The Future and Direction of Quality in
Post Acute Care
“Everyone’s talking….”
Cheryl Phillips, M.D.
SVP Public Policy and Advocacy
LeadingAge
– CMS
– Legislation
– Consumers
– State Medicaid Offices
– NQF
– NCQA
– Joint Commission
Who Drives Quality Measures in
PA/LTC?
MULTIPLE FORCES ARE DRIVING
CHANGE in Long Term Care
• New payers, new players, new rules
• Payment for quality – AKA Value-based
purchasing
• Restricted networks
• New “partners” – ACOs, bundled
payments, “non-traditional” health
care providers
• Proposed payment changes
• Big shifts in consumer expectations
High Level Look at Some of These
Forces
“Better, Smarter, Healthier Care”
Value-based
Payment for
PA/LTC
Current Measures
• CMS NH/HH Compare QMs
• Survey Findings
• Managed Care, ACOs and Bundled models –
including measures of utilization and service
• Length of stay
• 24/7 admission availability
• Utilization of Interact tool to reduce hospital admissions
• WIDE variety of state-level VBP measures
• Potential……NQF PA/LTC measure set
• Soon to be…….IMPACT measures
MEASURES OUT FOR PUBLIC
COMMENT NOW…
A Step by Step Guide to Building a Quality
Assurance
and Performance Improvement (QAPI) Program
in Your Nursing Home
Quality Measurement:
Our New Currency
CMS 5-Star Quality Rating
What Will Change?
NH Five-Star Quality Measures
• Long-stay residents
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–
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–
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% whose need for help with ADLs has increased
% of high risk residents with pressure ulcers
% of residents who have/had a catheter placed and left in their bladder
%of residents who were physically restrained
% of residents with a UTI
% of residents who self-report mod to severe pain
% of residents experiencing one or more falls with major injury
% of residents who received an antipsychotic medication
• Short-stay residents
– % of residents with pressure ulcers that are new or worsened
– % of residents who self-report mod to severe pain
– % of residents who newly received an antipsychotic med
Longer-Term Potential Further
Improvements to NH Compare
(per CMS)
• Dynamic consumer testing
• Interactiveness: Make the website more
interactive to refine search
• Staffing Data: Collect staffing data based on
payroll sources, submitted quarterly
• Quality Measures: Add new quality
measures (hospitalization measure…others?)
Longer-Term Potential Further
Improvements to NH Compare
• NH Characteristics + Capabilities: Add
additional information about nursing homes
– Private rooms
– Languages spoken
– Availability of specialty units (rehab,
ventilator support…)
• Satisfaction Surveys: Study potential
reporting of satisfaction survey results –
residents, families, staff
HR 4303: Protecting Access to
Medicare Act of 2014 (PAMA)
• All-cause, all-condition hospital readmission SNF
measure by 10/1/15
• Risk-adjusted potentially preventable hospital
readmissions for SNF by 10/1/16
• Quarterly feedback to SNFs
• Public reporting on NH Compare
• Establish a SNF VBP program with incentive/penalty
payments to SNF
IMPACT Act
• Improving Medicare Post-Acute Care
Transformation – “IMPACT”
• Legislation introduced in June, H.R. 4994/S. 2553
• Bipartisan, bicameral interest and support
• Passed House and Senate week of Sept. 15… now
Law
• In addition to new reporting requirements – sets
the path for new models of post-acute payment
Stated Goals of IMPACT
• Compare quality across post-acute settings
(hospitals originally included, but were exempted in
final bill)
• Improve hospital and PAC discharge planning
• Use information to reform PAC payments
(???site neutral)
• Public reporting
A Side Word on Site-Neutral
(the point
where true
site-neutral
occurs)
Home
Health
Skilled
Nursing
Home
Inpatient
Rehab
IMPACT Required Standardization
• PAC providers must report:
– Standardized resident assessment data
– Data on quality measures
– Data on resource use and other measures
• PAC assessment instruments must be modified to:
– Enable the submission of standardized data
– Compare data across all applicable providers
– ??? How this will align with current assessment
requirements
IMPACT Quality Measures
•
•
•
•
•
•
•
•
•
Functional status and changes
Cognitive function and changes
Skin Integrity
Special services, treatments, etc (resource use)
Medical conditions and co-morbidities
Other impairments
Medication reconciliation*
Major falls*
Patient preferences*
* CMS is currently behind in development of standardized reporting measure
IMPACT Resource Use Measure
• May include standardized assessment data in
addition to claims data
• Total est. Medicare spending per beneficiary
(will involve contractor to collect and report)
• Discharge to community
• All-condition, risk-adjusted potentially
preventable hospital readmission rates
Resources for PAMA and IMPACT
• Protecting Access to Medicare Act of 2014 (PAMA)
signed 4/1/14:
– https://www.govtrack.us/congress/bills/113/hr4302/text/
enr#link+11_215&nearest=H80C0CE9753E241C2B84F9141
D931FA6F
• Improving Medicare Post-acute Care Transitions
(IMPACT) Act of 2014, signed 10/6/14
– https://www.govtrack.us/congress/bills/113/hr4994
Aligning what CMS and Payors
Will be Looking For
•
•
•
•
•
•
•
Resource utilization (cost of care)
Adverse Events (falls, pressure wounds, etc)
Readmissions
Length of Stay
Return to home/community
Timeliness of service
Patient experience of care
What do we do??
https://interact2.net/
Working Together to Improve
Care, Communication, and
Continuity for our Residents
http://go.cms.gov/Nhqapi.
3,805
3,673
53
Consumers
Nursing Home
Staff Members
State-based
LANEs
Assisted Living, Residential Care and
Home Care/Personal Care Services
• Regional quality problems in
Residential Care/AL
• No federal quality regulatory system
now or likely in the future
• MULTIPLE states are looking at a
variety of quality measures and
oversight strategies
• Quality strategies for nursing homes
and home health can be applied to
assisted living
What does it mean to create a
culture of safety?
How can I use these quality tools
and measures to make that
happen?
Shift in thinking…
• Goal is to create an environment of
efficient, high quality, person-centered
care across PA/LTC
• Need to move to a “culture of safety”
• Need to understand “systems” within
PA/LTC and how to transform care BEFORE we
penalize
• Need to make the investment in workforce
(training and resources)
Questions, Discussion and Case
Studies…..