CMS Sponsored Quality Improvement Organization QIO Support Presented

CMS Sponsored Quality Improvement Organization (QIO) Support Presented by: Gwendolen Buhr, MD Associate Professor of Medicine, Geriatrics Duke University 11/6/2020 1

Objectives ► ► Understand how the CMS Quality Measures can drive the QAPI process for the nursing home Identify the quality measure components of the composite score that CMS uses to identify success for a QIP Determine what strategies from the NNHQCC Change Package can be the focus of the care provided by the nursing home’s services Identify available resources to improve quality in the nursing home

August 2014 – July 2019

CMS - QIO Contract Focus: Reducing Healthcare-Acquired Conditions in Nursing Homes QIN-QIO Focus: Support adoption of QAPI framework for quality improvement Improve composite score of 13 measures Reducing avoidable hospitalizations – ACO 35 CMS C. difficile reporting and reduction project, 2016 -2018

CMS – QIO Recruiting Nursing Homes Recruit at least 75% of all nursing homes to participate in the National Nursing Home Quality Care Collaboratives (NNHQCC) Special attention to recruiting “One-Star” homes Recruit high performing homes as “Peer-coaches”

QIN-QIO Tools Webinars ► Virtual Coaching ► Educational Workshops ► Collaboratives ► Website Resources ► Tracking Database (PIMS) ► Performance Data ► Patient Education Resources ► Change Package ►

CMS C. difficile Reporting and Reduction Project, 2016 -2018 ► ► ► Nursing homes will receive support to implement and sustain C. difficile infection (CDI) reporting into NHSN This effort will generate a national baseline of nursing home -onset C. difficile infection incidence and inform the feasibility of large-scale NHSN reporting by nursing homes Participating facilities will also receive training and support on CDI reporting and prevention activities including: ► ► ► Analysis and interpretation of CDI event data Training in LTC communication (Team. STEPPS) Implementation of antibiotic stewardship and CDI prevention

QAPI Quality Assurance and Performance Improvement ► ► QAPI is the coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving.

QAPI Definitions ► QA is the specification of standards for quality of service and outcomes, and a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is on-going, both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards. ► PI (also called Quality Improvement - QI) is the continuous study and improvement of processes with the intent to better services or outcomes, and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement. PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life. PI can make good quality even better.

Five Elements Element 1: Design and Scope Element 2: Governance and Leadership Element 3: Feedback, Data Systems and Monitoring Element 4: Performance Improvement Projects (PIPs) Element 5: Systematic Analysis and Systemic Action

QAPI Tools ► RCA (Root Cause Analysis) Ø Ø ► Fishbone diagram 5 Why’s (Preferred by nursing homes) PDSA Ø Plan Ø Do Ø Study Ø Act

RCA

RCA (Root Cause Analysis) Walk through your problem using the 5 -Whys PROBLEM STATEMENT followed by “Why’s”: WHY → → WHY→ WHY Exercise should be completed using a Multi-discipline Team Approach with those involved in resident care or facility depending on the issue being investigated.

F 520 Regulation 483. 75 (o) Quality Assessment and Assurance 1) A facility must maintain a quality assessment and assurance committee consisting of: (i) the director of nursing services; (ii) a physician designated by the facility and (iii) at least 3 other members of the facility’s staff. 2) (i) Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and (ii) develops and implements appropriate plans of actions to correct identified quality deficiencies.

Physician Involvement in Nursing Home Quality Improvement ► ► Be engaged in the QAPI process Advise on Quality Committees Review Quality Measures and Resident Level Activity Reports/available on CASPER Be engaged with Pharmacy, Nursing, and Therapy Consultants

Composite Score GOAL: 50% of centers have Quality Composite Score of 6. 0 OR LESS by January 2019 ► North Carolina: 78 Nursing Homes met the criteria for a Composite Score of <6. 0 by Q 117 (Information on Quality Measures available on CASPER or Corporate equivalent reports that are updated monthly following MDS uploads)

Composite Score (Goal <6) Comprised of 13 NQF-endorsed, long-stay quality measures from MDS Percent (%) of residents: 1. with one or more falls with major injury 2. with a UTI 3. who self-report moderate to severe pain 4. with pressure ulcer 5. with loss of bowels or bladder (incontinence) 6. with catheter inserted or left in bladder 7. physically restrained 8. whose need for help with ADL has increased 9. who lose too much weight 10. who have depressive symptoms 11. who received antipsychotic medications 12. assessed and appropriately given flu vaccine* 13. assessed and appropriately given Pneumococcal vaccine* *The direction of the two vaccination measures should be reversed because they are directionally opposite of the other measures. This is done by subtracting the numerator from the denominator to obtain a “new” numerator. By keeping all measure directions consistent, the composite score can be interpreted as: the lower, the better.

http: //www. alliantquality. org/content/composite-score

NC COMPOSITE SCORE PROGRESS 90 30 80 25 70 60 20 50 15 40 30 10 20 5 10 0 2015 Q 2016 Q 2017 Q 2 3 4 1 Series 1 14 23 28 40 47 65 71 78 Number of facilities with score <6 0 2015 Q 2016 Q 2017 Q 2 3 4 1 Series 1 25. 0 4. 5 7. 4 9. 0 12. 9 15. 2 21. 0 22. 9 25. 2 GOAL Percent of facilities with score <6

SC COMPOSITE SCORE PROGRESS 80 60 70 50 60 40 50 30 40 30 20 20 10 10 0 Cumulative # NNHQCC homes <=6. 0 0 2015 Q 22015 Q 32015 Q 42016 Q 12016 Q 22016 Q 32016 Q 42017 Q 1 33 41 47 53 58 64 66 71 Number of facilities with score <6 Cumulative % NNHQCC homes <=6. 0 GOAL 25 2015 Q 2016 Q 2017 Q 2 3 4 1 23. 4 29. 1 33. 3 37. 6 41. 1 45. 4 46. 8 Percent of facilities with score <6 50. 4

% of Facilities with Score <6 Ranking of States By % of Facilities with Composite Score <6 GA Composite Score Progress 1. 2 GA Composite Score Progess Percentage South Carolina 50. 4% 1. 2 1 Goal by 2019 0. 8 1 North Carolina 25% 0. 8 0. 6 0. 4 0. 2 0 Series 1 0 All States Series 1

Quality Measure Tip Sheets • Antipsychotic Medication • Falls • UTI • Incontinence • ADL’s • Pain • Pressure Ulcer • Depression • Catheter • Restraints • Weight Loss • Influenza Vaccine • Pneumococcal Vaccine http: //www. alliantquality. org/content /quality-improvement-resources-0

The Change Package ► The National Nursing Home Quality Care Collaborative (NNHQCC) focuses on systems improvement and several quality measures. ► Examples of systems: ─ Staffing ─ Compliance ─ Operations ─ Clinical Models ─ Communication ─ Leadership ─ Quality of Life indicators ─ Clinical outcomes http: //www. alliantquality. org/sites/default/files/NH_Change. Package_032615_Final_508. pdf

Change Package Strategies - a menu! 7 strategies 1. 2. 3. 4. 5. 6. 7. Leadership Recruit and retain staff Connect with residents Teamwork Learning Compassionate Clinical Care Solid Business Practices

Any Bright Ideas, Thoughts, Hunches, Gut Feelings ?

National Tools and Resources Ø Ø Ø NNHQI-National Nursing Home Quality Improvement Campaign Goal Setting Tools and Spreadsheets for tracking improvements Nursing Homes encouraged to submit data to receive reports including benchmarks for progress Step by step guides for improvement process https: //www. nhqualitycampaign. org/

National Tools and Resources cont. Ø Ø Ø INTERACT STOP and WATCH SBAR Tracking tools Care Paths Transfer form template Advance Planning tools http: //www. pathway-interact. com/interact-tools/interacttools-library/interact-version-4 -0 -tools-for-nursinghomes/

Stop and Watch/ Early Warning Tool ► Designed to be used by CNAs. Appropriate for everyone ► Need a process for restocking/ reordering, checking on resolution ► Nursing response to receiving these is critical

Care Paths: ► ► ► ► Symptoms/Signs What to do Criteria Next steps Notifications Orders Monitoring

Interacting with Your Hospitals Make Sure Everyone Knows Your Facility’s Capabilities This tool can be posted in the ER and in Case Managers’ offices

INTERACT Tools

https: //interact 2. net/tools_v 4. html

FREE Patient Education Resources http: //www. alliantquality. org/content/orders

Contact Information – North Carolina Adrienne Mims, MD MPH FAAFP, AGSF Vice President, Chief Medical Officer Medicare Quality Improvement Alliant Quality 1455 Lincoln Pkwy, Suite 800 Atlanta, GA 30346 O 678. 527. 3492 | C 770. 238. 9196 Adrienne. Mims@Alliant. Quality. org www. Alliant. Quality. org

Contact Information – South Carolina Nancy (Libby) Lawson, MEd, RN Quality Specialist, SC-AQIN/QIO Medicare Quality Improvement The Carolinas Center for Medical Excellence (CCME) 12040 Regency Parkway, Suite 100 Cary, NC 27518 803. 212. 7500 ext. 5619 nlawson@thecarolinascenter. org www. atlanticquality. org

This material was prepared by GMCF, for Alliant Quality, the Medicare Quality Innovation Network – Quality Improvement Organization for Georgia and North Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U. S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 11 SOW-GMCFQIN-C 2 -17 -48