Measuring Quality in a SNF for Medical Directors

5 Star Rating SystemQuality Reporting Program

Value Based Purchasing

Judy Wilhide Brandt, RN, BA, RAC-MT, C-NEjudy@judywilhide.com

909-800-9124

www. JudyWilhide.com

Five Star Rating System• Tool created by CMS in 2008 to help consumers

select and compare skilled nursing care centers. • Uses information from Health Care Surveys

(standard, focus and complaint), Quality Measures, and Staffing

• CMS intends to move to a five star-rating system for all of its "Compare" sites, "with a goal of full transition to star ratings by 2016,” – This will include hospitals.

Nursing Home Compare & Five Star Rating SystemReview

Actual Survey Reports (redacted for HIPPA)

Details each citation with state and national average

citations

Staffing

PT staff hours do not count in rating.

Short Stay

Flu Vaccine

New/worsened

PrU

New Antipsychotic

Self Report Mod/Severe

Pain

Pneumovax

★

★

★

Long Stay

Hi Risk PrU

Antipsychotic Use

Self Report Mod/Severe

Pain

UTI

Catheter

ADL Decline

★

★

★

★

★

★

Fall Major Injury

Restraint Use

Lo risk Incontinence

Weight loss

Depressive symptoms

Pneumovax

Flu Vaccine

Long Stay

★

★

NH Compare Quality Measures

Special Focus Facilities:(a) have had a history of serious quality issues

and (b) are included in a special program to

stimulate improvements in their quality of care.

Virginia North Carolina

2/23/15

Florida

New York Times 8/24/14• Receiving a high star rating has never been

more important to nursing homes. – Hospitals often use star ratings in referral decisions– Insurers consider them when setting up preferred

networks– Often a first stop for investors and lenders, who

consult them to decide whether a nursing home company is a safe bet.

– Many bundled payment projects require at least 3 stars

Five Star Rating System Details

Overall Star Rating ★

Quality Measures ★+1 for 5 stars -1 for 1 Star

Staffing ★+1 for 4 or 5 stars if above survey stars -1 for 1 Star

Survey ★3 years Annual 36 months complaint

You Shall Rise and Show Respect to the Aged

Example:

Overall Survey Staffing QM

HappyValley ★★ ★ ★★★★ ★★★★★

Peaceful Place ★★ ★★ ★★ ★★★★

RockingRetirement ★★★★ ★★★ ★★★★ ★★★★

SwingingCity ★★★★★ ★★★ ★★★★ ★★★★★

Terminal Towers ★★ ★★★★ ★ ★

Quintile definition: divided into five equal groups, based on performance

Best

Second best

Third best (or third worst)

Next to worst

Worst

Each Domain Divides all NFs into quintiles

• All domains use different methods• End result: assignment of 1-5 stars overall

★★★★★

★★★★

★★★

★★

★

Much above average

Above average

Average

Below average

Much below average

These quintiles are not always equally divided.

Survey Domain

• Comparison for survey stars is intra-state– Accounts for different types of surveys and different approaches to

the survey process among states

• Deficiencies are assigned points based on scope and severity

• All NFs in a state are lined up from best to worst and split into quintiles– Top 10% = 5 stars– Bottom 20% = 1 star

• Line-up and rating are based on intrastate comparisons– Survey agencies and processes vary widely across the

country.

Intra State Survey Comparisons

8.3 Virginia

3.7 North Carolina

5.3 Kentucky

7.3 IllinoisUS Average: 6.8

Average number of citations 2/23/15

Complaint Survey Weights

1/6

1/3

1/2

Revisits to ClearRevisit Number Noncompliance Points

First 0Second 50% of survey score added on Third 70% of survey score added on

Fourth 85% of survey score added on

CMS experience is that providers that fail to demonstrate restored compliance with safety and quality of care

requirements during the first revisit have lower quality of care than other nursing homes. More revisits are associated with

more serious quality problems.

You Shall Rise and Show Respect to the Aged

Intra-State ConsiderationsSince it’s all a ‘quintile system based on what percentage did the best and

worst, there is a wide variation between states in what the raw survey score number translates to.

Cut point table posted every month. The month your survey is calculated, they use this table to see how many stars to give you. Then your stars are fixed until

you get another survey.

10%20% 23.323.3 23.3

Staffing

• Considerable evidence of a relationship between nursing home staffing levels and resident outcomes.

• Staffing Study found a clear association between nurse staffing ratios and nursing home quality of care, identifying specific ratios of staff to residents below which residents are at substantially higher risk of quality problems.

You Shall Rise and Show Respect to the Aged

RNTotal Nurse

Staffing based on two case-mix adjusted measures, with equal weight.

Staffing Details

• Not a valid/reliable way to verify staffing adequacy

• Facility reports staff hours worked in the last full two week pay period that ends closest to day 1 of the survey

• Census is from day 1 of survey• Acuity is from end of last quarter closest to da

1 of survey– Based on RUG scores

Illustration:

Q1 Q2 Q3 Q4

Survey DateJuly 6

Target Date

Jun 29

No RUG Data for Q2 yet

Q1 RUG Data

Census

Staffing Stars assigned

Q1 Q2 Q3 Q4

Survey DateJuly 6

Target Date

Jun 29

Q2 RUG Available

Census

Staffing Stars assigned

Some time in the future:

New Staffing Stars assigned

Doing the math

Total Nurse Example3 reported/ 6 expected = ½ x 4.0309 =

2.0154 adjusted hours

You Shall Rise and Show Respect to the Aged

Hoursadjusted = (Hoursreported/Hoursexpected)*HoursNational average

National Average Hours per Resident Day Calculated April 2012Total Nurse: 4.0309

RN: 0.7472

Five Star Quality Measures

The measures were selected based on their validity and reliability, the extent to which facility

practice may affect the measure, statistical performance, and importance.

Three quarters of MDS data is averagedSNFs are assigned stars based on comparative data with other SNFs

5 Star Quality Measures8 long stay (over 100 CDIF)• ADL decline (Bed mob, toilet, transfer, eating)• High-risk residents with pressure ulcers (St 2, 3 and 4 only)• Indwelling catheter (exclusions: Neurogenic bladder, obstructive uropathy)• Physically restrained (other than side rail, daily)• UTI (Must have MD dx, tx, specific s/s, sig lab in 30 day lookback for MDS)• Self-report moderate to severe pain (From MDS interview only)• Fall with major injury (Fracture, dislocation, closed head inj w/altered

consciousness, subdural hematoma)• Antipsychotic Use (Exclusions: Schizophrenia, Tourette's, Huntington’s)• 3 short stay (< or = 100 CDIF)• New/worsened pressure ulcers (St 2, 3, 4 only)• Self-report moderate to severe pain (From MDS interview only)• Newly received antipsychotic (Exclusions: Schizophrenia, Tourette's,

Huntington’s)

IMPACT Act: SNF Quality Reporting System (QRS)

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/SNF-Quality-Reporting.html

9/18/14: Improving Medicare Post-Acute Care Transformation Act of 2014• Requires development of cross post-

acute setting quality comparisons for–Assessment and Quality Measures–Quality care and improved outcomes –Discharge Planning–Interoperability–Care coordination

SNFRequire skilled

therapy 5xW or

skilled Nsg 7xW

IRFTherapy15 hr wk

2 discMD 3xW

HHABe

homeboundRequire

intermittent skilled

therapy or nsg

LTCHStay > 25

days, rehab, resp ther,

head trauma,pain

mgt

Standardization

Post Acute Settings

Standardized Patient Assessment Data• Requirements for reporting assessment data:– Providers must submit standardized assessment data

through PAC assessment instruments– Data must be collected at admission and discharge for

each patient, or more frequently as required• Data categories:

– Functional status– Cognitive function and mental status– Special services, treatments, and interventions– Medical conditions and co-morbidities– Impairments– Other categories required by the Secretary

34

Use of Standardized Assessment Data:

HHAs: no later than January 1, 2019

SNFs, IRFs, and LTCHs: no later than October 1,

2018

QRP 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

Medication reconciliation

Transfer of health information and care preferences when an individual transitions

Resource use measures, including total estimated Medicare spending per beneficiary

Discharge to community

All-condition risk-adjusted potentially preventable hospital readmissions rates.

Finalized in FY16 Rule; Will be collected Oct 1 – Dec 31 2016Payment penalties will be for FY18 To be developed

Going Forward: New Measure Development will Evolve Over Time

Measure Specification

thru rulemaking

Collect Data for that measure 1

year later

Impose penalties 2 yrs

later

SNF QRP Measures Finalized in FY16 rule making

37

Percent of Residents or Patients with Pressure Ulcers That Are New or

Worsened (short stay)

Percent of Residents Experiencing One or More Falls with Major Injury (long stay)

ExistingSNF QMs

Percent of patients/residents with an admission and discharge functional

assessment and a care plan that addresses function (Part A stay)

New

Data Collection

• For these QRP Measures:– Collect data upon SNF admission & SNF discharge

• This is a new way to calculate QMs• Data only collected/calculated on resident in a

Part A SNF stay

QRP Measures• First round with these 3 will be collected for

three months only– Oct, Nov, Dec 2016

• Will only be collected on residents in a Medicare Part A stay– No other pay source, no MA plans

• Will be collected using:– PPS 5 day MDS (existing)– SNF Discharge (new)• Upon discharge from a Part A stay

– Even if remaining in the SNF afterwards

QRP Measures Initial YearData collected Q1 FY17Will have 5 ½ months to submit/correct data (5/15/17)

2% reduction in market basket update for ENTIRE FY18 for non-compliance

Non-Compliance

• Beginning FY18, 80% of all MDSs submitted must contain 100% of the data elements required to calculate the 3 QRP measures.– No dashes in ANY calculator fields!• Direct items• Covariates• Exclusions

• CMS intends to raise threshold going forward through rulemaking

Data collection period for penalties: Phase In(If CMS plans come to fruition)

Data Collected Penalties ApplyQ1 FY 2017 FY 2018

Q2, Q3, Q4 FY 2017 FY 2019FY 2018 FY 2020

We have one year to perfect data collection systems!We can expect more/different measures going forward

• Would include:– New unstageable pressure ulcers, including

suspected deep tissue injuries (sDTIs)– Stage 1 or 2 Pressure ulcers that become

unstageable due to slough/eschar

Future updates to Pressure Ulcer QM under CMS consideration: Would require revising QM and MDS

Percent of patients/residents with an admission and discharge functional assessment and a care plan that

addresses function

• In first three days of SNF stay, must be at least one fxn goal

• New section added to SNF MDS upon admit and DC only

• At the time of discharge, function is reassessed using the same 6-level rating scale, to evaluate success in achieving goals– Unplanned discharge: Fxl status reporting will not be

required

Percent of patients/residents with an admission and discharge functional assessment and a care plan that

addresses function

• Requires new data elements on PPS 5 day and “SNF discharge” assessments– SNF DC assessment will be at the time of DC from

the Part A stay, even if resident does not leave• 30% of SNF residents stay in facility after SNF discharge

• Initial goals and fxl status must be determined no later than day 3 of SNF stay

SNF measures under future consideration

• SNF 30-day all-cause readmission measure• Application of the payment standardized

Medicare spending per beneficiary• Percentage of residents at discharge

assessment, who are discharged to a higher level or to the community

• Potentially preventable readmissions• Drug regimen review with follow-up for

identified issues

VALUE BASED PURCHASING INITIATIVE

Protecting Access to Medicare Act (PAMA)

of 2014

Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)

Overview

• SNF payment rate must be based, in part, on performance on this measure starting Oct 1, 2018

• SNFs with the highest rankings must receive the highest incentive payments – SNFs with the lowest rankings receiving the lowest

(or zero) incentive payments. – Lowest 40 percent of SNFs (by ranking) will be

reimbursed less than they otherwise would be reimbursed without the SNF VBP program.

Funding: CMS will withold 2% of SNF Medicare payments starting 10/1/18

50-70% will be

incentive payments to SNFs.

CMS will keep 30-

50%

Measure estimates risk-standardized rate of all-cause, unplanned hospital readmissions of SNF Medicare beneficiaries within 30 days of discharge from their prior proximal acute hospitalization

• Claims based

• Readmissions within 30-day window are counted regardless of whether the beneficiary is readmitted directly from SNF or had been discharged from SNF

• Risk-adjusted based on patient demographics, principal diagnosis in prior hospitalization, comorbidities, and other health status variables that affect probability of readmission

• Excludes planned readmissions since these are not indicative of poor quality

Exclusions:• Hospital principal dx – cancer– rehabilitation, fitting of prosthetics, adjustment of devices– pregnancy

• Pts who did not have Medicare A coverage for 12 months preceding hospital discharge– Or for full 30 day window

• Post acute admission in 30 day window• More than 1 day between the hospital discharge and the SNF

admission• Discharge AMA

Based on Standardized Risk Ratio (SRR):

SNF’s Risk Standardized Readmission Rate (RSSR):SRR x Overall national raw readmission rate for all SNFs

Ratio > 1 = high qualityRatio < 1 = poorer quality

Calculation:

• CMS is required to replace this measure with an all-condition, risk-adjusted potentially preventable hospital readmission rate. CMS advises it intends to address this topic in future rulemaking.– Under development

PAYROLL BASED JOURNAL (PBJ)

PBJ: Payroll Based Journal• Staffing and census data be collected for each fiscal quarter

through the QIES ASAP System• Includes hours worked by each staff member each day within

the quarter– administration, physician services, nursing services, pharmacy

services, dietary services, therapeutic services, dental services, podiatry services, mental health services, vocational services, clinical laboratory services, diagnostic x-ray services, administration & storage of blood, housekeeping services, other services.

• Census data is census on the last day of the quarter.• Strict guidelines for timeliness of submission

– If out of compliance subject to enforcement actions not yet defined.

• Voluntary October 1, 2015. • Mandatory July 1, 2016

PBJ: Goals• Staffing is a vital components of a nursing home’s

ability to provide quality care. • Over time, CMS has utilized staffing data for a

myriad of purposes in an effort to more accurately and effectively gauge its impact on quality of care in nursing homes.

• The data, when combined with census information, can then be used:– To report on SNF staffing levels– To report on employee turnover and tenure

• Which can impact the quality of care delivered.

Submission Timeliness

• Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter.

• Facilities may enter and submit data at any frequency throughout a quarter.

• The last accepted submission received before the deadline will be considered the facility’s final submission.

Accuracy:

• Staffing information is required to be an accurate and complete submission of a facility’s staffing records. CMS will conduct audits to assess a facility’s compliance related to this requirement.

Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities PFR 7/16/15

• When this improved staffing data is collected at the nursing home level, more accurate and reliable estimates of the care hours provided by staff categories will be available, potentially leading to updated research and reconsideration of HPRD requirements and recommendations.

Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities PFR 7/16/15

• Our intent is to require facilities to make thoughtful, informed staffing plans and decisions that are focused on meeting resident needs, including maintaining or improving resident function and quality of life.

• We maintain that such an approach is essential to person-centered care.

• At this time, we have deferred deciding on any potential specific requirement pending evaluation of additional data that will be collected on payroll based staffing data.

FOCUSED SURVEYS: A NEW HORIZON

Focused Surveys

• MDS/Staffing: Pilot complete; In nationwide roll-out, Phase 1

• Dementia Care: Pilot complete, Expansion in 2015 on a voluntary basis– Texas conducting a comprehensive survey effort

with more states expected to participate• 7/17/15: Focused Survey on Medication

Safety Systems has begun pilot testing

Impact

• Small number chosen by methods not publically reported

• Surveys open or continue an enforcement cycle

• Once out of “pilot” also contribute to 5 Star rating

• May not be combined with annual survey• DISCUSSION

Questions/Discussion