The Future and Direction of Quality in Post Acute Care

“Everyone’s talking….”

Cheryl Phillips, M.D.SVP Public Policy and Advocacy

LeadingAge

Who Drives Quality Measures in PA/LTC?

– CMS– Legislation– Consumers

– State Medicaid Offices– NQF– NCQA– Joint Commission

Quality

Car

MULTIPLE FORCES ARE DRIVING CHANGE in Long Term Care

High Level Look at Some of These Forces

• 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

“Better, Smarter, Healthier Care”

Shared Savings ModelsBundled

Payments

Quality IncentivesPenalties

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

NO REGS YET!

Quality Measurement: Our New Currency

What Will Change?

CMS 5-Star Quality Rating

NH Five-Star Quality Measures• Long-stay residents

– % 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

Home Health

In-patient Rehab

Skilled Nursing Home

(the point where true site-neutral occurs)

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=H80C0CE9753E241C2B84F9141D931FA6F

• 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??

Working Together to Improve Care, Communication, and

Continuity for our Residents

https://interact2.net/

http://go.cms.gov/Nhqapi.

3,805Consumers

3,673Nursing

Home Staff Members

53State-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…..