quality measures presented for the doh by catharine b. petko, rn bsn myers and stauffer lc january...
TRANSCRIPT
Quality Measures
Presented for the DOH byCatharine B. Petko, RN BSN
Myers and Stauffer LCJanuary 12, 2012
References
• Revised RAI Manual: www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp#TopOfPage
RAI Manual Errata – 10/7/11• New MDS 3.0 form; Draft QM Manual:
www.cms.gov/NursingHomeQualityInits/30_NHQIMDS30TechnicalInformation.asp#TopOfPage
• Transition document and recorded training: www.cms.gov/SNFPPS/03_RUGIVEdu12.asp#TopOfPage
• Clarification documents: www.cms.gov/SNFPPS/Downloads/Provider_Call_FollowUp082311.pdf and https://www.cms.gov/SNFPPS/Downloads/NPC_Nov3_Clarification_FINAL.pdf
Quality Measures
• Use data from MDS 3.0 to calculate NF performance in various areas
• Considered valid and reliable; endorsed by National Quality Forum
• Identify ways NFs differ from each other• Not to be considered as benchmarks,
thresholds, guidelines, standard of care• May be used in Survey and Certification
process• Will be released on NH Compare
Disclaimer
• Latest information as of 1/13/2012• Draft Manual
V. 4.09/29/2011www.cms.gov/NursingHomeQualityInits/30_NHQIMDS30TechnicalInformation.asp#TopOfPage
Determining Short/Long Stays
• Target period: The span of time that defines the QM reporting period, e.g., a calendar quarter
• Short stay: An episode with cumulative days in the facility less than or equal to 100 days as of the end of the target period
• Long stay: An episode with cumulative days in the facility greater than or equal to 101 days as of the end of the target period
Stay
• The period of time between a resident’s entry into a facility and either a discharge or the end of the target period; or A set of contiguous days in the facility
Starts with either an admission entry (A0310F = 01 and A1700 = 1) or a reentry (A0310F = 01 and A1700 = 2)Ends with any discharge (A0310F = 10, 11 or 12) during the target period or the target period ends
Episode
• A period of time spanning one or more stays
Starts with an admission entry (A0310F = 01 and A1700 = 1)Ends with
a Discharge return not anticipated, ora Discharge return anticipated but the resident did not return within 30 day ora death in facility orthe end of the target period
Continuous Days in Facility
• The total number of days within an episode during which the resident was in the facility.
Sum of the number of days within each stay included in the episodeIf there were multiple stays interrupted by hospitalizations, count only the days the resident was in the facilityCount day of entry but not day of discharge
CDIF Example
• End of quarter: 12/31
Adm/Reenter Discharge/ End of Quarter
Days
9/1 10/15 44
11/10 12/31 51
Total days 95
Selecting QM Samples
• Select all residents whose latest episode either ends during the target period or is ongoing at the end of the target period
• Compute the CDIF100 days or less: include in short-stay sample101 days or more: include in long-stay sample
Selecting Short Stay Assessments
• Target assessmentOBRA (A0310A = 01-06), scheduled PPS assessment (A0310B = 01-06) or discharge (A0310F =10 or 11)Target date (A2000 or A2300) no more than 120 days before end of episode
• Initial assessmentAdmission (A0310A = 01), PPS 5-day or readmission/return (A0310B = 01 or 06) or discharge (A0310F =10 or 11)First record with target date greater than or equal to the admission dateTarget date no more than 130 days prior to target date of target assessment
• Look back scan: Previous assessments are scanned to determine whether certain events or conditions occurred during the look-back period
Selecting Long-Stay Assessments
• Target assessmentOBRA (A0310A = 01-06), scheduled PPS assessment (A0310B = 01-06) or discharge (A0310F =10 or 11)Target date (A2000 or A2300) no more than 120 days before end of episode
• Prior assessmentOBRA (A0310A = 01-06), scheduled PPS assessment (A0310B = 01-06) or discharge (A0310F =10 or 11)Target date is 46 – 165 days before the Target assessment
• Look-back scan: Scan all records with target dates no more than 275 days prior to Target assessment
Exclusions
• Numerator: Defines MDS responses needed to be counted in the QM
• Denominator: Establishes the population to which the numerator is being compared.
• May exclude residents withAdmission assessmentsIncomplete dataClinical factors
Influenza Vaccination QMs
• SS #0680/LS #0681: Percent of residents who are given appropriately, the influenza vaccine during the current or most recent influenza season
• Numerator: Residents meeting any of the following criteria:
Received the vaccine during current or most recent influenza season (O0250A In facility = 1 or O250C Outside of facility = 2) orResident declined vaccine (O0250C = 4) orResident ineligible (O0250C = 3)
• Denominator: All short-stay/long-stay residents with a target assessment except those with exclusions
Exclusions: O0250C = 1 Resident not in facility during current or most recent influenza season
Influenza Vaccination QMs (2)
• SS #0680A-C/LS #0681A-C: Each QM uses a different numerator
A. Received the vaccine during current or most recent influenza season (O0250A = 1 or O250C = 2) ORB. Resident declined vaccine (O0250C = 4) ORC. Resident ineligible (O0250C = 3)
• Denominator: All short-stay/long-stay residents with a target assessment except those with exclusions
Exclusions: O0250C = 1 Resident not in facility during current or most recent influenza season
Pneumococcal Vaccination QMs
• SS #0682/LS #0683: Percent of residents whose pneumococcal polysaccharide vaccine (PPV) status is up to date during the 12-month reporting period
• Numerator: Residents meeting any of the following criteria:
PPV status is up to date (O0300A = 1) orResident declined vaccine (O0300B = 2) orResident ineligible (O0300B = 1)
• Denominator: All short-stay/long-stay residents with a target assessment
Pneumococcal Vaccination QMs (2)
• SS #0682A-C/LS #0683A-C: Each QM uses a different numerator
A. PPV status is up to date (O0300A = 1) orB. Resident declined vaccine (O0300B = 2) orC. Resident ineligible (O0300B = 1)
• Denominator: All short-stay/long-stay residents with a target assessment
SS #0675 Decrease in Pain
• Percentage of short-stay residents who can self-report pain, are on a scheduled pain medication regimen at their initial assessment, and who report lowered levels of pain on their target assessment
• Numerator: must meet all criteriaSS residents with initial and target assessmentCan self-report pain (J0200=1) on bothOn scheduled pain medication regimen on initial assessment (J0100A=1)Report reduced pain on the target assessment
J0300 was 1; now 0 ORJ0400 response on target > on initial assessment ORJ0600A response on target < on initial assessment ORJ0600B response on target < on initial assessment
SS #0675 Decrease in Pain (2)
• Denominator: must meet all criteriaSS residents with initial and target assessmentCan self-report pain (J0200=1) on bothOn scheduled pain medication regimen on initial assessment (J0100A=1)
• Exclusions:Not included in numerator and J0300 or J0400 is 9 or dashNot included in numerator and either J0600A or B is not completed on one of the assessmentsResident had little/no pain on initial assessment
J0300 = 0 OR J0400 = 4 and J0600A/B report no pain
SS #0676 Report Moderate to Severe Pain
• Percent of SS residents with at least one episode of moderate/severe pain or horrible/excruciating pain of any frequency in last 5 days
• Numerator: meet either or both conditions
J0400=1 or 2 and J0600A=05 – 09 or J0600B=2 or 3 and/orJ0600A=10 or J0600B=4
SS #0676 Report Moderate to Severe Pain(2)
• Denominator: All SS residents with target assessment
Exclusions:Resident not included in numerator and one of the following is true:
J0200=0, dash, ^J0300=9, dash, ^J0300=1 but J0400=9, dash, ^ or J0600A=99, dash, ^ and J0600B=9, dash, ^ or J0600A=00
Covariates
• Any of two or more random variables exhibiting correlated variation
SS#0678 Percent of Residents with Pressure Ulcers That Are New or WorsenedLS #0677 Percent of Residents Who Self-Report Moderate to Severe PainLS #0686 Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder
SS #0678 New or Worsened PUs
• Percentage of short-stay residents with new or worsening Stage 2-4 PUs
• Uses look-back scan• Numerator: Number of worsened PUs
must be less than or equal to the number of PUs reported at that stage
M0800A >0 and <=M0300BI M0800B >0 and <=M0300CIM0800C >0 and <=M0300DI
SS #0678 New or Worsened PUs (2)
• Denominator: All residents with assessments eligible for look-back scan
Excluded if none of the assessments in the look-back scan have usable responses for M0800 (0-9, <= corresponding M0300 item [0-9]) Covariates: Resident required limited or more assistance in bed mobility; has bowel incontinence; has diabetes or PVD; has low BMI
LS #0674 Falls with Major Injury
• Percent of LS residents who have experienced one or more falls with major injury reported in the target period
• Numerator: LS residents with one or more look-back scan assessments that indicate one or more falls with major injury (J1900C = 1 or 2)
• Denominator: LS residents with one or more look-back scan assessments
Exclude J1800=dash or J1800=1 and J1900C = dash
LS #0677 Report Severe to Moderate Pain
• Percent of LS residents who report either (1) almost constant or frequent moderate to severe pain in the last 5 days or (2) any very severe/horrible pain in the last 5 days
• Numerator: On target assessment,J0400=1 or 2 AND J0600A=05-09 or J0600B=2 or 3 OR J0600A=10 or J0600B=4
LS #0677 Report Severe to Moderate Pain(2)
• Denominator: All LS residents with target assessment
Exclusions:Is admission assessment (A0310A=01 or A0310B=01, 06) ORNot included in numerator AND J0200 or J0300 or J0400 or J0600A/B were completed with 9, dash, ^ (skipped) OR J0600A=00
• Covariates: Independence/modified independence in decision making on prior assessment (C0500, C1000)
LS #0679 LS High-risk Residents with PUs
• Percentage of long-stay, high-risk residents with Stage II-IV PUs
• Numerator: Target assessment withHigh-risk indicators
Bed mobility (G0110A1) or Transfer (G0110B1) = 3, 4, 7, 8 ORComatose (B0100=1) ORMalnutrition (I5600=1) AND
Presence of stage II-IV PUs (M0300B1, C1 or D1 = 1-9 or I8000 has ICD-9 code for PU)
LS # 0679 LS High-risk Residents with PUs(2)
• Denominator: All high-risk residents with a target assessment
Exclusions:Is admission assessment (A0310A=01 or A0310B=01, 06)Resident not included in numerator AND any of M0300B1, C1 or D1 = dash
LS #0684 Residents with UTI
• Percentage of LS residents who have a Urinary Tract Infection
• Numerator: LS residents with I2300 = 1 on target assessment
• Denominator: All LS residents with a target assessment
Exclusions: Is admission assessment (A0310A=01 or A0310B=01, 06)I2300 = dash
LS #0685 Low Risk Residents with Incontinence
• Percent of long-stay low-risk residents who frequently lose control of their bowel or bladder
• Numerator: LS resident with H0300 or H0400=2 or 3
• Denominator: All LS residents with a target assessment except exclusions
LS #0685 Low Risk Residents with Incontinence(2)
• Exclusions:Is admission assessment (A0310A=01 or A0310B=01, 06)Not in numerator and H0300 or H0400=dashResident is high risk
Severe cognitive impairment (C1000=3 and C0700=1 of C0500<=7) ORTotal dependence in bed mobility or transfer or locomotion on unit (coded 4, 7, or 8)Not high risk and C0500 and C0700 or C1000 or G0110A1 or B1 or E1 are dash
Comatose (B1=1 or dash)Has indwelling catheter or ostomy (H0100A or H0100C = 1 or dash)
LS #0686 Catheter Inserted and Left in Bladder
• Percentage of residents who have had an indwelling catheter in the last 7 days
• Numerator: LS residents with H0100A=1 on target assessment
• Denominator: All LS residents with a target assessment
Exclusions: Is admission assessment (A0310A=01 or A0310B=01, 06)H0100=dashNeurogenic bladder (I1550) or obstructive uropathy (I1650) = 1 or dash
LS #0686 Catheter left in bladder(2)
• CovariatesFrequent bowel incontinence on prior assessment (H0400=2 or 3 Frequently or always incontinent)Pressure ulcers at stages 2 - 4 on prior assessment (M0300B1/C1/D1 = 1-9)
LS #0687 Use of Restraints
• Percent of LS nursing facility residents who are physically restrained on a daily basis
• Numerator: LS residents with P0100B or P0100C or P0100E or P0100F or P0100G = 2 on target assessment
• Denominator: All residents with target assessment
Exclusions: Not in numerator and P0100B or P0100C or P0100E or P0100F or P0100G = dash
LS #0688 Need More Help with ADLs
• Percent of long-stay residents whose need for help with late-loss ADLs has increased when compared to the prior assessment
• Numerator“Increase” = 2 or more coding points in one ADL or one point increase in coding points in two or more ADLsConsider late-loss ADLs only7 and 8 recoded to 4 for comparison
LS #0688 Need More Help with ADLs(2)
• Denominator: All residents with target and prior assessments
Exclusions:All late-loss ADLs indicate total dependence (4, 7, 8)Three late-loss ADLs indicate total dependence (4, 7, 8) and one is extensive assistance (3)Comatose (B0100=1)Life expectancy < 6 months (J1400) or Hospice care (O0100K2) are 1 or dashResident not in numerator and late loss ADLs = dash
LS #0689 Lose Too Much Weight
• Percentage of LS residents who had a weight loss of 5% or more in the last month or 10% or more in the last two quarters who were not on a physician prescribed weight-loss regimen noted in an MDS assessment during the selected quarter
• Numerator: K0300=2 Weight loss but not on weight loss regimen
• Denominator: LS residents with target assessment
Exclusions:Is admission assessment (A0310A=01 or A0310B=01, 06)K0300=dash on target assessment
LS #0690 Depressive Symptoms
• Percentage of LS residents who have had symptoms of depression during the 2-week period preceding the MDS 3.0 target assessment date
• Numerator: One of two conditions met
D0200A2 or D0200B2=2 or 3 AND D0300 = 10-27 ORD0500A2 or D0500B2=2 or 3 AND D0600 = 10-30
LS #0690 Depressive Symptoms(2)
• Denominator: All LS residents with target assessment
Exclusions:B0100 Comatose = 1 or dashResident not in numerator and some data is missing from the depression items (D0200A2 or D0200B2 or D0300=dash or ^ and D0500A2 or D0500B2 or D0600=dash or ^
