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Analytic Insights from CMS’ Five-Star and New Quality Measures

Jennifer Gross Jeff Merselis

American Healthcare Association October 2012

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MDS 3.0 Quality Measures

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Introduction • The nursing home Quality Measures (QMs) come from

MDS resident assessment data routinely collected at specified intervals – Posted on Nursing Home Compare – A subset of measures are used for the Five-Star calculation

• Quality Measures on the Nursing Home Compare website allow consumers, providers, states and researchers to compare information on nursing homes.

• Many nursing homes use this information to guide quality improvement efforts and monitor progress

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Changes in the MDS 3.0 Quality Measures • Although there are many similarities between

the MDS 2.0 and 3.0 QMs, the differences may affect your facility’s trigger rates – Resident Selection

– Record Selection

– Resident Assessment Method

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Resident Selection

MDS 2.0 MDS 3.0

Post-Acute Care (PAC): PPS 5-day and 14-day MDS

Short Stay (SS): </=100 cumulative days in facility

Chronic Care (CC): OBRA Quarterly, Annual, Significant Change, Significant Correction

Long-Stay (LS): =/>101 cumulative days in facility

Changes in the resident sample selection affect the denominator size for Short Stay and Long Stay measures • Short Stay sample may be larger than PAC due to 100 day time

period • Long Stay residents remain in LS sample even after reentry from

hospital

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Residents on Leave of Absence

• Residents who leave for a temporary home visit/therapeutic leave

• Residents who have a hospital observation stay <24 hours and are not admitted – Discharge assessment is not completed – These residents can trigger for incidents outside

the facility (e.g. fall w/fracture)

• LOA days still count towards resident’s Cumulative Days in Facility

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Record Selection

• Selection of MDSs used in the QM calculation no longer based solely on MDS reason for assessment (RFA)

• Resident’s span of time in the facility dictates which measures may trigger – An OBRA assessment may trigger a Short Stay

measure if the resident has </=100 CDIF

– A PPS assessment may trigger a Long Stay measure if =/> 101 CDIF

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Record Selection (cont.)

• Look-Back Scan: used to capture triggering conditions within the episode – May not be the most recent MDS

• Three measures with look-back scans – New/Worsening Pressure Ulcers (SS)

• Looks back up to the beginning of the episode

– Falls (LS)

– Falls with Major Injury (LS) • Look back up to a year (275 + 93 days)

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Resident Assessment Method

• Resident interview only for Pain assessment – Residents who were not interviewed excluded

from SS and LS measures

– Reduces denominator size

• New/Worsening Pressure Ulcers – Stage 2-4 only

– Section M0800 not completed on first assessment since most recent entry/reentry

• Excludes hospital acquired/worsened ulcers

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Resident Assessment Method (cont.)

• Symptoms of Depression – Uses either the PHQ-9© resident interview or staff

assessment • Little interest/pleasure in doing things or feeling

down/depressed/hopeless: half or more days AND

• Total severity score =/>10

• Influenza Vaccine (SS/LS) – If vaccine given for current flu season, carry forward

code on future assessments until next flu season begins

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New Antipsychotic Measures

• Different from the antipsychotic “surveyor measure” on CASPER – Fewer exclusions

• Incidence of Psychoactive Medication Use (SS) – Short-stay residents who did not receive antipsychotic

on initial assessment and do receive it on target assessment

• Prevalence of Psychoactive Medication Use (LS) – Long-stay residents who receive antipsychotic

• Both measures only exclude residents with Schizophrenia, Tourette’s or Huntington’s

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Average QM Rates 2.0-3.0

• The differences in data collection and record selection have resulted in different QM rates for measures that had “similar” MDS 2.0 counterparts

• Even though the actual QMs can’t be compared from MDS 2.0 to MDS 3.0, how the public sees your facility’s rates doesn’t change

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QM Rates 2.0-3.0: ADL

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QM Rates 2.0-3.0: Pain

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QM Rates 2.0-3.0: Pressure Ulcers

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Five-Star Quality Domain

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“The primary goal of this rating system is to provide residents and their families with an easy way to understand assessment of nursing home quality, making meaningful distinctions between high and low performing nursing homes.”

CMS’s Five-Star Technical Users’ Guide July 2012

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CMS’ Five-Star Program

• The rating system features an overall Five-Star rating based on facility performance for three types of performance measures: – Health Inspection (CASPER) – Staffing (CASPER) – Quality (Public Quality Measures)

• The rating system has been available to the public on Nursing Home Compare since December 18, 2008

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Quality Measures Domain

• Facility ratings for the quality measures are based on performance on 9 of the 18 QMs that are currently posted on the Nursing Home Compare web site – Based on MDS 3.0 assessments

• Include 7 Long-Stay (LS) measures and 2 Short-Stay (SS) measures

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Long-Stay Residents

• Percent of residents whose need for help with activities of daily living has increased

• Percent of high risk residents with pressure sores • Percent of residents who have/had a catheter inserted

and left in their bladder • Percent of residents who were physically restrained • Percent of residents with a urinary tract infection • Percent of residents who self-report moderate to

severe pain • Percent of residents experiencing one or more falls

with major injury

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Short Stay Residents

• Percent of residents with pressure ulcers (sores) that are new or worsened

• Percent of residents who self-report moderate to severe pain

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Included Assessments

• Long Stay measures are included in the score if the measure can be calculated for at least 30 assessments (summed across three quarters of data)

• Short Stay measures are included in the score only if data are available for at least 20 assessments

• Ratings are calculated using the three most recent quarters for which data are available

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Five-Star Quality Score Calculation

MDS 2.0 MDS 3.0

ADL measure weighted higher than other measures

ADL measure weighted equally with other measures

ADL measure ranked in percentiles based on State distribution

ADL measure ranked in deciles based on State distribution

All non-ADL measures ranked in quintiles based on National distribution

All non-ADL measures ranked in percentiles based on National distribution

Points assigned according to quintiles Points assigned according to percentiles

Total possible score ranges from 0-136 points

Total possible score ranges from 9-900 points

Changes in the Five-Star Quality Domain calculation from MDS 2.0 to MDS 3.0 requires attention from providers

• The basic premise is the same: lower QM rates=higher point values

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Star Cut-points for MDS Quality Measure Summary Score

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Quality Measure Score Thresholds

• Cut points for the QMs were set based on the QM distributions averaged across Q2-Q4 of 2011 – will be maintained for a period of at least two years,

after which CMS will review

• These thresholds were set so that the overall proportion of nursing homes in each rating category in July 2012 (when the QM rating based on MDS 3.0 is first reported) would be similar to what it was when the MDS 2.0 QM rating was frozen in March 2011.

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Comparison of Five-Star Quality Domain 2.0-3.0

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New Quality Rating – Old Quality Rating

Number of Facilities Percent of Facilities

-4 44 <1%

-3 445 3%

-2 1418 9%

-1 3205 21%

0 4967 33%

1 3251 21%

2 1435 9%

3 406 3%

4 62 <1%

Facility Star Rating Changes 2.0-3.0

Although the national distribution of star ratings remains the same, individual facilities will see changes in their own Quality ratings

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CMS August Update to Nursing Home Compare • Shifted QM 3-quarter time period from

March-December 2011 to July 2011-March 2012

• Facilities saw a resulting change in their publicly reported QM rates and star ratings

• Note the potential for changes with each quarterly update to NHC

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Facility Star Rating Changes July-August 2012 August 2012 Quality

Rating– July 2012 Quality Rating

Number of Facilities Percent of Facilities

-4 0 0%

-3 2 <1%

-2 60 <1%

-1 1857 12%

0 10425 68%

1 2939 19%

2 122 1%

3 10 <1%

4 0 0%

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Five-Star Changes and Your Facility

• Changes in the QMs can have an effect on your facility’s Quality and Overall Five-Star ratings – Keep on top of CMS updates to Five-Star

• The challenge: to understand these changes to put your facility’s rating in context and communicate with residents, families and the public

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Five-Star/QMs and Your Ability to Compete

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How was the Five-Star Quality Rating System designed to be used?

1. Help educate consumers about nursing home quality

2. Help improve provider quality

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How are Five-Star and MDS 3.0 QMs actually being used?

SNF’s marketing departments

Hospital Discharge planners

HUD lending/re-financing

Plaintiff attorneys

Insurance brokers

ACOs/ “Bundles”

Medicare Advantage Plans

Media

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1. Does the SNF that you work for have a marketing strategy?

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2. Does the SNF that you work for use Five Star rating in marketing efforts?

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3. Does the SNF that you work for use Quality Measures (QMs) in marketing efforts?

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4. Does the SNF that you work for sometimes lose referrals to other SNFs with a higher Overall Five Star rating?

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5. Does the SNF that you work for use the Overall Five Star rating in their marketing efforts to hospitals?

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6. Does the SNF that you work for use the Overall Five Star rating in their marketing efforts to ACOs?

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7. Does the SNF that you work for market your Five Star components (i.e. Survey, Quality, Staffing, etc.) separately?

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8. Was the SNF that you work for “surprised” by your 3.0 Quality Measure (QM) rating compared to your 2.0 QM rating?

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9. Do you find that the Quality Measures (QMs) enhance your overall marketing strategy?

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Strategies for Success

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Five Data-Driven Strategies for Using Five-Star and QMs to Market your Facilities More Effectively

1. Remember the who and why

2. Turn blunt instruments into sharp tools

3. Augment Five Star and QMs with other key metrics

4. Don’t rely solely on yesterday’s news

5. Turn weaknesses into strengths

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83%

17% With Issues

Without Issues

How is Your Data Quality?

Of the 83% of assessments with issues, on average each assessment had 2.41 issues.

Proportion of MDS Assessments with Issues (>5,000,000 assessments)

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QM Strategies for Success

• Review MDS Data for accuracy – Correct errors before CMS submission – Identify processes that impact accurate MDS coding

• Supporting documentation • Staff education

• Make Five-Star QMs part of facility quality improvement process – Trends and benchmarks

• Root Cause Analysis – Review other CASPER QMs and related care processes – Monitor positive outcomes to ensure good processes

are maintained

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Nursing Home Quality Assurance & Performance Improvement (QAPI) • Being rolled out by CMS in 2012

• Provides tools and resources to help facilities meet existing QAA requirements – Based on best practices

– Continuously identify and correct quality deficiencies

– Sustain performance improvement

• QAPI Element 3: Feedback, Data Systems and Monitoring – QMs can be incorporated into QAPI monitoring

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For More Information

• QM Users’ Manual – www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/NursingHomeQualityInits/Downloads/MDS30QM-Manual.pdf

• Five-Star User’s Guide – www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/CertificationandComplianc/Downloads/usersguide.pdf

• CMS’ QAPI Page – www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/SurveyCertificationGenInfo/QAPI.html

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Thank You!

• Jennifer Gross Senior Healthcare Specialist – jennifer.gross@pointright.com

• Jeff Merselis VP Business Development – jeff.merselis@pointright.com

• http://www.pointright.com