This material was prepared by New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
CMSMA_C2_201507_0147
Thank You for Joining!
New England Nursing Home Quality Care Collaborative
Massachusetts Learning & Sharing Webinar:
QAPI Data Techniques
August 25, 2015
Call-In Number: 855-309-6568
Access Code: 7523186
• Brockton Health Center • Brookside Rehabilitation
• Cape Regency Rehabilitation & Health Care Center
• Epoch of Brewster • Epoch of Norton
• Hathaway Manor Extended Care Facility • Healthbridge
• Jewish Healthcare Center • Kindred Great Barrington • laurel lake
• Life Care Center Of Acton
• Life Care Center Of Merrimack Valley
• Life Care Centers of America Northeast Division • Marquis Health Services
• Newton Wellesley Center For Alzheimer's Care • Northwood Rehab
• Penacook Place
• Queene Anne Nursing Home • Royal Braintree
• Royal Cape Cod Nursing & Rehabilitation Center • Royal Falmouth
• Royal Health Group • Royal of Fairhaven
• Royal Taber Street Nursing & Rehab
• St. Joseph Rehabilitation & Nursing Center
• Stonehedge Rehabilitation & Skilled Care Center • The Royal Megansett
• The TCU at Signature Healthcare/Brockton Hospital
• Thomas Upham House
• Victoria Haven Nursing Facility
8/25/2015 2
WELCOME NENHQCC
Participants!
Lori Nerbonne
Lori Nerbonne, BSN, RN
Senior Program Coordinator
Objectives
Objectives
8/25/2015 4
Understand the nursing home quality measures and
identify opportunities to improve your Five-Star
Quality Rating
Learn how to use data to monitor and evaluate QAPI
program performance
Use data as a tool to build relationships with
hospitals, ACOs and other partners
Hear from other participating nursing home teams on
how they are using data to drive quality
5
Navigating the Collaborative
Pre-Work Webinar Learning Module Action Period Continue onto the Next Learning Period
QAPI Pre-Work: click here View the NE-NHQCC: Transitions of Care Webinar (July 9, 2015) Click here
Click here to view all Learning Modules
Module 6: End-of-Life Care
Lesson 1 Lesson 2 Lesson 3 Lesson 4
Module 9: Getting a Seat at
the Referral Table
Coming Soon!
Update goals on Charter as needed
Start a PIP and share with your QIN-QIO state lead Track progress and
celebrate achievements Contact your QIN-QIO
state lead for assistance click here
Learning Period 3
July – Sept. 2015
Pre-Work Webinar Learning Module Action Period
Mark Your Calendars!
8/25/2015 7
Face to Face Learning & Sharing Days
October 29, 2015 & December 3, 2015
Value-Based Purchasing
Star Ratings
Habilitation Therapy for Dementia Care
Why is data important?
QAPI regulations
Five-Star Quality
Ratings
SNF Value-Based
Payment Programs
ACOs
New Focus on
Quality and Value
How is data used?
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Measure clinical outcomes
Drives quality improvement
Monitor improvement
Evaluate progress
Marketing tool
Data tells a story….
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Informs about what you are doing
well & what opportunities you have to
improve
Educates consumers about how your
facility leaders and staff are
performing
Tells whether changes or
improvements you make are working
or not
Demonstrates your commitment to
quality and improving outcomes
Using Data in
•
To identify opportunities for
P
erformance
I
mprovement
P
rojects
•
How you will track your
PIP
progress
•
What your end result is: are our changes
Sarah Dereniuk
Sarah Dereniuk, MHA, NHA
Program Administrator
Sharing Best Practices
The QAPI Journey:
Changing the way
we use data
D’Youville Senior Care
Andrea Rathbone,
Administrator
Data Sources
• Nursing Home Compare
• CASPER reports
• NE QIN-QIO Standard Analytic Report
(SAR)
• NE QIN-QIO Readmission Report
Nursing Home Compare
13 Long-Stay Quality Measures
% of residents with
increased need for
help with ADLs
% of high risk
residents with
pressure ulcers
(sores)
% of residents who
have/had a catheter
inserted and left in
their bladder
% of residents who
were physically
restrained
% of residents with a
urinary tract infection
% of residents who
self-report moderate
to severe pain
% of residents
experiencing one or
more falls with major
injury
% of residents who
received an
antipsychotic
medication
% of l low-risk
residents who lose
control of their
bowels or bladder
% of residents who
lose too much weight
% of residents who
have depressive
symptoms
% of residents
assessed and given
the seasonal
influenza vaccine
% of residents
assessed and given
the pneumococcal
5 Short-Stay Quality Measures
Percent of residents
with pressure ulcers
(sores) that are new or
worsened
Percent of residents
who self-report
moderate to severe pain
Percent of residents
who newly received an
antipsychotic
medication
Percentage of short-stay
residents assessed and
given the seasonal
influenza vaccine
Percentage of short-stay
residents assessed and
given the pneumococcal
Who uses Quality Measures
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Nursing Center Quality Team
Surveyors
Consumers
Referral Sources
Payors
Calculating your Five-Star Rating
Step 1: Start with the health inspections rating
Step 2: Add 1 star if the staffing rating is 4 or 5 stars and greater
than the health inspections rating. Subtract 1 star if the staffing
rating is 1 star.
Step 3: Add 1 star if the quality measures rating is 5 stars;
CASPER Quality Measure Reports
• MDS 3.0 Facility Characteristics Report
• MDS 3.0 Facility Level Quality Measure
Report
• MDS 3.0 Resident Level Quality Measure
Report
Understanding Quality Measures to
Identify Opportunities for Improvement
• Ratings for the Five-Star QM domain are
calculated using the three most recent
quarters for which data are available
• All of the QMs are given equal weight
• For each measure, 20 to 100 points are
assigned based on facility performance
QM Score
Quality Measure
# of QM
Points
is…
For QM Values
Between…
And…
Antipsychotic
Medications (long-stay)
100
80
0.00000000
0.08088237
0.08088236
0.14285715
60
0.14285716
0.19642856
40
0.19642857
0.26775956
20
0.26775957
1.00000000
Calculating your QM Rating
Monitor and Evaluate Performance
Resident & Family Satisfaction
Data
Now What?
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• Start a Performance
Improvement Plan (PIP)
• Use the Change
Package:
− Evidence-based strategies
− Change concepts
Change Package
• Successful practices
of high performing
nursing homes.
• Evidence-based
strategies
• Change concepts
• Actionable items
Download the
Change Package
:
For More Information
Download the
QAPI Program Packet
:
http://www.healthcarefornewengland.org/wp-content/uploads/QAPI-Packet_042915.pdf
• Included in the Packet:
– Charter and Sample
–
PIP and Sample
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Leadership in Dementia Care: OASIS
Curriculum Boot Camps/Booster Sessions
• Full Day Train-the-Trainer
“Boot Camp” sessions on
Sept 15th or Sept 16
th
• Half Day “Booster”
sessions on
Oct 21st or
Oct 28
th
• Contact Mass Senior Care:
Contact
8/25/2015 33
