jeannette c. petten rn, ms, rac-ct ehds calculation of qms resident method interval method
TRANSCRIPT
Jeannette C. Petten RN, MS, RAC-CT
eHDS Calculation of QMs
Resident MethodInterval Method
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Objectives
• The National Quality Forum• The Process – How a QM is ratified• eHDS Rules
- The 2 Methods- The Overriding rules
• The QMs• The Calculation of the QMs – an explanation
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The National Quality Forum NQF
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WHY The National Quality Forum (NQF)
U.S. Department of Health and Human ServicesContract #: HHSM-500-209-00010C
To help establish a portfolio of quality and efficiencymeasures for use in reporting on and improvinghealthcare quality to allow the federal government todetermine if healthcare spending is achieving the bestresults for patients and taxpayers
The contract is part of a provision in the MedicareImprovements for Patients and Providers Act of 2008
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National Quality Forum Mission
• A nonprofit organization that to improve the quality of American healthcare by:
• Building consensus on national priorities and goals for performance improvement and working in partnership to achieve them
• Endorsing national consensus standards for measuring and publicly reporting on performance
• Promoting the attainment of national goals through education and outreach programs.
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National Quality Forum Governance and Leadership
• Board of Directors - 27 MembersKey public and private leaders that represent major stakeholdersOversees the entire organization
• 3 Board Committees Guidance to specific NQF’s mission Work completed in partnership with other key organizations
• 8 Member CouncilsServes as advisors to the Board and the Board committeesDiverse multi-stakeholder organizations
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National Quality Forum The 3 Committees
• Consensus Standards Approval Committee (CSAC) Members - experts in health QI and performance measurement Considers standards recommended for endorsement Submits decision regarding endorsement to the Board
• Health Information Tech Advisory Committee (HITAC) Provides and offers expertise on HIT projects Provides specification of testing requirements for eMeasures Provides maintenance of the quality data set
• Leadership Network Members are the 8 elected chair of the member councils AND leaders from the public/private sector Provides guidance on education, and recognition programs
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National Quality Forum The 8 Member Councils
• Consumer Council Comprised of consumer organizations at the national, state, regional and local levels representing those receiving healthcare services
• Health Plan Council Comprised of healthcare plans and organizations involved in the administration of health insurance programs directly involved in paying for healthcare services
• Health Professionals Comprised of doctors, nurses, and clinician organizations who play an integral role in improving the quality of our healthcare system and provide a unique on-the-ground perspective of performance measurement and public reporting
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National Quality Forum The 8 Member Councils
• Provider Organizations Council Comprised of providers of healthcare that include hospitals, group practices, rehabilitation facilities, ambulatory care centers, long-term care facilities, and pharmacies who most often implement the endorsed measures
• Public/Community Health Agency Council Comprised of Public/Community Health Agencies that represent the population and community level
• Purchasers Council Comprised of employers, private corporations and government agencies whose interest is improving the quality, reducing cost, enhancing the health and productivity of the workforce
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National Quality Forum The 8 Member Councils
• Quality Measurement, Research, & Improvement (QMRI) Council Comprised of organizations that conduct research, education, or initiatives to improve healthcare quality, measurement, reporting, policy and quality centers, and information and data services providers and are essential to NQF members as the organization consider new measures, practices, frameworks, and guidelines for endorsement
• Supplier and Industry Council Comprised of the Supplier and Industry Council that include consultants, manufacturers of device and diagnostic products, medications, tools and other information and resources, and other service providers
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The PROCESS
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THE RATIFICATION PROCESS
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e Health Data Solutions Rules for QM Calculations
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e Health Data Solutions HAD To.............
• Made assumptions because the QMs did not define them either clear and/or consistently
• We decided on “Overriding rules” guiding all of the QMs for consistency
• We determined some “interpretive rules” for some of the QMs (fields were not determined)
• We decided on some rules that seemed to be in opposition of the RAI manual and completion of the MDS 3.0 (symptoms of depression)
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eHDS 2 Methods
• The Resident Method – includes all assessments including admissions and includes the most current assessment for a resident that is currently in the facility (and discharges if denoted)
• The Interval Method – only looks at those assessments that are completed by Admission date, ARD date or discharge date that corresponds to the time period being viewed
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New Concept: Long Term Assessment
Short Assessment• Long Term Resident
In the facility >100 daysDischarge/returns do NOT count against the 100 days
• Short Term ResidentIn the facility ≤100 days
Hypothesis Assessments completed and discharged prior to or 100 days were NOT included in ANY QM
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Overriding/General Rules
• Long Stay: Current admission date, ARD date or discharge date minus admission date >100 days
• Short Stay: Current admission date, ARD date or discharge date minus admission date ≤100 days
• Each day at 12:01 a.m. we look at all residents present in the facility to determine the 100 days
• Discharges do not affect the calculation of the 100 days if no NEW admission assessment
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Overriding/General Rules
• Will include quarterly assessments after >100 days (% changes in the long/short term QMS)
• PPS assessments ALWAYS considered Short Stay
• Will include admission and discharge assessments
• If resident in the facility 1 day in time period, will be included
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The QMs18 CLINICAL QMs
3 FACILITY SATISFACTION QMs
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10 long stay QMS are calculated the same as 2.0 with minor adjustments
• Percent assessments that self-report moderate to severe pain
• Percent of high-risk defined assessments w/ pressure ulcers
• Percent assessments assessed and appropriately given the seasonal influenza vaccine
• Percent assessments assessed and appropriately given the pneumococcal vaccine
• Percent assessments w/ reported urinary tract infection (CMS)
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10 long stay QMS are calculated the same as 2.0 with minor adjustments
• Percent of low-risk defined assessments with loss of bowel and/ or bladder control
• Percent assessments w/ reported catheter inserted and left in the bladder
• Percent assessments w/ reported use of physical restraints (CMS) (defined by bed and chair)
• Percent of assessments w/ reported help with daily activities has increased
• Percent assessments w/ reported weight loss (not on physician-prescribed weight-loss regimen)
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The Other 3 Long Stay QMs (2 new 1 revised by MDS 3.0)
• Physical therapy or nursing rehabilitation/restorative care with new balance problem
• Percent assessments reporting one or more falls with major injury
• Percent assessments w/ reported depressive symptoms
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1 New Short Stay QMs
• Percent of admission assessments on a scheduled pain medication and reported decrease in pain intensity or frequency in 14-day assessment
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4 short stay QMS are calculated the same as 2.0 with minor adjustments
• Percent assessments that self-report moderate to severe pain
• Percent assessments w/ reported pressure ulcers that are new or worsened (using 14- day PPS OR discharge assessment and will be looking at the fields that describe worsening as well as an increase)
• Percent assessments assessed and appropriately given the seasonal influenza vaccine
• Percent assessments assessed and appropriately given the pneumococcal vaccine
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The 3 Satisfaction QMS
• CAHPS® Nursing Home Survey: Discharged Resident Instrument
• CAHPS® Nursing Home Survey: Long-Stay Resident Instrument
• CAHPS® Nursing Home Survey: Family Member Instrument
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Calculation of the QMs
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NUMERATOR/DENOMINATOR
• THE CALCULATION IS A RATIO OR FRACTION: NUMBERATOR DIVIDED BY THE DENOMINATOR
To change the number to a percent divided by 100Example: 50/100=0.5
0.5X100=50%
Numerator: The number in the population with the defined criteria
(Defined by NQF)
Denominator: The defined population (Defined by NQF)
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LONG STAY QM#1:Physical therapy or nursing restorative care
with new balance problem
• Denominator: Current assessment with a decrease in the balance test from a sitting to a standing position
• Numerator:Physical therapy provided ≤121 days (last 4 months)Walking Nursing restorative program ≤121 days (last 4 months)
• Exclusions: BIMS score of ≤7
CPS score of ≥5 Life expectancy of less than 6 months Hospice while a resident
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LONG STAY QM#2:Percent assessments reporting one or more falls
with major injury
• Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly assessment or a discharge assessment
• Numerator:Fall(s) with a major injury
• Exclusions: Comatose
Missing relevant information
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LONG STAY QM#3 AND SHORT STAY QM#15:Percent assessments that self-report
moderate to severe pain
• Denominator: Long Stay: Admission, quarterly, annual, significant change, significant correction of an annual or quarterly assessment or a discharge assessment
Short Stay: 14-Day PPS assessments in time period
• Numerator:Reporting moderate frequency and intensity of pain ORReporting severe pain
• Exclusions: None
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LONG STAY QM#4Percent of high risk defined assessments
w/ pressure ulcers • Denominator:
All admission, quarterly, annual, significant change, significant correction of an annual or quarterly assessment or a discharge assessment
• Numerator: Reporting of a Stage 2, 3 or 4 Pressure Ulcer ORReporting the ICD-9 for a Stage 2, 3 or 4 Pressure Ulcer
• Exclusions: None
• High Risk Resident Comatose A diagnosis of Malnutrition Bed Mobility or Transfer/Extensive Assistance to Did Not Occur
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LONG STAY QM#5 AND SHORT STAY QM#17Percent assessments assessed and appropriately
given the seasonal influenza vaccine
• Denominator: LONG STAY: All assessments that the ARD or discharge date is >100 days and in the reporting period of October 1 to June 30 SHORT STAY: All assessments that the admission, ARD or discharge date is <100 days during the reporting period of October 1 to June 30
• Numerator: The vaccine is reported as given in the facility ORThe vaccine was given outside the facility, not eligible or declined when asked
• Exclusions: None
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LONG STAY QM#6 AND SHORT STAY QM#18Percent assessments assessed and appropriately
given the pneumococcal vaccine
• Denominator: LONG STAY: All assessments that the ARD or discharge date is >100 days during the reporting period SHORT STAY: All assessments that the admission, ARD or discharge date is <100 days during the reporting period
• Numerator: The vaccine is reported as being up-to-date ORThe vaccine was not given due to not eligible or declined when asked
• Exclusions: None
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LONG STAY QM#7Percent assessments w/ reported
urinary tract infection
• Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly or discharge assessment >100 days
• Numerator: Reported urinary tract infection
• Exclusions: None
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LONG STAY QM#8Percent of low-risk defined assessments with
loss of bowel and/ or bladder control• Denominator:
All admission, quarterly, annual, significant change, significant correction of an annual or quarterly or discharge assessment >100 days
• Numerator: Reported frequently or always incontinent of urine Reported frequently or always incontinent of bowel
• Exclusions: Comatose BIMS score of ≤7 CPS score of 5 or 6 Walk in Room totally dependent to Did Not Occur Reported indwelling urinary catheter
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LONG STAY QM#9Percent assessments w/ reported catheter
inserted and left in the bladder
• Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly or discharge assessment >100 days
• Numerator: Reported frequently or always incontinent of urine Reported indwelling urinary catheter
• Exclusions: Reported diagnosis of a Neurogenic Bladder Reported diagnosis of a Obstructive Uropathy
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LONG STAY QM#10Percent assessments w/ reported use of
physical restraints
• Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly or discharge assessment >100 days
• Numerator: Reported use of bed trunk or limb restraints OR Reported use of chair trunk or limb restraints or a chair that prevents rising
• Exclusions: None
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LONG STAY QM#11Percent of assessments w/ reported help with
daily activities has increased• Denominator:
All admission, quarterly, annual, significant change, significant correction of an annual or quarterly or discharge assessment >100 days
• Numerator: Reported 2 ADLs performance decreased 1 level OR Reported 1 ADL performance decreased 2 or more levels as compared to the most prior assessment
• Exclusions: Comatose All the late loss ADLs (bed mobility, transfer, toileting, eating) are totally dependent to Did not occur Reported receiving hospice care while a resident
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LONG STAY QM#12Percent assessments w/ reported weight loss
• Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly or discharge assessment >100 days
• Numerator: Reported weight loss but not on physician-prescribed weight-loss regimen
• Exclusions: None
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LONG STAY QM#13Percent assessments w/ reported
depressive symptoms
• Denominator: All admission, quarterly, annual, significant change, significant correction of an annual or quarterly or discharge assessment >100 days
• Numerator: Interview of mood and a PHQ-9© score of ≥10 Staff assessment and a PHQ-9-OV score of ≥10 If missing 3 areas of staff assessment, then D0500A≥2 or D0500≥2 AND a score of ≥2 for five of D0500A-I
• Exclusions: Comatose
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SHORT STAY QM#14Percent of assessments on scheduled pain regimen
and reported decrease in pain intensity or frequency
• Denominator: All residents with a 5-day PPS assessment and 14-day assessment or a discharge assessment (whichever comes first)
• Numerator: On a scheduled pain medication regimen and a decrease in pain frequency OR On a pain medication regimen and a decrease in pain intensity
• Exclusions: None
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SHORT STAY QM#16Percent assessments w/ reported pressure ulcers
that are new or worsened
• Denominator: All residents with a discharge assessment ≤100 days with a prior 5-day PPS assessment or an OBRA admission
• Numerator: Reported new Stage 2, 3 or 4 Pressure Ulcers OR Reported worsening of Stage 2, 3 or 4 Pressure Ulcers as compared to the most prior assessment
• Exclusions: None
DISCUSSION AND
QUESTIONS