impact act for long-term acute care hospitals · will be reported starting april 1, 2016, for...
TRANSCRIPT
IMPACT Act for Long-Term Acute Care Hospitals
Mary DalrympleManaging Director, LTRAX
Kristen Smith, MHA, PT Senior Consultant, Fleming-AOD
Overview
Objectives
▪ What is the IMPACT Act?
▪ Effect via LTCH Quality Reporting Program▪ Data collection▪ Cross-cutting measures
▪ Future Effects▪ Post-acute care payment▪ Data will follow the patient
▪ Newly Proposed Discharge Planning CoPs
▪ Discuss Preparation and Considerations for Future Changes
IMPACT Act
Data Capture▪ 2014 law that called for more data, and standardized data
from post-acute care settings (LTCHs, SNFs, HHAs and IRFs)▪ Changes across existing assessments for each setting
▪ LTCH CARE Data Set▪ New quality metrics that derive the same calculations across
PAC settings
Purpose▪ Foundation to revise the post-acute care payment system▪ Payment based on patient, not setting▪ Improve transitions of care for patients
IMPACT Act: How it Works
Expansion of quality reporting▪ A barnacle on the LTCH QRP barge
▪ Uses the same assessment tool (LTCH CARE Data Set) or claims data
▪ Currently reporting on a subset of QRP topics
Measure domains that are minimally required:▪ Functional status, cognitive status, and changes in both▪ Skin integrity and changes in skin integrity▪ Medication reconciliation▪ Major falls▪ Transfer of health information and care preferences▪ Resource use (including Medicare spending per beneficiary)▪ Discharge to community▪ Potentially preventable readmissions
IMPACT Act: How it Works
Expansion of data sharing▪ Patient assessments and other data follow patient through
health care systems▪ Piggybacking on LTCH CARE Data Set to make data standard
and easier to transfer
Standardization domains that are minimally required:▪ Functional status▪ Cognitive function and mental status▪ Medication reconciliation▪ Special services, treatments, and interventions▪ Medical conditions and co-morbidities▪ Impairments
IMPACT Act: Changes Now
Standardization of LTCH CARE Data Set, v.3:▪ Interruptions section changed to match IRF assessment▪ B0100. Comatose wording changed slightly to match SNF
assessment▪ Functional Status labels changed to align with SNF and IRF
assessments▪ Minor changes for internal consistency among LTCH CARE
Data Set questions
IMPACT Act: Measures
New Quality Reporting Measures:▪ Will be reported starting April 1, 2016, for FY2018 payment
determination▪ Barnacle on existing submission and penalty barge
▪ Data transmitted via LTCH CARE Data Set or claims data▪ If not reported, reimbursement will be cut by two percentage points
▪ Identified as “cross-cutting” or “cross-setting”
IMPACT Act: Pressure Ulcers
Cross-Setting Pressure Ulcer Measure▪ Percent of Residents or Patients with Pressure Ulcers that are New or
Worsened (NQF #0678)▪ Stage 2-4 pressure ulcers that are new or worsened▪ Same as existing LTCH QRP measure ▪ LTACH, SNF & IRF
▪ Computed separately▪ Different patient populations▪ Limited comparability
Numerator: Number of patient stays where discharge assessment indicates one or more new or worsened Stage 2-4 pressure ulcers.
Denominator: Number of patient stays with complete admission and discharge assessments, excluding expired patients (complete assessments need discharge PU data and admission risk-adjustment data).
IMPACT Act: Falls
Cross-Setting Falls▪ Application of Percent of Residents Experiencing One or More
Falls with Major Injury (NQF #0674)▪ Major injury defined as bone fracture, joint dislocation, closed
head injury with altered consciousness, or subdural hematoma▪ LTCH, SNF & IRF
▪ Similar limitations
Numerator: Number of patient stays showing one or more falls with major injury.
Denominator: Number of patient stays with complete discharge assessments (all discharge types; complete assessments include falls data).
IMPACT Act: Function
Cross-Setting Function▪ Long-Term Care Hospital Patients with an Admission
and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF #2631)
▪ Recorded discharge goal is evidence that a care plan with a goal has been established
▪ Uses a subset of data collected for the LTCH QRP version of this measure
▪ LTCH, SNF & IRF▪ Similar limitations
Numerator: Number of patient stays showing functional assessments for each self-care and mobility activity, and at least one self-care or mobility goal
▪ Discharge functional assessments not required for unplanned and expired discharges, but those patients still counted in the measure.
Denominator: Number of patient stays.
IMPACT Act: Function
Cross-Setting MeasureGG0130. A. Eating
B. Oral hygieneC. Toileting hygiene
GG0170. B. Sit to lyingC. Lying to sitting on side of bedD. Sit to standE. Chair/bed-to-chair transferF. Toilet transferH. Does the patient walk?I. Walk 10 feetJ. Walk 50 feet with two turnsK. Walk 150 feetQ. Does the patient use a wheelchair/scooter?R. Wheel 50 feet with two turnsRR. Type of wheelchair/scooterS. Wheel 150 feetSS. Type of wheelchair/scooter
LTCH QRP MeasureAll cross-setting measure items, plus…
GG00130. D. Wash upper body
GG0170. A. Roll left and right
BB0700. Expression of ideas and wantsBB0800. Understanding verbal content
C1610. A-B. CAM: Acute Onset and Fluctuating CourseC. CAM: InattentionD. CAM: Disorganized ThinkingE. CAM: Altered Level of Consciousness
H0350. Bladder Continence
IMPACT Act: Cross-Cutting Measures
Future measure domains (at minimum):▪ Functional status, cognitive status, and changes in both▪ Skin integrity, and changes in skin integrity▪ Medication reconciliation▪ Major falls▪ Transfer of health information and care preferences▪ Resource use (including Medicare spending per beneficiary)▪ Discharge to community▪ Potentially preventable readmissions
IMPACT Act: Cross-Cutting Measures
2015 CMS Measures Under Consideration list:▪ Resource Use Measures: Medicare spending per beneficiary;
Potentially preventable hospital readmission rates; Discharge to community (claims)
▪ Deadline Oct. 1, 2016▪ Medication reconciliation (claims)
▪ Deadline Oct. 1, 2018
Being actively contemplated…▪ Communicating and providing transfer of health information
and care preferences▪ Deadline Oct. 1, 2018▪ Process started with new Discharge Planning CoPs
▪ Functional outcomes▪ Cognition outcomes▪ And more ….significant research opportunity for CMS
IMPACT Act: Data Standardization
Standardization domains minimally required▪ Function▪ Cognitive function and mental status▪ Special services, treatments, and interventions▪ Medical conditions and co-morbidities▪ Impairments▪ Other categories …research underway
Deadline: Oct. 1, 2018
IMPACT Act: Patients
Data Follows the Patient▪ Expectation that assessment data will be known to the patient’s
family, as well as follow the patient from setting-to-setting▪ Purpose of supporting the patient’s goals, needs, and preferences▪ Major change in focus from facility participation and reporting of
aggregated data to individual patient care▪ “Interoperability”▪ Effort for consumer input on the data that should be collected and
transferred
Discharge Planning CoPs
IMPACT Act Mandate▪ Modify the Conditions of Participation for hospitals (including LTCHs)
related to discharge planning
Proposed Requirements▪ All inpatients have a written discharge plan▪ Current discharge planning requirements revised▪ Specific discharge instructions for all patients
Discharge Planning: Six Standards
1. Design: Create written policies and procedures for discharge planning process that are approved by hospital’s governing body
2. Applicability: All inpatients (and certain outpatients)
3. Discharge Planning Process : who and when ▪ Within 24 hours of admission or registration▪ Completed before discharge or transfer (without delaying discharge), and
updated throughout to reflect changes in patient’s condition▪ Practitioner treating the patient must be involved in ongoing goals and
treatment preferences in light of discharge plan▪ Patient’s caregiver to be involved in planning and informed of final plan
Discharge Planning: Six Standards
3. Discharge Planning Process▪ Hospital must consider the availability of caregivers and community-
based care, their services, and their ability to provide the necessary care▪ Evaluate patient’s current and past medical history, needs, and
readmission risk▪ Consider patient’s goals and treatment preferences ▪ Hospitals must assist patients and caregivers with selecting a PAC
provider by using and sharing data on IMPACT Act quality and resource use measures.
▪ PAC data must be relevant and applicable to the patient’s goals of care and treatment preferences.
▪ Use currently available, publicly reported quality data until IMPACT Act public reporting finalized
▪ Ongoing review of representative sample of discharge plans, including patients readmitted within 30 days
Discharge Planning: Six Standards
4. Discharged to Home / Community▪ Discharge instructions provided at the time of discharge or transfer▪ Include warning signs and symptoms, how to respond, and who
to contact▪ Include medication reconciliation and medication instructions▪ Include documentation of follow-up care, appointments, tests, etc.▪ Copy sent to practitioners responsible for follow-up care within 48 hours of
discharge, pending test results within 24 hours of availability▪ Hospital must have a post-discharge follow-up process
5. Discharged to another facility▪ Highly recommended to use an electronic Continuity of Care system▪ Minimum requirements for data shared at transfer specified
6. Post-Acute Care Services▪ Hospitals provide a list of available post-acute care facilities▪ Hospital must disclose any financial interest in referred post-acute
care facility
Many Reports
Medpac: unified post-acute PPS▪ Payment system based on patient characteristics▪ Presented initial findings
▪ Establish common payment rate per time period▪ Establish common case-mix adjustment▪ Massive modeling project to predict cost, form basis for
common payment▪ Payment would set fixed payments for routine & therapy
services, plus additional payment for non-therapy ancillary services
▪ Ongoing meetings, with report due June 30, 2016
CMS: unified post-acute PPS▪ Collect common patient assessment data beginning in 2018▪ After collecting two years worth of data, recommend approaching
Congress for a unified post-acute PPS
Conclusions
IMPACT Act’s impact:▪ Expand scope of data collected in the LTCH▪ Expand scope of quality measures imposed on LTCHs▪ Expand public visibility of facility’s performance on quality measures▪ Put assessment data in hands of patients, families, and other
facilities▪ Inform patient decisions about care choice▪ Drive policy decisions about PAC reimbursement▪ Potentially reshape the post-acute care landscape
Tips for Preparation
Immediate Needs: New Measures (April, 2016)• Functional Measures
• Documentation revisions• Assessment
• Assessment reference period• Training• Data collection/Reporting
• Falls• Documentation and Communication• Incident Reporting
• Delineation of Injury Type• Timing for communication
• Real-time Communication• Daily Huddles
• Data Collection and Reporting
CARE Data/QRP Coordinator
Existence in other Post-Acute Settings• IRF-PAI/PPS Coordinator- Acute Inpatient Rehabilitation• MDS Coordinator- Skilled Nursing Facilities• OASIS Care Coordinator- Home Health
Evolution of these Roles• Origin primarily reimbursement-based• Documentation review and data entry• Currently coordinates (depending on setting)
• Documentation improvement for coding• Medicare reimbursement• Compliance
• Quality Reporting
CARE Data/QRP Coordinator
Role in the LTACH Setting• Oversight of quality reporting program
• Processes• Documentation• Data collection• Data entry• Performance (compliance)
• Hospital Education/Training• Wound coordinator• Infection control preventionist• Therapy/Nursing
• Patient Experience• Ambassador program• Survey distribution
CARE Data/QRP Coordinator
Advantages of the QRP Coordinator• Accountability
• One individual responsible• Reports to the DQM
• Dedicated Internal Resource• CMS QRP Manual• LTRAX• NHSN
• Ensures Compliance• Reduces risk of non-compliance • Reduces risk of incomplete data• Reduces variation
• Improves Performance
Director of Quality
Quality Data (Internal)• Compliance with CMS QRP• Performance across quality indicators
• Synonymous definitions• Performance improvement initiatives
• Preparation for public reporting
Quality Data (External)• Consumers• Referral Sources• Payers
Case Management
Resource Utilization• Reimbursement Changes
• LTCH criteria• Length of Stay Management• Costs
Care Management/Discharge Planning• Additional Requirements• Care Transitions• Reducing Re-Admissions
Quality• Ensuring high quality while controlling costs
Committee: UR/Quality
Merging UR with Quality• Director of Case Management• Director of Quality• Chief Financial Officer• Chief Executive Officer
Pertinent Metrics• Resources Measures
• Case Mix Index• Length of Stay• Revenue per patient day• Cost per patient day
• Quality Measures• QRP Indicators• Patient Satisfaction
• Discharge Measures• Disposition
