 3.0 Quality Measure Reports Manual: https://www.qtso.com/download/guides/casper/cspr_sec11_mds_prvdr.pdf