Event ID: 3182794Event Started: 2/24/2017 2:26:40 PM ET

Welcome to improving the physical restraints long stay quality measure. How is this quality measure triggered? Recorded webinar. I'm Lisa and I'm a quality improvement facilitator at telogen-- Telligen. This webinar includes becoming familiar with the quality measure specifications using the MDs 3.0 quality measures manual and understanding how that triggers the quality measure, making the connection between MDS items and 3.0 specifications, provide a systematic method for verifying the accuracy of the quality measure score and tips for improvement. 

The long stay physical restraint quality measure is reviewed in your annual survey. It is included in public reporting on nursing home compare and data available to nursing home providers to track performance. The CMS Casper quality measure reports are found in the key system and provided to all facilities who report from MDS 3.0 submissions. The nursing home compare five-star rating also includes this specific measure within the calculation of the five star rating. This quality measure is one of 13 measures included in the nursing home quality care collaborative composite measure score. Participants in the national nursing home collaborative focus on these long stay measures as they represent larger systems within the long-term care setting. The goal is to achieve a score of six or less at least once.

The physical restraint is a long stay quality measure. There is no short stay quality measure for physical restraints. This reports the long stay residents who are physically restrained on a long stay basis over a 7 day look back period defined in the resident assessment incident manual. The definition of a long stay and quality measure users manual refers to an episode of cumulative days in the facility. Cumulative days in the facility must be greater than or equal to 101 days. Only days within the facility count for the cumulative days in the facility. Detailed information can be found in the MDS 3.0 quality measures users manual. These are three critical reports-- manuals use to improve your quality measures. They changed recently so it is critical that you have a process to remain current by checking the CMS website frequently.

The first is the quality ratings system technical users guide. This manual will assist you with understanding how your five-star rating was calculated across all three domains. Next is the MDS 3.0 quality users manual . The quality measure is triggered using MDS items. Finally, the resident assessment users manual or RAI manual is used to complete the MDS. Instructs on proper reporting and actually provides

guidance on all of the measures. Specific guidance and for all measures is found in appendix C, care area assessment.

As you explore improving the quality measure it is best to verify the definitions. Physical restraints are defined as any manual method or physical or mechanical device material or equipment attached or adjacent to the body of the resident. So that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. This report shows the calculation of the facility for each quality measure and titled MDS 3.0 facility level quality measure report. It is found in the-- system, the acronym is quality improvement evaluation system. Quality measures are listed on the left. The catheter description is highlighted. S Stands for short stay and L stands for long stay. As you look at the report you will see your facility's current numerator, denominator, the facility is observed percent, the adjusted percent, the state average, the national average for each QM. On the right side you see your facilities percentile income parities-- in comparison to the national scope.

The facility adjusted percent is used in the calculation of this quality measure. This is the resident level quality measure report. It is often used as a companion to the facility level report, simply put, it is a roster of all residents and identifies which measures were coded for each individual resident. As you can see if there is an ex--- an X in the box, that resident has been identified as having triggered that quality measure. The purpose of the report is to identify trends who you can focus improvement efforts on.

Once you have determined who has been identified for the quality measure, you must refer to the MDS 3.0 quality measures manual to understand the conditions that trigger the quality measure. As you can see every measure includes a description, and covariates.

The numerator is constraints [ Indiscernible -- low volume ] and a target assessment except for those with exclusions. Exclusions are conditions listed when residents are not in the numerator. There are no covariates for this measure but you can learn more about them using the MDS 3.0 quality measures manual. We will now examine the numerator, denominator, and exclusions for this measure.

Let's review the denominator for the physical strength quality measure which includes all residents with a target assessment. That is defined as the reason for the assessment which includes federal assessments such as admission annual quarterly and significant changes and corrections as well as a scheduled PPS assessment. In this case it is everyone in your building.

The numerator reflects the actual number of residents who are impacted by this quality measure condition. Each MDS item has an assigned code specific to the

descriptions related to the quality measure and defines the frequency of its use. Let's look at the Met-- the measure for the numerator. The restraints they are focusing on is trunk limb and chair-- rising and focuses on if it is in a bed or a chair only. The numerator does not include bed rails which is a common misconception for this measure. The quality measure specification also identifies exclusions which are conditions that exclude the resident from both the numerator and denominator in the quality measures. In this case if there is a card for the five types of restraints listed above then it would be excluded from the quality measure.

We have just reviewed the specific details for the long stay physical restraint quality measure numerator denominator and exclusions. Let's let's take a moment to connect this with the actual MDS items. The box on the right in our specific questions with what must be coded. This slide is a snapshot of that very section where physical restraints are coded. On the left there are three options for frequency, zero not used, used, less than daily, and used daily. On the right side you can see types of restraints that may be used in bed, out of bed, or in a chair. Outlined in red are the frequency and types of restraints that will trigger the quality measure. In summary, this is only triggered if the frequency is-- has scored a number two, used daily, and item T0100 letters B,C, E, F, and G.

Long stay physical restraints are included in the five-star calculation and can impact your overall rating. Let's review the table on the left and it is from the five-star technical users guide and indicates the point range needed to earn 125 stars in the quality measure domain. There are 16 measures and each can earn 20-100 points. A minimum of 105 points are needed to earn a star in the quality measure domain. The table on the right identifies the point ranges and value for the recorded quality measure percentage. The only way to earn 100 points is to have zero physical restraints. A quality measure rate greater than 1.42% will earn the minimum points of 20. Many nursing homes who score greater than zero are aiming for improvement.

The first step is to make certain that your staff have a clear understanding of the definition and the word. You can do this by reviewing the interpretive guideline-- guidelines, and the CMS survey certification memo or just call Telligen. 

Some things to consider. You may want to review the process for restraint reduction and elimination. Consider trialing a right restraint holiday for any resident currently being restrained which would be a PDSA. If you are considering trialing a restraint holiday it would require 24 hours without application of a physical restraint. You would need a plan for the interdisciplinary team that occurs prior to removing this-- restraint and you may want to consider scheduling the trial during the seven day look back period.

To support your improvement efforts, Telligen recommends the following, review your Casper data for all residents coded with a physical restraint in the MDS. Review the physical restraint definition. Verify accuracy reviewing quality measure numerator, denominator, and exclusions from the quality measure specifications in the MDS 3.0 quality measures users manual. Formalize and implement the required systematic and gradual process toward reducing restraints. Create a folder on your computer with all current critical resources and share that with everyone. This concludes this presentation. Please review these resources and save them for future reference. For questions please contact one of our quality innovative network staff listed on this slide, thank you.

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Welcome to today's webinar entitled improving your facility's urinary tract infection long stay quality measure. I'm carry and I'm a quality-- I am Carrie and I'm a quality improvement facilitator at Telligen. Today's webinar include becoming familiar with quality specifications, understanding how MDS coding triggers a quality measure and tips for improvement. These are three critical resource manuals that everyone needs to be familiar with. The first is the five-star quality ratings system technical users guide.

This manual will assist you with understanding how your five-star was cut-- calculated across all three domains. Next is the MDS 3.0 quality measures user manual. This explains how each quality measure is triggered by the MDS, and finally the manual that every coordinator should use, the resident assessment instrument users manual or the RAI manual which breaks down the entire MDS and instructs on proper coding and reporting. The definition-- 

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Welcome to today's webinar entitled improving your facility's urinary tract infection long stay quality measure. I'm trying to and I'm a quality improvement facilitator at Telligen. The objectives for this webinar include becoming familiar with the quality measure specifications, understanding how the MDS coding triggers the quality measure and tips for improvement. These are three critical resource manuals that everyone needs to be familiar with. The first is the five-star quality rating systems technical users guide. This manual will assist you with understanding how your five-star was calculated across all three domains. Next is the MDS 3.0 quality measures

users manual which explains how each quality measure is triggered by the MDS. Finally, the manual that every coordinator should use, the resident assessment instrument users manual, or the RAI manual which breaks down the entire MDS and instructs on proper coding and reporting. The definition of long stay refers to an episode of cumulative days in the facility that is greater than or equal to 101 days. Only cumulative days count toward the CDIF. The urinary tract infection quality measure is used in your CMS Casper quality measure report, the nursing home compare five-star rating, five-star preview reports that are reported on Casper, nursing home quality care collaborative composite measures score, and it is reviewed in your annual survey process.

When you look at your MDS quality measure report you will see the quality measures listed in the column on the left. I have UTI long stay highlighted here. The S is for short stay measures and L is for long stay measures. The report shows your facilities calculations for each quality measure. As you look at the report you will see the current numerator, denominator, the observed percent, the adjusted percent, the state average, and national average for each quality measure. On the right side you will see your facilities percent in comparison to the national group and it is a great report to review to see what areas need improvement. 

If you check out your facilities Casper report, you will see what is triggered for specific residents. This is a blind report that your facility will be listed under the resident name column. I have UTI highlighted here. If a specific resident would trigger for that quality measure it is marked with an X which help you identify what needs improvement. 

UTI specific specifications are listed in the quality measure users manual which explains how the quality measure is triggered. Here is a screenshot of the percent of residents with urinary tract infection. The numerator would equal residents that trigger for the UTI, your denominator is the target assessment except for those with exclusions, and the exclusions are the target assessment is an admission assessment or a readmission assessment or the urinary tract infection value is missing or I-2300 is dashed. Under section I checking I-2300 will trigger this quality measure. This is the only way the quality measure is triggered. Make sure to review this section carefully if using an EHR that pre-populates your diagnoses with a new record is opened. If the UTI ICD 10 code is listed it may pull into this section. Mark them as resolved or inactive which will help with this common issue.

The UTI had a look back period of 30 days instead of 7. I-2300 is only if all of the following are met. The physician, nurse practitioner, physician's assistant-- assistant or other authorized licensed staff as permitted by state law has given a diagnosis of a UTI in the last 30 days. Signs or symptoms attributed to the UTI which may or may

not include but not limited to fever, urinary symptoms, peer urethral site burning sensation, frequent urination of small amounts, pain or tenderness, confusion or change in mental status, changing character of urine, are documented. The resident has significant wrap-- laboratory findings. The attending physician should determine the lover-- level of significant findings and whether or not a culture should be obtained. The term significant when discussing clinical medical or laboratory findings refers to measures of supporting evidence that are considered when developing or assigning a diagnosis and therefore reflect clinical judgment. Number four, a current medication or treatment for UTI has been done in the last 30 days.

For MDS coding purposes, they are treated the same as any other UTI. As stated in the manual the CDC does not recommend routine antimicrobial treatment for attempting to eradicate colonization of M RSA-- or any other antimicrobial organism.

Here are some strategies to use. Make sure to properly hydrate and nutrition. Promote healthy voiding habits and promote [ Indiscernible -- multiple speakers] good hygiene. User Casper quality measure reports to drill down data to the resident level and assess the residence that trigger for UTI. Make sure to check for coding areas and assess the coding accuracy, then develop individualized care plans for those who trigger for UTIs and measure overall effectiveness of quality improvement intervention.

For questions please contact one of the Telligen QA and QIO-- QIN QIO staff on this slide. Thank you.

Welcome to today's recorded webinar, improving the percent of residents who have or had a catheter inserted in the bladder long stay quality measure. How is this quality measure triggered? I am Lisa and I may quality improvement facilitator at Telligen. The objective for this webinar includes one, becoming familiar with the quality measure specifications using the MDS 3.0 quality measures manual, number two, understanding how MDS coding triggers the quality measure, making the connection with the MDS items in MDS 3.0 quality measure specifications, three, provide a systematic method for verifying the accuracy of your quality measure score, and 4, tips for improvement.

The long stay catheter quality measure is reviewed in your annual survey as well as your public reporting on the nursing home compare website and in data available to the nursing home providers to track performance. The CMS Casper quality measure reports are found in the key system and provided to all facilities with reports from the MTS-- MDS 3.0 submissions. The five-star rating also includes this specific measure in the calculation of the five-star rating. Additionally, this quality measure is one of the 13 quality measures included in the nursing home quality care collaborative composite measures score. Participants of the national nursing home collaborative focus on these long stay measures as they represent larger systems within the long-term care setting. The goal is to achieve a score of 6 or less at least once.

Catheter is a long stay quality measure and it reports the percentage of residents who have had an indwelling catheter at any time during the last seven days using a look back period defined within the resident assessment incident manual. The definition of long stay in the 3.0 quality measures users manual refers to an episode of cumulative days in the facility. Cumulative days in the facility must be greater than or equal to 101 days. Only days within the facility count toward the cumulative days in the facility. Detailed information can be found in the MDS 3.0 quality measures users manual. These are three critical resource manuals used to understand and improve your quality measures. They changed recently and it is critical you have a process to remain current by checking the CMS website.

First is the five-star quality rating systems technical users guide. This manual will assist you with understanding how your five-star rating was calculated across all three domains. Next is the MDS 3.0 quality measures users manual which explains how each quality measure is triggered using MDS items. The resident assessment incident users manual is for completing the MDS. It instructs on proper coding and reporting and provides guidance on all the measures. Specific guidance is found in appendix C, care area assessment.

As you explore improving the quality measure it is always best to verify the definition. This measure is only focusing on indwelling catheters for the purpose of continuous drainage or of urine and includes-- and tubes. 

This report shows your facilities calculation for the quality measure and is titled MDS 3.0 facility level quality measure reports. It is found in this key system, quality improvement evaluation system, that is the acronym. The quality measures are listed on the left. The catheter description is highlighted. On this report, S stands for short stay and L stands for long stay. As you look at the report you will see your facilities current pneumonic-- numerator, denominator, the observed percent of your facility, your facility is adjusted percent, the state average and national average for each QM. On the right side you see your facilities percentile in comparison to the national group. The facility adjusted percent is used in the calculation of this quality measure. 

This is the resident level quality measure report. It is often used as a companion to the facility level report. Simply put it is a roster of all residents and identifies which measures were coded for each individual resident. As you can see if there is an ask in the box, that specific resident has been identified as having a catheter. The purpose of this report is to identify the trends of residents so you can focus on improvement efforts.

Once you have determined who has been identified for the quality measure, you must refer that to the quality measures manual to understand the conditions that trigger this quality measure. As you can see, every measure includes the description, measure specification, and some have covariates. In this example, the numerator is your long stay residents that identified those with a catheter. The denominator is all long stay residents with a target assessment except for those with exclusions. The exclusions are defined as conditions listed when residents are not in the numerator. There are three covariates for this measure which means this quality measure is risk-adjusted based on certain risk factors which are not related to quality of care but which are related to quality measure outcomes. For information on covariates, refer to the MDS 3.0 quality measures manual.

Let's examine further these measures. Numerator, denominator, and exclusions.

Let's review the denominator. This includes all residents with a target assessment. The target assessment is defined as the reason for the assessment which includes federal over assessment such as annual quarterly and significant changes in corrections as well as schedule PPS assessments. The numerator reflects the number of residents that were impacted by this quality measure. Each item has an assigned code specific to the descriptions related to the quality measure and defines the frequency.

Let's look at the measure specifications. This measure is only looking for residents with an indwelling catheter during the defined target period.

The quality measure specifications also identify exclusions. These are conditions that exclude the resident from both the numerator and the denominator in the quality measure. In this case there are 4 items that would result in a resident with a catheter not be included in the reported quality measure weight. This measure will not be triggered if the target assessment is an admission assessment. Or a Medicare perspective-- perspective system or a five day readmission return assessment. This measure will not be triggered if there is an indication of indwelling catheter status is missing. This measure will not be triggered if it involves a resident with a diagnosis of neurogenic bladder and or obstructive neuropathy and these diagnoses are included in the MDS. Many nursing homes have found if they make certain they have these diagnoses in both the chart in MDS, there measure rates-- quality measure rates will decrease.

We have just reviewed the specific details for the long stay catheter measure-- numerator, denominator, and exclusions. Let's take a moment to connect this with the actual MDS item. This slide is a snapshot of the section where catheter is coded. The quality measure has a 7 day look back period only. During the look back period it places Xan-- in the appropriate box. This is the only selection that can drive the quality measure. It is 80100 and X would be placed in the box for letter a. The long star-- the quality measure is also included in the calculation and can impact your overall five-star rating. This is from the technical users guide and indicates the point range needed to earn one through five stars in the quality measure domain. There are 60 measures and each can earn 20-100 points. A minimum of 905 total points are needed to earn a star. The table on the right identifies the point ranges and values for the catheter quality measure percentage. The quality measure percentage of 2.9% would yield a provider 80 of a possible 100 points. In many cases many providers are aiming to achieve 100% of this quality measure by implementing CDC core strategies. CDC core prevention strategies include insert catheters only for appropriate indications and those are defined as acute urinary retention and bladder outlet obstruction, assist with healing open sacral or perennial wounds. The CDC core prevention strategy also suggests that you leave catheters in place only as long as they are needed and to remove them as soon as possible. Additionally you can avoid use by focusing on the elderly, people with impaired immunity, and using it for the management of incontinence. They asked us to consider alternatives to indwelling catheters including intermittent catheterization, bladder ultrasound scanners and external catheters.

For those aiming to sustain or reduce the long stay catheter quality measure, they may benefit by evaluating your process. Take a look at those who are admitted or

readmitted with a catheter. Do you monitor or verify for the appropriate diagnosis that we discussed earlier? How does the facility monitor the pressure of the healing process if an indwelling catheter is used to maintain skin integrity or comfort? And then we must work together to avoid UTI. You can do this by evaluating your process for staff proficiency and perennial and catheter care, handwashing and hydration.

To support your improvement efforts, Telligen recommends the following, -- with a catheter. Review MDS and-- indwelling catheter definition. Verify coding accuracy reviewing quality measure numerator, denominator, and exclusions from the quality measure specifications in the MDS 3.0 quality measures users manual. Formalize and implement the required systematic evaluation for catheter use.

Here are a list of resources referenced from the presentation. For questions, please contact one of the Telligen QIN-QIO staff listed on this slide. Thank you. 

Welcome to today's webinar entitled improving your facilities percent of residents who self-report moderate or severe pain long stay quality measure. I am Carrie and I'm a quality improvement facilitator at Telligen. The objectives for today's Representative-- webinar include becoming familiar with the quality measure specifications , understanding how the MDS coding triggers the quality measure and tips for improvement. Here are three critical resource manuals that everyone needs to be familiar with. The first is the five-star quality rating system technical users guide. This manual will assist you with understanding how your five-star was calculated across all three domains. Next is the MDS 3.0 quality measures user manual. This manual explains how each quality measure is triggered by the MDS. Finally, the manual that every coordinator should use, the resident assessment instrument user's manual or the RAI manual breaks down the entire MDS and instructs on proper coding and reporting. 

The definition of long stay refers to an episode of cumulative days in the facility or CDIF that is greater to or equal to 101 days . Only days with in the facility count toward the CDIF. 

The pain quality measure is used in CMS Casper quality reports, nursing home compare five-star rating, 5 star preview reports as reported on Casper and the nursing home quality care collaborative composite measure score. On Casper facility level report, the quality measures are listed on the left. I have highlighted the residence who self-report moderate to severe pain long stay measure. On this report, S stands for short stay and L stands for long stay. This shows your facilities calculation for each quality measure. As you look at the report you will see your facilities current numerator, denominator, the observed percent, adjusted percent, the state average, and the national-- national average for each quality measure. On the right you will see your facilities percentile in comparison to the national group. This is a great report to review to see areas that need improvement.

If you check out your facilities 3.0 resident level quality report you will be able to see what quality measures are triggered for specific residence which is a blinded report but the residents will be listed under the resident name column. As you can see, I have long stay pain measure highlighted here. If that specific resident would trigger for the measure you can mark that with an X. This helps you know what you need focus for improvement. 

The long stay pain measure specifications are listed in the quality measures user manual. Remember this manual explains how the quality measure is triggered. Here is a screenshot of the 3.0% of residents who self-report moderate to severe pain long stay measure. The numerator includes long stay residents that trigger for the pain measure. The denominator is all residents with a target exception except for those with-- inclusions. The long stay measure has a covariate. This quality measure is risk-adjusted based on certain factors which are not related to quality of care but which are related to the quality measure outcomes. For more information on covariates refer to the MDS 3.0 quality measures users manual. For quality measures that have covariates you will see a facility adjusted percent recorded on the 3.0 facility quality measures report on the Casper reports.

The numerator consists of long stay residents with a select target assessment where the target assessment meets either or both of the following conditions. Condition one, the resident reports almost constant or frequent moderate to severe pain in the last five days. Both of the following conditions must be met for the resident trigger. Almost constant or frequent pain, J0 400 is coded as a one or two, and at least one episode of moderate to severe pain, J0 600 a is coded as five, six, seven, eight, or 9. J 600 be-- B is coded with one, two, or three. 

Residents report severe or horrible pain in any frequency or J J0 600 J is coded as a 10-- J0 600 a is coded as a 10 or J 600 be is coded as a 4. All residents with a select target assessment except for exclusions, which include the target assessment is an admission assessment, 5 day assessment or PPS readmission return assessment. The resident is not included in the numerator, the resident did not meet the pain symptom condition, and any of the following conditions are true. The pain assessment interview is not completed, the pain present item was not completed and for residents with pain or hurting in any time, any of the following are true. The frequency item was not completed, neither of the pain intensity items were completed, or the pain numeric intensity item concludes no pain. If a resident is unable to participate, the resident will not trigger for this quality measure.

Has stated, no predetermined definitions are offered to the resident related to frequency of pain. The response should be based on the interpretation of the resident of the frequency option. Facility policy should provide standardized tools to use without the facility to ensure consistency in the interpretation and documentation of the resident pain. Remember that pain is subjective.

Tips for improving the pain quality measure.

Pain is everyone's responsibility. Educate everyone to recognize pain and to know the process for reporting residents who are in potential pain to the nurse. Start an

interdisciplinary pain team, review residents with moderate or worse pain and consider care plan adjustments. Make pain the fifth vital sign. Screen residents daily upon admission or readmission. Pain should be monitored on every shift throughout the nursing home by all staff. 

Know your residence. Observe and document baseline behavior in every resident the special emphasis on people with cognitive impairment. No the preference on how they want pain treated. Review routine and PR and pain medications for residents and update as needed. Change to regularly scheduled medications when there is a pattern of consistent PRN medication use. Update with physicians as needed for change management as needed. 

Give pain medication before activities, treatment and therapy using a proactive approach, it helps to keep residents comfortable. 

Use pharmacological and nonpharmacological pain interventions. Nonpharmacological treatments such as range of motion, heat, whirlpool, art and music therapy, aromatherapy, distraction, may reduce pain significantly with or without the use of medication. Delivery of some of these nonpharmacological interventions for pain management may be shared with interdisciplinary team members with the added benefit of improving quality of life.

Consult with residents, family and staff, all team members need to be consulted in pain management with care planning, monitoring and documenting.

In conclusion to improve your facilities pain quality measure use your Caspi-- Casper quality measure reports to drill down data to the resident level and assess residents that trigger for pain. Make sure to check for coding area-- errors and assess accuracy, then develop individualized care plans for those who trigger for pain and measure the overall effectiveness of quality improvement interventions.

For questions please contact one of the staff listed on the slide. Thank you.

Welcome to today's webinar entitled improving the vaccination long stay quality measures. I'm trying to enemy quality improvement facilitator at Telligen -- I'm Carrie and I'm a quality improvement facilitator. Today's webinar includes becoming familiar with the specification, understanding how coding triggers the quality measure, and tips for improvement. Here are three critical resource manuals that everyone needs to be for me with. First is the five star quality rating system technical users guide which will assist you with understanding how your five star was calculated across all three domains. Next is the MDS 3.0 quality measures users manual. This manual explains how each quality measure is triggered by the MDS and finally, the manual that every coordinator should use, the resident assessment users manual which breaks down the entire MDS and instructs on proper coding and recording.

The definition of long stay refers to an episode of cumulative days in the facility or CDI off-- or CDIF greater than or equal to 109 days. Only days within the facility count toward the CDIF .

Both the flu and pneumonia vaccine quality measures are used in the five-star preview reports and are publicly reported on nursing home compare and used in the nursing home quality care collaborative composite measures score.

Here is a screenshot of the nursing home five-star preview reports that can be accessed through Casper. Both of the vaccination measures are listed in this report.

On the nursing home compare website the vaccination quality measures are displayed publicly. This site shows what the state and national averages are for quality measures which helps compare the facility against the state and the nation.

The influenza quality measure is only calculated once a year. The target period of October 1 of the prior year to June 30 of the current year and reports for October 1 through March 31 influenza season. I will discuss the quality measures specific in upcoming slides.

The influenza measures specifications are listed in the quality measures users manual. Your numerator is the resident meeting specific criteria on selected influenza vaccination assessments and-- except for those with exclusions. The only exclusion to that exclusion is the residents age on the selected target vaccination assessment 179 days or less. 

The MDS coding that triggers this quality measure is in section oh. To be counted they meet any of the criteria on the vaccination assessment. Resident received the vaccine during the most recent season either in the facility or outside the facility, the resident was offered and declined the influenza vaccine or the resident was ineligible due to other indications. And of collective hypersensitivity to eggs or other components in the vaccine, a history of--'s syndrome after a previous vaccination or bone marrow transplant within the past six months. The denominator is all long stay residents with selected influenza vaccination assessment except for those with exclusions and the exclusion is the resident age on the target date of the selected assessment as 179-- is 179 days or less. The only reason they would not be counted are highlighted in red which will bring down your facilities percent in the quality measure.

Here are the quality measures broken down so that it is easier to understand. By asking these questions is easier to figure out if they are being calculated or coded correctly. Even if the resident did not receive the vaccine in the facility during the

most recent season, they will not bring your facility-- your facilities percent down if they receive the vaccination.--@Facility, were not eligible due to contraindications, or offer the vaccine and declined. Make sure to capture these reasons on the MDS.

An annual checklist can be found on the CDC website and is a great checklist and will help staff prepare for flu season.

Once the vaccine has been administered for the current season, this value is carried forward until the new influenza season begins. Assess on admission, document if or when they had the vaccination. The resident has the right to decline. Make sure to have good documentation of this so it can be captured on the MDS. Give as appropriate, do not give if the resident has an allergy to eggs, the vaccine or any component. It is recommended that annual influenza vaccination from October through March or as the physician orders. Early fall is the optimal vaccination period. 

Next up is the pneumococcal vaccination measures specification as listed in the quality measures user manual. This quality measure is straightforward. To be counted in the numerator and resident meets any of the criteria on the selected target assessment and have an up to date vaccination status. They were offered and declined the vaccine or were ineligible due to medical contraindications such as anaphylactic hypersensitivity to components of the vaccine, bone marrow transplant within the last 12 months of receiving a course of chemotherapy within the past 2 weeks. Your denominator is all long stay residents with a select target assessment.

Here the quality measures are broken down a little bit further. Asking these questions will help with coding accuracy. Is the resident up to date on their pneumococcal vaccinations? If the answer is yes the vaccine is up to date, or no, the vaccine is not and was offered and declined or the resident was not eligible due to medical contraindications, these residents will all count in the numerator. If the answer is no and the reason is not offered, this will lower your facilities percent in this quality measure. 

Here are some tips for the vaccination. Assess residence on admission, PCV 13 and PC SV 23. 

Search for records of the vaccination from transferring organizations, the primary care physician, state immunization systems, residents, family, and etc. If it is uncertain, consult with a physician. It is okay to give the vaccine with the pneumococcal vaccination but give in separate syringes and separate injection sites. Don't give the resident if the resident is allergic to any of the components of the vaccine and again, the resident has the right to decline. Make sure to get documentation so this can be coded on the MDS. 

On the CDC website there is an algorithm to help with proper pneumococcal vaccination schedules. This shows the specific criteria to follow to ensure that the resident is up to date on the vaccination.

Why isn't your facility getting 100% in both vaccination measures? Could there be a coding error? Is it because of misunderstanding of the quality measure or because of lack of or incomplete vaccination screening? To conclude this webinar here are some tips to improve the vaccination quality measure. Assess everyone on admission for vaccination records. Perform chart audits to assure there is vaccination-- information for vaccinations on every chart. Track vaccinations using your EMR written records, spreadsheets, templates, and state-specific databases. For questions, please contact one of the Telligen QIN-QIO staff listed on this slide. Thank you.

[ event concluded ]