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October 10, 2007 1 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter, & Company, P.C., Beaverton, Oregon 1-800-547-3159

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Page 1: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 1

F-6. Pay for Performance. Are You Ready?October 10, 2007

presented by: Joy Morrow, RN, PhD., Senior Clinical ConsultantHansen, Hunter, & Company, P.C.,

Beaverton, Oregon1-800-547-3159

Page 2: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 2

Long Term Care Culture Changes

1990 – OBRA, MDS assessment tool, emphasis on social model as well as clinical assessment

1998 – PPS, Medicare skilled service payments based on acuity, clinical assessment

Page 3: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 3

2006 And On

Value based purchasing for Medicare (& Medicaid) services, Pay for Performance model introduced, health care service payments based on quality and efficiency (cost)

Page 4: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 4

Research

Evidence-based studies It is about outcomes It is about cost It is about how the two meet for quality of care

Page 5: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 5

Secretary Leavitt Reports to Congress

Improvement has occurred on clinical quality measures

Need for more improvement to succeed in promoting broader, more rapid improvement that results in high levels of quality for Medicare beneficiaries and efficient use of Medicare resources

Page 6: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 6

FOUR STRATEGIES:If Adopted by Providers Can Lead To High Performance

Measurement & reporting of quality Adoption & use of health information

technology (“more computerized records”) Redesign of care processes (“treatment

protocols, screenings, disease management, follow up, etc.)

Change in organizational culture & management

Page 7: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 7

CMSs Quality Improvement Roadmap

Work through partnerships: HHS, other Fed & state agencies, health professionals, etc.

Publish quality measures & info to beneficiary, purchaser, professional, provider, others

Pay to support providers in doing the right thing; improving quality, avoiding unnecessary costs, promoting competition to improve quality

Page 8: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 8

Improvement Map (cont)

Assist practitioners & providers in taking the necessary steps to make care more effective & less costly, incl. use of electronic health systems

CMS will become active partner in creating & using evidence of healthcare technologies to bring innovations to pts more rapidly, & help Drs. & pts use txs Feds pay more effectively

Page 9: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 9

CMSs Goals

Through quality improvement initiatives Will modernize Medicare through pay for

performance and Competitive bidding programs

Page 10: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 10

Pay for Performance (P4P)

Value based purchasing Quality based purchasing Performance based health care service

purchasing

Page 11: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 11

How does cost of care combine with positive outcomes?

Through payment methods (i.e. pay for performance) & other incentives to obtain patient focused high quality care at the most reasonable cost

Page 12: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 12

CMS believes that States are interested in…

Ways to improve quality of care in flexible programs that control costs & provide value for dollars spent and that

Payments are directed toward care that will improve health status of citizens

Page 13: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 13

Pay for Performance is one method of value based, quality based purchasing

Incentive payments will be made to facilities who meet certain criteria based on quality measures from several sources

Page 14: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 14

How is this Pilot Program Funded?

The pilot requires budget neutrality or cost effectiveness (“savings”)

Funding will come from reduced avoidable hospitalizations

Page 15: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 15

Performance Measures/Quality Measures

Critical to the process of assessing improvements in quality & providing info to consumers

Nursing Homes were one of the first health care providers to be required to implement/use quality measures

Page 16: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 16

Who Is Involved in Pay for Performance?

Hospitals Physician office practices/Ambulatory care Home Health Nursing Homes Medicare B: PT & OT Dialysis providers And more

Page 17: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 17

CMS Describes the QIO Program

Substantial contribution to efficiency of resource use in Medicare

Program will increase focus in areas where their costs can be substantially offset by quality improvements that increase efficiency

Page 18: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 18

QIO Program Contracting for Projects to Develop Evidence Base for Improving Quality & Efficiency

Preventing hospital admission for patients in nursing homes

Improving transitions of care for patients moving across settings

Measuring & improving palliative & hospice care

Improving quality & efficiency of care for pts w/multiple chronic illnesses

Page 19: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 19

QIO Nursing Home Campaign Will Assess These Measurable Goals

Reducing high risk pressure ulcers Reducing use of daily restraints Improving pain management in long term &

short term, post acute residents Establishing individual targets for improving

quality Assessing res & family satisfaction w/quality

of care

Page 20: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 20

Nursing Home Campaign (cont)

Increasing staff retention Improving consistent assignment of nursing

home staff, so res regularly receive care from same care givers

THE ABOVE MEASURES ARE IN ADDITION TO THE QIO PROGRAM AS IT HAS BEEN IN THE PAST

Page 21: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 21

QIO Scope of Work Measures (subtasks)

Clinical Measures: Restraints, Pressure Ulcers, Pain, Depressive Symptoms

Non-clinical Measures: Staff retention, Resident satisfaction, Staff turnover, Target-setting on clinical measures, Process changes on clinical measures

Page 22: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 22

Other Pay for Performance Programs

Improvement in patients with certain chronic diseases

Pt & OT therapy outcomes for Med B Certain hospital clinical conditions Post acute payment reform demonstration Medicaid P4P

Page 23: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 23

Post Acute Payment (PAC) Reform Demonstration

Scheduled to start in April 2008 Diagnoses or diagnostic conditions specified

by Secretary Leavitt would require a comprehensive assessment at hospital discharge to help determine appropriate post acute care placement

Page 24: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 24

Post Acute Care Demonstration (cont)

The Post Acute Care placement based on pt needs & pt clinical characteristics

Data on fixed & variable costs for each pt & on care outcomes would be gathered

Standardized assessment instrument to measure functional status & other factors during tx & at discharge across PAC settings

Page 25: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 25

NURSING HOMES: Pay for Performance

Quality Measures from MDS Sec W (immunizations) Surveys Staffing levels Avoidable hospitalizations

Page 26: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 26

Recommended Measures by Abt Associates Inc. (demonstration design)

Nursing home staffing Rate of potentially avoidable hospitalizations MDS-based resident outcome measures Outcomes from state survey inspections

Page 27: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 27

How will Performance be measured for Nursing Homes?

Answers to the MDS including:1. Subset of MDS driven quality measure

(nursing home compare)2. Resident immunization rates (Sec W) Outcomes from surveys Staffing levels (licensed and certified

nursing assistant hrs per res day) & rewards for high staff retention &/or low turnover

Page 28: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 28

Performance Measures for Nursing Homes (cont)

Potentially avoidable hospitalizations, both long and short stay

Page 29: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 29

Avoidable Hospitalizations; Short Stay Residents

Potentially avoidable hospitalizations: short stay residents, % of short stay res with a hospitalization w/in 30 days of admit or 7 days of discharge if length of stay is less than 23 days for a potentially avoidable hospitalization

Source of info: Medical record

Page 30: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 30

Potential Problems to Consider

Could be “bad outcome gaming”; not sending someone to hospital

Need to consider patient request to go to hospital

How do we deal with families that insist on transfer?

Need to consider code status

Page 31: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 31

Who Is Reviewing Record?

What is the criteria for determining that a hospitalization was potentially avoidable?

What does documentation say? Nurses notes Physician notes Lab reports Assessments Etc.

Page 32: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 32

Avoidable Hospitalization: Long Stay Resident

Source of information: Medical Record

Page 33: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 33

Recommended Risk Adjustment for Potentially Avoidable Hospitalizations

Age ADL score Bedfast Cognitive Performance Scale Congestive Heart Failure Do Not Resuscitate Dysphagia

Page 34: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 34

Risk Adjustment (cont)

Feeding tube present Hypertension with complications Renal failure Requires assistance to eat Respiratory disease

Page 35: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 35

DISCUSSION

Page 36: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 36

Specific MDS questions that are calculated

ADL decline Pain Physical restraints Urinary Tract Infections Pressure sores, high risk, low risk Worsening of depression or anxiety Bedfast

Page 37: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 37

Specific MDS info (cont)

Indwelling catheter Incontinence, low risk Mobility decline (locomotion, self

performance) Weight loss Delirium and/or pain on post acute residents Section W

Page 38: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 38

Other Measures/Survey Focus Issues

Process measures Resident satisfaction Quality of life measures New measures will be added as new data

becomes available

Page 39: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 39

Possible Process Issues

Treatments, timing, protocols for wound care Treatment, timing, results for pain

management Decisions, interventions for acute symptoms Incident, complaint management Care plans, follow up

Page 40: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 40

Per CMS, Information Re: Nursing Home Process Issues Will Come From:

Survey QIO interaction/feedback

Page 41: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 41

Possible Post Acute Care Process for Nursing Homes

How quickly did RN assess and intervene Was care plan implemented appropriately Were current orders carried out Was physician notified and new orders

received and implemented Was documentation appropriate Were skilled services performed within the

facility (i.e. O2, lab work, IVs, wound tx, etc.)

Page 42: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 42

Resident Satisfaction/Survey

Interviews with resident Interviews with family Interviews with significant other Interviews with legal representative

Page 43: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 43

Quality of Life

Individualized activities Resident specific activity preferences Consistent direct care giver Food preferences What is most important to this specific

resident? Cognitively impaired/specific issues

Page 44: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 44

Guide to Quality Measures

There is a compendium of all of the current quality measure throughout all health care delivery systems

Page 45: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 45

General Categories: Compendium of Quality Measures

Access/children Acute Myocardial Infarction: ASA given, Ace

inhibitor given, Smoking cessation info, beta blockers ordered, thrombolytic agent w/in 30 mins of hosp arrival, time to pericutaneous coronary intervention is 120 mins or less, death w/in 30 days

Ambulatory care: hospitalization rate for all conditions, acute & chronic, children

Page 46: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 46

Compendium (cont.)

Asthma: meds in ER & disch. w/steroids, medical record management, pharmacologic therapy management, hospital readmit rate

Osteoarthritis: diagnoses, pain management (incl. risk factors), exercise education

Hospital discharge process Children with special needs % of pts who return to ER w/in 7 days

Page 47: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 47

Compendium (cont)

Coronary artery disease: artery graft pts who have bypass surgery, % of pts w/prior MI who were prescribed beta blockers, % pf pts who had lipid profile, % of pts on lipid lowering meds, cholesterol levels post cardiac event, % of pts w/diabetes &/or vascular disease & on ASA

Page 48: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 48

Compendium (cont.)

Dental Depression: screening, med management,

length of tx, follow up, suicide risk, & other Diabetes: lab work & results incl. lipid

management, blood pressure management, retinol exams, foot exams, neuropathy monitoring, ASA therapy, pt management, smoking cessation, flu vaccine, hosp admits, amputations

Page 49: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 49

Compendium (cont)

Efficiency: (chronic conditions, diabetes, cardiac condition, asthma, COPD, uncomplicated hypertension, ER discharge instructions)

End Stage Renal Disease: dialysis manage-ment, fistula issues, catheters, pts w/grafts, lab work & management, survival rate

Page 50: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 50

Compendium (cont.)

Heart failure: detailed discharge instructions from hospital stay, left ventricular function assessment, med management, smoking cessation info, weight recorded, mortality w/in 30 days

HIV/AIDS: med mngmt, pt mngmnt, lab work, screenings, vaccinations, other

Page 51: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 51

Compendium (cont)

Home health: improvement in ambulation, bathing, management of meds, pain management, dyspnea, urinary incontinence, hospitalizations, discharges from home health

Hypertension: blood pressure management & control

ICU care: stress ulcer prophylaxis, DVTs, length of stay

Page 52: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 52

Compendium (cont.)

Infection: hospital; central lines, UTIs, Language/demand for interpreter Medication management: allergies,

therapeutic monitoring, geriatric med knowledge/management

Mental Health: children, general, #s of pts, & ADHD w/meds

Neo-natal Care

Page 53: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 53

Compendium (cont) NURSING HOME

ADL decline: incidence, source; MDS Pain: prevalence, prevalence, source; MDS Physical restraints: prevalence, source; MDS UTIs, prevalence: source; MDS Pressure sores: High and low risk,

prevalence, source; MDS Worsening depression or anxiety:

prevalence, source; MDS

Page 54: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 54

Prevalence vs. Incidence

Prevalence – a measurement of residents with a particular condition (quality measure) at one point in time

Incidence – The frequency of new occurrence of a particular QM condition over a period of time. The result of a comparison of two points in time (comparing info from two MDSs)

Page 55: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 55

Compendium (cont) NURSING HOMES

Bedfast: prevalence, source; MDS Indwelling catheters: prevalence,source;MDS Incontinence,low risk:prevalence,srce;MDS Mobility decline, locomotion self performance

decline: prevalence, source; MDS Wt loss: (more than 5 % in 30 days or 10 %

in 6 mos, incidence, source; MDS Delirium: post acute pts,prvl,source; MDS

Page 56: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 56

Compendium (cont) NURSING HOMES

Pain: post acute res,prevalence,source;MDS Pressure sores: post acute res,prvl,src;MDS Staffing: RNs, hrs per pt day,source; payroll

data Staffing: Total nursing (RN, LPN, aides) hrs

per res day, source; payroll data Turnover %: overall turnover % for nursing

staff, source; payroll data

Page 57: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 57

Compendium (cont) NURSING HOMES

Satisfaction: Res experience of care in nursing home, source; survey

Potential avoidable hospitalizations: long stay res, source: medical record

Page 58: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 58

Compendium (cont) NURSING HOMES

Potentially avoidable hospitalizations: short stay residents, % of short stay res with a hospitalization w/in 30 days of admit or 7 days of discharge if length of stay is less than 23 days for a potentially avoidable hospitalization

Source: Medical record

Page 59: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 59

Compendium (cont)

Nursing sensitive: American Nurses Assoc. & JCAHO will look at pressure ulcers, nursing hrs per pt day, hrs of productive work by nursing staff w/direct care responsibilities, death among surgical pts (failure to rescue), % of pts w/hosp acquired pressure ulcers on dy of prevalence study, prevalence of restraints, on day of study

Page 60: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 60

Compendium (cont)

Obesity: documentation in record Obstetrics: c.sections, live births, deaths,

perineal lacerations Patient Safety: hospitals, falls, ER pts leaving

AMA or w/out being seen, computerized physician orders, numerous hospital untoward occurrences & responses.

Page 61: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 61

Compendium (cont.)

Pneumonia: tx in hosp Prenatal care: ambulatory care & hosp Prevention: influenza & pneumonia vaccine,

cancer screenings, smoking cessation, Chlamydia screening, services for children, ambulatory care setting

Page 62: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 62

Compendium (cont.)

Respiratory: ER care & hosp pediatric care Satisfaction: hosp, health plan, ambulatory

care Sickle Cell Anemia: hosp readmission Surgical infection prevention: hosp

Page 63: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 63

What Should We Do To Get Ready?

Knowledgeable MDS nurses are essential:

a. For accurate MDS completion

b. Regulatory compliance

c. Quality measure/quality indicator accuracy

d. Appropriate reimbursement

Page 64: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 64

Competent RNs (& LPNs) to Perform Skilled Nursing Services

RNs who accurately assess RNs with critical thinking skills Licensed nurses who professionally

document Licensed nurses who can perform skilled

care: IVs, respiratory care, wound care, catheterizations, blood draws, etc.

Continuing skills education needed

Page 65: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 65

Essential & Accurate Policies & Procedures

Have only the P & Ps you need Have P & Ps in place that assure conformity

w/federal regs re: immunizations Review your state regs on eating assistants

and all issues of res nutrition Review P & Ps for accidents and follow up Review & enhance end of life P & Ps Review abuse investigation P & Ps

Page 66: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 66

Embrace Methods to Enhance Consumer Satisfaction

Designate best staff w/excellent communication & listening skills to handle res & family issues

Take time to build res & family relationships to ensure open dialog re: services offered & what constitutes reasonable & necessary hospitalization

Build consumer confidence in clinical staff

Page 67: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 67

Professional Communication w/Res & Families

Educate and re-educate RNs and LPNs regarding how to communicate clinical information to residents and family

Educate all staff regarding what info they may share, how to refer to another staff person, etc.

Page 68: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 68

Resident/Family Satisfaction Survey

Overall assessment Activities Environment (appearance, noise, odor,

home-like, etc.) Food Autonomy/privacy Clinical care & tx (physician & nurse)

Page 69: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 69

Res Satisfaction (cont)

Personal care (aides) Staff interaction (clinical and non-clinical)

Page 70: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 70

Know Your Reports

Aspen (Federal complaint tracking system) Oscar (which now includes payroll data) Complaints, internal and reported Complaint review and resolution process Incident tracking and resolutions Survey Etc.

Page 71: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 71

Work On Staff Retention

Be creative in examining issues that enhance longevity

Establish a Registered Nurse/LPN focus group

Establish a Certified Nursing Assistant focus group

Page 72: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 72

Consumer Satisfaction

Listen to individual consumer perceptions of quality

Such as, food, types of activities, friendly staff importance, consistent care giver importance, idiosyncrasies that can be accommodated

Handle complaints efficiently, effectively. Resolve issues.

Page 73: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 73

Infection Control

Review infection control management Educate & re-educate staff re: infection

transmission and hand washing. Consider anti-bacterial gel dispensers

Improve systems UTIs, wound infections, & other facility

acquired infections may translate to avoidable hospitalizations

Page 74: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 74

Pressure Ulcers

Emphasize importance of immediate identification and treatment of pressure issues

Have highly competent wound specialist on staff (w/one back up) who knows latest & best treatments

Have standing orders/protocols approved by medical director and primary physicians

Page 75: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 75

Pressure Ulcers/Wound Care (cont.)

Continually assess and modify treatment as indicated

Wound nurse could be DON, Asst. DON, staff development nurse, anyone who is passionate about wound care. Does not have to be dedicated person in small facility or a wound consultant. On your staff is better.

Page 76: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 76

Cognitively Impaired

Improve your programs Consider vocation boxes More music, color, and touch for severely

impaired

Page 77: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 77

We Must Improve Our Documentation

Consider having documentation “guru” If incident occurs or a re-hospitalization is

considered, have “guru” assist in profess- ional appropriate documentation

Document sound clinical reasons for re-hospitalization

Educate/re-educate on accurate, professional documentation

Page 78: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 78

Documentation Also Includes

An accurate assessment A care plan that is individualized Follow up and updating of the care plan Use critical thinking as you document

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October 10, 2007 79

Surveys (Current Emphasis)

Will look at Res Satisfaction Will look at unnecessary drugs, pharmacy

issues, pharmacy reviews

Page 80: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 80

Staffing

Know your actual daily staffing ratios Recommend RN staffing on post acute units More research details:- Very lg difference in RN staffing levels

between hosp based and free standing nursing homes

- Abt recommendation focused only on RN staffing

Page 81: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 81

Hospital Based vs. Freestanding Nursing Homes

Median RN hrs per res day .75 for hosp based and .25 for free standing

75th percentile of RN hrs per res day was 1.76 for hosp based & .39 for free standing

10% of hosp based had 2.77 or more RN hrs per res day & 10 % of free standing had .56 or more RN hrs per res day

Page 82: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 82

Details on Hospitalization Research

Nursing Homes with staffed with more RNs have less hospital readmissions

Nursing Homes with LPN staffing have more hospital readmissions

RN staffing for post acute care seems to make a difference

Page 83: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 83

Hospitalization Research (cont)

Nursing Homes with more staff (esp. more RNs), more physicians available, physician extenders, nurse aide training, and less RN turnover had fewer hospitalizations

(Median RN hrs

Page 84: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 84

Quality of Life

Activities Restraints; Is it possible to get to zero? Pain management Incontinence Food What does the res really care about? Almost everything relates to quality of life

Page 85: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 85

Activities:Detail; Cognitively Impaired

Mild to moderate cognitive impairment: a. File cabinet with junk mail for homicide

detective, business executiveb. Homemaker stuff, laundry (we know this)c. Vocational boxes; demographic, i.e.

forestry, military, etc.d. Do generic ones & have families help create

individualized ones if needed

Page 86: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 86

Activities (cont)

e. “Coffee Klatches”; “beer” and cards or sports, cocktail parties (time warped back to normal conversation)

f. Food – variety is not as important as individual pattern (peach pie with unwhipped whip cream)

g. Pot lucks, picnics, etc.

Page 87: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 87

Activities (cont.)

h. Historic preference is good but remember that he/she could change their mind

i. “Garage sales” – room personalization

j. Restorative programs = one on one time, touch, mobility, etc.

Page 88: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 88

Incontinence

Take resident to bathroom!!! Respond when resident calls out Team care for incontinence & to prevent it Know resident habits and take them to BR or

commode before urgent crisis Peri-care!!!! Odor abatement- BR doors closed, odor

neutralizers, laundry handling

Page 89: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 89

Skilled Assessments: Sometimes Overlooked in Long Term Care

Lung issues: auscultation, deep breathing, turning, coughing, O2 Sats

Heart issues: B/P, pedal pulses, SOB assessment, pulse, and respiration

Two part assessments: assessment with and without activity

Critical thinking Other

Page 90: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 90

POTENTIALLLY AVOIDABLE HOSPITALIZATIONS

Nurses must assess using critical thinking skills

May need to require second staff opinion when deciding if someone should go to hospital

Again, accurate professional documentation is essential

Page 91: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 91

Ambulatory Care Sensitive Conditions

Conditions that are thought to not need hospitalization if appropriately treated in outpatient setting; such as:

- Congestive heart failure- Chronic Obstructive Pulmonary Disease- Urinary Tract Infection- Pneumonia

Page 92: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 92

Ambulatory Care Conditions (cont)

Dehydration Diabetes Other

Page 93: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 93

Breakdown of Percentages Recommended for Nursing Home Performance Scores

Staffing: 30 % Potentially avoidable hospitalizations: 30 % MDS based outcomes: 20 % Survey Deficiencies: 20 %

Page 94: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 94

Other Potential Performance Measures

End of life care Resident perspectives on their nursing home

care (satisfaction) Medication errors Use of electronic medical records Whether home collects & monitors res care

experience & uses data

Page 95: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 95

Potential Performance Measures (cont)

Nursing home staff immunizations Screening & tx of pain & depression Short-stay quality measure based on disch to

community Presence & role of medical director

Page 96: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 96

Pay for Performance: Now & “Then”

Surveyors looking at issues in a new way QIOs looking at issues thru P4P “eyes” Medical record reviews including more than

“reasonable & necessary” evaluations Complaint investigations may change some Increased focus on MDS accuracy Other

Page 97: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 97

Pay for Performance Now & “Then” (cont)

Medicare Veteran’s health care Long Term Care Insurance HMO co-pay Etc.

Page 98: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 98

Seven States Have Developed P4P Plans For Medicaid Physician Services

Arizona Connecticut Idaho Massachusetts Missouri Ohio West Virginia

Page 99: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 99

Medicare Physician Group Practices (P4P) Examples

Chronic Disease Management: diabetes and heart failure

-High cost/high risk patient management

-Transition management Expanding palliative & hospice care

Page 100: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 100

Physician Group Practices P4P (cont)

Modify physician practice patterns & behavior:

- Encourage physicians to consider health of panel of pts rather than individual pts

- Delegation: physician extenders Information technology

Page 101: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 101

Everett, Washington Physician Clinic

Project: Improve care delivery for seniors

a. Robust (more healthy) seniors – generally benefit from enhanced access to care; appropriate enrollment in disease manage-ment services for diabetes, congestive heart failure, coronary artery disease, & hyper-tension; & appropriate delivery of preventative services

Page 102: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 102

Everett (cont)

b. Pre-frail seniors – generally do not utilize health care resources in optimal ways; it is believed they can benefit from improved discharge planning to reduce ER & hosp use

C. Frail seniors – often utilize high-cost hosp & SNF care; it is believed they can benefit from improved access to palliative care (to relieve suffering) & earlier hospice facility utilization when appropriate

Page 103: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 103

University of Michigan Project

Care Management & Disease Management- Enhance communication between providers,

improve pt compliance, self-management, & access to necessary services

- Transitional care to reduce readmissions & “medical home” care to reduce readmissions

Page 104: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 104

Michigan Project (cont)

Transition management:- Timely appointment scheduling, improve

availability of pt contact info, provide appropriate discharge counseling, reduce social barriers (transportation to appts, cost of meds), provide home care; also post discharge calls w/in 24 hrs of hosp disch

Page 105: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 105

Michigan Project (cont)

“Medical Home”- Reducing first admissions, avoiding hosp

admissions- Vulnerable elderly, dual eligibles w/mental

health & social probs, end-stage renal disease

- Visiting nurse, pt education, self manage-ment support, advanced disease support

Page 106: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 106

Medicaid Nursing Home P4P Programs

Iowa currently has nursing P4P program Kansas, Minnesota, Texas, Vermont have

either studied or tested the concepts in their states

Page 107: October 10, 20071 F-6. Pay for Performance. Are You Ready? October 10, 2007 presented by: Joy Morrow, RN, PhD., Senior Clinical Consultant Hansen, Hunter,

October 10, 2007 107

F-6. Pay for Performance. Are You Ready?

MORE QUESTIONS AND DISCUSSION

Joy Morrow, RN, PhD [email protected]: 503-701-9155