![Page 1: David Gifford SVP Quality & Regulatory Affairs Congressional briefing Washington DC June 23 rd, 2014 IMPACT ACT OF 2014](https://reader036.vdocuments.us/reader036/viewer/2022082820/56649e965503460f94b99eae/html5/thumbnails/1.jpg)
David Gifford
SVP Quality & Regulatory Affairs
Congressional briefing
Washington DC
June 23rd, 2014
IMPACT ACT OF 2014
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“IMPACT ACT OF 2014”
Legislation has four parts :
1. Incorporate standardized assessment
2. Public reporting of common quality measures
3. Provide quality measures to consumers when transitioning to a PAC provider
4. HHS and MedPAC to conduct several
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“IMPACT ACT OF 2014” Part 1• Incorporate standardized assessment(s) (e.g. CARE tool)
into existing assessment tools across PAC providers (LTCH, IRF, SNF, & HH) and acute care hospitals for• Pressure ulcers• Functional status• Cognitive status• Special Services
• Collect data at admission and discharge• Applies also to acute care hospitals
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“IMPACT ACT OF 2014” Part 2• Develop & Publicly report quality measures across
settings• Rehospitalizations & hospitalizations • Hospitalizations after discharge from PAC provider• Discharge to community• Pressure ulcers• Medication reconciliation • Incidence of major falls• Patient preferences • Efficiency measure(s): Avg Total Medicare Spend per Beneficiary• Plus any other measures Secretary wants
• Measures must be approved by National Quality Forum• Public reporting starting in Oct 2018
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Using information across settings• Clinical Care• Quality Improvement • Accountability measurement
• Public reporting• Network selection• Payment (e.g. Value Based Purchasing)• Policy evaluations & decisions
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Questions to ask about measures • Data source
• Is it reliable and valid?• Is consistent and comparable
• Wording of assessment• Rating scale used• Frequency of assessment
• Measure definition• Who does the measure apply to (e.g. denominator)• Who is counted in the measure (e.g. numerator)• Does the measure need to be risk adjusted?
• What are clinical and non-clinical characteristics used in risk adjustment
• Is the measure reliable and valid?
• How to compare providers based on measure results• How do you use measure results for
• Quality improvement• Network selection• Payment
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ADL Questions & Ratings Vary IRF HH SNF LTCH Hospitals
Bathing 0-7 0-6 0-4; 0-3 None NoneEating 0-7 0-5 0-4; 0-3 None NoneGrooming 0-7 0-3 0-4;0-3 None NoneDressing- Total- Upper body- Lower body
NA0-70-7
NA0-30-3
0-4;0-3
NANA
None None
Transfers bed, chair 0-7 0-3 0-4;0-3 None None
Toileting- Overall- Transferring- Hygiene
0-70-7
0-40-3
0-4;0-3
NANA
None None
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Rating of questions
IRF7 = completely independent
6 = modified independence
5 = supervision (subject = 100%)
4 = minimal assistance (subject = 75% of more)
3 = moderate assistance (subject = 50% or more)
2 = max assistance (25% or more)
1= total assistance
0 activity did not occur
OASIS0 = able to bath self independently
1 = with the use of devices, is able to bath self
2 = able to bathe in shower or tub with the intermittent assistance of another person
3 = able to participate in bathing self in shower or tub but requires presence of another person
4 = unable to use the shower to tub but table to bathe self independently with or without the use of devises at the sink, in chair or on commode
5 = unable to use the shower or tub but able to participate in bathe self in bed, at the sink or in bedside chair with assistance or supervision of another person
6 = unable to participate effectively in bathing and is bathed totally by another person
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Rating of questions
MDS
• IRF – average function• OASIS – typical ability• MDS – most dependent
0 = independent– no help provided
1 = supervision– oversight help only
2 = physical help limited to transfer only
3 = physical help in part of bathing activity
4 = total dependence
8 = activity did not occur
Rating Instructions
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Wording of questions: Bathing
IRF-PAI: “Bathing”
OASIS: “Current ability to wash entire body safely, Excludes grooming (washing face, washing hands, and shampooing hair)”
MDS: “How resident takes full-body bath/shower, sponge bath, and transfers in /out of tub/shower (excludes washing of back and hair)”
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Cognitive Function Assessment
IRF-PIA OASIS MDS LTCH Hospitals
Memory Rate assistance
Is it ok >1x wk
Recall 3 words
None None
Orientation none yes Yr, month,
day
None None
Decision Making
Problem Solving
1-7
Ok with ADLs0,1
Decision Making
1-4
None None
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Pressure Ulcer Ratings
IRF HH SNF LTCH Hospitals
Count yes yes yes None NoneStage for worst ulcer
yes yes yes None None
Dimensions L x W L x W x D L x W x D None None
Tissue Type Yes (0-4 )
Yes(0-3)
Yes(1-4)
None None
Presence at admission
yes yes yes None None
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Tissue Type ratings differ• IRF
1 = epithelial tissue2 = granulation tissue3 = slough4 = necrotic tissue
• HH0 = newly epithelialized1 = fully granulating2 = early/partial granulation3 = not healing
• SNF1 = epithelial tissue2 = granulation tissue3 = slough4 = necrotic tissue
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SAMPLE SIZE
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Focus on all cause all disease• National Quality Forum & CMS require minimum number
of patients in each measure (e.g. minimum denominator size) which is usually 25-30• Implications for measures that are not all cause or disease specific
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# of Facilities vs # of Part A Admissions
2009 2010 2011
Number of
Facilities
% of
Total
Number of
Facilities
% of
Total
Number of
Facilities% of
Total
TOTAL 15,453 15,449 15,395
Low volume (≤ 100 stays/ year)
6,766 44%
6,744 44%
7,773 50%
Moderate volume (101-200 stays/ year)
4,678 30%
4,591 30%
4,449 29%
High volume (201-300 stays/ year)
2,061 13%
2,103 14%
1,784 12%
Very high volume (>300 stays/ year)
1,948 13%
2,011 13%
1,389 9%
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# Part A admissions for Top 15 Hospital DRGs by Facility annual volume of Part A admissions
Low Vol
(<100/yr)Mod Vol
(100-200/yr)High Vol
(200-300/yr)Very High Vol
>300/yr
DRG CategoriesSNF stays
2009% of All
SNF StaysSNF stays
2009% of All
SNF StaysSNF stays
2009% of All
SNF StaysSNF stays
2009% of All
SNF Stays
TOTAL 451,119 2,230,389 637,920 2,230,389 437,273 2,230,389 704,077 2,230,389
1. Orthopedic surgery on lower extremity 55,309 2.5% 81,156 3.6% 65,495 2.9% 135,074 6.1%
2. Respiratory 67,714 3.0% 83,695 3.8% 50,532 2.3% 67,725 3.0%
3. Cardiac surgery 9,884 0.4% 15,817 0.7% 12,679 0.6% 25,233 1.1%
4. Cardiac medical management 37,728 1.7% 54,067 2.4% 35,906 1.6% 54,766 2.5%
5. GI hospitalizations (surgical and medical) 31,422 1.4% 44,580 2.0% 30,825 1.4% 48,380 2.2%
6. Renal failure 11,820 0.5% 17,963 0.8% 11,627 0.5% 16,826 0.8%
7. Amputations 3,704 0.2% 5,228 0.2% 3,346 0.2% 4,973 0.2%
8. Spinal surgery 2,663 0.1% 4,258 0.2% 3,880 0.2% 8,484 0.4%
9. Other major musculoskeletal surgery 4,916 0.2% 8,181 0.4% 6,811 0.3% 13,105 0.6%
10. Other musculoskeletal medical mgmt 23,126 1.0% 34,940 1.6% 25,768 1.2% 44,136 2.0%
11. Multiple significant trauma 1,242 0.1% 1,797 0.1% 1,226 0.1% 1,977 0.1%
12. Infections & parasitic dis. (plus sepsis) 52,428 2.4% 74,247 3.3% 47,122 2.1% 64,947 2.9%
13. Psychiatric 6,146 0.3% 7,509 0.3% 4,233 0.2% 5,298 0.2%
14. Stroke and related conditions 18,863 0.8% 26,840 1.2% 17,522 0.8% 25,819 1.2%
15. Other 124,154 5.6% 177,642 8.0% 120,301 5.4% 187,334 8.4%
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Average volume Medicare Admissions per SNF for #1 Admitted diagnosis
Low Vol
(<100/yr)Mod Vol
(100-200/yr)High Vol
(200-300/yr)Very High Vol
>300/yr
# of SNFs (%) 7,773 (50%) 4,449 (29%) 1,784 (12%) 1,389 (9%)
DRG CategoriesSNF stays
2009% of All
SNF StaysSNF stays
2009% of All
SNF StaysSNF stays
2009% of All
SNF StaysSNF stays
2009% of All
SNF Stays
TOTAL 451,119 2,230,389 637,920 2,230,389 437,273 2,230,389 704,077 2,230,389
1. Orthopedic surgery on lower extremity 55,309 2.5% 81,156 3.6% 65,495 2.9% 135,074 6.1%
Avg # of Medicare Admissions per year 7.1 18.2 36.7 96.6
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RISK ADJUSTMENT
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Change in Decile Rank from Actual to Risk Adjusted SNF Rehospitalization
Change in decile rank between Actual vs Risk adjusted rate # SNFs
% of Total
No data 2619 18.59-8 1 0.01-7 2 0.01-5 5 0.04-4 51 0.36-3 218 1.55-2 693 4.92-1 1818 12.900 4272 30.321 2717 19.282 1126 7.993 401 2.854 116 0.825 33 0.236 15 0.117 4 0.038 1 0.01