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Analytic Insights from CMS’ Five-Star
        and New Quality Measures

                 Jennifer Gross
                  Jeff Merselis
      American Healthcare Association
               October 2012


1
MDS 3.0 Quality Measures


2
Introduction
    • The nursing home Quality Measures (QMs) come from
      MDS resident assessment data routinely collected at
      specified intervals
       – Posted on Nursing Home Compare
       – A subset of measures are used for the Five-Star calculation
    • Quality Measures on the Nursing Home Compare
      website allow consumers, providers, states and
      researchers to compare information on nursing homes.
    • Many nursing homes use this information to guide
      quality improvement efforts and monitor progress



3
Changes in the MDS 3.0 Quality
    Measures
    • Although there are many similarities between
      the MDS 2.0 and 3.0 QMs, the differences may
      affect your facility’s trigger rates
      – Resident Selection
      – Record Selection
      – Resident Assessment Method




4
Resident Selection
    MDS 2.0                                    MDS 3.0
    Post-Acute Care (PAC): PPS 5-day and 14-   Short Stay (SS): </=100 cumulative days in
    day MDS                                    facility
    Chronic Care (CC): OBRA Quarterly,         Long-Stay (LS): =/>101 cumulative days in
    Annual, Significant Change, Significant    facility
    Correction

    Changes in the resident sample selection affect the denominator size
    for Short Stay and Long Stay measures
    • Short Stay sample may be larger than PAC due to 100 day time
       period
    • Long Stay residents remain in LS sample even after reentry from
       hospital



5
Residents on Leave of Absence
    • Residents who leave for a temporary home
      visit/therapeutic leave
    • Residents who have a hospital observation
      stay <24 hours and are not admitted
      – Discharge assessment is not completed
      – These residents can trigger for incidents outside
        the facility (e.g. fall w/fracture)
    • LOA days still count towards resident’s
      Cumulative Days in Facility

6
Record Selection
    • Selection of MDSs used in the QM calculation
      no longer based solely on MDS reason for
      assessment (RFA)
    • Resident’s span of time in the facility dictates
      which measures may trigger
      – An OBRA assessment may trigger a Short Stay
        measure if the resident has </=100 CDIF
      – A PPS assessment may trigger a Long Stay
        measure if =/> 101 CDIF

7
Record Selection (cont.)
    • Look-Back Scan: used to capture triggering
      conditions within the episode
      – May not be the most recent MDS
    • Three measures with look-back scans
      – New/Worsening Pressure Ulcers (SS)
         • Looks back up to the beginning of the episode
      – Falls (LS)
      – Falls with Major Injury (LS)
         • Look back up to a year (275 + 93 days)

8
Resident Assessment Method
    • Resident interview only for Pain assessment
      – Residents who were not interviewed excluded
        from SS and LS measures
      – Reduces denominator size
    • New/Worsening Pressure Ulcers
      – Stage 2-4 only
      – Section M0800 not completed on first assessment
        since most recent entry/reentry
         • Excludes hospital acquired/worsened ulcers

9
Resident Assessment Method (cont.)
     • Symptoms of Depression
       – Uses either the PHQ-9© resident interview or staff
         assessment
          • Little interest/pleasure in doing things or feeling
            down/depressed/hopeless: half or more days
                                         AND
          • Total severity score =/>10
     • Influenza Vaccine (SS/LS)
       – If vaccine given for current flu season, carry forward
         code on future assessments until next flu season
         begins

10
New Antipsychotic Measures
     • Different from the antipsychotic “surveyor
       measure” on CASPER
       – Fewer exclusions
     • Incidence of Psychoactive Medication Use (SS)
       – Short-stay residents who did not receive antipsychotic
         on initial assessment and do receive it on target
         assessment
     • Prevalence of Psychoactive Medication Use (LS)
       – Long-stay residents who receive antipsychotic
     • Both measures only exclude residents with
       Schizophrenia, Tourette’s or Huntington’s

11
Average QM Rates 2.0-3.0
     • The differences in data collection and record
       selection have resulted in different QM rates
       for measures that had “similar” MDS 2.0
       counterparts
     • Even though the actual QMs can’t be
       compared from MDS 2.0 to MDS 3.0, how the
       public sees your facility’s rates doesn’t change



12
QM Rates 2.0-3.0: ADL




13
QM Rates 2.0-3.0: Pain




14
QM Rates 2.0-3.0: Pressure Ulcers




15
Five-Star Quality Domain


16
“The primary goal of this rating system is to
     provide residents and their families with an
     easy way to understand assessment of
     nursing home quality, making meaningful
     distinctions between high and low performing
     nursing homes.”
                         CMS’s Five-Star Technical Users’ Guide
                         July 2012




17
CMS’ Five-Star Program

     • The rating system features an overall
       Five-Star rating based on facility performance
       for three types of performance measures:
       – Health Inspection (CASPER)
       – Staffing (CASPER)
       – Quality (Public Quality Measures)
     • The rating system has been available to the
       public on Nursing Home Compare since
       December 18, 2008

18
Quality Measures Domain
     • Facility ratings for the quality measures are
       based on performance on 9 of the 18 QMs
       that are currently posted on the Nursing
       Home Compare web site
       – Based on MDS 3.0 assessments
     • Include 7 Long-Stay (LS) measures and 2
       Short-Stay (SS) measures


19
Long-Stay Residents
     • Percent of residents whose need for help with activities
       of daily living has increased
     • Percent of high risk residents with pressure sores
     • Percent of residents who have/had a catheter inserted
       and left in their bladder
     • Percent of residents who were physically restrained
     • Percent of residents with a urinary tract infection
     • Percent of residents who self-report moderate to
       severe pain
     • Percent of residents experiencing one or more falls
       with major injury

20
Short Stay Residents

     • Percent of residents with pressure ulcers
       (sores) that are new or worsened

     • Percent of residents who self-report moderate
       to severe pain



21
Included Assessments
     • Long Stay measures are included in the score if
       the measure can be calculated for at least 30
       assessments (summed across three quarters of
       data)
     • Short Stay measures are included in the score
       only if data are available for at least 20
       assessments
     • Ratings are calculated using the three most
       recent quarters for which data are available


22
Five-Star Quality Score Calculation
     MDS 2.0                                    MDS 3.0
     ADL measure weighted higher than other     ADL measure weighted equally with other
     measures                                   measures
     ADL measure ranked in percentiles based    ADL measure ranked in deciles based on
     on State distribution                      State distribution
     All non-ADL measures ranked in quintiles   All non-ADL measures ranked in
     based on National distribution             percentiles based on National distribution
     Points assigned according to quintiles     Points assigned according to percentiles
     Total possible score ranges from 0-136     Total possible score ranges from 9-900
     points                                     points

 Changes in the Five-Star Quality Domain calculation from MDS 2.0 to MDS 3.0
 requires attention from providers
     • The basic premise is the same: lower QM rates=higher point values


23
Star Cut-points for MDS Quality Measure
     Summary Score




24
Quality Measure Score Thresholds
     • Cut points for the QMs were set based on the QM
       distributions averaged across Q2-Q4 of 2011
        – will be maintained for a period of at least two years,
          after which CMS will review

     • These thresholds were set so that the overall
       proportion of nursing homes in each rating category in
       July 2012 (when the QM rating based on MDS 3.0 is
       first reported) would be similar to what it was when
       the MDS 2.0 QM rating was frozen in March 2011.


25
Comparison of Five-Star Quality
     Domain 2.0-3.0




26
Facility Star Rating Changes 2.0-3.0
     New Quality Rating –
                                 Number of Facilities         Percent of Facilities
      Old Quality Rating
              -4                           44                          <1%
              -3                          445                          3%
              -2                         1418                          9%
              -1                         3205                          21%
              0                          4967                          33%
              1                          3251                          21%
              2                          1435                          9%
              3                           406                          3%
              4                            62                          <1%

     Although the national distribution of star ratings remains the same, individual
                facilities will see changes in their own Quality ratings

27
CMS August Update to Nursing Home
     Compare
     • Shifted QM 3-quarter time period from
       March-December 2011 to July 2011-March
       2012
     • Facilities saw a resulting change in their
       publicly reported QM rates and star ratings
     • Note the potential for changes with each
       quarterly update to NHC


28
Facility Star Rating Changes July-
      August 2012
      August 2012 Quality
             Rating–            Number of Facilities   Percent of Facilities
     July 2012 Quality Rating
                -4                       0                     0%
                -3                       2                     <1%
                -2                      60                     <1%
                -1                     1857                    12%
                0                      10425                   68%
                1                      2939                    19%
                2                       122                    1%
                3                       10                     <1%
                4                        0                     0%


29
Five-Star Changes and Your Facility
     • Changes in the QMs can have an effect on
       your facility’s Quality and Overall Five-Star
       ratings
       – Keep on top of CMS updates to Five-Star
     • The challenge: to understand these changes to
       put your facility’s rating in context and
       communicate with residents, families and the
       public

30
Five-Star/QMs and Your
        Ability to Compete


31
How was the Five-Star Quality Rating
     System designed to be used?

     1. Help educate consumers about nursing home quality

     2. Help improve provider quality




32
How are Five-Star and MDS 3.0 QMs
     actually being used?
        SNF’s marketing departments
        Hospital Discharge planners
        HUD lending/re-financing
        Plaintiff attorneys
        Insurance brokers
        ACOs/ “Bundles”
        Medicare Advantage Plans
        Media



33
1. Does the SNF that you work for have
     a marketing strategy?




34
2. Does the SNF that you work for use
     Five Star rating in marketing efforts?




35
3. Does the SNF that you work for use
     Quality Measures (QMs) in marketing
     efforts?




36
4. Does the SNF that you work for
     sometimes lose referrals to other SNFs
     with a higher Overall Five Star rating?




37
5. Does the SNF that you work for use
     the Overall Five Star rating in their
     marketing efforts to hospitals?




38
6. Does the SNF that you work for use
     the Overall Five Star rating in their
     marketing efforts to ACOs?




39
7. Does the SNF that you work for market
     your Five Star components (i.e. Survey,
     Quality, Staffing, etc.) separately?




40
8. Was the SNF that you work for “surprised”
     by your 3.0 Quality Measure (QM) rating
     compared to your 2.0 QM rating?




41
9. Do you find that the Quality Measures
     (QMs) enhance your overall marketing
     strategy?




42
Strategies for Success


43
Five Data-Driven Strategies for Using Five-Star and
     QMs to Market your Facilities More Effectively

     1. Remember the who and why
     2. Turn blunt instruments into sharp tools
     3. Augment Five Star and QMs with other
        key metrics
     4. Don’t rely solely on yesterday’s news
     5. Turn weaknesses into strengths



44
How is Your Data Quality?
     Proportion of MDS Assessments with Issues (>5,000,000
     assessments)


                      17%
                                                With Issues
                                                Without Issues
                                83%




      Of the 83% of assessments with issues, on average each
                    assessment had 2.41 issues.


45
QM Strategies for Success
     • Review MDS Data for accuracy
        – Correct errors before CMS submission
        – Identify processes that impact accurate MDS coding
           • Supporting documentation
           • Staff education
     • Make Five-Star QMs part of facility quality
       improvement process
        – Trends and benchmarks
           • Root Cause Analysis
        – Review other CASPER QMs and related care processes
        – Monitor positive outcomes to ensure good processes
          are maintained
46
Nursing Home Quality Assurance &
     Performance Improvement (QAPI)
     • Being rolled out by CMS in 2012
     • Provides tools and resources to help facilities
       meet existing QAA requirements
        – Based on best practices
        – Continuously identify and correct quality deficiencies
        – Sustain performance improvement
     • QAPI Element 3: Feedback, Data Systems and
       Monitoring
        – QMs can be incorporated into QAPI monitoring

47
For More Information
     • QM Users’ Manual
       – www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
         Instruments/NursingHomeQualityInits/Downloads/MDS30QM-
         Manual.pdf
     • Five-Star User’s Guide
       – www.cms.gov/Medicare/Provider-Enrollment-and-
         Certification/CertificationandComplianc/Downloads/usersguide.
         pdf
     • CMS’ QAPI Page
       – www.cms.gov/Medicare/Provider-Enrollment-and-
         Certification/SurveyCertificationGenInfo/QAPI.html


48
Thank You!
     • Jennifer Gross Senior Healthcare Specialist
       – jennifer.gross@pointright.com


     • Jeff Merselis VP Business Development
       – jeff.merselis@pointright.com


     • http://www.pointright.com


49

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Analytic Insights from CMS's Five-Star and New Quality Measures

  • 1. Analytic Insights from CMS’ Five-Star and New Quality Measures Jennifer Gross Jeff Merselis American Healthcare Association October 2012 1
  • 2. MDS 3.0 Quality Measures 2
  • 3. Introduction • The nursing home Quality Measures (QMs) come from MDS resident assessment data routinely collected at specified intervals – Posted on Nursing Home Compare – A subset of measures are used for the Five-Star calculation • Quality Measures on the Nursing Home Compare website allow consumers, providers, states and researchers to compare information on nursing homes. • Many nursing homes use this information to guide quality improvement efforts and monitor progress 3
  • 4. Changes in the MDS 3.0 Quality Measures • Although there are many similarities between the MDS 2.0 and 3.0 QMs, the differences may affect your facility’s trigger rates – Resident Selection – Record Selection – Resident Assessment Method 4
  • 5. Resident Selection MDS 2.0 MDS 3.0 Post-Acute Care (PAC): PPS 5-day and 14- Short Stay (SS): </=100 cumulative days in day MDS facility Chronic Care (CC): OBRA Quarterly, Long-Stay (LS): =/>101 cumulative days in Annual, Significant Change, Significant facility Correction Changes in the resident sample selection affect the denominator size for Short Stay and Long Stay measures • Short Stay sample may be larger than PAC due to 100 day time period • Long Stay residents remain in LS sample even after reentry from hospital 5
  • 6. Residents on Leave of Absence • Residents who leave for a temporary home visit/therapeutic leave • Residents who have a hospital observation stay <24 hours and are not admitted – Discharge assessment is not completed – These residents can trigger for incidents outside the facility (e.g. fall w/fracture) • LOA days still count towards resident’s Cumulative Days in Facility 6
  • 7. Record Selection • Selection of MDSs used in the QM calculation no longer based solely on MDS reason for assessment (RFA) • Resident’s span of time in the facility dictates which measures may trigger – An OBRA assessment may trigger a Short Stay measure if the resident has </=100 CDIF – A PPS assessment may trigger a Long Stay measure if =/> 101 CDIF 7
  • 8. Record Selection (cont.) • Look-Back Scan: used to capture triggering conditions within the episode – May not be the most recent MDS • Three measures with look-back scans – New/Worsening Pressure Ulcers (SS) • Looks back up to the beginning of the episode – Falls (LS) – Falls with Major Injury (LS) • Look back up to a year (275 + 93 days) 8
  • 9. Resident Assessment Method • Resident interview only for Pain assessment – Residents who were not interviewed excluded from SS and LS measures – Reduces denominator size • New/Worsening Pressure Ulcers – Stage 2-4 only – Section M0800 not completed on first assessment since most recent entry/reentry • Excludes hospital acquired/worsened ulcers 9
  • 10. Resident Assessment Method (cont.) • Symptoms of Depression – Uses either the PHQ-9© resident interview or staff assessment • Little interest/pleasure in doing things or feeling down/depressed/hopeless: half or more days AND • Total severity score =/>10 • Influenza Vaccine (SS/LS) – If vaccine given for current flu season, carry forward code on future assessments until next flu season begins 10
  • 11. New Antipsychotic Measures • Different from the antipsychotic “surveyor measure” on CASPER – Fewer exclusions • Incidence of Psychoactive Medication Use (SS) – Short-stay residents who did not receive antipsychotic on initial assessment and do receive it on target assessment • Prevalence of Psychoactive Medication Use (LS) – Long-stay residents who receive antipsychotic • Both measures only exclude residents with Schizophrenia, Tourette’s or Huntington’s 11
  • 12. Average QM Rates 2.0-3.0 • The differences in data collection and record selection have resulted in different QM rates for measures that had “similar” MDS 2.0 counterparts • Even though the actual QMs can’t be compared from MDS 2.0 to MDS 3.0, how the public sees your facility’s rates doesn’t change 12
  • 14. QM Rates 2.0-3.0: Pain 14
  • 15. QM Rates 2.0-3.0: Pressure Ulcers 15
  • 17. “The primary goal of this rating system is to provide residents and their families with an easy way to understand assessment of nursing home quality, making meaningful distinctions between high and low performing nursing homes.” CMS’s Five-Star Technical Users’ Guide July 2012 17
  • 18. CMS’ Five-Star Program • The rating system features an overall Five-Star rating based on facility performance for three types of performance measures: – Health Inspection (CASPER) – Staffing (CASPER) – Quality (Public Quality Measures) • The rating system has been available to the public on Nursing Home Compare since December 18, 2008 18
  • 19. Quality Measures Domain • Facility ratings for the quality measures are based on performance on 9 of the 18 QMs that are currently posted on the Nursing Home Compare web site – Based on MDS 3.0 assessments • Include 7 Long-Stay (LS) measures and 2 Short-Stay (SS) measures 19
  • 20. Long-Stay Residents • Percent of residents whose need for help with activities of daily living has increased • Percent of high risk residents with pressure sores • Percent of residents who have/had a catheter inserted and left in their bladder • Percent of residents who were physically restrained • Percent of residents with a urinary tract infection • Percent of residents who self-report moderate to severe pain • Percent of residents experiencing one or more falls with major injury 20
  • 21. Short Stay Residents • Percent of residents with pressure ulcers (sores) that are new or worsened • Percent of residents who self-report moderate to severe pain 21
  • 22. Included Assessments • Long Stay measures are included in the score if the measure can be calculated for at least 30 assessments (summed across three quarters of data) • Short Stay measures are included in the score only if data are available for at least 20 assessments • Ratings are calculated using the three most recent quarters for which data are available 22
  • 23. Five-Star Quality Score Calculation MDS 2.0 MDS 3.0 ADL measure weighted higher than other ADL measure weighted equally with other measures measures ADL measure ranked in percentiles based ADL measure ranked in deciles based on on State distribution State distribution All non-ADL measures ranked in quintiles All non-ADL measures ranked in based on National distribution percentiles based on National distribution Points assigned according to quintiles Points assigned according to percentiles Total possible score ranges from 0-136 Total possible score ranges from 9-900 points points Changes in the Five-Star Quality Domain calculation from MDS 2.0 to MDS 3.0 requires attention from providers • The basic premise is the same: lower QM rates=higher point values 23
  • 24. Star Cut-points for MDS Quality Measure Summary Score 24
  • 25. Quality Measure Score Thresholds • Cut points for the QMs were set based on the QM distributions averaged across Q2-Q4 of 2011 – will be maintained for a period of at least two years, after which CMS will review • These thresholds were set so that the overall proportion of nursing homes in each rating category in July 2012 (when the QM rating based on MDS 3.0 is first reported) would be similar to what it was when the MDS 2.0 QM rating was frozen in March 2011. 25
  • 26. Comparison of Five-Star Quality Domain 2.0-3.0 26
  • 27. Facility Star Rating Changes 2.0-3.0 New Quality Rating – Number of Facilities Percent of Facilities Old Quality Rating -4 44 <1% -3 445 3% -2 1418 9% -1 3205 21% 0 4967 33% 1 3251 21% 2 1435 9% 3 406 3% 4 62 <1% Although the national distribution of star ratings remains the same, individual facilities will see changes in their own Quality ratings 27
  • 28. CMS August Update to Nursing Home Compare • Shifted QM 3-quarter time period from March-December 2011 to July 2011-March 2012 • Facilities saw a resulting change in their publicly reported QM rates and star ratings • Note the potential for changes with each quarterly update to NHC 28
  • 29. Facility Star Rating Changes July- August 2012 August 2012 Quality Rating– Number of Facilities Percent of Facilities July 2012 Quality Rating -4 0 0% -3 2 <1% -2 60 <1% -1 1857 12% 0 10425 68% 1 2939 19% 2 122 1% 3 10 <1% 4 0 0% 29
  • 30. Five-Star Changes and Your Facility • Changes in the QMs can have an effect on your facility’s Quality and Overall Five-Star ratings – Keep on top of CMS updates to Five-Star • The challenge: to understand these changes to put your facility’s rating in context and communicate with residents, families and the public 30
  • 31. Five-Star/QMs and Your Ability to Compete 31
  • 32. How was the Five-Star Quality Rating System designed to be used? 1. Help educate consumers about nursing home quality 2. Help improve provider quality 32
  • 33. How are Five-Star and MDS 3.0 QMs actually being used?  SNF’s marketing departments  Hospital Discharge planners  HUD lending/re-financing  Plaintiff attorneys  Insurance brokers  ACOs/ “Bundles”  Medicare Advantage Plans  Media 33
  • 34. 1. Does the SNF that you work for have a marketing strategy? 34
  • 35. 2. Does the SNF that you work for use Five Star rating in marketing efforts? 35
  • 36. 3. Does the SNF that you work for use Quality Measures (QMs) in marketing efforts? 36
  • 37. 4. Does the SNF that you work for sometimes lose referrals to other SNFs with a higher Overall Five Star rating? 37
  • 38. 5. Does the SNF that you work for use the Overall Five Star rating in their marketing efforts to hospitals? 38
  • 39. 6. Does the SNF that you work for use the Overall Five Star rating in their marketing efforts to ACOs? 39
  • 40. 7. Does the SNF that you work for market your Five Star components (i.e. Survey, Quality, Staffing, etc.) separately? 40
  • 41. 8. Was the SNF that you work for “surprised” by your 3.0 Quality Measure (QM) rating compared to your 2.0 QM rating? 41
  • 42. 9. Do you find that the Quality Measures (QMs) enhance your overall marketing strategy? 42
  • 44. Five Data-Driven Strategies for Using Five-Star and QMs to Market your Facilities More Effectively 1. Remember the who and why 2. Turn blunt instruments into sharp tools 3. Augment Five Star and QMs with other key metrics 4. Don’t rely solely on yesterday’s news 5. Turn weaknesses into strengths 44
  • 45. How is Your Data Quality? Proportion of MDS Assessments with Issues (>5,000,000 assessments) 17% With Issues Without Issues 83% Of the 83% of assessments with issues, on average each assessment had 2.41 issues. 45
  • 46. QM Strategies for Success • Review MDS Data for accuracy – Correct errors before CMS submission – Identify processes that impact accurate MDS coding • Supporting documentation • Staff education • Make Five-Star QMs part of facility quality improvement process – Trends and benchmarks • Root Cause Analysis – Review other CASPER QMs and related care processes – Monitor positive outcomes to ensure good processes are maintained 46
  • 47. Nursing Home Quality Assurance & Performance Improvement (QAPI) • Being rolled out by CMS in 2012 • Provides tools and resources to help facilities meet existing QAA requirements – Based on best practices – Continuously identify and correct quality deficiencies – Sustain performance improvement • QAPI Element 3: Feedback, Data Systems and Monitoring – QMs can be incorporated into QAPI monitoring 47
  • 48. For More Information • QM Users’ Manual – www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/Downloads/MDS30QM- Manual.pdf • Five-Star User’s Guide – www.cms.gov/Medicare/Provider-Enrollment-and- Certification/CertificationandComplianc/Downloads/usersguide. pdf • CMS’ QAPI Page – www.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/QAPI.html 48
  • 49. Thank You! • Jennifer Gross Senior Healthcare Specialist – jennifer.gross@pointright.com • Jeff Merselis VP Business Development – jeff.merselis@pointright.com • http://www.pointright.com 49