Quality Measurement in Skilled Nursing Facilities Five Star ......Quality Measures Stars Change:...
Transcript of Quality Measurement in Skilled Nursing Facilities Five Star ......Quality Measures Stars Change:...
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Quality Measurement in Skilled Nursing FacilitiesFive Star Rating System
Judy Wilhide Brandt, RN, BA, RAC-MT, QCP, CPC, [email protected]
November 2018
Overview
Quality Measures
MDS Based
Five Star
Survey
SNF QRP
Claims Based
Five Star
SNF QRP
SNF VBP
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Five Star Rating System
Overview: Survey Rating will be overall rating unless influenced by Staffing or QM Ratings
Survey Rating Overall rating
Staffing Rating If 4 or 5 stars and above survey rating, add a star
QM Rating If 5 stars add a star
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Overview: Survey Rating will be overall rating unless influenced by Staffing or QM Ratings
Survey Rating Overall rating
Staffing Rating If one star, subtract a star
QM Rating If one star, subtract a star
Name Overall Survey Staffing QM
1 ★★ ★★ ★ ★★★★★2 ★★★★★ ★★★★ ★★★★★ ★★★3 ★★★★ ★★★★ ★★★ ★★★★4 ★★★★ ★★★ ★★★★★ ★★★5 ★ ★★ ★ ★★★6 ★★★★★ ★★★★ ★★★ ★★★★★
Examples
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5 Star Details: Ratings posted monthly
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Survey Stars Change:
With any survey packet that is forwarded or a successful appeal*
Staffing Stars Change:
Quarterly
Quality Measures Stars Change:
Quarterly
*‘frozen’ year after 11/28/17
Understanding the Preview Report
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Preview of what will post at the end of the month.
Five Star Preview Report
This one was posted in shared Casper folder “the middle” of April for posting at
the end of April 2018
Quality Measures Included in the QM Rating
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Preview Report
Preview Report
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M U K I D I
Survey Star Rating
Survey Star RatingWill be overall rating unless influenced by staffing or quality measures
Will not include surveys done after 11/28/17* for “approximately” one year
Includes two most recent annual surveys prior to 11/28/17 (Cycle 1 = most recent annual, Cycle 2 = annual prior
to Cycle 1 annual survey)
Includes substantiated complaints for two most recent complaint cycles prior to 11/28/17
Complaint cycle 1: 11/28/16 – 11/27/17Complaint cycle 2: 11/28/15 – 11/27/16
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Surveys since 11/27/17 WILL be posted to NH Compare, but will not be counted in star rating for approx. one year.
60% 40%
Note: complaint reporting periods do not match Star calculation periods
Cycle 1 Cycle 2
Immediate Jeopardy to Health
or Safety*
No Actual Hard with Potential for
than Minimal Harm
Actual Harm
No Actual Harm with Potential
for Minimal Harm
J50 Points
(75 Points)
G20 Points
K100 Points
(125 Points)
H30 Points
(40 Points)
L150 Points
(200 Points)
I45 Points
(50 Points)
D4 Points
A0 Points
E8 Points
B0 Points
F16 Points
(20 Points)
C0 Points
*If IJ * past non-compliance, G-level (20 points) assigned
Scope & Severity Grid
Few Some Many
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J50 Points
(75 Points)
K100 Points
(125 Points)
H30 Points
(40 Points)
L150 Points
(200 Points)
I45 Points
(50 Points)
F16 Points
(20 Points)
Certain tags under:• 483.10 Resident Rights• 483.40 Behavioral Health Services • 483.45 Pharmacy Services • 483.70 Administration (SW
qualifications > 120 beds)• 483.80 Infection Control (influenza
and pneumococcal vaccines)
All tags under:• 483.12 Freedom from Abuse,
Neglect, and Exploitation • 483.24: Quality of Life• 483.24: Quality of Care
Substandard quality of care
Cycle 1 Annual60%
Cycle 2 Annual40%
February 2018: Standard and Complaint Survey Weighing in Survey Stars
*Surveys done for first year of new LTCSP will not be used for Survey Star Rating for that first year.
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Reported on NH Compare, not used in calculations
2 Ds 1 D
(8*.60) + (4*.40) = 6.4
Preview Report
Revisits to ClearRevisit Number Noncompliance Points
First 0Second 50% of survey score added on
Third 70% of survey score added onFourth 85% of survey score added on
Bulk point add-on for revisits
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Survey Star Details
Cutpoints vary based on current state distribution
SNF rating held constant until you have survey event
While Special Focus Facility, overall max can be 3 stars
If 1 star in survey, max overall can be 2 stars
Same citation in annual & complaint counted once if within 15 days, worst one counts
10%5 Stars20%
1 Star
23.3%4 Stars
23.3%3 Stars
23.3%2 Stars
Survey Star Distribution
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Staffing Stars
Staffing Star Computation
Staffing star ratings are calculated quarterly based on PBJ data submitted prior to deadline, always a quarter behind.
April 18 July 18 Oct 18 Jan 19
CY Q4 17 CY Q1 18 CY Q2 18 CY Q3 18
CY = Calendar Year
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RNTotal Nurse
Staffing based on two case-mix adjusted measures, with equal weight.
Registered Nurse Director of Nursing
Registered Nurse with Administrative Duties
Registered NurseLicensed Practical/Vocational
Nurse with Administrative Duties
Licensed Practical/Vocational Nurse
Certified Nurse AideNurse Aide in Training
Medication Aide/Technician
RN Staffing
Registered Nurse Director of Nursing
Registered Nurse with Administrative Duties
Registered Nurse
Total Nurse Staffing
Note: LPNs with administrative
duties do not count as RNs
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Doing the math
Total Nurse Example3 reported/ 6 expected = ½ x 3.2285 =
1.61425 adjusted hours
Hoursadjusted =
(Hoursreported/Hoursexpected)*HoursNational average
National Average Hours per
Resident Day
Calculated April 2018
Total Nurse: 3.2285
RN: 0.3804
National average hours = National mean of expected hours across all facilities
active on March 31, 2018 and that had submitted valid nurse staffing data for
October 1 – December 31, 2017 (CY Q4).
• Z0100 Medicare RUG IV-66 Score from most
recent OBRA or scheduled PPS MDS assessment
for current residents on last day of quarter.
• Active resident = resident who, on the last day of
quarter, has most recent (non-DC/Death) MDS
transaction less than 180 days old
• For CY Q1 2018: Last OBRA/scheduled PPS closest
to 3/31/18, will use ARD 10/2/17 or later.
• Another way missing DC/death will hurt your rating.
• Census will be too large and acuity will count RUG IV-66 scores for folks not present on last day of quarter.
Hours Expected:
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Hours Expected
• Expected hours calculated by summing nursing times in minutes (from STRIVE Study
Appendix Table A1 Five Star Guide) connected to each RUG category across all residents in category and across all categories.
• Total minutes then divided by number of residents included in calculations.
Time in Minutes
RUG RN Total Nurse ResidentsRUC 27.8 243.16 6HB1 21.65 178.92 8
RN Example:Time in minutes * number in category: (27.8*6)+(21.65*8) = 340.0Divided by total number in all categories: 340/14 = 24.2875Divided by 60: 24.2875/60 = .4048Expected RN HPRD = .4048
Adjusted RN = 0.379Adjusted total = 3.1159
The percentile cut points (data boundaries between star categories) were determined using the data available as of March 2018. • First update of cut points since December 2011• Changes in expected staffing due to transition to RUG-IV• Cut points set so that changes due to RUG-IV would not impact overall distribution
of the five-star ratings• So proportion of nursing homes in each rating category would initially (April
2018) be the same as it was in March 2018. • CMS will evaluate whether further rebasing is needed on a quarterly basis.
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Census using MDS Data• Select reporting period: Q4 2017• Extract MDS assessment data for all residents of a facility beginning 1 year prior
to the reporting period to identify all residents that may resident in the facility.• For Q4 17, scan Oct 1 2016 – Dec 31, 2017 looking for submitted records
• Identify discharged residents:• If there is a discharge assessment, use that discharge date.• If there is an MDS assessment followed by at least 150 days with no
subsequent MDS record, assume discharge on day 150.• Everyone with an MDS assessment and an interval shorter than 150 days will be
assumed to be a resident for that particular day.• All MDS data extractions will be after required completion and submission
deadlines have passed.
Take home message: All MDS records must be completed and submitted timely. Once the staffing data is calculated, it will not be recalculated for subsequent MDS submissions. The larger your census artificially appears, the more short-staffed you will appear.
Five Star
Quality Measures
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Overview: 16 Five Star Quality Measures
13MDS Based
3Claims Based
4 Short Stay
9 Long Stay
Not based on pay source
Calculated once per resident, per quarter
If QM Rating is Five Stars
Short Stay Original Part A only
Calculated per stayCould be more than once per resident
If QM Rating is One Star
Add overallstar
Subtractoverall star
QM Star Rating Unchanged in April 2018 Updates
Cumulative Days in the Facility CDIF: Does not count temporary absences
>100 CDIFLong Stay
<100 CDIFShort Stay
Temporary absence: Time between DCRA & Reentry
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JulAugSepOctNovDec
OctNovDecJanFebMar
JanFebMarAprMayJun
AprMayJunJul
AugSep
Short Stay MDS Based Measures: Include a rolling 6 month target period
Long Stay MDS Based Measures: Include a three month target period
OctNovDec
JanFebMar
AprMayJun
JulAugSep
Resident Level Preview Report has names of all SS and LS residents in MDS based QM computation
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LS High-risk pressure ulcers SS new/worse pressure ulcers
LS moderate to severe pain SS moderate to severe pain
LS antipsychotic use SS newly received antipsychotic
LS indwelling catheter
LS UTI
SS improvements in function LS ability to move worsened
LS physically restrained
LS fall with major injury
LS ADL decline
M U K I D I
Original Medicare A OnlyPer stay, not per resident
Four quarters of dataRecalculated every 6 months
April and October
Claims based measures
SS residents successfully community discharge
SS residents emergency department visit
SS residents re-hospitalization
Oct 2018: July 1 2017 – June 30 2018
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Provider 1234567 State National
2015Q2 2015Q3 2015Q4 2016Q1 4Q avgRating Points1 4Q avg 4Q avg
MDS 3.0 Long-Stay MeasuresLower percentages are better.Percentage of residents experiencing one or more falls with major injury
1.1% 1.1% 2.1% 4.4% 2.2% 80.00 3.5% 3.3%
Percentage of residents who self-report moderate to severe pain2
1.0% 3.3% 5.7% 5.9% 4.0% 80.00 9.2% 8.2%
Percentage of high-risk residents with pressure ulcers
6.4% 3.8% 6.1% 5.3% 5.4% 60.00 6.1% 5.8%
Quality Measure Points Low HighAverage from
preview report
Points assigned
LS Falls w/major injury
100 0.00000000 0.01315789
0.022 8080 0.01315790 0.0240384860 0.02403849 0.0351105240 0.03511053 0.0503597320 0.05035974 1.00000000
Cutpoint table from QM ManualUnchanged in April 2018
Each QM has it’s own cutpoint table
1 star 325 - 7892 stars 790-8893 stars 890-9694 stars 970-10545 stars 1055-1600
870
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SS new/worsened pressure ulcers
SS newly received antipsychotic
LS physically restrained
“Low Prevalence”Must have four quarter average of zero to get 100 points
SS New/worsened pressure ulcer
100 0.00000000 0.0000000075 0.00021394 0.0069269150 0.00692692 0.0156624725 0.01566248 1.00000000
SS Newly prescribed antipsychotic
100 0.00000000 0.0000000080 0.00000000 0.0099999860 0.00999999 0.0191256740 0.01912568 0.0348623720 0.03486238 1.00000000
LS Restraints100 0.00000000 0.0000000060 0.00067115 0.0142450320 0.01424504 1.00000000
M U K I D I
Claims Based
Measures
Hospital Readmission SS
100 0.00000000 0.13839278
19.6 6080 0.13839279 0.1871627960 0.18716280 0.2188620340 0.21886204 0.2568912120 0.25689122 1.00000000
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Deeper DiveTechnicalSpecifications
OBRA
• Admission• Quarterly• Annual• Significant
change• Significant
Correction
Scheduled PPS
• 5 Day• 14 Day• 30 Day• 60 Day• 90 Day
OBRA Discharge
• Return anticipated
• Return not anticipated
Target Records uses for both Long and Short Stay MDS Based Measures
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Almost Constantly
or Frequently
Almost Constant
Frequently
Occasionally
Rarely
Short Stay & Long
Stay
Moderate to
Severe Pain
INTERVIEW ONLY
5-9
Moderate or
Severe
10
Very Severe,
horrible
May be done any time in 5 day lookback
If more than one interview in lookback, RAI manual silent on which one to use.
Short Stay: New or Worsened Pressure Ulcers
• SS Look Back Scan is entire SS episode• Covariates•M0800 ONLY if A0310E = 0
Any number > 0 for any MDS in lookback scan
***Not on MDS 3.0 beginning Oct 1, 2018
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Long stay high risk pressure ulcer
High Risk ifany one present
St 2,3 or 4 PU in M0300
Bed Mobility 3,4,7,8
orTransfer 3,4,7,8
orComatose
andMalnutrition I5600
Percent of Short-Stay Residents Who Newly Received an Antipsychotic Medication (look back scan)
Initial Assessment
Any subsequent assessment = > 0
Exclusions:Schizophrenia (I6000)
Tourette’s Syndrome (I5350)Huntington’s Disease (I5250)
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Long Stay Antipsychotics
Exclusions
UTI
Long Stay UTI Target Assessment
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Long Stay Catheter
Neurogenic bladder
excluded
“urinary retention” is a “signs and symptoms” diagnosis
Obstructive uropathy excluded
Catheter on target
assessment
Symptoms and signs are acceptable for reporting when the provider has not established a related, definitive (confirmed) diagnosis.
Trunk restraint
Used Daily
Limb restraint Chair prevents
rising
Long Stay Restraint Use
Bed rails & Other Restraints do not trigger this QM
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ARD 10/5/16QuarterlyNo Major injury Fall
AnnualFall Major Injury
QuarterlyNo Major Injury Fall
Fall happened Mar 10, 2016
ARD 1/5/17
Q1: Jan 1 –Mar 31
Target AssessmentNo Major Injury Fall
ARD 7/5/16
275 Day lookback scan from ARD of target Assessment: June 5, 2016
ARD 6/4/16
Fall withMajor Injury
When Major Injury happens, set ARD to get clock running
300 points
ExclusionsADL Quality Measures
SS improvements in function
LS ability to move worsened
LS ADL decline
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O0100K: Hospice while resident Exclusions
SS improvements in function
LS ability to move worsened
LS ADL decline
J1400: Prognosis
SS improvements in function
LS ability to move worsened
LS ADL decline
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Long Stay ADL Decline
One declines by two points
Two decline by one point
Bed Mobility
Transfer
Eating
Toileting
Self Performance
SS improvements in function
LS ability to move worsened
Both risk adjusted in new ways: Covariates:
Move worsened: age, gender, vision, oxygen use, Assistance in other ADLs, severe cognitive impairment
Fxl improvements; age, gender, severe cognitive impairment, Assistance in other ADLs, heart failure, CVA, Hip fracture, Other fracture,
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5 Day or Admit
Discharge Return Not Anticipated
Transfers
3
2
Locomotion on Unit
3
3
Walking in Corridor on
unit
8
1
10
6
Mid-loss ADL (MADL)
Total
G011
0 Se
lf Pe
rform
ance
If total on DCRNA lower: ImprovedNote: 7 or 8 added as “4”
Short-stay improvements in function
Exclusions1.Residents satisfying any of the following conditions:1.1. Comatose (B0100 = [1]) on the 5-day or admissionassessment, whichever was used in the QM.1.2. Life expectancy of less than 6 months (J1400 = [1]) on the 5-day or admission assessment, whichever was used in the QM.1.3. Hospice (O0100K2 = [1]) on the 5-day or admission assessment, whichever was used in the QM.1.4. Residents with G0110B1, G0110D1, or G0110E1 missing on any of the assessments used to calculate the QM (i.e., discharge assessment, and 5-day or admission assessment, whichever was used in the QM).1.5. Residents with no impairment (sum of G0110B1, G0110D1 and G0110E1 = [0]) on the 5-day or admission assessment, whichever was used in the QM.1.6. Residents with an unplanned discharge on any assessment during the care episode (A0310G = [2])
Improvements in Function
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Assessment
Target
Prior
Locomotion on Unit
1
0
G0110 Self Performance
If score on target is higher than prior: worsened
Note: • 7 or 8 added as “4”
• Prior must be 45 to 165 days before target
Percentage of long-stay residents whose ability to move independently worsened
M U K I D I
Claims based measures
SS residents successfully community discharge
SS residents emergency department visit
SS residents re-hospitalization
Details
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Age and Sex ESRD
hospital LOS prior to SNF admitNumber of inpatient hospital stays in
year preceding SNF stay
Time in ICU prior to SNF admit Principal diagnosis (ICD code)
Ever got Medicare due to disability Co-morbidities (ICD codes)
Items used in risk adjustment for the three claims based measures: Obtained from hospital claims
Claims-based Measures
Part A stay that begain within one day of hospital discharge (IRF/LTCH excluded)
Included
None are simple fractions. Actual numberator & denominator are risk adjusted based on characteristics present around the start of SNF stay
Risk Adjustments
• Not enrolled in Medicare for risk period• Missing data • Hospice any time in risk period• Comatose on 1st MDS• No 1st MDS
Excluded Stays
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• Unplanned hospital inpatient or outpatient observation stay
• Within 30 days of entering SNF• Regardless of whether they were discharged
from SNF prior to hospital readmission
Part A Stays in which resident had:
Percentage of short-stay residents who were re-hospitalized after a nursing home admission
Eating Foot infection Radiation Seizure disorder Cough during meals Fell in last month
Walk in room Diabetic foot ulcer Trach Ulcerative colitis Dialysis Fell in 2-6
months
Walk in corridor Internal bleeding IV Med Wound infection Heart failure IV Fluid
Wanders Dehydrated Vent UTI Dementia (all) Feeding tubeTwo person
assist Daily pain Transfusions Chemo Rejected care Diabetes
Cognitive status not intact Surgical wound Antibiotics Pneumonia Insulin Respiratory
failure
Acute change in mental status
Total bowel incontinence Anemia Venous/ Arterial
ulcers Viral hepatitis Cancer
Rarely understood
Shortness of breath Septicemia Oxygen Ostomy care Prognosis
Entered from: Acute hospital CVA 1st MDS since entry is SignificantChange
MDS items used in risk adjustment: unplanned
readmission
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• Unplanned ED stay without acute admit or inpatient observation stay
• Within 30 days of entering SNF• Regardless of whether they were discharged
from SNF prior to hospital readmission
Part A Stays in which resident had:
Percentage of short-stay residents who have had an outpatient emergency department visit
Isolation Anticoagulant Radiation Seizure disorder Dialysis Fell in last month
Walk in room Internal bleeding Trach Respiratory therapy
Heart failure Fell in 2-6 months
Walk in corridor Dehydrated Orthostatichypotension
COPD Rejected care IV Fluid
Wanders Daily pain Vent UTI Insulin Feeding tube
Two person assist Surgical wound Transfusions Pneumonia Viral hepatitis Respiratory failure
Cognitive status not intact
Speech Therapy Antibiotics Venous/ Arterial ulcers
Ostomy care Cancer
Acute change in mental status
Shortness of breath
Anemia Oxygen Rarely Understood
Prognosis
1st MDS since entry is SignificantChange
MDS items used in risk adjustment: ED Visit
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Percentage of short-stay residents who were successfully discharged to the community
Beneficiary stay that:• Had an MDS discharge assessment indicating discharge to ‘community’
within 100 calendar days of the start of the episode; AND within 30 days of this discharge the beneficiary: • Was not admitted to a nursing home • Did not have an unplanned inpatient hospital stay• Did not die
Psychotic Disorder Schizophrenia Married Interpreter needed Resident expectations (Q) Malnutrition
HTN Hyperkalemia Hip/other fx CVA Anxiety disorder Manic Depression
ADL Dependence Foot infection Radiation Seizure disorder Depression Weight loss
Balance problem Diabetic foot ulcer Understands others Paraplegia Dialysis Fell in 2-6 months
Hemiplegia Swallowing disorder (K0100) IV Med Wound infection Heart failure IV Fluid
s/s delirium Suctioning Vent UTI Dementia (all) Feeding tube
Medicare RUG Vision Impairment Transfusions Chemo MS Diabetes
Cognitive Impairment Surgical wound Quadraplegia Pneumonia Huntington’s Parkinson’s
Acute change in mental status Incontinence Anemia ID/DD or related
condition Viral hepatitis Cancer
Makes self understood Shortness of breath Septicemia Oxygen injections Antipsychotics
Entered from:Psych hospital Any behavior, wander, reject care, hallucination, delusion Mech Alt diet COPD
MDS items used in risk adjustment: Successful
Discharge
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Other MDS Based Quality Measures, not part of Five Star
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Antianxiety or hypnotic medication: Two separate measures
• Casper• Prevalence of Antianxiety/Hypnotic Use
(Long Stay) N033.1
Exclusions:• Schizophrenia (I6000 = [1]). • Psychotic disorder (I5950 = [1]). • Manic depression (bipolar disease)
(I5900 = [1]). • Tourette’s syndrome (I5350 = [1]). • Huntington’s disease (I5250 = [1]). • Hallucinations (E0100A = [1]). • Delusions (E0100B = [1]). • Anxiety disorder (I5700 = [1]). • Post-traumatic stress disorder
(I6100 = [1]).
• NH Compare & Casper• Percent of Residents Who Used
Antianxiety or Hypnotic Medication (Long Stay) N036.1
Exclusions: • Life expectancy of less than 6
months (J1400 = [1]). • Hospice care while a resident
(O0100K2 = [1]).
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• Long Stay Prevalence of Falls: All falls on any assessment in the LS look-back scan
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Long Stay Behavior Symptoms Affecting Others:
Anything more than zero in any of these
boxes
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Long Stay Low Risk Bowel/Bladder Incontinence
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Severe cognitive
impairment
Locomotion on unit4,7,8
Transfer4,7,8
Bed Mobility
4,7,8
High Risk
Everyone deemed low risk coded
frequently/always incontinent of
bowel or bladder
Exclusions: Ostomy, catheter
Long Stay weight Loss
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Non-physician prescribed weight loss
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Long Stay Depressive Symptoms
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Score >=10And
Little interest or pleasure7-14 days
Down, depressed, hopeless7-14 days
OR
Uses Interview or
Staff Assessment
The Vaccine Quality Measures: Short & Long Stay
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Not on Casper Reports, Not Five Star
SNF State Nation
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Assessed and Appropriately
Given the Pneumococcal
Vaccine Up to date
Offered/declined
Medically Contraindicated
Special rules for influenza vaccination measures
• Flu vaccination measures are calculated once per year. In a normal year where the influenza season begins on October 1 and ends of March 31, the target period will coincide with these dates
• End-of-episode date will be March 31 for an episode that is ongoing at the end of the influenza season and that March 31 should be used as the end date when computing CDIF and for classifying stays as long or short for the influenza vaccination measures.
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Percentage of Appropriate Vaccines
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Numerator
Or
Code 2, Received outside of this facility
Code 3, Not eligible—medical contraindication
Code 4, Offered and declined
Percent of Residents Assessed and AppropriatelyGiven the Seasonal Influenza Vaccine (Long Stay)
Percentage of Appropriate Vaccines
DenominatorAll long-stay residents with a selected influenza vaccination assessment, except those with exclusions.ExclusionsResident’s age on target date of selected influenza vaccination assessment is 179 days or less. {pediatric NH}
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NO other exclusions!
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Percentage of Appropriate Vaccines
•Measure calculated once a year with target period October 1 of the prior year to June 30 of the current year and reports for the October 1 through March 31 influenza season.• Scan all assessments with target dates on or after October 1 of
the most recently completed influenza season.• Select the record with the latest target date with:• Qualifying reason for assessment
• OBRA, scheduled PPS or discharge• Target date on/after October 1st of the most recently completed influenza
season, and A1600 entry date is on or before March 31st of the most recently completed influenza season.
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Long Stay Claims Based Measure: Number of hospitalizations per 1,000 LS Days
This claims-based quality measure will be reported on Nursing Home Compare
starting in October 2018, and integrated into the Five-Star Quality Rating System
in April 2019. It reports the ratio of unplanned hospitalizations per 1,000 long-stay
resident days for non-Medicare A Long Stay residents
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SNF VBP: One Measure only
Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM NQF #2510)
First year:
To be replaced by:
FY 17 Proposed Measure:SNF 30-Day Potentially Preventable Readmission Measure (SNFPPR)
Changes/additions/deletions to VBP measures would come in future rule-making
Two ways to earn points:
Achievement Performance: Happy Valley SNF’s rate of all-cause readmissions (SNFRM) in CY 2017 compared to the national rate in CY 2015
BenchmarkAchievement Threshold
0 pointsRate ≤ threshold
100 points
Rate ≥ benchmark
Mean of top decile of national SNF
performance (10th
percentile) during CY 2015
25th percentile of national SNF
performance during CY 2015
Achievement Score
1 to 99 points
Rate between the two
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Two ways to earn points:
Improvement Performance: Happy Valley SNF’s rate of all-cause readmissions (SNFRM) in CY 2017 compared to it’s own rate in CY 2015
BenchmarkImprovement Threshold
0 pointsRate ≤ threshold
100 points
Rate ≥ benchmark
Mean of top decile of national SNF performance
(10th percentile) during CY 2015
Your SNF’s performance during
CY 2015
Improvement Score
1 to 89 points
Rate between the two
Calculating Performance:
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CMS is required to pay the better of Achievement or Improvement
Your rate would be 80%i.e.: 80%of residents included in measure were not rehospitalized
If actual readmission rate is 20%i.e.: 20% of residents included in measure were rehospitalized
Higher numbers will be betterCMS thinks this is easier for public to understand
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Questions/Discussion