ltc trend tracker publications publication …...ltc trend tracker publications publication...

LTC Trend Tracker Publications

Publication Frequency Description Your Top-Line Quarterly Summary of Five-Star Your Quality Initiative Progress

Semi-annual Progress on AHCA Quality Initiative

Your Resident Profile Semi-annual Data to help complete required Facility Assessment

Your PAC Scorecard (First release in 2019q4)

Quarterly Data to share with referral partners

Your AL Top-Line Quarterly Progress on NCAL Quality Initiative and data uploaded to Trend Tracker

“QRPT-2019Q2-335579.Carthage_Center_For_” — 2019/8/5 — 15:39 — page 1 — #1

Your Top-LineCenter For Rehabilita on And Nursing

111 West Street, City, ST 13619

Publica on Number: 2019-Q2

Survey Ra ngYour center is ranked 374th out of 617 centers in your state.For more on how your survey score was calculated and to seeif you a Special Focus Facility Candidate, see page 2

For more on your survey score, see .

Staffing Ra ngYour center’s StaffingRa ng is currently basedon2019-Q1Payroll-BasedJournal (PBJ) data. See page 3 for your ra ng breakdown and how youcan improve it.

For more on your staffing breakdown, see Page 3.

Quality Measure Ra ngThe greatest opportunity to improve your QM ra ng is on LSED Visit, where you are currently earning 15 points based ona rate of 1.92.

See your performance on all Quality Measures on Page 4.

Overall Ra ngYour Overall Ra ng Calcula on

+ 2 Stars (From your Survey Ra ng being 2 Stars)

+ 0 Stars (From your Staffing Ra ng being 2 Stars)

+ 0 Stars (From your Quality Ra ng being 2 Stars)

2 Stars is your Overall Ra ng

1

https://www.eventscribe.com/2019/AHCANCAL/

https://www.ahcancal.org/research_data/trendtracker/Pages/default.aspx


Your Survey Score and State RankingThe table below shows how your survey score is calculated and where it ranks within your state. Your statesurvey rank impacts whether your facility is a candidate for Special Focus Facility designa on.

Score Breakdown Deficiencies (#)Ini al Revisits Total StandardScore # Score Score Health Complaint Total

Cycle

on 2019-04-26 20 0 0 20 3 3 5Cycle

on 2017-10-19 32 1 0 32 6 2 7Cycle

on 2016-06-24 32 1 0 32 7 0 7

Weighted 3-Cycles 202 + 32

3 + 326 = 26 To have had another star

you needed a score < 23.3State Survey Rank Your center is ranked 374th out of 617Special Focus Facility In the Program? No Candidate for the Program? No

State Distribu on of Survey ScoresThe histogram below show the distribu on of survey scores within your state. The cut points to determine starra ngs is done by CMS to have a fixed percentage of buildings at each star level.

The dashed black line (- -) in the histogram represents where your survey score ranks.

State SummarySurvey Star Ra ng SNF Centers Survey Score Range

5 Stars 63 (10%) <5.34 Stars 151 (25%) 5.3-13.33 Stars 144 (23%) 13.3-23.32 Stars 133 (22%) 23.3-40.71 Stars 123 (20%) >40.7

2



Your Registered Nurse (RN) and Total Nursing Staff (TNS) Hours per Resident Day (HPRD)

Adjusted RN HPRD =0.555Reported

0.429Expected×0.3804NationAvgExpected = 0.487

Adjusted TNS HPRD =3.411Reported

3.301Expected×3.2285NationAvgExpected = 3.319

Your Staffing Star Ra ngs (Overall Staffing= 2⋆, RN = 2⋆)Overall Staffing Star (X marks your facility)

1.049

0.731

0.508

0.317Adjusted

RNHP

RDan

dRN

Star

Rang

3.108 3.580 4.038 4.408

Adjusted Total Nursing HPRD

Average Daily Census & Days with No RN HoursCMS calculates your average daily census using MDS. Star ng in April 2019, nursing homes with4 or more days with no RN hours will receive a 1 star staffing ra ng.

2018-Q1 2018-Q2 2018-Q3 2018-Q4 2019-Q1Avg Daily Census 87.1 85.5 85.9 80.9 84.9Days with No RN Hours 0 0 0 0 0

Your Staffing Ra ng BreakdownThe data shown here is your center’s PBJ data for 2019-Q1. It led to an Overall Staffing Ra ng of 2 Stars and RNStaffing Ra ng of 2 Stars.

1⋆

2⋆

3⋆

4⋆

5⋆5⋆

4⋆

3⋆

2⋆

1⋆

0.487

3.319

3



Your Quality Ra ng BreakdownBelow is a breakdown of how your aggregate Quality Ra ng of 2 Stars, a Short-Stay Quality Component ra ngof 1 Star, and a Long-Stay Quality Component ra ng of 3 Stars was derived.

Short-Stay Quality Ra ngNext Cut-Point

Measure Time Period Rate Points Indicator Rate PointsSS Pain 2018q2-2019q1 3.3% 100 - -SS Func onal Improvement 2018q2-2019q1 69.5% 90 70.4% 105SS ED Visit 2018q1-2018q4 13.0% 45 12.7% 60SS An psycho cs 2018q2-2019q1 2.1% 40 1.7% 60QRP Pressure Ulcer 2017q4-2018q3 2.3% 40 1.6% 60QRP Discharge to Community 2016q4-2017q3 32.5% 30 37.1% 45SS Readmission 2018q1-2018q4 33.3% 15 30.3% 30Star Ra ng Release Month Ra ng Points Next Star Ra ng Needed PointsSS QM Ra ng July 2019 1 Star (360 * (1250/900)) = 500 2 Stars 542Long-Stay Quality Ra ng

Next Cut-PointMeasure Time Period Rate Points Indicator Rate PointsLS Mobility 2018q2-2019q1 9.6% 135 8.2% 150LS An psycho cs 2018q2-2019q1 8.7% 120 7.5% 135LS Hospitaliza on 2018q1-2018q4 1.32 105 1.31 120LS Catheter 2018q2-2019q1 1.0% 80 0.5% 100LS ADL 2018q2-2019q1 16.1% 60 15.9% 75LS Pressure Ulcer 2018q2-2019q1 7.3% 60 5.8% 80LS Fall 2018q2-2019q1 4.4% 40 3.6% 60LS Pain 2018q2-2019q1 7.8% 40 6.8% 60LS UTI 2018q2-2019q1 4.2% 40 2.7% 60LS ED Visit 2018q1-2018q4 1.92 15 1.91 30Star Ra ng Release Month Ra ng Points Next Star Ra ng Needed PointsLS QM Ra ng July 2019 3 Stars 695 4 Stars 710Aggregate Quality Ra ng

Next Cut-PointStar Ra ng Release Month Ra ng Points Next Star Ra ng Needed PointsQM Ra ng July 2019 2 Stars (500 + 695) = 1195 3 Stars 1264

Notes: 1. Total Short-Stay QMpoints aremul plied by a factor of 1250/900 so short- and long-staymeasures are weightedequally in the aggregate quality ra ng. 2. Need at least 6 Long-Stay measures and 4 Short-Stay to have respec vecomponent ra ngs. 3. SS Pressure Ulcer and SS Discharge to Community are Quality Repor ng Program (QRP) measures4. Source- July 24, 2019 Release of Nursing Home Compare

Indicator Key Descrip on- Red Circle 30 or less points earned- Yellow Circle 40 - 90 points earned- Green Circle 100 or more points earned- Gray Circle Measure points imputed due to small denominator (i.e.

Not enough residents mee ng measure inclusion criteria)

4



The AHCA/NCAL Quality Ini a ve (2018-2021)The table below shows your center’s most current data as of July 25. For more on the ini a ve visit thiswebpage.

Short-Stay Long-Stay

MeasureBaselineRate

Goal Latest Rate MeasureBaselineRate

Goal Latest Rate

Hospitaliza ons

PointRightPro30

15.3%(2016Q2-2017Q1) <13.8% 18.5%

(2017Q4-2018Q3)

PointRightPro-

LongStay13.7%

(2016Q2-2017Q1) <12.3% 13.9%(2017Q4-2018Q3)

An psycho cs

NursingHome

Compare4.3%

(2016Q2-2017Q1) < 3.9% 2.1%(2019Q1)

NursingHome

Compare7.9%

(2016Q2-2017Q1) < 8.0% 8.7%(2019Q1)

CustomerSa sfac on

CoreQResident

TBD(Data Missing) >90.0% N/A

(Data Missing)

CoreQResident


(Data Missing)

CoreQFamily


(Data Missing)

Func onalImprovement

AHCASelf-Care

TBDComming Soon TBD N/A

AHCAMobility

TBDComming Soon TBD N/A

Data SourcesSurvey, Staffing, and Five-Star Quality data (pages 1-4) come from July 24, 2019 release of Nursing Home Com-pare, which is updated monthly. Quality Ini a ve data (page 5) from LTC Trend Tracker as of July 25, 2019.

5


https://www.ahcancal.org/quality_improvement/qualityinitiative/Pages/default.aspx

https://educate.ahcancal.org/products/infection-preventionist-specialized-training-ipco

“YRPL‐2019S1‐015014.Eastview_Rehabilitat” — 2019/8/8 — 11:51 — page 1 — #1

Your Resident Profile

Rehabilitation and Healthcare Center 1234 Merry LaneHappy, US 98765

Publication: 2019 1st Semiannual

https://educate.ahcancal.org/


Your Resident Profile: Your Resident Profile provides the information you need to begin the resident profile portions of the annualFacility Assessment required under CMS’s Requirements of Participation (§483.70(e)). The purpose of the Fa‐cility Assessment is to help a facility determine the resources required to provide person‐centered care and theservices residents need in both day‐to‐day operations and emergencies. CMS’s Quality Improvement Organiza‐tions (QIO) have provided a Facility Assessment template http://qioprogram.org/facility‐assessment‐tool. Wehave adapted the first section to provide a profile of your resident population using your most recent data.Definitions:

Episode: period of time a person is in your facility from admission to discharge or deathResident day: any day a resident was physically in your facility

More detailed information available at:https://educate.ahcancal.org/products/facility‐assessment‐elements‐phase‐ii‐48370‐administration‐tool

Resident Statistics by Year Jan 2017‐Dec 2017 Jan 2018‐Dec 2018Average Census

Licensed Beds: 92 92MDS Calculated Daily Census: 88 92

PBJ Daily Census: 84 80Daily Total Nursing Staffing HPRD: 4.77 3.98

CountsHigh‐Level

PBJDaily RN Staffing HPRD: 0.52 0.49

Resident Statistics by Year in CategoryEpisodes

Episodes% of All

in CategoryResident Days

Resident Days% of All

in CategoryEpisodes

Episodes% of All



Disease or Condition CategoryCancer: N/A* N/A* 586 3% N/A* N/A* 638 3%

Heart/Circulation: 287 87% 29,484 93% 168 81% 31,229 93%Gastrointestinal: 56 18% 7,262 24% 33 15% 7,847 24%

Renal Insufficiency, Renal Failure, or ESRD: 21 6% 3,036 9% N/A* N/A* 2,021 6%Other Genitourinary: 104 30% 9,678 30% 57 27% 12,188 36%

Tuberculosis: N/A* N/A* 101 <1% 0 0% 0 0%Urinary Tract Infection (UTI): 30 9% 119 <1% N/A* N/A* 89 <1%

Wound Infection: 91 27% 7,939 24% 48 24% 11,069 33%Multi‐Drug Resistant Organism (MDRO): N/A* N/A* 73 <1% 0 0% 0 0%

Other Infections: N/A* N/A* 0 0% N/A* N/A* 0 0%Diabetes Mellitus: 180 54% 14,985 48% 98 48% 16,245 48%

Other Metabolic Disorders: 130 39% 14,509 45% 65 30% 14,823 45%Musculoskeletal: 175 51% 19,078 60% 113 54% 21,944 66%

Alzheimer’s, Non‐Alz. Dementia, Tourette’s: 151 45% 19,689 63% 97 48% 18,976 57%Aphasia, CVA, TIA, Stroke, Cerebral Palsy: 108 33% 11,870 36% 71 33% 13,706 42%

MS, Huntington’s, Parkinson’s: 15 3% 1,431 6% N/A* N/A* 1,139 3%Traumatic Brain Injury: N/A* N/A* 365 <1% N/A* N/A* 365 <1%

Seizure Disorders: 71 21% 7,515 24% 32 15% 6,296 18%Hemiplegia, Paraplegia, Quadriplegia: 82 24% 7,198 24% 50 24% 9,010 27%

Other Neurological Disorders: 0 0% 0 0% 0 0% 0 0%Anxiety, Depression, Bipolar, Mood Disorders: 187 57% 19,200 60% 94 45% 18,467 54%

Psychotic Disorder, Schizophrenia: 78 24% 6,716 21% 36 18% 6,500 18%PTSD: N/A* N/A* 168 <1% N/A* N/A* 261 <1%

Other Psychiatric/Mood Disorder: 0 0% 0 0% 0 0% 0 0%Pulmonary: 85 24% 6,338 21% 47 24% 7,493 21%

Vision: 152 45% 17,577 54% 100 48% 19,425 57%

Conditionsand

Diseases

Hearing Loss: 17 6% 1,934 6% 18 9% 3,430 9%Your Resident Profile Continued on Next Page

*Suppressed due to CMS cell suppression policies for restricted data. Source: MDS 3.0 data Jan 2017‐Dec 2018https://www.resdac.org/articles/cms‐cell‐size‐suppression‐policy

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http://qioprogram.org/facility-assessment-tool

https://educate.ahcancal.org/products/facility-assessment-elements-phase-ii-48370-administration-tool

https://www.resdac.org/articles/cms-cell-size-suppression-policy


Your Resident Profile Continued: Eastview Rehabilitation and Healthcare Center (015014)Jan 2017‐Dec 2017 Jan 2018‐Dec 2018

Resident Statistics by Year in CategoryEpisodes

Episodes% of All



in CategoryEpisodes

Episodes% of All



Disease or Condition Category Cont.Moderate to Severe Cognitive Deficits: 134 39% 11,384 36% 85 42% 15,205 45%

Delirium: 11 3% 225 <1% N/A* N/A* 111 <1%Down Syndrome, Autism, Intellectual Disability: N/A* N/A* 418 <1% N/A* N/A* 718 3%

Conditionsand

Diseases

Swallowing Disorders/Modified Diet: 100 30% 11,206 36% 65 30% 12,116 36%Special Care or Treatments

Cancer (chemotherapy, radiation): N/A* N/A* N/A* N/A* N/A* N/A* 0 0%Suctioning: 12 3% 553 3% N/A* N/A* 953 3%

Oxygen Therapy: 46 15% 1,959 6% 26 12% 2,727 9%Tracheostomy: N/A* N/A* 472 <1% N/A* N/A* 945 3%

Ventilator/Respirator: N/A* N/A* 0 0% N/A* N/A* 43 <1%BiPAP/CPAP: N/A* N/A* 165 <1% N/A* N/A* 0 0%

IV Therapies (parent./IV feeding or IV meds): N/A* N/A* 59 <1% N/A* N/A* 138 <1%Transfusion: 0 0% 0 0% N/A* N/A* 14 <1%

Dialysis: 18 6% 1,494 6% N/A* N/A* 2,091 6%Parenteral/IV Feeding: 0 0% 0 0% 0 0% 0 0%

Feeding Tube (NG, PEG): 82 24% 7,967 24% 48 24% 7,591 24%Indwelling Catheter: 61 18% 2,096 6% 30 15% 2,587 9%

Ostomy: 21 6% 829 3% 12 6% 1,422 3%Pressure Ulcers (any): 81 24% 3,264 9% 49 24% 4,921 15%

Wound Care: 40 12% 1,588 6% 29 15% 2,509 6%End of Life Care (hospice/respite): 15 3% 758 3% N/A* N/A* 920 3%

Isolation/Quarantine (ID): 25 6% 331 <1% 21 9% 1,969 6%Receiving OT Therapy: 114 33% 3,397 12% 68 33% 1,999 6%Receiving PT Therapy: 112 33% 3,326 9% 67 33% 2,295 6%

Receiving Speech Therapy: 110 33% 3,310 9% 63 30% 2,256 6%Behavioral Support: 34 9% 1,593 6% 20 9% 1,067 3%

MDS Medication CategoryInjections: 122 36% 7,612 24% 81 39% 8,473 24%

Insulin: 97 30% 8,268 27% 59 30% 10,167 30%Antipsychotic: 79 24% 6,558 21% 39 18% 5,430 15%Antianxiety: 66 21% 4,635 15% 32 15% 4,887 15%

Antidepressant: 185 54% 15,635 48% 102 48% 16,429 48%Hypnotic: 16 6% 862 3% 12 6% 1,229 3%

Anticoagulant: 79 24% 4,399 15% 47 24% 6,335 18%Antibiotic: 81 24% 620 3% 44 21% 328 <1%Diuretic: 87 27% 6,802 21% 54 27% 8,623 27%Opioids: 0 0% 0 0% 0 0% 0 0%

Other Acuity IndicatorsAverage BIMS: 12.6 8.4 10.5 8.4

AssistanceAcuity and

Average ADL Score: 8.4 6.3 8.4 8.4Ethnic or Cultural Element

Preferred Language Not English: N/A* N/A* 730 3% N/A* N/A* 730 3%CulturalEthnic and

Married: 44 12% 2,930 9% 12 6% 2,655 9%*Suppressed due to CMS cell suppression policies for restricted data. Source: MDS 3.0 data Jan 2017‐Dec 2018https://www.resdac.org/articles/cms‐cell‐size‐suppression‐policy

2


https://www.resdac.org/articles/cms-cell-size-suppression-policy

“ALTL-2019Q1-A12111.Avalon_at_Bridgewate” — 2019/6/4 — 17:52 — page 1 — #1

Your Assisted Living Top-LineYour AL Community

123 Universe, Nexus, NJ 12345

Publica on: 2019 - 1st Quarter

AL QUALITY MEASURES

Hospital Readmissions Hospital Admissions0.0% 4.0%

Q1 2019 Q1 2019CoreQ Resident Sa sfac on CoreQ Family Sa sfac on98.0% NO DATA

Q2 2018 Q1 2019Off-Label Use of An psycho cs0.0%

Q1 2019

AL OPERATIONAL MEASURES

Direct Care Staff Turnover Overall Staff Turnover5.0% 8.1%

2018 2018Occupancy Rate90.1%

Q1 2019

WHAT DOES THIS DATA MEAN?

Learn more about your performance over me and progress on the Quality Ini a ve for AssistedLiving goals (where applicable) on the following pages.

Indicates aQuality Ini a vemeasure for Assisted Living. Learnmore at h p://QualityIni a ve.ncal.org

AHCA/NCAL NATIONAL QUALITY AWARDS PROGRAM

Congratula ons on receiving Bronze in 2015!To find out how to con nue the journey to Silver, click here.

www.LTCTrendTracker.com | [email protected]

1

http://QualityInitiative.ncal.org

https://www.ahcancal.org/quality_improvement/quality_award/Pages/default.aspx

http://QualityInitiative.ncal.org

mailto:[email protected]

https://www.ahcancal.org/ncal/Pages/index.aspx


YOUR COMMUNITY COMPARED TO THE NATIONAL AVERAGE

Na onal averages based on data submi ed to LTC Trend Tracker as ofMay 31, 2019. Turnoverdata is for 2018. All othermeasures are for Q1 2019. The sample size for the na onal averagesare as follows: DCS Turnover - 129, An psycho cs - 187, Readmissions - 187, CoreQ Family -160, CoreQ Resident - 204.

If no bar appears for your community above, data is missing for the latest me period. Na-onal averages for different me periods are available within LTC Trend Tracker and can be

trended alongside your community’s data. To view turnover data within LTC Trend Tracker,your account administrator must grant you the appropriate privileges.

AHCA/NCAL RESOURCES TO KNOW

• How do I use LTC Trend Tracker as an Assisted Living? Find out with this on-demandahcancalED course.

• Have you heard about the AL Cost Calculator? It is a new, online tool available exclu-sively to members of NCAL. Check out www.ALCostCalculator.org to learn how it canbenefit your organiza on.

• The new Workforce Reserouce Center has tools to address staff stability and turnover.

2

https://educate.ahcancal.org/products/how-do-i-use-ltc-trend-tracker-as-an-assisted-living#tab-product_tab_overview

https://www.ahcancal.org/ncal/operations/alcostcalculator/Pages/default.aspx

https://www.ahcancal.org/facility_operations/workforce/Pages/default.aspx



Reduce Hospitaliza ons

Measure(Source):

HospitalReadmissions(LTC Trend Tracker)

NumeratorDefini on

Number of residents sentback to the hospitalwithin 30 days ofadmission from thehospital

DenominatorDefini on

Number of residentsadmi ed to thecommunity directly fromthe hospital.

Performance Rate(Date):

0.0%(Q1 2019)

Goal Rate <20%Goal Met?(Performance <20%): Yes

Here is a summary of hospital readmission data submi ed for the last five quarters.

2018-Q1 2018-Q2 2018-Q3 2018-Q4 2019-Q1Months of Data 3 3 3 3 3Numerator 1 0 1 0 0Denominator 9 1 2 3 4Rate 11.1% 0% 50% 0% 0%

Measure(Source):

Hospital Admissions(LTC Trend Tracker)

NumeratorDefini on

Number of residents whospent the night in ahospital (includes bothadmi ed and observa onstays)


Number of residents inthe community.

Here is a summary of hospital admission data submi ed for the last five quarters.

2018-Q1 2018-Q2 2018-Q3 2018-Q4 2019-Q1Months of Data 3 3 3 3 3Numerator 14 8 7 6 8Denominator 184 200 191 200 200Rate 7.6% 4% 3.7% 3% 4%

3



Increase Sa sfac on

Measure(Source):

CoreQ ResidentSa sfac on(LTC Trend Tracker)

NumeratorDefini on

Number of residentrespondents with anaverage score greater toor equal to 3.0 on all theCoreQ ques ons


Number of valid residentresponses


98.0%(Q2 2018)

Goal Rate >90%Goal Met?(Performance >90%): Yes

Here is a summary of CoreQ Resident Sa sfac on data submi ed for the last four quarters.

2017Q3-2018Q2 2017Q4-2018Q3 2018Q1-2018Q4 2018Q2-2019Q1Survey Date 07/01/17Numerator 24 NA NA NADenominator 24 NA NA NARate 98% NA% NA% NA%

Measure(Source):

CoreQ FamilySa sfac on(LTC Trend Tracker)

NumeratorDefini on

Number of familyrespondents with anaverage score greater toor equal to 3.0 on all theCoreQ ques ons


Number of valid familyresponses


NO DATA(Q1 2019)

Goal Rate >90%Goal Met?(Performance >90%): No

Here is a summary of CoreQ Family Sa sfac on data submi ed for the last four quarters.

2017Q3-2018Q2 2017Q4-2018Q3 2018Q1-2018Q4 2018Q2-2019Q1Survey DateNumerator NA NA NA NADenominator NA NA NA NARate NA% NA% NA% NA%

4



Reduce Off-Label An psycho cs

Measure(Source):

Off-LabelAn psycho cs(LTC Trend Tracker)

NumeratorDefini on

Number of residents withan off-label an psycho cdrug prescribed


Number of residents inthe community


0.0%(Q1 2019)

Goal Rate <15%Goal Met?(Performance <15%): Yes

Here is a summary of off-label an psycho c data submi ed for the last five quarters.

2018-Q1 2018-Q2 2018-Q3 2018-Q4 2019-Q1Months of Data 3 3 3 3 3Numerator 0 0 0 0 0Denominator 184 200 191 200 200Rate 0% 0% 0% 0% 0%

Occupancy Rate

Measure(Source):

Occupancy Rate(LTC Trend Tracker)

NumeratorDefini on

Number of residents inthe community

DenominatorDefini on Number of beds

Here is a summary of occupancy data submi ed for the last five quarters.

2018-Q1 2018-Q2 2018-Q3 2018-Q4 2019-Q1Months of Data 3 3 3 3 3Numerator 184 200 191 200 200Denominator 222 222 222 222 222Rate 82.9% 90.1% 86% 90.1% 90.1%

5


“QIPP-2018S2-123456.Demo_QI_Publica on” — 2018/9/17 — 10:45 — page 1 — #1

Your Quality Ini a ve ProgressDemo Center

Center’s Address

Publica on: 2018 - 2nd Semi-Annual

Short-Stay Long-StayMeasure Latest Rate Goal Goal Met? Measure Latest Rate Goal Goal Met?

Hospitaliza ons

PointRightPro30

12.2%(2017Q1-2017Q4)

<14.9%

PointRightPro-

LongStay

9.7%(2017Q1-2017Q4)

<10.0%

An psycho cs

Nursing HomeCompare

0.0%(2018Q1) < 1.0%

NursingHome

Compare

9.7%(2018Q1) <10.6%

CustomerSa sfac on

CoreQResident

N/A(Data Missing) >90.0%

CoreQResident


CoreQFamily


Func onalImprovement

AHCASelf-Care

TBDComming Soon TBD

AHCAMobility

TBDComming Soon TBD

Background

The 2018-2021 AHCA Quality Ini a ve has four aims: 1) Reduce Hospitaliza ons, 2) Reduce Off-Label Use ofAn psycho cs, 3) Increase Customer Sa sfac on, and 4) Improve Func on. They align with CMS ini a ves,such as SNF Value-Based Purchasing and metrics used by managed care (see graphic below). Thus, improve-ment in these areas is not only beneficial to residents, but also to an organiza on’s opera onal viability.

Execu ve Summary

You have achieved at least one goal in 2 of the 4 focus areas. Overall, you have achieved the goal for 4 of the 9measures. The table below summarized overall progress and pages 3-4 provide detailed performance.Customer Sa sfac on CoreQ data comes from LTC Trend Tracker, where your sa sfac on vendor can uploaddata on your center’s behalf. For more on CoreQ, visit CoreQ.org.AHCA is s ll working on calcula ng the two func onal improvement measures using MDS assessments.

1


http://www.coreq.org/


Short-Stay Long-StayCenters inKY Mee ngQI Goal (%)

StateAverageRate

Your Center’sRate (State Rank)

Centers inKY Mee ngQI Goal (%)

StateAverageRate

Your Center’sRate (State Rank)

Hospitaliza ons36.1% 16.1%

(2017Q1-2017Q4)

12.2% (40th)

Top 1/3

45.8% 12.5%(2017Q1-2017Q4)

9.7% (55th)

Top 1/3

An psycho cs55.1% 1.6%

(2018Q1)

0.0% (1st)

Top 1/3

45.8% 13.0%(2018Q1)

9.7% (72nd)

Middle 1/3

ResidentSa sfac on

2.6% 63.4%(2017Q4-2018Q3) N/A (N/A) 4.4% 62.3%

(2017Q4-2018Q3) N/A (N/A)

FamilySa sfac on

4.0% 77.1%(2017Q4-2018Q3) N/A (N/A)

Table Abbrevia ons and Notes: QI = Quality Ini a ve, N/A = Not Available. State ranking is Not Available ifeither the center’s data does not meet the appropriate sample size or response rate requirements, or there arefewer than 5 centers with data.

AHCA/NCAL Quality Ini a ve Resources

• Building Preven on into Every Day Prac ce- Your fellow nursing home administrators and cliniciansknow the challenges you face. Learn how they overcome these challenges in this online series.

• The AHCA/NCAL Na onal Quality Awards Program- Leverage systems thinking into providing efficient,high-quality care. For a discounted applica on fee, submit your intent to apply by November 8, 2018.The applica on deadline is January 31, 2019.

• ahcancalED!- Your one stop shop for on-demand learning and webinars.

• Share Your Story!- Have you implemented an innova ve idea or significantly improved the quality ofcare in your center? Help others learn from you by comple ng this online form, so AHCA/NCAL canwork with you to spread your best prac ces and recognize you.

Data SourcesOff-Label An psycho c data is from the August 22, 2018 release of Nursing Home Compare. Hospitaliza ondata is derived fromMDS 3.0 assessments by AHCA/NCAL and published on LTC Trend Tracker. CoreQ CustomerSa sfac on data is submi ed by users or vendors to LTC Trend Tracker and was pulled on Sep 10, 2018.

Performance Summary within the State of Kentucky

2

https://educate.ahcancal.org/products/building-prevention-into-every-day-practice

https://www.ahcancal.org/quality_improvement/quality_award/Pages/default.aspx

https://educate.ahcancal.org/

https://www.ahcancal.org/quality_improvement/qualityinitiative/Pages/YourStory.aspx



Reduce Hospitaliza ons

Measure(Source):

PointRight Pro30(Trend Tracker)

Baseline Rate(Date):

16.5%(2016Q2-2017Q1)


12.2%(2017Q1-2017Q4)

Performance Rank(Popula on Size):

40th(Out of 217)

Percent Change(Baseline -> Performance): -26%

Goal Rate <14.9%Goal Met?(Performance <10% or Pct.Change -10%):

Yes

Measure(Source):

PointRightProLongStay(Trend Tracker)


10.7%(2016Q2-2017Q1)


9.7%(2017Q1-2017Q4)


55th(Out of 219)

Percent Change(Baseline -> Performance): -9.5%


Yes

Reduce An psycho cs

Measure(Source):

SS An psycho cs(NHC)


0.7%(2016Q2-2017Q1)


0.0%(2018Q1)


1st(Out of 207)


Goal Rate < 1.0%Goal Met?(Performance <1% or Pct.Change -10%):

Yes

Measure(Source):

LS An psycho cs(NHC)


11.7%(2016Q2-2017Q1)


9.7%(2018Q1)


72nd(Out of 212)



Yes

3



Improve Customer Sa sfac on

Measure(Source):

CoreQ SS Resident(Trend Tracker)


TBD(Data Missing)


N/A(Data Missing)


N/A(Out of NA)

Percent Change(Baseline -> Performance): N/A

Goal Rate >90.0%Goal Met?(Performance >90% or Pct.Change +10%):

No

Measure(Source):

CoreQ LS Resident(Trend Tracker)


TBD(Data Missing)


N/A(Data Missing)


N/A(Out of NA)



No

Measure(Source):

CoreQ LS Family(Trend Tracker)


TBD(Data Missing)


N/A(Data Missing)


N/A(Out of NA)



No

4


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