The Quality Initiative

2015-2018

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The American Health Care Association (AHCA) has broadened its Quality Initiative* to further improve the quality of care in America’s skilled nursing care centers. The expansion of the Initiative will challenge members to apply the Baldrige Excellence Framework to meet measurable targets in eight critical areas by March 2018. These areas are aligned with the Centers for Medicare & Medicaid Services (CMS)’ Quality Assurance/Performance Improvement (QAPI) program and federal mandates, such as Five-Star and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act.

As momentum builds, quality continues to advance.

  • The profession has broadened its Quality Initiative to further improve the quality of care in America’s skilled nursing care centers. 
  • The expansion of the Initiative will challenge members to apply a systematic approach, such as the nationally recognized Baldrige Excellence Framework, to achieve more ambitious targets in eight critical areas (4 existing and 4 new) with a special focus on Organizational Success, Short-Stay and Post-Acute Care Quality, and Long-Term and Dementia Care Quality.
  • These areas are aligned with the Centers for Medicare & Medicaid Services (CMS)’ Quality Assurance/Performance Improvement (QAPI) program and federal mandates, such as Five-Star and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act

THE GOALS

I. Organizational success — a formalized structure pays dividends in quality.

Studies show that health care centers that apply a systematic, comprehensive, data-driven approach to their organization consistently outperform those that do not in terms of quality.

The expanded Quality Initiative places a premium on organizational success — setting a clear blueprint for improvements in key areas.

  1. Increase Staff Stability
    • The more consistent the staff is, the more they understand and are able to effectively attend to each individual’s needs — affirming our commitment to delivering person-centered care.
    • Target: By March 2018, members will strive to decrease turnover rates among nursing staff (RN, LPN/LVN, CNA/LNA) by 15% or achieve and maintain at or less than 40% overall.
    • Measurement: AHCA will measure progress using staffing data members submit to LTC Trend TrackerSM starting in May.  LTC Trend TrackerSM will allow members to upload, track and benchmark their turnover and retention information.  By the end of 2016, the Centers for Medicare & Medicaid Services (CMS) also plan to implement a nationwide system of electronic reporting on turnover and retention in the Five-Star Quality Rating System that will provide a national data source for all nursing centers.
  2. Adopt Customer Satisfaction Questionnaire and Measure
    • The happiness and peace of mind of patients, residents and their families is an important measure of how well our centers are doing in meeting patient needs.
    • Target: Our goal is to have at least 25% of members measure and report long-stay resident and family satisfaction and/or short-stay satisfaction using the Core-Q survey — a standardized measurement tool that includes three questions for long-stay residents and their families and one question for short-stay patients.
    • Measurement: The American Health Care Association is working with leading survey vendors to incorporate the CoreQ survey into their questionnaires and is building functionality to allow members to submit and track their results in LTC Trend TrackerSM. Progress will be measured using composite measures.  This functionality is in development and will be complete by October 2015
  3. Reduce the Number of Unintended Health Care Outcomes
    • A report by the Office of Inspector General (OIG) in 2014 found that 22% of patients in skilled nursing centers experienced an unintended health care outcome, which could be classified into three areas: medication related, care practice related and infections. 
    • Approximately, two-thirds were considered potentially preventable based on review of the medical record by physician and nurse reviewers. Approximately, one third of all unintended health care outcomes resulted in a hospitalization. 
    • Many of the measures outlined in the IMPACT Act (e.g. pressure ulcers, falls, medication reconciliation, rehospitalization) can be classified as measures related to unintended healthcare outcomes.
    • Target: Our goal is to reduce the number of unintended healthcare outcomes by March 2018. Measurement: Progress will be measured using composite measures of multiple quality measures related to unintended health care outcomes (such as combining rehospitalizations, pressure ulcers, falls, etc). This measure is under development and will be completed by March 2016 at which time a specific target reduction will be set.

II. Short-term and post-acute care quality — getting patients well and getting them home.

Skilled nursing care centers are serving a growing number of patients requiring short-term rehabilitation and post-acute care.

Ensuring that the unique needs of this population are met is a focus of the expanded Quality Initiative.

  1. Safely Reduce Hospital Readmissions
    • Currently, one in six patients admitted to a skilled nursing care center from a hospital are readmitted to the hospital within 30 days during their nursing care stay.
    • This not only has negative physical, emotional and psychological impacts on these individuals, but also costs government programs like Medicare billions of dollars.
    • This past year, Congress passed the Protecting Access to Medicare Act of 2014 that implements a Skilled Nursing Facility (SNF) Value Based Purchasing (VBP) program that imposes a 2% withhold on all SNF Part A payments, of which, between 50%–70% may be earned back based on a center’s rehospitalization rates. 
    • Target: By March 2018, we want to safely reduce the number of hospital readmissions within 30 days during a skilled nursing center stay by an additional 15% OR achieve and maintain a low rate of 10%.
    • Measurement: Progress will continue to be measured by using the PointRight® Pro 30™ rehospitalization metric, which has been endorsed by the National Quality Forum (NQF).
  2. Improve Discharge Back to the Community
    • The Medicare Payment Advisory Commission (MedPAC), the IMPACT Act and changes to the Five-Star Quality Rating System all call for measuring discharges back to the community, not to mention its importance for managed care plans, ACOs, and bundled payment models.
    • This measure focusses on the proportion of patients admitted from a hospital to a skilled nursing center who are discharged back to the community within 100 days.
    • Target: By March 2018, we want to improve discharge back to the community by 10% or achieve and maintain a high rate of at least 70%.
    • Measurement: AHCA will measure progress of this goal by using a risk adjusted MDS based measure developed by Brown University, which has been added to LTC Trend TrackerSM.
  3. Adopt Functional Outcome Measures
    • The Medicare Payment Advisory Commission (MedPAC), the IMPACT Act, and CMS have all called for the development of functional improvement measures that are based on self-care and mobility.
    • These measures will be publicly reported and will likely be added to the Five-Star Quality Rating System.
    • Target: The objective is to have 25% of members adopt the use of the mobility and self-care sections of the Continuity Assessment Record and Evaluation (CARE) tool and report functional outcome measures using AHCA’s LTC Trend TrackerSM web-based tool.
    • Measurement: AHCA is working with therapy vendors to incorporate the Continuity Assessment Record and Evaluation (CARE) tool to calculate these two outcome measures in its LTC Trend TrackerSM. This functionality is in development and will be complete by October 2015. The NQF is also currently reviewing both measures for endorsement.

III. Long stay and dementia care quality — ensuring quality of life and quality of care.

Long stay and dementia care quality objectives continue to focus on safely reducing hospital readmissions and the use of antipsychotic medications

Members have made significant achievements in these areas over the last three years, and the expanded Quality Initiative includes even more ambitious goals.

  1. Safely Reduce the Off-Label Use of Antipsychotic Medications
    • Studies have demonstrated that antipsychotic medications provide only a small benefit for a limited set of individuals with dementia, but pose a large risk of adverse events.
    • In 2012, the CMS launched the National Partnership to Improve Dementia Care in Nursing Homes, which AHCA supported, setting the goal of a 15% reduction. That goal was achieved as of the end of 2014.  In September 2014, CMS along with AHCA and others set new goals to continue reducing the use of antipsychotic medications. 
    • Target: Continuing the progress made in the initial version of the Quality Initiative, we want to safely reduce the off-label use of antipsychotics in long-stay nursing center residents by an additional 10%* by Dec. 2015; 15% by Dec. 2016.
    • Measurement: The progress of this goal is measured by using the CMS quality measure on the prevalence of off-label use of antipsychotic medications in skilled nursing care centers for long-stay residents, which is published on Nursing Home Compare.
  2. Safely Reduce Hospitalizations
    • When an individual who resides in a skilled nursing care center long term is hospitalized, there are increased risks of acquiring infections, pressure ulcers, weakness and delirium — which impact the resident’s quality of life as well as health.
    • Nearly half of AHCA members focus principally on serving a long-stay population.
    • Avoiding unnecessary hospitalizations is in alignment with MedPAC, Medicaid Managed Care, Medicare Managed Care and CMS, which have all called for measuring long-stay hospitalization rates.
    • Target: By March 2018 we want to safely reduce hospitalizations among long-stay residents by 15% or achieve and maintain a low rate of 10% or less.
    • Measurement: The Association will use a risk-adjusted MDS based measure that PointRight developed with an AHCA workgroup.  Results for each skilled nursing care center in the country will be made available in LTC Trend TrackerSM by October 2015.

MEASUREMENT

Sector performance will be tracked.

AHCA will use CMS data and measures to track progress of the goals. Members can view their progress using AHCA’s LTC Trend TrackerSM, a web-based, data collection and benchmarking tool.

TOOLS AND RESOURCES

AHCA is making available a wealth of tools and resources to assist members.

The Association has a number of tools and resources to assist member organizations in accomplishing the goals of the Quality Initiative, including LTC Trend TrackerSM and the AHCA National Quality Award Program.

For more information, visit www.qualityinitiative.ahcancal.org.

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