UNDERSTANDING THE AHCA/NCAL QUALITY INITIATIVES FOR VALUE ADDED SUPPLY CHAIN MANAGEMENT David Gifford MD MPH American Health Care Association Washington DC Oct 6th, 2014
AHCA Quality Initiative Goals Safely reduce 30-day hospital readmissions by 15% by 2015 Reduce nursing staff turnover by 15% by 2015
Increase customer satisfaction to 90% by 2015 Safely reduce the off-label use of antipsychotics by 15% by the end of 2013 QualityInitiative.ahcancal.org
AHCA Quality Initiative Progress
Baseline 2011
Rehosp antipsychotic
18.3 23.6
Percent Members Current Change from Change from With 15% 2014 Baseline Baseline Reduction
15.7 19.1
-2.6 -4.5
-14.2% -19.1%
50.8% 54.2%
State Avg SNF Rehospitalizations 2013 Q4
Nat Avg
Getting Worse Getting Better
Change in Rehospitalization Rate
Change in State AHCA Member SNF Rehospitalizations 2011 Q4 to 2013 Q4
National Average 4.9% reduction 33,290 readmissions avoided since 2011
State Avg Use of Antipsychotics 2014 Q1
Getting Worserse Getting Better
Change in State Antipsychotic Use: AHCA Members 2011 Q4 to 2014 Q1
38 States >15% Goal
AHCA Members Achieving Goals by end of 2013 • Members achieving each of AHCA Goals 2011 to 2013 Rehospitalization Antipsychotic use Turnover Satisfaction
2012 2719 4332 1363 823
2013 4707 4935 1324 1071
• Members achieved >1 Quality Initiative Goals 1 goal 2 goals 3 goals 4 goals
2012 3752 1938 447 67
2013 3624 2846 763 108
Table Discussion Why did we pick these four goals? • Discuss at your table the reason you think these
four goals were chosen over all the other issues facing LTC providers?
Adopting “Evidence Based Practices”
Strategies to adopt EBP
• Believe change is needed • Staff should lead effort • Workflow redesign
Evidence Based Practices
• Need Tools, • Knowledge, and • Skills to use the tools
Outcome
Technical vs Adaptive Change • Balance technical vs adaptive changes • Technical changes often do not work
because the adaptive changes needed to get staff to adopt and utilize the technical change have not been addressed. • New form vs workflow redesign to complete the new form
Quality Initiative Recognition Program • Recognize members • who attained AHCA/NCAL Quality Initiative goals • Tiered approach • the more goals achieved, the more recognition received • All recognized members will be honored at Quality
Symposium in Austin, TX in 2015 • Achieve all 4 goals: • Special recognition at Quality Symposium • Featured in Provider Magazine • Featured in a national AHCA/NCAL press release
Intervention Approaches • Clinical “Patient” level interventions - the clinical process of care necessary to achieve good patient outcomes (e.g. immunizations) • System “Provider” level interventions - the systems and approaches providers use to implement clinical process of care (e.g. standing orders for immunizations) • Changing provider behavior strategies - approaches external organizations/individuals use to change provider practices (e.g. educational seminars CME) to adopt clinical or system interventions
Strategies to Change Behavior Less Effective but commonly used • Education • Penalties • Regulations & Standards • Technical Assistance
More Effective but less commonly used • Rewards & incentives • Financial • Non-financial • Audit & feedback • Peer mentoring &
collaboration • Endorse by respected individual • Academic detailing
• Social media & marketing
Balancing Top downs vs Bottom up Leadership • Top down Leadership • Set the vision • Set the goal • Provide resources need to achieve goal • Remove barriers to accomplishing the goal • Reward success and hard work • Bottom Up Leadership • Allow the staff to figure out how to accomplish the goal • Support staff in implementing tools
Successful Implementation Strategies • Rely on staff to design & test implementation strategy • Learn from Peers • Learning collaboratives • Visit other facilities
• Get at the adaptive change that is needed • Ask “what is the problem/issue we are trying to
solve?” • How will what we/you propose help us solve the problem? • Avoid “1 and Done” approach to implementation
N of 1 Trials (rapid cycle PDSA)
Pilot test on 1 unit, 1 staff, 1 resident, 1 day
Find staff her are supportive of new program Optimal if they are respected by peers Announce that know you are pilot testing a new program Promote the 1 unit, “1 staff” who are conducting the pilot Make changes based on staff feedback After a few changes, add additional staff 1 at a time Continue to make changes after each pilot test
Table Discussion What are the implications for… • Adoption of new “equipment” • Professional development
THE BUSINESS CASE FOR LOWER HOSPITAL READMISSION RATES
20
Why Readmissions? Why Now? Hospital readmissions represent a huge opportunity for potential savings to the Medicare program • Hospital Readmissions Reduction Program (HRRP) •
• • • •
•
Sec. 3025 of the ACA Began October 1, 2012 FY 2015 IPPS Final Rule solidified increase in penalty to 3% effective Oct. 1, 2014 CMS expanding this model to other provider types
Rapid ACO and MCO expansion and heightened urgency to link payment to outcomes
Use of Long Term Care Services Home 35%2
Hospit al
20%1
SNF 23%1
ER 1. 2. 3. 4.
Mor et al., 2010 MedPAC 2010 Commonwealth 2011 Jencks NEJM 2009
19%4
Assisted Living Nursing Home Death
20%3
Why Hospitals care about you • CMS has implemented a payment penalty to hospitals
with high 30 d readmission rates for discharges with diagnosis of • CHF • Pneumonia • Myocardial infarction
• Hospitals participating in ACO or Bundle payment demos
can only achieve savings by reducing rehospitalization rates • Partnering with LTC providers • Referring to low readmission providers • Admitting patients directly from ER and clinics
Hospital Readmissions: The Business Case • Hospitals, ACOs, MCOs all care about SNF readmission • Decreases stress and workload for nurses associated
with transfer & admission paperwork • SGR fix contained SNF VBP rehospitalization 2% withhold SNF Part A payments • Will soon be publicly reported on nursing home compare
ACO/MCOs use of measures • Network Selection • Discharge referrals • Quality monitoring • Payment incentives/disincentives
Linking Payment to Quality • Withholds • Bonus payment • Higher base rates • Shared savings
SNV VBP LEGISLATION 2014
SNF Rehospitalization linked to payment • SGR fix contained legislation that links SNF
rehospitalization to SNF Medicare Part A payments • Uses a with-hold approach • 2% “mathematical” withhold to create incentive pool • Incentive pool is 50-70% of the withhold
• Incentive pool is “returned” to facilities based on their
rehospitalization performance score • Performance score is based on rehospitalization rate OR degree of
improvement from prior year(s) • Top performers most or all of their withhold and possibly more • Middle performers will receive some of their withhold • Bottom performers receive less than their withhold or nothing • First adjustment to a SNF’s market basket will be in Oct 2018 (FY 19)
SNF Rehospitalization linked to payment • Requires public reporting of SNF rehospitalization • Confidential feedback reports in 2016 • Public reporting in 2017 • Development of a potentially avoidable rehospitalization measure for use in 2019 • All measures need to be risk adjusted
SNF National Rehospitalization 2013 Q4 National Average 17.3%
At risk for • 2% payment penalty; • Dropped from MCO/ACO Networks
WHERE DO I GET MY DATA?
Where Can I Get Data on My Rates? • Use Long Term Care Trend Tracker • Free AHCA member benefit • www.ltctrendtracker.com • OnPoint-30 risk adjusted measure from PointRight • CMS antipsychotic quality measure • Staffing turnover from AHCA’s annual survey • Advancing Excellence • Free excel tracking tools • INTERACT excel spread sheet tracking tool • Antipsychotic tracking tool • Staffing turnover monthly tracking tool
A FREE online tool for AHCA Members Survey History Resident Characteristics
Your Member Resource
Staffing Information & Turnover Cost Report and Medicare Utilization CMS Five Star Rating SNF Rehospitalization & DC to community
www.ltctrendtracker.com
QUALITY MEASURES FOR SNF POST ACUTE CARE
AHCA PAC Measures • 30 Day rehospitalization measure • Discharge Back to the Community • Length of Stay • Improvement in Functional Status • Change in Mobility • Change in Self-Care • Customer Satisfaction
(now available) (now available) (Dec 2014) (Oct 2014)
(Jan 2015)
Use of AHCA PAC Measures • NQF is reviewing AHCA/PointRight
rehospitalization measure • ACOs/MCOs currently using AHCA PAC measures • 3 MA Pioneer ACOs (Rehosp & Satisfaction) • 1 MA dual-eligible MCO (Rehosp & Satisfaction) • 1 NJ ACO (Rehosp & Discharge to Community) • 1 SC Care Management Company (Rehosp)
New Measure Available Discharge Back to Community % of all individuals admitted to a center from a hospital (regardless of payor or diagnosis) and who were not in a center in the prior 100 days who were discharged back to the community and remained out of any SNF for at least 30 days.
Distribution of Discharge Back to Community Rates National Avg 57.9
State Avg DC to Community Rate
Minnesota
HOSPITAL READMISSIONS
Rehospitalization Measures • All measure have same format
% = Numerator
Denominator
# of persons sent to hospital # of persons admitted to SNF
• National measures based on claims • Excludes ER visits & observation stays • Excludes Medicare Advantage & private insurance • Most measures • Fail to risk adjust for differences in patients • Claims allow for limited clinical information to risk adjust
AHCA SNF 30-Day Rehospitalization • Readmissions = all patients admitted to a SNF from a
hospital for SNF Part A services who are sent back to any hospital for any reasons within the next 30 days for either inpatient admission or observation status
Risk Adjustment Variables Used • Demographic • Age >65 • Male • Medicare as Primary Payor • Functional Status • Total Bowel Incontinence • Eating dependent • Needs 2 person assistance in ADLs • Cognitive Impairment (Dementia) • Prognosis • End Stage prognosis poor • Recently rehospitalized • Hx of Respiratory Failure • Receiving Hospice Care • Clinical Conditions • Daily pain • Pressure Ulcer Stage >2 (split into 4 variables) • Venous Arterial Ulcer • Diabetic Foot Ulcer
• Diagnoses • Anemia • Asthma • Diabetes Mellitus • Hx of Viral Hepatitis • Hx of Septicemia • Hx of Heart Failure • Hx of Internal bleeding • Services & treatments • Dialysis • Insulin prescribed • Ostomy care • Cancer Chemotherapy • Receiving Radiation Therapy • Continue to receive IV Medication • Continue to receive oxygen • Continued tracheostomy care
Risk Adjustment Method
(
)
Actual Rehospitalization National Expected Rehospitalization X Average
=
Risk Adjusted Rate
• National Average = 18.0 • Example 1: Actual > Expected • (actual 20.0) ÷ (expected 15.0) = 1.33 * 18.0 = 24.0 • Example 2: Actual < Expected • (actual 20.0) ÷ (expected 30.0) = 0.66 * 18.0 = 12.0
Actual to Expected Ratio >1 you rehospitalized more people than expected
Using Measurement isn’t enough “You can’t fatten a cow by weighing it.”* --Ancient Proverb
Its all about attitude A Medicare MCO calls the administrator to see if they want to be a preferred provider in their network but they require evidence that facility is using the INTERACT program and reviewing all of their readmissions? The administrator gets the INTERACT-II program material (www.INTERACT2.net). The QA committee starts to review all rehospitalizations but can’t find any that are preventable. Their rates do not decline and the MCO drops them from their network.
Factors Associated with low rehospitalizations • 47 Nursing homes in NY (N=26,746 patients) • Measured Clinical and non-clinical factors associated with
rehospitalization rates • Three strongest predictors #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 1Young
Y et al. Clinical and Nonclinical Factors Associated with potentially preventable hospitalizations among nursing home residents in NYS. JAMDA 2011;12:364-371.
Strategies to Reduce Hospitalizations INTERACT III Is a comprehensive program that uses these strategies • Track your rehospitalizations • Improve Communication • Externally (e.g. with hospital/ER) • Internally (e.g. between nursing & physicians)
• Identify small changes in a resident’s status early on • Change Staffing • Consistent Assignment • Reduce staff turnover • Utilize nurse practitioners • Advance Care Planning
INTERACT II Program Tools • Comprehensive approach to reduce hospitalizations • Acute care transfer log to track/measure rehospitalizations • QI Improvement review tool • Evaluation to assess each hospitalization (Root cause analysis)
• Standard Transfer Form • Communication Tool with Physicians (SBAR) • Resident assessment tool & algorithms • Stop & Watch and Care Paths
• Advance care planning resources
http://www.interact2.net
INTERACT EFFECTIVENESS Facilities
All INTERACT facilities (N = 25)
Mean Hospitalization Rate per 1000 resident days (SD) Pre intervention
During Intervention
3.99 (2.30)
3.32 (2.04)
Mean Change (SD)
- 0.69 (1.47)
4.01 (2.56)
3.13 (2.27)
- 0.90 (1.28) 0.69
Not engaged facilities (N = 8)
3.96 (1.79)
3.71 (1.53)
- 0.26 (1.83) 0.72
Comparison facilities (N = 11)
0.02 0.01
Engaged facilities (N = 17)
p value
2.69 (2.23)
2.61 (1.82)
- 0.08 (0.74)
Ouslander et al, J Am Geriatr Soc 59:745–753, 2011
Relative Reduction
17% 24% 6% 3%
QUALITY AWARD PROGRAM
Quality Award Program • Based on Baldrige Performance Excellence for Health Care • Three levels of distinction (Bronze, Silver, & Gold) • Bronze: Organizational Profile • • • •
Principal Stakeholders and their Expectations Key Performance Measures of Success/Failure Strategic Opportunities and Challenges Description of the Performance Improvement System
• Silver and Gold: Framework for Performance Excellence • • • • • • •
Leadership Strategic Planning Customer Focus Workforce Focus Operations Focus Measurement, Analysis and Knowledge Management Results
• Similar framework to CMS QAPI program
Brief History • Launched in 1996 • Approx. 10,000 applications and 4,000 awards • Criteria based on the Baldrige Performance
Excellence Program • The mission of the AHCA/NCAL National Quality
Award program is to promote and support the application of continuous quality improvement in AHCA/NCAL member organizations
3 Levels of Distinction • Organizations must achieve the award at each level to
continue to the next level 1.
Bronze – Commitment to Quality (5 pages)
2.
Silver – Achievement in Quality (20 pages)
3.
Gold – Excellence in Quality (55 pages)
AHCA Member Participation 18% Have not Applied 4% Applied but no Award
76%
• •
Applied and Received Award
Approximately 3,022 facilities have submitted an application at any level since 1996 o 2,720 of those facilities are current members as of Oct 2011 Approximately 2,217 facilities have received an award at any level since 1996 o 2,070 of those facilities are current members as of Oct 2011
NCAL Assisted Living Participation 3% 6% Have not Applied Applied but no Award Applied and Received Award 91%
•
•
Approximately 289 AL facilities have submitted an application at any level since 1996 o 265 of those facilities are current members as of Oct 2011 Approximately 191 facilities have received an award at any level since 1996 o 186 of those facilities are current members as of Oct 2011
# of Quality Award Recipients Gold: 18
Silver: 395
Bronze: 3611
2015 Quality Award Program • 2015 Bronze, Silver and Gold Application Packets now
available • Criteria changes from 2014 • Bronze and Silver Criteria has been modified slightly based on
applicant feedback • Gold applicants will continue to respond to the 2013-2014 Baldrige
Criteria- no changes • Visit Quality Award Website Qa.ahcancal.org to download
copies of new criteria • New applicants can also email
[email protected] with the subject line “Starter Kit”
2015 Program Cycle – Dates and Deadlines • Intent to Apply Deadline • Bronze Application Deadline • Silver and Gold Application Deadline • Bronze Applicant Notification • Silver Applicant Notification • Gold Applicant Notification
November 13, 2014 January 29, 2015 February 12, 2015 June 1, 2015 July 6, 2015 August 14, 2015
All deadlines listed are at 8 p.m. EST
Resources • Bronze Criteria Series: • Free web video series covering each question on Bronze Criteria • Each video is less than 5 minutes • AHCA/NCAL Management Series: • Free web video series covering each section of the Baldrige criteria • Trend Tracker • Classroom training
Recertification Policy • New policy implemented in 2014 • Recipients have 3-years to apply for next award level to
continue as an active recipient • Recipients who become inactive will be considered “past
recipients” of the program • For complete details; visit qa.ahcancal.org
Value of Quality Award • Silver & Gold recipients have better • Quality Measures • Staff Retention & less turnover • Resident Satisfaction • Occupancy • 5 Star Ratings • Aligns with CMS QAPI program • Financial performance
Value of Quality Award % Facilities Deficiency Free
Percent of Facilities with Health Citation-Free Inspections
18% 15% 12% 9% 6% 3% 0%
2010Q1
2010Q2
2010Q3
2010Q4
2011Q1
2011Q2
AHCA Golden & Silver
2011Q3
2011Q4
% Receiving 4 or 5 Stars % Facilities 4 or 5 Stars
100 90 80
73
70 60 50
43
40 30 20 10 0 Quality Award Recipients
All Others
Hospitalization Rates 30 25
30 D SNF Rehospitalizatio n
Long Stay Hospitalization 20.5
20 16.6
16.9
17.7
15 10 5 0 Quality Award National Recipients Avg
Quality Award National Recipients Avg
IMPACT ACT OF 2014
PAC Reform legislation “IMPACT ACT OF 2014” Legislation has four parts : 1. Incorporate standardized assessment 2. Public reporting of common quality measures 3. Provide quality measures to consumers when transitioning to a PAC provider 4. HHS and MedPAC to conduct several
“IMPACT ACT OF 2014” Part 1 • Incorporate standardized assessment(s) (e.g. CARE tool)
into existing assessment tools across PAC providers (LTCH, IRF, SNF, & HH) and acute care hospitals for • Pressure ulcers • Functional status • Cognitive status • Special Services
• Collect data at admission and discharge • Implement by Oct 2018 • Applies also to acute care hospitals
“IMPACT ACT OF 2014” Part 2 • Develop & Publicly report quality measures across
settings • Rehospitalizations & hospitalizations • Hospitalizations after discharge from PAC provider • Discharge to community • Pressure ulcers • Medication reconciliation • Incidence of major falls • Patient preferences • Efficiency measure(s): Avg Total Medicare Spend per Beneficiary • Plus any other measures Secretary wants
• Measures must be approved by National Quality Forum • Public reporting starting in Oct 2018
“IMPACT ACT OF 2014” Part 3 & 4 • Hospitals and PAC providers need to provide quality and
efficiency measures to beneficiaries to help them with their decision making • Modify conditions of participation to incorporate QMs into the
discharge planning process
• Payment penalty of 2% for failure to collect and report
data • Requires several studies and reports • MedPAC and HHS develop plan to link quality to payment • Review Risk adjustment methodologies • Review use of socio-economic status in risk adjustment
AHCA RESOURCES
It Pays to Know!
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Staff Stability Toolkit This toolkit, from Healthcentric Advisors, is a "how-to" guide to stabilize staffing with practical tools for both immediate and long-term use. It combines concepts, practices, exercises, and tools to assist you in the systematic process of determining the root cause of a problem and identifying potential interventions. Can order from AHCA book store www.ahcapublications.org/ProductDetails.asp?ProductCode= 8281
Staff Stability Resources • AHCA Toolkit: 4 Key Strategies to Retain New Hires and • • • • •
Reduce Employee Turnover Cost of Turnover Calculator A Guide to Staff Stability for Leaders Consistent Assignment – A Resource Guide Improving Staff Satisfaction The Staff Stability Toolkit (w/ CD-ROM)
http://QualityInitiative.ahcancal.org
Consistent Assignment • Residents consistently have the same caregivers. • Residents are more comfortable with staff they know and
who know them, their personal preferences and their needs. • Staff assignments are consistent when staff care for the same residents every time they work. • Fosters development of close, caring relationships; enhances intrinsic rewards of the job for caregivers.
Contact Information David Gifford MD MPH SR VP for Quality & Regulatory Affairs American Health Care Association 120 L St. NW Washington DC 20005
[email protected] 202-898-3161 www.ahcancal.org
