Improving Quality Measuresin atom Alliance Nursing Homes

When it comes to Composite Scores, the lower the better. Scores are comprised of 13 long-stay quality measures. The Centers for Medicare & Medicaid Services (CMS) has set a national goal for nursing homes to achieve a 6.00 or less.

Opportunities

Top three opportunities for improvement in atom Alliance states

Reducing antipsychotic medication

Reducing incontinence

Reducing assistance with activities

of daily living (ADLs)

In Indiana, quality improvement advisors identified nursing facilities with composite scores between 6.10 and 7.00 to focus on their immunization (flu and pneumonia) quality measures. It helped nursing homes reach their improvement goals to ensure that more of their residents received both immunizations and it was documented accurately.

In Kentucky, quality improvement advisors partnered with the state health department in nine regional nursing home collaboratives to work on Quality Assurance and Performance Improvement (QAPI) projects. Advisors provided data and best practices to improve the nursing homes’ measures and lower their composite scores.

In Tennessee,quality improvement advisors hosted one-on-one virtual meetings with nursing home administrators and providers. Advisors coached them how to drill down into their data to determine which measure to target for a specific performance improvement project (PIP) that helped lower their composite score.

In Mississippi, quality improvement advisors attended stakeholders’ regional meetings to maximize face-to-face opportunities with nursing home administrators. This fostered trust and allowed the advisors to offer targeted resources for individual nursing homes to improve critical measures.

In Alabama, quality improvement advisors sent monthly reminders to nursing home administrators for them to complete their Quality Assurance and Performance Improvement (QAPI) Self-Assessment (either initial or follow-up). This helped the facilities stay on track with their improvement efforts and make quality improvement a top priority.

Results

From Q1 2015 through Q2 2017

The average Composite Score among participating homes improved from 8.43 to 7.97.

40% of the participating homes (465 of 1172) haveachieved the Composite Score goal of < 6.00.

Our work across the five states has resulted in these successes:

This material was prepared by atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Content presented does not necessarily reflect CMS policy. 17.ASC2.12.033

For more information:www.atomAlliance.org

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