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Nursing Home Quality Measures Workshop

Nursing Home Quality Measures Workshop . Presented in collaboration with:. Learning Objectives. 1. Define the role of the QIO in nursing home quality improvement. 2. Describe the purpose of the CMS Nursing Home Quality Initiative. 3. Understand differences between

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Nursing Home Quality Measures Workshop

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  1. Nursing Home Quality Measures Workshop Presented in collaboration with:

  2. Learning Objectives 1. Define the role of the QIO in nursing home quality improvement 2. Describe the purpose of the CMS Nursing Home Quality Initiative 3. Understand differences between CHSRA Quality Indicators & Publicly Reported Quality Measures 4. List key components of quality measures 5. Identify MDS items used to calculate quality measures

  3. Objective #1 • Define the role of the Quality Improvement Organization in nursing home quality improvement

  4. Who are the QIOs? • Quality Improvement Organizations (QIOs) - formerly PROs • Under contract with Centers for Medicare & Medicaid Services (CMS) • National Network of QI Experts • Improving clinical care systems • Beneficiary education • Independent review/oversight

  5. QIO’s Role in theMedicare Program Mandated by Congress in 1982: • To protect integrity of Medicare Trust Fund • Improve quality of health care • Protect the Medicare beneficiary

  6. HSAG: Arizona QIO Health Services Advisory Group, Inc. • Private, For Profit, Arizona-based • Founded in 1979 by Arizona doctors and nurses • 125 employees, and over 175 part-time physician advisors and reviewers

  7. HSAG: Arizona QIO • Staff includes physicians, epidemiologists, project managers, nurses, bio-statisticians, health data analysts, communication specialists, etc.

  8. The HSAG Mission To positively affect the quality of health care by providing information and expertise to those who deliver and those who receive health services. www.hsag.com

  9. HSAG: Arizona QIO • 7 years experience working in Nursing Home setting • Pneumococcal and Immunization • Pressure ulcers • Mortality rates • Therapy services • CHSRA QIs

  10. Transitioning to 7 SOW(Scope of Work) Nursing Home Setting 7 SOW • Intensive, media-based program to beneficiaries & providers about publicly reported quality data • Focus on performance measures in NHs 6 SOW • Improvement projects in alternate settings, including Nursing Home (NH)

  11. New CMS Mandates • Promote use of publicly reported performance data • Nursing Homes October 2002 • Home Health Agencies by 2003 • Hospitals (?) 2004 • Establish Consumer Advisory Council • New options for resolution of beneficiary concerns

  12. QIO is a COLLABORATIVE PARTNER • COLLABORATIVE and CONFIDENTIAL (not regulatory) • Not part of the State Survey Agency or process (not writing deficiencies) • CMS funds QIOs

  13. Partnership for Success • Trade and Professional Associations • AHCA and AzAHA, ACHCA, AMDA • Corporate Leadership • Arizona Department of Health Services • AHCCCS, Health Plans • Ombudsman • Advocacy Groups • AARP

  14. Objective #2 • Describe the purpose of the CMS Nursing Home Quality Initiative

  15. CMS’s Overview Summary • Quality can be measured • Quality can be improved • The systems put in place to improve quality typically are both sustainable and blind to socio-economic status Barbara Paul, MD, CMS Baltimore Office Quality Measurement and Health Assessment Group

  16. CMS’s Strategy Overview

  17. Purpose of the CMS Nursing Home Quality Initiative(NHQI) • Provide an additional data source to assist consumers’ decision making when selecting a nursing home • Assist facilities with quality improvement strategies to improve systems of care

  18. National Rollout of NHQI • Six State Pilot: April – September 2002 • CO, FL, MD, OH, RI, WA • National NHQI begins November 2002 • Public reporting of measures • Quality improvement addressing systems of care

  19. Overview of QIO Tasks

  20. October: Quality Measure Workshops November: Recruitment of facilities for quality improvement work December: Select 3-5 QMs to focus quality improvement by December 15, 2002 Jan/Feb: Begin quality improvement work with facilities Select facilities by February 3, 2003 Starting the Initiative

  21. CMS Release ofQuality Measurement Scores • Mid-November (12th?) • CMS to post QMs on Nursing Home Compare web site www.medicare.gov • CMS has purchased 60-65 newspaper ads around the country for early November

  22. Full page newspaper ads in major markets

  23. Publicly Reported Quality Measures • Post Acute: Pain, Walking Improvement, Delirium* • Chronic: ADL decline, Infections, Pain, Pressure Ulcers*, Restraints *Reported two ways - with and without additional level of risk adjustment at facility level

  24. Objective #3 • Understand differences between CHSRA* Quality Indicators & Publicly Reported QMs *Center for Health Systems Research and Analysis, University of Wisconsin-Madison

  25. CHSRA Indicators vs. Publicly Reported Quality Measures • Indicators vs. Measures • Some clinical concepts overlap, some don’t • Short stay and long stay measures • Risk adjustment strategies • Inclusions and Exclusions may be different • QMs only calculated on a quarterly basis

  26. Differences between CHSRA QIs and NHQI QMs NHQI QM Corresponding CHSRA QI? CHRONIC QMS ADL Decline Yes Infections (Spectrum of infections) No(UTI only) Pain No Pressure Sores Yes Physical Restraints Yes POST ACUTE QMS Delirium No Pain No Walking Improvement No See Appendix A of Resource Manual for details

  27. Validation of CMS Quality Measures for Public Reporting: A Summary of Study Results

  28. Purpose of the Study Validation: Which of the 45 tested long-term and post-acute care quality indicators actually reflect quality of care? • Included nine measures from the CMS 6-state pilot project • Measures were selected from a larger set of existing and potential quality measures

  29. The Players • Funding agency: CMS • Contractors: ABT Associates • Subcontractors: • Brown University • HRCA Research and Training Institute • Draft report delivered August 2002

  30. Study Facilities • 209 freestanding and hospital-based facilities • exclusions: < 50 beds, mean age < 50 years • 6 states: CA, IL, MO, OH, PA, TN • 5,758 chronic and post-acute patients • Study facilities larger, more non-profit, less rural than other facilities in state

  31. Methods Step 1: Define “high quality care” for comparison with QM results Step 2: Assess study facilities to see if they deliver “high quality care” Step 3: Compare results of this assessment with QI results

  32. Step 1: Definition of “High Quality Care” • Expert clinical panels • Lists of care processes, practices, or structural elements that experts felt would differentiate “good” from “bad” performing homes

  33. Examples of What Should beFound in “Good-Performing”Homes: Pressure Ulcers • Standardized risk assessment • Policies and procedures to address risk factors • Programs for implementing and monitoring an individual’s risk factors • Mechanisms to identify early tissue injury • Pressure reduction

  34. Step 2: Assessing Quality Data collection tools • Medical record review • Environmental walk-through/resident observation • Administrative questionnaire

  35. Step 3: Comparing Assessed Quality with QM Results • Measure statistical association between each QM and assessed quality for that QM • Degree of association is measurement of degree of validity

  36. Validity of Post-Acute Care QMs from CMS Six-State Pilot ValidityCategory Delirium* high Pain* high Maintenance or improvementhigh in walking* *tested with FAP

  37. Validity of Chronic Care QMs from CMS Six-State Pilot ValidityCategory Late-loss ADL worsening high Infection* high Pain* high *tested with FAP

  38. Validity of Chronic Care QMs from CMS Six-State Pilot Validity Category Pressure sores (high/low risk)* high Daily restraints mid Unexpected weight loss* low *tested with FAP

  39. Other Findings Fromthe Study • MDS reliability • QM validity with and without FAP

  40. MDS Reliability • Reliability: Reproducibility • How closely do two MDS assessors agree on MDS data elements? • Assessments by research nurses compared with assessments by facility staff • Statistical testing to see how closely researchers’ MDS data match facility staff’s MDS data

  41. Summary • Eight of the nine QMs in the CMS six-state pilot sufficiently valid and reliable for national public reporting • Weight loss measure not included (low validity) www.cms.hhs.gov/providers/nursinghomes/nhi

  42. Objective #4 • List key components of quality measures

  43. Terms for Calculating Quality Measures • Record selection • Numerator • Denominator • Exclusions • Covariates • Facility Admission Profile (FAP) --Covariate at facility level

  44. Record Selection • DEFINITION: The time period from which the MDS assessments are drawn to calculate the quality measures

  45. Record Selection • PAC QMs use Medicare (post-acute) MDS assessments from past 6 months (e.g., national rollout data are from January - June 2002) • Chronic QMs use OBRA (chronic) MDS assessments from past 3 months (e.g., national rollout data is from April-June 2002)

  46. MDS Data Flow

  47. MDS Assessments Used in Chronic QM Calculations • Target assessment [t] • Prior assessment [t-1] • Most recent full assessment

  48. Target Assessment • DEFINITION Assessment that occurs within the designated time period used to calculate the measure

  49. Prior Assessment • DEFINITION Assessment that occurs prior to the target assessment

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