Nursing Home Quality Measures Workshop

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Nursing Home Quality Measures Workshop

• Presented in collaboration with

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Learning Objectives

• 1. Define the role of the QIO in nursing
• home quality improvement

2. Describe the purpose of the CMS Nursing
Home Quality Initiative
3. Understand differences between CHSRA
Quality Indicators Publicly Reported
Quality Measures
4. List key components of quality measures
5. Identify MDS items used to
calculate quality measures
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Objective 1

• Define the role of the Quality Improvement
  Organization in nursing home quality improvement

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Who are the QIOs?

• Quality Improvement Organizations (QIOs) -
  formerly PROs
• Under contract with Centers for Medicare
  Medicaid Services (CMS)
• National Network of QI Experts
• Improving clinical care systems
• Beneficiary education
• Independent review/oversight

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QIOs Role in theMedicare Program

• Mandated by Congress in 1982
• To protect integrity of Medicare Trust Fund
• Improve quality of health care
• Protect the Medicare beneficiary

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HSAG Arizona QIO Health Services Advisory
Group, Inc.

• Private, For Profit, Arizona-based
• Founded in 1979 by Arizona doctors and nurses
• 125 employees, and over 175 part-time physician
  advisors and reviewers

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HSAG Arizona QIO

• Staff includes physicians, epidemiologists,
  project managers, nurses, bio-statisticians,
  health data analysts, communication specialists,
  etc.

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The HSAG Mission
To positively affect the quality of health care
by providing information and expertise to those
who deliver and those who receive health services.
www.hsag.com
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HSAG Arizona QIO

• 7 years experience working in Nursing Home
  setting
• Pneumococcal and Immunization
• Pressure ulcers
• Mortality rates
• Therapy services
• CHSRA QIs

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Transitioning to 7 SOW(Scope of Work)
Nursing Home Setting

• 6 SOW
• Improvement projects in alternate settings,
  including Nursing Home (NH)

• 7 SOW
• Intensive, media-based program to beneficiaries
  providers about publicly reported quality data
• Focus on performance measures in NHs

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New CMS Mandates

• Promote use of publicly reported performance data
• Nursing Homes October 2002
• Home Health Agencies by 2003
• Hospitals (?) 2004
• Establish Consumer Advisory Council
• New options for resolution of beneficiary concerns

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QIO is a COLLABORATIVE PARTNER

• COLLABORATIVE and CONFIDENTIAL (not regulatory)
• Not part of the State Survey Agency or process
  (not writing deficiencies)
• CMS funds QIOs

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Partnership for Success

• Trade and Professional Associations
• AHCA and AzAHA, ACHCA, AMDA
• Corporate Leadership
• Arizona Department of Health Services
• AHCCCS, Health Plans
• Ombudsman
• Advocacy Groups
• AARP

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Objective 2

• Describe the purpose of the CMS Nursing Home
  Quality Initiative

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CMSs Overview Summary

• Quality can be measured
• Quality can be improved
• The systems put in place to improve quality
  typically are both sustainable and blind to
  socio-economic status
• Barbara Paul, MD, CMS Baltimore Office
• Quality Measurement and Health Assessment Group

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CMSs Strategy Overview
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Purpose of the CMS Nursing Home Quality
Initiative (NHQI)

• Provide an additional data source to assist
  consumers decision making when selecting a
  nursing home
• Assist facilities with quality improvement
  strategies to improve systems of care

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National Rollout of NHQI

• Six State Pilot April September 2002
• CO, FL, MD, OH, RI, WA
• National NHQI begins November 2002
• Public reporting of measures
• Quality improvement addressing systems of care

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Overview of QIO Tasks
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Starting the Initiative

• October Quality Measure Workshops
• November Recruitment of facilities for
  quality improvement work
• December Select 3-5 QMs to focus
  quality improvement by
• December 15, 2002
• Jan/Feb Begin quality improvement work with
  facilities
• Select facilities by February 3,
  2003

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CMS Release ofQuality Measurement Scores

• Mid-November (12th?)
• CMS to post QMs on Nursing Home Compare web site
• www.medicare.gov
• CMS has purchased 60-65 newspaper ads around the
  country for early November

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(No Transcript)
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Full page newspaper ads in major markets
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Publicly Reported Quality Measures

• Post Acute Pain, Walking Improvement, Delirium
• Chronic ADL decline, Infections, Pain, Pressure
  Ulcers, Restraints
• Reported two ways - with and without additional
  level of risk adjustment at facility level

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Objective 3

• Understand differences between CHSRA Quality
  Indicators Publicly Reported QMs
• Center for Health Systems Research and Analysis,
  University of Wisconsin-Madison

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CHSRA Indicators vs. Publicly Reported Quality
Measures

• Indicators vs. Measures
• Some clinical concepts overlap,
• some dont
• Short stay and long stay measures
• Risk adjustment strategies
• Inclusions and Exclusions may be different
• QMs only calculated on a quarterly basis

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Differences between CHSRA QIs and NHQI QMs

• NHQI QM Corresponding CHSRA QI?
• CHRONIC QMS
• ADL Decline Yes
• Infections (Spectrum of infections) No(UTI
  only)
• Pain No
• Pressure Sores Yes
• Physical Restraints Yes
• POST ACUTE QMS
• Delirium No
• Pain No
• Walking Improvement No
• See Appendix A of Resource Manual for details

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Validation of CMS Quality Measures for Public
Reporting A Summary of Study Results
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Purpose of the Study

• Validation Which of the 45 tested long-term
  and post-acute care quality indicators actually
  reflect quality of care?
• Included nine measures from the CMS 6-state pilot
  project
• Measures were selected from a larger set of
  existing and potential quality measures

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The Players

• Funding agency CMS
• Contractors ABT Associates
• Subcontractors
• Brown University
• HRCA Research and Training Institute
• Draft report delivered August 2002

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Study Facilities

• 209 freestanding and hospital-based facilities
• exclusions lt 50 beds, mean age lt 50 years
• 6 states CA, IL, MO, OH, PA, TN
• 5,758 chronic and post-acute patients
• Study facilities larger, more non-profit, less
  rural than other facilities in state

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Methods

• Step 1 Define high quality care for comparison
  with QM results
• Step 2 Assess study facilities to see if they
  deliver high quality care
• Step 3 Compare results of this assessment with
  QI results

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Step 1 Definition of High Quality Care

• Expert clinical panels
• Lists of care processes, practices, or structural
  elements that experts felt would differentiate
  good from bad performing homes

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Examples of What Should beFound in
Good-PerformingHomes Pressure Ulcers

• Standardized risk assessment
• Policies and procedures to address risk factors
• Programs for implementing and monitoring an
  individuals risk factors
• Mechanisms to identify early tissue injury
• Pressure reduction

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Step 2 Assessing Quality

• Data collection tools
• Medical record review
• Environmental walk-through/resident observation
• Administrative questionnaire

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Step 3 Comparing Assessed Quality with QM Results

• Measure statistical association between each QM
  and assessed quality for that QM
• Degree of association is measurement of degree of
  validity

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Validity of Post-Acute Care QMs from CMS
Six-State Pilot

• Validity Category
• Delirium high
• Pain high
• Maintenance or improvement high
• in walking
• tested with FAP

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Validity of Chronic Care QMs from CMS Six-State
Pilot

• Validity Category
• Late-loss ADL worsening high
• Infection high
• Pain high
• tested with FAP

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Validity of Chronic Care QMs from CMS Six-State
Pilot

• Validity
• Category
• Pressure sores (high/low risk) high
• Daily restraints mid
• Unexpected weight loss low
• tested with FAP

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Other Findings Fromthe Study

• MDS reliability
• QM validity with and without FAP

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MDS Reliability

• Reliability Reproducibility
• How closely do two MDS assessors agree on MDS
  data elements?
• Assessments by research nurses compared with
  assessments by facility staff
• Statistical testing to see how closely
  researchers MDS data match facility staffs MDS
  data

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Summary

• Eight of the nine QMs in the CMS six-state pilot
  sufficiently valid and reliable for national
  public reporting
• Weight loss measure not included (low validity)
• www.cms.hhs.gov/providers/nursinghomes/nhi

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Objective 4

• List key components of quality measures

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Terms for Calculating Quality Measures

• Record selection
• Numerator
• Denominator
• Exclusions
• Covariates
• Facility Admission Profile (FAP)
• --Covariate at facility level

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Record Selection

• DEFINITION The time period from which the MDS
  assessments are drawn to calculate the quality
  measures

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Record Selection

• PAC QMs use Medicare (post-acute) MDS assessments
  from past 6 months (e.g., national rollout data
  are from January - June 2002)
• Chronic QMs use OBRA (chronic) MDS assessments
  from past 3 months (e.g., national rollout data
  is from April-June 2002)

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MDS Data Flow
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MDS Assessments Used in Chronic QM Calculations

• Target assessment t
• Prior assessment t-1
• Most recent full assessment

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Target Assessment

• DEFINITION
• Assessment that occurs within the designated
  time period used to calculate the measure

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Prior Assessment

• DEFINITION
• Assessment that occurs prior to the target
  assessment

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Most Recent Full Assessment

• DEFINITION
• This assessment is the most recent full
  assessment in the 17 months that precede the
  target assessment

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Chronic Care Record Selection Example
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MDS Assessments Used in Post-Acute QM
Calculations

• SNF PPS 5-Day assessment (prior assessment for
  post-acute QMs)
• SNF PPS 14-day assessment (target assessment for
  post-acute QMs)

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Time Periods for QMs

• QMs will be calculated on a quarterly basis,
  beginning October 2002
• Data from Quarter 2 of 2002 to be used for
  November release
• QMs scores on Nursing Home Compare to be
  refreshed each Quarter

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Numerator

• DEFINITION
• Total number of residents with condition (not
  including exclusions)

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Denominator

• DEFINITION
• Total number of residents who could have
  condition (not including exclusions)

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Reporting of Measures

• Measures with small denominator sizes will not be
  posted on NH Compare
• Post-Acute Measures with less than 20 in the
  denominator
• Chronic Measures with less than 30 in the
  denominator

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Nursing Home Quality Initiative

• Understanding the Risk Adjustment

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Risk Adjustment

• Why Adjust?
• To level the playing field
• Want to be able to compare apples to apples
• To take into account the types of residents in
  facilities, so that QM scores can be compared
  between facilities in each state and in the
  nation
• To ensure that differences in the QM scores are
  not due to factors other than the care provided
  by facilities

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What to Risk Adjust For?

• Resident Characteristics related to the QM
  outcome which are beyond the control of the
  facility (i.e., cognitive impairment)
• Facility admitting practices that do not directly
  reflect the quality of care (i.e., types of
  residents admitted to the facility)

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What NOT to RiskAdjust For?

• Factors under control of the facilities (i.e.,
  supports, activities, device use, etc.)

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Risk Adjustment Techniques

• 4 Techniques to Risk Adjust
• Stratification
• Exclusions
• Resident-level risk adjustment
• Facility-level risk adjustment

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Risk Adjustment Examples

• Stratification (used only in the current QIs)
• Pressure Ulcers among high risk population
• Those with difficulty moving, comatose,
  dehydrated, or end stage disease
• Pressure Ulcers among low risk population
• All others

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Risk Adjustment Examples

• Exclusions (omitting residents from the QM
  calculations)
• Ex. Improvement in Walking
• Exclude those who are comatose, end stage
  disease, or on hospice
• QMs only having exclusions PAC Pain, Infections,
  Restraints, ADL Decline, Pressure Ulcers without
  the FAP

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Risk Adjustment Examples

• Resident-level risk adjustment
• Example
• Percent of Residents with Chronic Pain
• Takes into account those who have difficulty
  making daily decisions. This may indicate that
  they are cognitively impaired, and it may be
  harder to detect pain in these residents.
  Residents who can verbalize pain may be reporting
  more pain to the staff.

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Resident Level Adjustments

• Covariates
• Individual resident characteristics or health
  conditions that may contribute to worse outcomes
  for a particular quality measure
• Examples
• Cognitive skills for chronic pain
• Prior residential history for delirium

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Facility Level Adjustment

• Facility Admission Profile (FAP)
• Just another covariate
• Reflects resident population admitted over 12
  month period
• Clinical feature tied to the QM
• Intended to capture differences in admitting
  characteristics of individual facilities

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Risk Adjustment Example

• Facility-level risk adjustment
• Example
• Improvement in Walking for post-acute care
  residents
• Average score of walking in room and walking in
  corridor among SNF PPS 5-day assessments over
  previous year

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Risk Adjustment in Publicly Reported Quality
Measures

• All QMs employ one or more of these 4 risk
  adjustment techniques, EXCEPT stratification
• CHSRA QIs only use high/low risk (stratification)

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How Does Risk Adjustment Work?

• Observed Score
• Score obtained from calculation of the numerator
  divided by the denominator after exclusions are
  applied to the data.

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How Does Risk Adjustment Work?

• Expected Score
• Determine resident characteristics associated
  with worse outcomes
• Apply credit to the QM scores for facilities
  whose residents have these characteristics
• Predict a score for each facility

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Comparing Observed Scores to Expected Scores

• The expected score is compared to the observed
  (Num/Denom) for the facility and an adjusted
  score is calculated.

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How Does Risk Adjustment Work?

• Observed scores that are lower than the expected
  score will be adjusted downward
• better than expected
• Observed scores that are higher than the expected
  score will be adjusted upward
• worse than expected

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Exception

• PAC Quality Measure
• Walking as well or better
• Higher score indicative of better performance

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How Does Risk Adjustment Work?

• Adjusted Score
• Facility-level score calculated on the basis of
  observed score, expected score and national
  average observed QM score

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Adjusted Score Calculation

• e natural logarithm base
• OBS Observed Score
• EXP Expected Score
• NAT National Average Observed Score

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BREAK
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Objective 5

• Identify MDS items used to calculate quality
  measures

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Publicly Reported Quality Measures

• Derived from MDS data only
• Post Acute Pain, Walking Improvement, Delirium
• Chronic ADL decline, Infections, Pain, Pressure
  Ulcers, Restraints
• Reported two ways - with and without additional
  level of risk adjustment at facility level

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Post Acute Care Quality Measures

• Percentage of Short Stay Residents with Pain
• Percentage of Short Stay Residents with Delirium
• Percentage of Short Stay Residents Who Walk as
  Well or Better on 14 Day Assessment as on 5 Day
  Assessment
• Reported twice - both with and without FAP

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Percentage of Short Stay Residents with Pain

• Definition
• The percent of short-stay residents who have
  moderate pain daily or excruciating pain at any
  time.

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Percentage of Short Stay Residents with Pain

• Assessment Used
• SNF PPS 14-Day (AA8b7)

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Percentage of Short Stay Residents with Pain

• Numerator
• The number of residents who have moderate pain
  daily (J2a2 J2b2) OR excruciating pain at any
  time (J2b3)

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Percentage of Short Stay Residents with Pain

• Denominator
• All residents with a valid SNF PPS 14 Day
  assessment

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Percentage of Short Stay Residents with Pain

• EXCLUSIONS
• Missing values for J2a or J2b on 14-day
  assessment
• Inconsistent values on J2a and J2b (example
  excruciating pain (J2b3) but no pain under
  frequency (J2a0))
• No new post-acute care admissions over past year

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Percentage of Short Stay Residents with Pain

• COVARIATES
• None
• FACILITY ADMISSION PROFILE
• None

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Percentage of Short Stay Residents with Delirium

• Definition
• The percent of short-stay residents who have
  symptoms of acute confusion
• NOTE Delirium is not dementia or senility

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Percentage of Short Stay Residents with Delirium

• Assessment Used
• SNF PPS 14-Day (AA8b7)

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Percentage of Short Stay Residents with Delirium

• Numerator
• All residents with new or persistent delirium
  symptoms on 14 day assessment.

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Symptoms of Delirium

• Easily distracted (B5a)
• Periods of altered perception or awareness of
  surroundings (B5b)
• Episodes of disorganized speech (B5c)
• Periods of restlessness (B5d)
• Periods of lethargy (B5e)
• Mental function varies over the course of the day
  (B5f)

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Percentage of Short Stay Residents with Delirium

• Denominator
• All residents with a valid SNF PPS 14 day
  assessment.

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Percentage of Short Stay Residents with Delirium

• EXCLUSIONS (based on 14-Day MDS)
• Comatose (B1)
• End-stage disease (J5c)
• Hospice (P1ao)
• Missing data on delirium (B5a - B5f)
• No post-acute care admissions over past year

or status unknown due to missing data
93
Percentage of Short Stay Residents with Delirium

• COVARIATE
• Prior Residential History is an indicator of long
  term disability
• Prior residential history - AB5a thru AB5e are
  checked and AB5f is not checked
• Based on most recent admission assessment

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Percentage of Short Stay Residents with Delirium

• FACILITY ADMISSION PROFILE
• Prevalence of any delirium symptom among SNF PPS
  5-day assessments (AA8b1) over previous 12
  months.
• B5a through B5f2

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Percentage of Short Stay Residents with Delirium

• This measure is reported twice - both WITH and
  WITHOUT FAP
• Consumer Language
• of short-stay residents with delirium
• of short-stay residents with delirium using an
  additional level of risk adjustment

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Percentage of Short Stay Residents Who Walk as
Well or Better

• Definition
• The percentage of short-stay residents who walk
  as well or better on day 14 as on day 5 of their
  stay
• NOTE In this measure, higher percentages are
  better
• on Day 14 as on Day 5

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Percentage of Short Stay Residents Who Walk as
Well or Better

• Assessments Used
• SNF PPS 14-day (AA8b7) with a valid SNF PPS
  5-day (AA8b1)

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Percentage of Short Stay Residents Who Walk as
Well or Better

• Numerator
• Number of residents who maintain or improve in
  their ability to walk in corridor (G1da) or in
  room (G1ca) from 5 day to 14 day MDS

99
Percentage of Short Stay Residents Who Walk as
Well or Better

• Denominator
• All residents with a valid 5 AND 14 Day SNF PPS
  assessment

100
Percentage of Short Stay Residents Who Walk as
Well or Better

• EXCLUSIONS (based on 14 Day MDS)
• Comatose (B1)
• End-stage disease (J5c)
• Hospice (P1ao)
• Ventilator dependent (P1al)
• Or status unknown due to missing data
• (continued)

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Percentage of Short Stay Residents Who Walk as
Well or Better

• EXCLUSIONS (continued)
• Quadriplegic (I1z)
• Paraplegic (I1x)
• G1c(A) or G1d(A) is missing
• No post acute admissions in past year
• Or status unknown due to missing data

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Percentage of Short Stay Residents Who Walk as
Well or Better

• COVARIATES
• None
• FACILITY ADMISSION PROFILE
• Ability to walk in a room or corridor among all
  admissions over past year

103
Percentage of Short Stay Residents Who Walk as
Well or Better

• FACILITY ADMISSION PROFILE
• Mean sum of walking in room or corridor among
  SNF PPS 5-day assessments (AA8b1) over previous
  12 months.
• G1c(A) and G1d(A)

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Percentage of Short Stay Residents Who Walk as
Well or Better

• NOTES
• 8s (activity did not occur) are converted to 4s
  (total dependence) on G1d(A) and G1c(A) before
  summing these items.
• Assessments with missing values for G1c(A) or
  G1d(A) are excluded

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Chronic Care Quality Measures
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Chronic Care Quality Measures

• Percentage of Residents with Pain
• Percentage of Residents with Infections
• Percentage of Residents with Pressure Sores
• Percentage of Residents with Physical Restraints
• Unexpected Loss of Function in Some Basic Daily
  Activities

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Percentage of Residents with Pain

• Definition
• The percent of residents with either a moderate
  level of pain occurring every day or excruciating
  pain at any time.

108
Percentage of Residents with Pain

• Assessment Used
• OBRA Full (AA8a 01-excluded, 02, 03, or 04) or
  Quarterly (AA8a 05 or 10)

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Percentage of Residents with Pain

• Numerator
• The number of residents who have moderate pain
  daily (J2a2 J2b2) or excruciating pain at any
  time (J2b3)

110
Percentage of Residents with Pain

• Denominator
• All residents with a valid quarterly or full
  assessment

111
Percentage of Residents with Pain

• EXCLUSIONS
• Target Assessment is an admission assessment
  (AA8a01)
• Missing values for J2a or J2b
• Inconsistent values on J2a and J2b example
  excruciating pain (J2b3) but no pain under
  frequency (J2a0)
• No chronic care admissions over past year

112
Percentage of Residents with Pain

• COVARIATES
• Independence or modified independence in daily
  decision-making (B4)
• Indicator of cognitive impairment, which makes
  it harder to assess pain
• FACILITY ADMISSION PROFILE
• None

113
Percentage of Residents With Infections

• DEFINITION
• The percent of residents with any of the
  following infections or health conditions
• Pneumonia (I2e)
• Respiratory infection (I2f)
• Septicemia (I2g)
• Urinary tract infection (I2j)
• Viral hepatitis (I2k)
• Wound infection (I2l)
• Fever (J1h)
• Recurrent lung aspiration (J1k)

114
Percentage of Residents With Infections

• Assessment Used OBRA Full (AA8a 01-excluded,
  02, 03, or 04) or Quarterly (AA8a05 or 10) with
  carry forward from most recent full assessment in
  some states.

115
Percentage of Residents With Infections

• Numerator
• The number of residents with the listed
  infections or health conditions on the target or
  most recent full assessment

116
Percentage of Residents With Infections

• Denominator
• All residents with a valid quarterly or full
  assessment

117
Percentage of Residents with Infections

• EXCLUSIONS
• End-stage disease (J5c)
• Hospice (P1ao)
• Admission assessment (AA8a01)
• UTI item (I2j) is missing
• Or status unknown due to missing data
• (continued)

118
Percentage of Residents with Infections

• EXCLUSIONS (continued)
• Missing data on last full assessment for any of
  the other infections or health conditions (I2e,
  I2f, I2g, I2k, I2l, J1h, J1k)
• No chronic care admissions over past year

119
Percentage of Residents With Infections

• COVARIATES
• None
• FACILITY ADMISSION PROFILE
• None

120
Percentage of Residents With Infections

• Some states use a 2 page quarterly that only
  contains UTIs (rest of infections must be carried
  forward from last full assessment)
• Includes AZ through 2nd Quarter 2002
• Other states use 3 page quarterlies that collect
  pneumonia, respiratory infection, septicemia,
  wound infections, hepatitis, and UTIs
• Includes AZ beginning 3rd Quarter 2002

121
Percentage of Residents With Infections

• This measure is reported despite limitations
  because prevention and treatment of infections is
  a high profile area for quality improvement

122
Percentage of Residents With Pressure Sores

• DEFINITION
• The percent of residents who are have one or
  more pressure sores.

123
Percentage of Residents with Pressure Sores

• Assessment Used OBRA full AA8a 01-excluded,
  02, 03, 04 or Quarterly AA8a05 or 10

124
Percentage of Residents with Pressure Sores

• Numerator
• Number of residents with one or more pressure
  ulcers (Stage 1-4) (M2agt0 or ICD-9 code of 707.0
  on I3)

125
Percentage of Residents with Pressure Sores

• Denominator
• All residents with a valid full or quarterly
  assessment

126
Percentage of Residents with Pressure Sores

• EXCLUSIONS
• Admission assessment (AA8a01)
• M2a is missing
• No chronic care admissions over past year

127
Percentage of Residents With Pressure Sores

• COVARIATES
• None
• FACILITY ADMISSION PROFILE
• Percent of residents with pressure sores upon
  admission over past 12 months

128
Percentage of Residents With Pressure Sores

• This measure is reported twice
• both WITH WITHOUT FAP
• Handout
• EXAMPLE Calculation of Chronic Care Pressure
  Ulcer (PU) Quality Measures

129
Percentage of Residents in Physical Restraints

• DEFINITION
• The percent of residents who are in physical
  restraints daily.
• NOTE This measure does not include bed or side
  rails

130
Percentage of Residents in Physical Restraints

• Assessment Used OBRA Full AA8a 01- excluded,
  02, 03, 04 or Quarterly AA8a05 or 10

131
Percentage of Residents in Physical Restraints

• Numerator
• Number of residents who are physically restrained
  daily (P4c, P4d, or P4e 2)
• Denominator
• All residents with a quarterly or full assessment

132
Percentage of Residents in Physical Restraints

• EXCLUSIONS
• Admission assessment (AA8a 01)
• P4c, P4d, or P4e has a missing value.
• No chronic care admissions over past year

133
Percentage of Residents in Physical Restraints

• COVARIATES
• None
• FACILITY ADMISSION PROFILE
• None

134
Percentage of Residents Who Had an Unexpected
Loss of Function in Some Basic Daily Activities

• DEFINITION
• The percentage of residents whose need for
  help doing basic daily activities is greater than
  their need for help on a prior assessment.
• AKA Decline in Late Loss ADLs

135
Decline in Late Loss ADLs

• Assessments Used OBRA Full AA8a 01, 02, 03, or
  04 or Quarterly AA8a05 or10

136
Decline in Late Loss ADLs

• Numerator
• Residents with worsening self-performance
• two or more ADLs or
• 2 level decrease in one ADL
• Bed mobility (G1aA)
• Transfer (G1bA)
• Eating (G1hA)
• Toilet Use (G1iA)

137
Decline in Late Loss ADLs

• Denominator
• All residents with a quarterly or full assessment
  and a prior assessment

138
Decline in Late Loss ADLs

• EXCLUSIONS
• End-stage disease (J5c)
• Hospice (P1ao)
• Comatose (B1)
• Or status unknown due to missing data
• (continued)

139
Decline in Late Loss ADLs

• EXCLUSIONS (continued)
• Missing data on ADLs
• All four Late-Loss ADLs have a value of 4 or 8
  on the prior assessment
• No chronic care admissions over past year
• G1a(A), G1b(A), G1h(A), or G1i(A)

140
Decline in Late Loss ADLs

• COVARIATES
• None
• FACILITY ADMISSION PROFILE
• None

141
Nursing Home Quality Measures

• The ten nursing home publicly reported quality
  measures are described in the NHQI
• Quality Measures Resource Manual, version3.1,
• October 2002

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FAQs

• Handout
• Nursing Home Quality Initiative
• Frequently Asked Q A
• Includes CMS links to related NHQI documents

143
Next Steps

• Begin to talk to residents, families, and staff
  about quality measures.
• Evaluate MDS coding to ensure accuracy
• Look at care processes that lead to the outcome
  of the quality measure
• Watch for additional assistance from HSAG

144
QIO Contacts

• Health Services Advisory Group
• Marianne Canady 602-665-6113
• e-mail azpro.macandy_at_sdps.org
• Kathleen Bauer 602-745-6205
• e-mail azpro.kbauer_at_sdps.org

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Important Websites

• CMS Website
• www.cms.hhs.gov/providers/nursinghomes/nhi
• Health Services Advisory Group, Inc
• www.hsag.com
• Arizona Department of Health Services
• www.hs.state.az.us/als/ltc/bulletins.htm
  

146
Thank You!

• Please complete the evaluation form included with
  the session handouts.