New Quality Measures the Traditional Survey Process

1. New Quality Measures & the Traditional Survey Process

2. Objectives Review the new Quality Measures Casper Reports Review of Four QM’s for Survey Review of changes to the CMS Forms CMS 802 CMS 672

3. Nursing home QM’s have four intended purposes: To give… Information about the Quality of Care at nursing homes to help the public choose a nursing home 2. Prompt consumers to talk to nursing home staff about the Quality of Care 3. To give data to the nursing home to help them with their Quality Improvement efforts. 4. To give data to the State Survey Agency for inspection.

4. QM Data Availability The MDS 3.0 Facility and Resident Quality Measure Preview reports now available. Reports are similar to the MDS 2.0 Facility and Resident Quality Measure Preview reports with noted differences: More QMs than are on the Reports i.e. Flu and Pneumococcal (long and short stay) Four old QIs retained for survey use and will appear on Nursing Home Compare The reports contain Quality Measure data for the fourth quarter (Q4) of 2011. The publicly-reported short-stay measure data are based on a six-month time frame, from July 1, 2011 through December 31, 2011. The long-stay measure data are based on a three-month time frame, from October 1, 2011 through December 31, 2011. The reports contain Quality Measure data for the fourth quarter (Q4) of 2011. The publicly-reported short-stay measure data are based on a six-month time frame, from July 1, 2011 through December 31, 2011. The long-stay measure data are based on a three-month time frame, from October 1, 2011 through December 31, 2011.

5. Short Stay Self-Reported Moderate to Severe Pain New/Worsened Pressure Ulcers* Flu Vaccine Pneumococcal Vaccine Risk-adjusted Quality Measure using resident-level covariates for public reporting. Short Stay Measures have a total of 10, 4 of which are for Flu and 4 for PPV, leaving only 4 unique Measures: Pain, Pressure Ulcer’s, Flu and PPV Risk-adjusted Quality Measure using resident-level covariates for public reporting. Short Stay Measures have a total of 10, 4 of which are for Flu and 4 for PPV, leaving only 4 unique Measures: Pain, Pressure Ulcer’s, Flu and PPV

6. Long Stay Flu Vaccine Pneumococcal Vaccine Self-Reported Moderate to Severe Pain * High-Risk Residents with Pressure Ulcers Physical Restraints Falls with Major Injury Risk-adjusted Quality Measure using resident-level covariates for public reporting. Long Stay Measures have a total of 16, 3 of which are for Flu and 3 for PPV, leaving only 12 unique Measures: Falls with Major Injury, Pain, Pressure Ulcer’s, Flu, PPV, UTI, Low Risk Residents who lose control of B/B, Catheter Inserted and left, Physical Restraints, Residents’ with increased need for help with ADL’s, Residents who lost too much weight and Depressive Symptoms. Risk-adjusted Quality Measure using resident-level covariates for public reporting. Long Stay Measures have a total of 16, 3 of which are for Flu and 3 for PPV, leaving only 12 unique Measures: Falls with Major Injury, Pain, Pressure Ulcer’s, Flu, PPV, UTI, Low Risk Residents who lose control of B/B, Catheter Inserted and left, Physical Restraints, Residents’ with increased need for help with ADL’s, Residents who lost too much weight and Depressive Symptoms.

7. Long Stay Depressive Symptoms Urinary Tract Infection Catheter Inserted and Left in Bladder* Low-Risk Residents Who Lose Bowel/Bladder Control Excessive Weight Loss Need for Help with ADLs Has Increased Risk-adjusted Quality Measure using resident-level covariates for public reporting. Long Stay Measures have a total of 16, 3 of which are for Flu and 3 for PPV, leaving only 12 unique Measures: Falls with Major Injury, Pain, Pressure Ulcer’s, Flu, PPV, UTI, Low Risk Residents who lose control of B/B, Catheter Inserted and left, Physical Restraints, Residents’ with increased need for help with ADL’s, Residents who lost too much weight and Depressive Symptoms. Risk-adjusted Quality Measure using resident-level covariates for public reporting. Long Stay Measures have a total of 16, 3 of which are for Flu and 3 for PPV, leaving only 12 unique Measures: Falls with Major Injury, Pain, Pressure Ulcer’s, Flu, PPV, UTI, Low Risk Residents who lose control of B/B, Catheter Inserted and left, Physical Restraints, Residents’ with increased need for help with ADL’s, Residents who lost too much weight and Depressive Symptoms.

8.  Viewing Reports To view the reports, log in to the CASPER Reporting application, select the 'Folders' button and locate the desired facility shared folder. The shared folders will be identified as 'st LTC facid', where ‘st’ is the 2-character postal code of the state in which the facility is located and ‘facid’ is the state-assigned Facility ID. These reports are not the same as the Five Star Facility Preview reports. Any questions about the MDS 3.0 Facility and Resident Quality Measure Preview Reports should be directed to the QIES Help Desk at help@qtso.com or 1 (888) 477-7876. Any questions regarding the Five Star reports should be emailed to BetterCare@cms.hhs.gov. These reports are not the same as the Five Star Facility Preview reports. Any questions about the MDS 3.0 Facility and Resident Quality Measure Preview Reports should be directed to the QIES Help Desk at help@qtso.com or 1 (888) 477-7876. Any questions regarding the Five Star reports should be emailed to BetterCare@cms.hhs.gov.

9.  Viewing Reports

10. New QM Casper Reports Facility Quality Measure Report Facility Monthly Comparison Report Quality Measure Resident Level Report Quality Measure Package Report (option) Includes the above reports plus the MDS 3.0 Submission Statistics by Facility Report The reports contain Quality Measure data for the fourth quarter (Q4) of 2011. The publicly-reported short-stay measure data are based on a six-month time frame, from July 1, 2011 through December 31, 2011. The long-stay measure data are based on a three-month time frame, from October 1, 2011 through December 31, 2011. Comparison Group date range options include six-month intervals, beginning 10/01/2010. The most recent six-month period available for reporting state and national comparison data ends three months prior to the current month. The reports contain Quality Measure data for the fourth quarter (Q4) of 2011. The publicly-reported short-stay measure data are based on a six-month time frame, from July 1, 2011 through December 31, 2011. The long-stay measure data are based on a three-month time frame, from October 1, 2011 through December 31, 2011. Comparison Group date range options include six-month intervals, beginning 10/01/2010. The most recent six-month period available for reporting state and national comparison data ends three months prior to the current month.

11. Facility QM Report Displays the quarterly numerator, denominator and percent values for each of the publicly-reported MDS 3.0 Quality Measures. The preview report allows facilities to see their measure percent values prior to being posted on the Nursing Home Compare website. For each QM, the MDS 3.0 Facility Quality Measure Report shows the facility percentage and how the facility compares with other facilities in their state and in the nation. This report helps facilities identify possible areas for further emphasis in facility quality improvement activities or investigation during the survey process. The MDS 3.0 Facility Quality Measure Report displays QM numerator and denominator counts for a select period and facility. It includes the facility’s observed and adjusted triggered percentages as well as state and national average percentage comparisons and a national ranking for each measure. The criteria selection page (Figure 26-2) for the MDS 3.0 Facility Quality Measure Report presents State, Facility ID, Begin Date (mm/dd/yyyy), End Date (mm/dd/yyyy), and Comparison Group options. The date the most recent quality measure data were calculated is indicated. For each QM, the MDS 3.0 Facility Quality Measure Report shows the facility percentage and how the facility compares with other facilities in their state and in the nation. This report helps facilities identify possible areas for further emphasis in facility quality improvement activities or investigation during the survey process. The MDS 3.0 Facility Quality Measure Report displays QM numerator and denominator counts for a select period and facility. It includes the facility’s observed and adjusted triggered percentages as well as state and national average percentage comparisons and a national ranking for each measure. The criteria selection page (Figure 26-2) for the MDS 3.0 Facility Quality Measure Report presents State, Facility ID, Begin Date (mm/dd/yyyy), End Date (mm/dd/yyyy), and Comparison Group options. The date the most recent quality measure data were calculated is indicated.

14.  Facility Monthly Comparison Report The MDS 3.0 Resident Preview report displays the list of residents who triggered one or more of the publicly reported MDS 3.0 Quality Measures. For the Influenza or Pneumococcal vaccination measures, only residents who did not receive the vaccinations are The MDS 3.0 Monthly Comparison Report presents observed or adjusted percentages for each QM for a select facility, the state, and the nation. It allows easy comparison of these percentages for each measure for a specified six-month period. Since the report is intended for public use, data for measures with small denominators (less than 30 for long-stay measures and less than 20 for short-stay measures) or high-triggered percentages are suppressed. Data for this report are calculated on the first day of each month using accepted assessment records with target dates two months prior to the month of calculation. The criteria selection page (Figure 26-6) for the MDS 3.0 Monthly Comparison Report presents State, Facility ID, Begin Month (mm/yyyy), and End Month (mm/yyyy) options. The MDS 3.0 Monthly Comparison Report presents observed or adjusted percentages for each QM for a select facility, the state, and the nation. It allows easy comparison of these percentages for each measure for a specified six-month period. Since the report is intended for public use, data for measures with small denominators (less than 30 for long-stay measures and less than 20 for short-stay measures) or high-triggered percentages are suppressed. Data for this report are calculated on the first day of each month using accepted assessment records with target dates two months prior to the month of calculation. The criteria selection page (Figure 26-6) for the MDS 3.0 Monthly Comparison Report presents State, Facility ID, Begin Month (mm/yyyy), and End Month (mm/yyyy) options.

17.  Resident Level Report The MDS 3.0 Resident Preview report displays the list of residents who triggered one or more of the publicly reported MDS 3.0 Quality Measures. For the Influenza or Pneumococcal vaccination measures, only residents who did not receive the vaccinations are The MDS 3.0 Resident Level Quality Measure Report identifies the residents (active and discharged) that were included in the calculations for the selected facility and period that were used to produce the MDS 3.0 Facility Quality Measure Report. The report lists the residents by name and indicates the measures, if any, triggered by each. The criteria selection page (Figure 26-4) for the MDS 3.0 Resident Level Quality Measure Report presents State, Facility ID, Begin Date (mm/dd/yyyy), and End Date (mm/dd/yyyy) options. The date the most recent quality measure data were calculated is indicated. The MDS 3.0 Resident Level Quality Measure Report identifies the residents (active and discharged) that were included in the calculations for the selected facility and period that were used to produce the MDS 3.0 Facility Quality Measure Report. The report lists the residents by name and indicates the measures, if any, triggered by each. The criteria selection page (Figure 26-4) for the MDS 3.0 Resident Level Quality Measure Report presents State, Facility ID, Begin Date (mm/dd/yyyy), and End Date (mm/dd/yyyy) options. The date the most recent quality measure data were calculated is indicated.

20. Even though CASPER MDS 3.0 QM reports and Nursing Home Compare (NHC) use identical sample selection and measure calculation logic, there may be differences between the results that are reported by the two systems. The reasons for these differences are: • Measures Included. The CASPER MDS 3.0 QM reports and the reports on NHC contain many of the same measures. However, each system contains some QMs that are not reported by the other system. • Timing. NHC data are run once a quarter, whereas the CASPER MDS 3.0 QM data are updated more frequently. It is, therefore, likely that the assessment database changed between the time the NHC statistics were computed and the time the CASPER MDS 3.0 QM statistics were computed. The CASPER MDS 3.0 QM statistics reflect all assessments, including modifications, that were submitted since the NHC statistics were computed. • Reporting Periods. Every QM is based upon the selection of a target assessment. For NHC, the target assessment must have a reference date within the most recent 3 months for long-stay measures and the most recent 6 months for short-stay measures. On the CASPER MDS 3.0 QM Reports, you are allowed to customize the length of the selection period (by adjusting the beginning and ending date of the report). If the selection periods you select are different from those used for NHC, the results may differ. • Averaging Across Quarters. The results that are presented on NHC are averaged across several calendar quarters while the results on the CASPER MDS 3.0 QM reports are for only a single reporting period. • Risk Adjustment. These adjusted percentages may not match the percentages reported on NHC because of the way the risk adjustment calculations are performed. One of the factors used in the risk adjustment calculations is the national average for the QM at the time of calculation. Since the calculations are usually performed at different times for the two systems (see “Timing” above), the national means may differ and the percentages may be different on the two sets of reports. Even though CASPER MDS 3.0 QM reports and Nursing Home Compare (NHC) use identical sample selection and measure calculation logic, there may be differences between the results that are reported by the two systems. The reasons for these differences are: • Measures Included. The CASPER MDS 3.0 QM reports and the reports on NHC contain many of the same measures. However, each system contains some QMs that are not reported by the other system. • Timing. NHC data are run once a quarter, whereas the CASPER MDS 3.0 QM data are updated more frequently. It is, therefore, likely that the assessment database changed between the time the NHC statistics were computed and the time the CASPER MDS 3.0 QM statistics were computed. The CASPER MDS 3.0 QM statistics reflect all assessments, including modifications, that were submitted since the NHC statistics were computed. • Reporting Periods. Every QM is based upon the selection of a target assessment. For NHC, the target assessment must have a reference date within the most recent 3 months for long-stay measures and the most recent 6 months for short-stay measures. On the CASPER MDS 3.0 QM Reports, you are allowed to customize the length of the selection period (by adjusting the beginning and ending date of the report). If the selection periods you select are different from those used for NHC, the results may differ. • Averaging Across Quarters. The results that are presented on NHC are averaged across several calendar quarters while the results on the CASPER MDS 3.0 QM reports are for only a single reporting period. • Risk Adjustment. These adjusted percentages may not match the percentages reported on NHC because of the way the risk adjustment calculations are performed. One of the factors used in the risk adjustment calculations is the national average for the QM at the time of calculation. Since the calculations are usually performed at different times for the two systems (see “Timing” above), the national means may differ and the percentages may be different on the two sets of reports.

21. Currently we operate Traditional Survey under a Survey & Cert Memo eliminating use of QM reports that went dark October 2010 New reports become available April 2012 Traditional Survey is being revised to accommodate use of the new QM Reports Procedures for offsite review will be the same as they were previously but language is updated to describe what is on the new reports The new MDS 3.0 Quality Measure (QM) reports were made available to users on April 1, 2012; however, our modified survey process will remain in place until further notice. Other revisions to the traditional survey process; for example, changes to the 802/672 forms and instructions, as well as Appendix P revisions, are still being completed. The new MDS 3.0 Quality Measure (QM) reports were made available to users on April 1, 2012; however, our modified survey process will remain in place until further notice. Other revisions to the traditional survey process; for example, changes to the 802/672 forms and instructions, as well as Appendix P revisions, are still being completed.

22. For Long Stay Residents Only Falls Psychoactive Medication Use in Absence of Psychotic or Related Condition Anti-anxiety/Hypnotic Medication Use Behavior Symptoms Affecting Others Theses 4 are from the old Qis but did not make the approval process from the National Quality Forum. These QMs are also available to the Facilities via Casper. The new MDS 3.0 Quality Measure (QM) reports were made available to users on April 1, 2012; however, our modified survey process will remain in place until further notice. Other revisions to the traditional survey process; for example, changes to the 802/672 forms and instructions, as well as Appendix P revisions, are still being completed. Theses 4 are from the old Qis but did not make the approval process from the National Quality Forum. These QMs are also available to the Facilities via Casper. The new MDS 3.0 Quality Measure (QM) reports were made available to users on April 1, 2012; however, our modified survey process will remain in place until further notice. Other revisions to the traditional survey process; for example, changes to the 802/672 forms and instructions, as well as Appendix P revisions, are still being completed.

23. For Long Stay Residents Only Numerator Residents with one or more look-back assessments that indicate a fall (J1800=1) Denominator All long stay residents Exclusions All look-back scan assessments not assessed (J1800=dash)

24. For Long Stay Residents Only Numerator N0400A=1 (assessments 3/31/12 or before) N0410A=1-7 (assessments 4/1/12 or after) Denominator All long stay residents Exclusions Schizophrenia, Psychotic disorder, Manic depression, Tourette’s, Huntington’s, Hallucinations, Delusions

25. For Long Stay Residents Only Numerator N0400B=1 (assessments 3/31/12 or before) or N0400D=1 (assessments 3/31/12 or before) N0410B=1-7 (assessments 4/1/12 or after) or N0410D=1-7 (assessments 4/1/12 or after) Denominator All long stay residents Exclusions Schizophrenia, Psychotic disorder, Manic depression, Tourette’s, Huntington’s, Hallucinations, Delusions, Anxiety Disorder

26. For Long Stay Residents Only Numerator E0200A=1, 2, 3 or E0200B=1, 2, 3 or E0200C=1, 2, 3 or E0800=1, 2, 3 or E0900=1, 2, 3 Denominator All long stay residents Exclusions Target assessment is a discharge, dash or karat at any of the above items

27. Roster/Sample Matrix (802 form) echoed the MDS 2.0 fields, plus additional ones surveyors wanted Form is changing to accommodate our new list on the QM Reports plus additional ones QM items in bold, in same order as QM Report (same as before) Instructions (Surveyor and Provider) updated to MDS 3.0 fields

29. Fields have stayed the same as they are programmed into CMS mainframe Instructions updated with MDS 3.0 fields

30. MDS 3.0 RAI Manual V1.08 Published January 20, 2012 (www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp) Effective date – APRIL 1, 2012 Format Changes: Only pages with actual changes have been updated & is indicated by the footer “April 2012” Unchanged pages are indicated with the footer “October 2011”