THE FINAL RULE,
VALUE BASED
PURCHASING, AND
OTHER HOT TOPICS
BHS Clinical Services Group
September 2015
 Familiarize
and/or re-familiarize your
understanding of the multitude of regulatory
and payment changes occurring across the
healthcare continuum
 Identify
the steps each community can
implement to be best prepared for the
transformation
 Attain
the top 10th percentile of quality utilizing
Competency Based Training
OBJECTIVES
In the past 6 months you’ve learned:

Cuts to Medicare Payment rates by 2% is coming (PAMA & VBP)

Hips & knees bundles will be controlled by the hospitals (CMS
Bundles)

MDS Focused Surveys started for validating MDS accuracy

Dementia Care Focused surveys have started

CMS is adding new 5 Star quality measures in 2016 (IMPACT)

Changes to the MDS effective October 1, 2016 (IMPACT)

Payroll data must be submitted to CMS (PBJ)

Changes ICD-9 coding to ICD 10 (ICD-10)

Revised SNF requirements of participation regulations (ROP)

Hospitals are asking if you are using Interact to reduce rehospitalizations
HHS PAYMENT REFORM
 HHS
announced targets to increase the
number of payments that are linked to
quality outcomes by 2018

“We are setting clear goals – and establishing a clear timeline --for
moving from volume to value in Medicare payments”

“Our first goal is for 30% of all Medicare provider payments to be in
alternative payment models that are tied to how well providers care for
their patients, instead of how much care they provide – and to do it by
2016. Our goal would then be to get to 50% by 2018”

“Our second goal is for virtually all Medicare fee-for-service payments
to be tied to quality and value; at least 85% in 2016 and 90% in 2018”
HHS Secretary Burwell Jan 26, 2015
-
David Gifford, MD, MPH, American Health Care
Association
Comprehensive person-centered care planning §483.21

Require proposed baseline care plan be completed within 48
hours of a resident’s admission.

Increased coordination and updating to PASARR

Mandatory members of IDT – add NA with responsibility for the
resident, appropriate member of the food and nutrition services
staff, social worker.
THE PROPOSED FINAL RULE

Facility Assessment – Annually

Determine resources needed to “care for its residents competently
both day to day operations and emergencies”

Resident capacity and number of residents / Care required by the
resident population

Staff education and competencies required

Determining staffing requirements

Emergency Preparedness planning

Physical environment needs for the population

Ethnic, cultural, religious factors (r/t food and activities)

Services provided (e.g. rehab, respiratory care)

HIM needs

QAPI development
THE PROPOSED FINAL RULE


Physician Credentialing

MD/NP/PA present prior to sending a resident to the
ED or hospital unless emergent

Lab results must go to the exact person who ordered
it
Social Worker FT basis;

Asking if other gerontology degrees would work in
place of a SW

Activity Director qualifications

Sufficient Staff with competencies

Respiratory Therapist
THE PROPOSED FINAL RULE

Behavioral Health

Competencies:

Propose to require that staff must have the appropriate
competencies and skills to provide behavioral health care and
services, which include caring for residents with mental and
psychosocial illnesses and implementing non-pharmacological
interventions. “Trauma Informed” staff

Extending decreasing ALL psychotropic drug use (even include
opioids, “and any other drug that result in effects similar to the
drugs listed above (anti-psychotic, anti-depressant, anti-anxiety,
hypnotic…)
THE PROPOSED FINAL RULE

Infection Prevention and Control Program (PICP)

Infection Prevention and Controls Officer(s) (IPCO).

Specialized training (undefined)

Major responsibility of the individual assigned

Ethics

QAPI within 1 year after the date on which the regulations are
promulgated

And much more…!
THE PROPOSED FINAL RULE
(COMMENTS DUE WITH EXTENDED
DEADLINE TO OCTOBER 14, 2015

Protecting Access to Medicare Act


Improving Medicare Post-Acute Care Transformation


IMPACT
Value Based Purchasing


PAMA
VBP
Payroll Based Journal

PBJ
PAYMENT AND QUALITY
Top 10% in
Quality of Care
and Life Measures
Excellent patient experience + Excellent Care = The Right Reimbursement
Link to Proposed Final Rule:
http://www.gpo.gov/fdsys/pkg/FR-2015-07-16/pdf/2015-17207.pdf
Protecting access to Medicare act (PAMA) of
2014 links SNF rehospitalization to SNF Medicare
Part A payments
 Uses
a with-hold approach

2% “mathematical” withhold of SNF Part A payments

50-70% of the withhold is used to create an incentive
pool

SNFs can earn back their 2% withhold based on their
rehospitalization performance score;

Rehospitalization score is a combination of level of
achievement and improvement, which ever is better

First adjustment to a SNF’s payment will be in Oct 2018 based
on performance likely starting in early to mid 2016
David Gifford, MD, MPH, American Health Care Association
“IMPACT ACT OF 2014”
Legislation has five parts :
1.
Incorporate standardized clinical assessments
2.
Public reporting of common quality measures
3.
Provide quality measures to consumers when transitioning
to a PAC provider
4.
Interoperability of information at transfer
5.
HHS and MedPAC to conduct several studies
PAC REFORM
 Incorporate
standardized assessment(s) (e.g.
CARE tool) into existing assessment tools across all
PAC providers (LTCH, IRF, SNF, & HH) for




Pressure ulcers
Functional status
Cognitive status
Others as directed by Secretary
 Collect
standard data at admission and
discharge
 Fully Implement by Oct 2018
“IMPACT ACT OF 2014” - PART 1


Publicly report quality measures across PAC settings

Rehospitalizations

Discharge to community

Pressure ulcers

Medication reconciliation

Incidence of major falls

Functional Status

Patient preferences

Efficiency measure(s): Avg Total Medicare Spend per Beneficiary

Plus any other measures Secretary wants
Measures to be approved by National Quality Forum (NQF)
“IMPACT ACT OF 2014” PART 2
Red Txt specified by CMS in 2016 Proposed rules for SNF, IRF & LTCH
ESTIMATED TIMELINE FOR SNF VBP
IMPLEMENTATION
Withhold Starts
SNF comments
Post withhold in
Proposed Rule
Analyze
Data
Collect
Data
Measurement Period
Oct
2015
July
2016
Oct
2016
Oct
2017
Oct
2018
Oct
2019
SNF NATIONAL REHOSPITALIZATION RATES
Likely to receive
2% back
At risk for full 2% penalty
All Policies involve re-hospitalizations:

HRRP program financially penalizes hospitals with high 30 day readmission rates

ACOs & bundle payment models can only financially work by
lowering re-hospitalizations over 90 days

SNF VBP Statute requires CMS to implements a 2% withhold of SNF
Part A payments that can be returned based on your rehospitalization rates

IMPACT act of 2014 requires CMS to measure and publicly report
collection of PAC quality measures including re-hospitalization
and Discharge to community

Re-hospitalization rates will be added to Five Star

Protecting Access to Medicare Act (PAMA) of 2014 – contains
VBP section with re-hospitalization metrics.
David Gifford, MD, MPH, American Health Care Association

Adverse Events, OIG 2014 – findings show AE’s increase
re-hospitalizations
WHERE DO WE FOCUS?

Adverse Events

Medication Related
37%

Care Related
37%

Infection Related
27%

Contributing to Re-hospitalization and lengthened length of stay
OIG Adverse Events in SNF Report; February 2014
WHERE DO WE FOCUS?

Re-hospitalizations

Discharge to the Community

Length of Stay

5 Star Rating


5 Star: QM’s

5 STAR Staffing

Survey Preparedness
Capacity & Competency Based Training (K-S-A)
WHERE DO WE FOCUS?

QM’s with Highest Impact on VBP:

Pain

Pressure Ulcer

Satisfaction

Falls with Major Injury

Re-hospitalization

Discharge to Community
WHERE DO WE FOCUS?

Specifies three measures

New or worsening pressure ulcers


Falls with injury


Based on MDS SNF long stay falls measure
Functional assessment at admission and discharge with goals


Based on MDS SNF short stay pressure ulcer measure
Based on Section IV of CARE tool (self-care & Mobility)
Specify changes to MDS

Adds section GG for self-care & mobility items from CARE tool

Changes to Discharge Assessment

Adds falls and section GG CARE items

Requires discharge assessment at discharge from SNF Part A
coverage
FY 2016 PROPOSED RULE
5 STAR OVERALL SCORING METHODOLOGY
Step 1: Initial star rating based on State ranking on your Survey Score
Step 2: Add or subtract one Star based on Staffing component

Subtract 1 star if staffing rating is 1 star

Add 1 star if staffing is 4 or 5 stars & > Survey rating
Step 3: Add or subtract 1 Star based on QM component


Subtract 1 star if QM rating is 1 star
Add 1 star if QM rating is 5 stars
WHERE DO WE FOCUS?
Value Based Purchasing

5 Star management – no return of the 2% if a community is not
at least a 3 Star Community

What can I control:


Can plan on Staffing point with focus

Can plan of QM’s with focus
What can be managed but not controlled:

Survey management not totally predictable

Must have low scope and severity deficiencies

Must pass the 1st re-survey
WHERE DO WE FOCUS?

Nurse Transition Coordinator


Alignment with referral
sources
On-going progress towards
goal discussions

“Real” discharge planning

Warm hand offs

Appointment set up

Patient goal setting

Transportation

Advanced Care Planning

Socio-economical factors

Patient / care giver education

Follow-up calls

Medication Reconciliation at
each transition


“Bed-side Care Conferences
Patient satisfaction interview
process
KEY COMPONENTS OF A
SUCCESSFUL TRANSITION


Cost of Care

Alignment with referral
sources

By co-morbids?

Length of Stay (LOS)

Interoperability

St Catherine University
possible grant

Admission Criteria (Capacity)

Alignment of brands (e.g.
type of dressings)

NURSE TRANSITIONS
COORDINATOR
Importance of Partnering

Transparency

Shared Risk

Removing Barriers
KEY COMPONENTS FOR
SUCCESSFUL TRANSITIONS
5 Questions to Ask the Elderly based on Atul Gwande’s Book: “Being Mortal”
1. What is your understanding of where you are and of your illness?
2. What are your fears and worries for the future?
3. What are your goals and priorities?
4. What outcomes are unacceptable to you? What are you willing to
sacrifice and not?
5. What would a good day look like?
From Atul Gwande’s book: “Being Mortal”
David Gifford, MN, MPH, AHCA/NCAL’s summary of “Being Mortal”
ADVANCE CARE PLANNING TO
REDUCE RE-HOSPITALIZATIONS

Target individuals at high risk:

How can you determine who is at high risk for readmission?

Prior hospitalization in past 12 months is strong predictor

ICU stay

Long Hospital LOS (such as >10 days)

How many risk factors that are used in OnPoint-30 Measure does the
resident have


Quick and simple approach is to add up the number of 33 risk adjusted
variables a person has at admission to SNF
Use systems to prevent adverse events that lead to hospitalizations

Medication errors for medications that require monitoring

Falls (often related to orthostatic hypotension)

Infections
David Gifford, MD, MPH, American Health Care Association
TARGET INDIVIDUALS AT HIGH RISK




Demographic

Diagnoses

Age >65

Anemia

Male

Asthma

Medicare as Primary Payor

Diabetes Mellitus

Hx of Viral Hepatitis

Hx of Septicemia

Hx of Heart Failure

Hx of Internal bleeding
Functional Status

Total Bowel Incontinence

Eating dependent

Needs 2 person assistance in ADLs

Cognitive Impairment (Dementia)
Prognosis

Services & treatments

End Stage prognosis poor

Dialysis

Recently rehospitalized

Insulin prescribed

Hx of Respiratory Failure

Ostomy care

Receiving Hospice Care

Cancer Chemotherapy

Receiving Radiation Therapy

Continue to receive IV Medication

Continue to receive oxygen

Continued tracheostomy care
Clinical Conditions

Daily pain

Pressure Ulcer Stage >2 (split into 4 variables)

Venous Arterial Ulcer

Diabetic Foot Ulcer
RISK ADJUSTMENT VARIABLES
USED

Three strongest predictors from per JAMDA article:
1.
Training provided to nursing staff on how to communicate
effectively with physicians about a residents condition
2.
Physicians who practice in this nursing home treat residents within
the nursing home whenever possible, saving hospitalization as a
last resort
3.
Provided better information and support to nurses and aides
surrounding end-of-life care
FACTORS ASSOCIATED WITH LOW
REHOSPITALIZATIONS
1Young
Y et al. Clinical and Nonclinical Factors Associated with potentially preventable
hospitalizations among nursing home residents in NYS. JAMDA 2011;12:364-371.
Educate
Knowledge
Skill
Train
Attitude
COMPETENCY BASED TRAINING:
KSA
Practice
Clinical Needs of the Center
Competency Based Training
Critical thinking via Simulation
CLINICAL CAPACITY
Assess Referral
Source Needs
Create Admission
Criteria
Assess Gap
Between
Admission Criteria
and Current Skill
Level
RAISING CAPACITY OF THE CARE
CENTER
• Reduce HF
Hospitalizations
Train
• Red Flag
Warning Signs
• Practice
Interventions
Using Expected
Scenarios
Educate
BUILDING CRITICAL THINKING
Practice

Use INTERACT PROGRAM
 Use all its components
 Its all about implementation
 FYI: MatrixCare is not updating Interact and will be using
AMDA Clinical Practice Guidelines
Root cause analysis of each hospitalization

Start with the view point: 100% are preventable
 Risk stratify each admission for re-hospitalization risk
Treat rehospitalizations as trigger to have end-of-life discussion



David Gifford, MD, MPH, AHCA/NCAL
DATA DRIVEN DECISIONS
CMS SNF-RM
POINTRIGHT PRO 30

MDS based

Part A claims only

All payer

Part A SNF FFS

30 day window

30 day window

During SNF stay only

During & after SNF stay

All cause readmission

All cause readmission

Observation included

No observations

Includes elective admits

Excludes elective admits
DATA: CMS SNF RM VS POINTRIGHT PRO 30

PointRight Pro 30 Rehospitalization* (now available)

Discharge Back to the Community

Length of Stay

Improvement in Functional Status*
(now available)
(now available)

Mobility (based on CARE tool)

Self-Care (based on CARE tool)

Customer Satisfaction***

Long Stay Hospitalization

Unintended Healthcare Outcomes
(now available)**
(now available)
(Oct 2015)
(Mar 2016)
DATA: AHCA DEVELOPED PAC
MEASURES
*
NQF endorsed measures
** Requires use of CARE tool linked with MDS admission data
*** Requires use of AHCA CoreQ satisfaction questionnaire

Silver & Gold recipients have better

Survey Scores and fewer deficiencies

Quality Measures

5 Star Ratings

Rehospitalization rates

Staff Retention & less turnover

Occupancy
VALUE OF QUALITY AWARD

Know your capacity and competency



Re-evaluate your associate education/skill
Focus on re-hospitalization rates

Transitions of care

Interact 4.0

Root Cause Analysis
5 Star Program:

Focus on QM & Staffing in the 5 Star Program

Survey Management – tools within the 360

MUST pass re-survey

Focus on the upcoming new QM’s from IMPACT

Cost of Care

Don’t forget data integrity of MDS (Triple Check, MDS Audits, PointRight)

Keep up with the professional reading & be networked
ACTIONS
APPENDIX
What is the CCJR Proposal?
Comprehensive Care for Joint Replacement (CCJR)
Proposed Rule
 The proposal would
 Test 90 day bundled payments for lower extremity joint




replacement (Hips & Knees)
Apply to FFS Medicare Beneficiaries only
Apply to hospitals in 75 Metropolitan Statistical Areas (MSAs)
Run for five years
Waives 3 day stay
o Begin January 1, 2016 and end December 31, 2020
Payment & Pricing: Link to Quality
 Hospitals must meet minimum threshold on 3 quality metrics
to receive their bonus:
1.
Hospital Level Risk Standardized Complication Rate (RSCR) for elective
Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA)
2.
Hospital Level 30 Day, All Cause Risk Standardized Readmission Rate
(RSRR) Following THA or TKA
3.
Satisfaction based on Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAPHS) Survey
 Additional financial incentive to submit data on a patient-
reported functional outcome measure

Collect data on your performance & share with
hospitals

Rehospitalization rate during SNF stay & after SNF
discharge

Discharge to community rate

LOS

Improved function

Satisfaction score

Improve your rates on the measures that count

Maintain 3 Star rating or higher
TIPS ON HOW TO SUCCEED IN
CCJR