Nutrition Assessment and Interventions to Improve · PDF fileSkin integrity and changes in...

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The IMPACT ACT of 2014 and Nutrition:

Value Based Purchasing Quality Measures

April 28, 2016

Presenter: Brenda Richardson, MA, RDN, LD, CD, FAND

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Session Objectives

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Recognize Quality Measures and the focus for nutrition

with Value Based Purchasing (VBP).

Identify current “best practice” for nutrition screening

and assessment.

Describe nutrition interventions to improve Quality

Measures.

Overview

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The IMPACT ACT Incorporates standardized assessment, including

components of the CARE tool, into existing assessment tools across PAC providers;

Utilizes Measure Domains that are standardized;

Requires development and public reporting of quality measures across settings

Applies measures that are approved by National Quality Forum (NQF) or through notice and comment rulemaking;

Requires Hospitals and PAC providers to provide quality measures to consumers when transitioning to a PAC provider;

Requires Health and Human Services (HHS) and Medicare Payment Advisory Commission (MedPAC) to conduct studies and reports to link payment to quality; and

Adds $11 million in funding for CMS to use payroll data to measure staffing in SNF setting.

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Session Objectives

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and assessment.


Measures.

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Measure Domains to be standardized

Skin integrity and changes in skin integrity

Functional Status, Cognitive Function, and Changes in Function and Cognitive Function

Incidence of major falls

All‐condition Risk‐adjusted Potentially Preventable Hospital Readmissions Rates

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Understanding the “Improving Medicare Post-Acute Transformation Act of 2014 (IMPACT)” is essential for the RDN /NDTR/DSM practicing in the following settings:

Skilled Nursing Facilities (SNF) Long Term Acute Care Hospitals (LTAC)

Inpatient Rehabilitation Facilities (IRF) Home Health Agencies (HHA)

Acute Care***

RDNs, NDTRs, CDMs should note nutrition-relatedmeasure domains with:• Functional Status/ Cognitive Function

• Skin Integrity

• Falls or Major Injury

• Hospital Readmissions

THE RDN, NDTR, CDM

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• Must be aware of the changes in the healthcare landscape, such as in the IMPACT Act, to remain a relevant and significant member of the health care team.

• Must use their unique knowledge, skills, and abilities to play a significant role in improvement; (i.e., healing time of pressure ulcers, changes in cognitive function, reducing hospital readmissions and eliminating major falls) through evidenced-based research, nutrition specific interventions, education, coordination of care/monitoring/evaluation.

• In addition, can help post-acute care settings achieve positive clinical outcomes, quality measure improvement, cost savings, and provide an improved quality of life for the patient/resident.

THE RDN, NDTR, CDM

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• Must monitor and evaluate interventions and adjust as needed. Must be mindful of knowing when alternative methods of feeding may need to be considered, if consistent with the individual's advance/directives and goals of therapy. Or when appropriate palliative or hospice care must be considered.

• Education and interventions should be person-centered using the information obtained during the time in the post-acute care settings and may include adding fortified foods at each meal, easy to eat high calories snacks and supplements between meals, and fluids offered before and after each meal.

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DISCHARGE PLANNING

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• The RDN plays an essential role in discharge planning of patients/residents at risk for malnutrition, pressure areas, falls, etc. utilizing patient/resident and family interventions and education.

• It is imperative that the RDN meet with patients/residents prior to discharge to ensure effective care coordination.

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Skin Integrity and Changes in Skin Integrity

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NQF #0678

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Domain Description:

• This quality measure reports - the percent of Residents or Patients with Stage 2-4 Pressure Ulcers that are new or worsened (short stay). NQF #0678

• Calculated using standardized assessment data from the MDS 3.0 assessment instrument for SNF residents, the LTCH CARE data set for LTCH patients, the IRF-PAI for IRF patients and the OASIS assessment instrument for HHA.

• Reporting of standardized assessment data begins on October 1, 2016 for LTCH, IRFs, SNFs, and January 1, 2017 for HHAs.

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Rationale/Background: • Pressure ulcers are recognized as a serious medical condition causing pain,

decreased quality of life, and increased mortality.

• Pressure ulcers typically result from prolonged periods of uninterrupted pressure on the skin, soft tissue, muscle or bone.

• An estimated 2.5 million people in the US develop pressure ulcers yearly.

• Pressure ulcers are a high-cost adverse event across the PAC continuum. 0.4% to 38% in acute care, 2.2% to 23.9% in SNFs and NHs, and 0%-17% in home care.

• The Federal Register reports the average cost for a hospital stay related to Pressure Ulcers was $40,381.

• Using data from 2009-2010, severe (Stage 3 and Stage 4) pressure ulcers acquired during a hospital stay were estimated to have increased CMS payments across 90-day episodes of care by at least $18.8 million a year.

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Outcome Measure:

• NQF #0678 measure is intended to encourage SNF/Nursing Homes (NHs), LTCHs, IRFs, and HH to:

Prevent pressure ulcer development or worsening.

Closely monitor and appropriately treat existing pressure ulcers.

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• Facility/Agency QAPI program should include Pressure Ulcer Outcomes/Measures to: (continued)

Prevent pressure ulcer development through early identification of individuals at risk, using evidence based prevention methods and systems to ensure adequate nutrition i.e. develop facility pressure ulcer guidelines/protocol(s).

Prevent pressure ulcer worsening through a facility developed monitoring/evaluation system.

Develop a pressure ulcer prevention and treatment training program for the staff.

Collaborate between the resident/client, family and members of the healthcare team to help achieve patient/client goals set.

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Recommendations: • Each undernourished patient/client should be screened and assessed for

nutritional risk at admission using reliable validated tools with a referral made to a RDN or NDTR.

• The RDN and NDTR should utilize the Nutrition Care Process to develop an individualized care or discharge plan that is consistent with and based the individual’s nutrition and hydration status, medical condition and personal preferences.

• If Pressure Ulcer Clinical Practice guidelines are not available the facility/agency could utilize the NPUAP Clinical Practice Guidelines which summarizes the supporting evidence for pressure ulcer prevention and treatment.

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Recommendation Continued: • Daily administration of a therapeutic vitamin and mineral supplement may be

considered if poor oral intake or deficiencies are suspected.• Individuals not taking in their assessed needs; diet liberalization, oral

nutritional supplements (ONS), fortified food and/or nutrient dense food may be considered.

• Adequate calories, protein, fluids, vitamins and minerals are required by the body for maintaining tissue integrity and preventing tissue breakdown.

• Managing Pressure Ulcers requires treatment and ongoing prevention. Two detailed and annotated clinical algorithms (Nestle Health Science® ) provide a prototype for prevention and treatment of Pressure Ulcers in clinical/home settings.

• The algorithms are available at www.RD411.com.Inc.• Review of the Case Study and Template available at

www.eatrightpro.org/impact.

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Functional Status, Cognitive Function, and Changes in Function

and Cognitive Function

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Functional Status, Cognitive Function, and Changes in Function and Cognitive FunctionDomain Description:

• Functioning is a broad term that covers various components and several levels (e.g., body, person, society). An umbrella term that encompasses all body structures and functions, activities, and participation in daily life.

• Examples of functioning within the components of body structures and functions include swallowing, bladder and bowel continence and mobility.

• Examples of functioning within the area of activities include eating, bathing, and dressing.

• Examples of functioning in the area of participation, include working and participating in recreational activities.

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Rationale/Background:

• Functional status is measureable and can determine assistance needed for activities of daily living and mobility.

• Outcomes for degree of assistance may have an impact on morbidity in the post-acute setting.

• Helps determine appropriate level of care and associated costs for care.

Outcome Measure:

Functional status may be enhanced with adequate hydration and nutrition intake.

• Areas are measured in care settings using specific tools: MDS, OASIS, LTAC Care and IRF-PAI.

• In place for improved care and outcomes as persons are discharged and admitted from centers of care.

• Increases efficiency with care delivery and optimizes levels of care improvement.

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Recommendations:

Self-Care:

• Eating: Be a leader for eating nutritional adequate and acceptable food with eating dependence and assistance.

• This includes working with IDT members including restorative staff, occupational therapists and assistants, trained home health aides.

• This is an opportunity for training and education.

• Suggestions include review of adaptive devices and uses, positioning for eating, mechanics of self feeding.

• Nutrition evaluation for adequacy and referral to professional intervention by RDN/NDTR is specifically highlighted as an important process for training para professionals and members of IDT members.

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Recommendations:

Oral Hygiene:

• Use of cleaning tools - electric toothbrushes, training for frequency of cleaning teeth and devices, availability of cleaning solutions and paste.

• Impact of good oral care for aspiration and taste acuity can be explored as a precursor for adequate food and fluid intake.

Muscle strength:

• For self-care, mobility, is implied with respect to nutrition adequacy for calories, muscle anabolism and fluid maintenance.

• Education and training for resident and care providers is an area of importance after interventions and care planning has been completed with nutrition care process.

• Physical assessment for strength (hand grip, walking time and distance and chair stands) can be incorporated for measurements of improvement.

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Recommendation:

• Review for nutrition assessment for appropriate interventions using nutrition care process.

• Appropriate interventions can be interpreted with use of algorithms for references in all care settings

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Incidence of Major Falls

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NQF# E0674

Incidence of Major FallsDomain Description: Correlates to the CMS Measure Domain: Incidence of Major Falls: NQF Number: 0674• This measure reports the percent of patients, residents, and persons who have

experienced one or more falls with major injury reported in the target period or look-back period.

• "Falls that result in a major injury" are defined as: falls that result in a major injury such as bone fractures, joint dislocations, closed head injuries, subdural hematoma, and altered consciousness, among other major injuries.

Definition: Falls - The Minimum Data Set (MDS) defines a fall as unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). • An episode where a resident lost his/her balance and would have fallen, if not for

staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.

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Incidence of Major FallsRationale/Background: • Falls and fall-related injuries are a major public health problem.

• Falls threaten independence and increase risks of mortality in the aging.

• Psychologically, falls can limit activities, reduce mobility, and decrease quality of life.

• Fall risks are multifactorial and include nutrition-related risks.

Falls and Malnutrition:

• Malnutrition is associated with an increased risk of being a faller and with impaired activity.

• Malnourished residents who receive nutritional intervention have a lower risk of being a faller.

RDNs and NDTRs should be part of the multidisciplinary team to identify nutritionally high-risk older adults and provide evidence-based

interventions for prevention and management.

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Incidence of Major FallsOutcome Measure: Reduction in the percent of patients, residents, and persons who have experienced one or more falls with major injury reported in the target period or look-back period.

Recommendations: Initial review of literature appears to support that malnutrition plays an important role in the prevention of falls in the aging.

By implementing best practice tools for nutrition we can prevent and reduce falls by:

• Providing early identification of older adults with a higher risk of falling.

• Training multidisciplinary team to use screening instrument to determine risk.

• Identifying and managing malnutrition in accordance with scope and standards of practice including use of nutrition focused physical exams as one tool for nutrition assessments.

• Implementing fall prevention interventions as a multidisciplinary team effort.

• Monitoring Quality Measures for falls trend data and execute QAPI program for nutrition components to prevent falls.

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Incidence of Major Falls

Additional Resources:

• Centers for Disease Control and Prevention, Home and Recreation: http://www.cdc.gov/homeandrecreationalsafety/

• National Institutes of Arthritis and Musculoskeletal and Skin Diseases: Preventing Falls and Related fractures:http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Fracture/prevent_falls.asp

• National Council on Aging, Fall Prevention:https://www.ncoa.org/healthy-aging/falls-prevention/

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All-condition Risk-adjusted Potentially Preventable Hospital

Readmissions Rates

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NQF# 4210

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All-condition Risk-adjusted Potentially Preventable Hospital Readmissions Rates

Domain Description: Being “all-condition, risk-adjusted potentially preventable hospital readmission rates”.

Rationale/Background: Hospital Readmissions

• An admission to an acute care hospital within 30 days of discharge from an acute care hospital.

• Can be from any cause; does not have to be from the original diagnosis.

• Readmission does not need to be to the same hospital, but is counted in the original hospital statistics.

• Readmission can be a from a SNF, rehabilitation hospital, home health, long term care hospital.

Outcome Measure: Reduce unplanned readmissions.

Goals are to reduce costs while improving patient care.

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Background Information: OIG Report 2013

• > 825,000 Medicare beneficiaries admitted to hospital from SNFs (> 30% admitted multiple times)

• Approximately 1.3 million admissions

• > $14 billion dollars

• risks to residents for harm and other negative outcomes

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“Protecting Access to Medicare Act of 2014” (PAMA)

• Enacted April 1, 2014

• Sections 215- added subsections to section 1888 of the Social Security Act for:

• Quality Measures (QM) for SNFs based on:

• Rate of hospital readmissions of Medicare beneficiaries discharged to a SNF and a

• Value Based Purchasing (VBP) program where Medicare payments to SNFs will be adjusted based on their performance scores on the quality measures established.

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PAMA: Two Hospital Re-Admission Measures

• All-cause, all-condition hospital readmission measure.

• All-condition, risk-adjusted rate of potentially preventable readmissions.

• Public reporting by October 1, 2017 for the Nursing Home Compare Website.

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Value Based Purchasing (VBP)

• Medicare SNF payments will be subject to a 2% withhold starting October 1, 2018.

• Evaluation will be based on ratio of actual readmissions to their expected readmissions relative to the national average.

• Facilities in the bottom 40% will see per diems reduced while those finishing higher will receive full per diem (and may be eligible for a bonus).

NOW IS THE TIME TO START REVIEWING PROCESSES AND PROTOCOLS REALTED TO HOSPITAL READMISSIONS!!!

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Care Transition is more important than ever!

• New CMS guidelines.

• Emerging payment models.

• Competitive marketplace.

• Focus is on coordinated care for the resident/patient/client.

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http://healthy-transitions-colorado.org/

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CARE TRANSITION IS KEY and NUTRITION plays an important role!

• Hospital to SNF

• SNF to hospital

• SNF to home

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Resident

Hospital

SNFHome

NUTRITION

• Focus on prevention and management of malnutrition

• Malnutrition occurs in ALLsettings

• Medical Nutrition Therapy (MNT)

• Outcomes: quality of care, costs, quality of life

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Acute-Hospitalized = Nutritionally Vulnerable

• As of 2013, 14.1% of the population in the US was >65 years, yet accounted for the greatest utilization of healthcare services.

• 34.9% of all hospital stays

• greater mean length of stay and cost per stay than any other age group.

• Older adults have a ↑ number predisposing conditions with comorbid illnesses and disabilities = more vulnerable to adverse events during hospitalization.

• Combination of susceptibility and reduced ability to overcome stressors leads to poor long term outcomes and commonly results in loss of independence.

• Decline of all these physiological parameters can potentially be directly related to reduced energy intake.

• When energy intake is insufficient to meet the demands of the body either due to starvation, acute illness or chronic disease/disability, then malnutrition becomes the driver that leads to the further deterioration of functional abilities and inability to recover from disease.

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Pre- and Post-surgical Concerns Reflect Nutritional Vulnerability

• >1/3 of all surgical procedures are on ages ≥65 years; and has postoperative complications than for younger patients, resulting in permanent declines in cognitive and physical function

• Poor nutritional status presents an especially high risk situation for older adults undergoing surgery because it:

• increases the risks for more complications during hospitalization

• and poor outcomes after discharge related to more infections, poor healing, and increased mortality.

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Pre- and Post-surgical Concerns Reflect Nutritional Vulnerability-cont.

• The biggest cause for alarm in older adults after surgery is insufficient action to fully address malnutrition and nutritional risk.

• Screening for malnutrition in adults admitted into the hospital is conducted 90 % of the time;

• Known validated screening tools are used only 37.5% of the time.

• Results of a national survey (2012-13) of nutritional screening practices in the US revealed that <40% of those identified to be malnourished actually receive a clinical intervention.

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We ARE getting better in Etiology-based malnutrition definitions and diagnosis.

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White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012; 112(5):730–8.

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Resource: Alliance Nutrition Care Model

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Toolkit: http://malnutrition.com/getinvolved/hospitalnutritiontoolkitWebsite: http://malnutrition.com/alliance

Post Hospital Syndrome• Transient period of generalized risk for a wide range of

adverse events (acquired condition of vulnerability)

• Period of 30 days after discharge from a hospital-risks from stress that occurred from the experience in the hospital along with lingering effects of the acute illness.

• Sleep deprivation

• Pain

• Discomfort

• Meds

• NPO

• ↓ intake food and fluids

• Restricted therapeutic dietsSource:N Engl J Med. 2013 January 10; 368(2): 100–102. doi:10.1056/NEJMp1212324. Post-Hospital Syndrome – A Condition of Generalized Risk, Harlan M. Krumholz, M.D. 77

Nutrition and Care Transitions - Acute

• Coordinate nutrition into discharge planning with acute providers.

• Determine what info is needed and agree on process for proving information: Forms/EHR

• Current diet order (standardize diet order terminology)

• Dysphagia – Diet consistency levels? Liquids?

• Therapeutic diet terminology

• Liberalization with frail elderly

• Provide information on overall intake of food and fluids.

• Nutrition Assessment/Recommendations/Discharge

• Share any validated malnutrition risk screening scores. 78

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SNF Nutrition and Care Transitions Systems-cont

• Nutrition screening and referral process

• Process for nutritional “high risk” residents

• Are your weight and heights procedures done according to “best practice” and accurate?

• Focus on “Person Centered Care”

• Liberalize diet to avoid stringent restrictions that may lead to ↓ intake and risk of illness, infections, and wt. loss.

• Review supplement policies, “real food”, “fortified foods”

• Transitional care plan for nutrition focused on 30 days after admission

• Integrate into QAPI

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SNF- Nutrition and Care Transitions-Home - cont.

• Integrate into QAPI

• For SNF to Home: Incorporate nutrition into comprehensive discharge planning.

• Follow-Up services needed (cooking, grocery shopping, etc.)

• Access to food? Financially able to purchase food? Is assistance needed? (caregivers, community? Meals on Wheels? Area Agency for Aging?)

• Consider making a Direct Contact after discharge

• Phone call next day

• Once a week for a month

• Once a month for 3 months

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Alliance to Advance Patient Nutrition http://malnutrition.com/alliance

Session Objectives




and assessment.


Measures.

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The IMPACT ACT of 2014 and Nutrition:

Value Based Purchasing Quality Measures

Thank YouPresenter: Brenda Richardson, MA, RDN, LD, CD, FAND

Email: [email protected]

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