Home Health Quality Reporting and Overview of the Impact Act

Marcia Cederdahl, RN, BS, CHPN Director, Regulatory Guidance

Objectives At the end of the presentation, participants will be able

to: Discuss the Improving Medicare Post-Acute Care

Transformation (IMPACT) Act of 2014. State the five Post Acute Care (PAC) providers

mandated to participate in QRP. Acknowledge the purpose(s) of the Impact Act. Understand the changes that occurred in home health

agencies with the passage of the Impact Act.

IMPACT Act of 2014 This bipartisan bill was signed into law by President Obama

on October 6, 2014. The bill requires post-acute care (PAC) providers to report

standardized patient assessment data and quality measure data.

Section 3004 of the Affordable Care Act mandates the establishment of PAC quality reporting programs (QRP) for long-term care hospitals (LTCH), inpatient rehab facilities (IRF) and hospices.

The improving Medicare Post-Acute Care Transformation Act of 2014 mandates the establishment of QRP for skilled nursing facilities (SNF).

Section 1895 of the Social Security Act mandates the establishment of home health agencies (HHA) QRP.

Home health agencies provide skilled nursing or therapies to beneficiaries who are homebound.

Purpose of the IMPACT Act Improve Medicare beneficiary outcomes. Provide access to longitudinal data to

facilitate coordinated care. Enable comparable data and quality across

PAC settings. Improve hospital discharge planning. Research. Transparency in data reporting Person-centered and goals driven care

planning and discharge planning.

Why the attention on Post-Acute Care?

Escalating costs associated with PAC. Lack of data standards/interoperability

across PAC.Goal of establishing payment rates

according to the individual characteristics of the patient, not the care setting.

Meaningful Measures Initiative Launched in 2017, the purpose of this initiative is to:

Improve outcomes for patients

Reduce data reporting burden and costs on clinicians and other healthcare providers

Focus CMS’s quality measurement and improvement efforts to better align what is most meaningful to patients.

Why implement the Meaningful Measures Initiative? There are too many measures and disparate measures.

Administrative burden of reporting.

Lack of simplified ways to focus on critical areas that matter most for clinicians and patients.

Meaningful Measures: Guided by Four CMS Strategic Goals

1. Empower patients and doctors to make decisions about their healthcare.

2. Support innovative approaches to improve quality, accessibility, and affordability.

3. Usher in a new era of state flexibility and local leadership.

4. Improver the CMS customer experience.

The Meaningful Measures Framework The four CMS strategic goals are encircled by six cross-cutting

criteria:1. Eliminating disparities2. Tracking to measurable outcomes and impact3. Safeguarding public health4. Achieving cost savings5. Improving access for rural communities6. Reducing burden

Meaningful Measures Objectives Address high-impact measure areas that safeguard public health.

Are patient-centered and meaningful to patients, clinicians, and providers.

Are outcome-based where possible.

Fulfill requirements in programs’ statutes.

Minimize level of burden for providers.

Identify significant opportunity for improvement.

Address measure needs for population-based payment through alternative payment model.

Align across programs and/or with other payers.

Meaningful measure areas achieve high-quality healthcare and meaningful outcomes for patients.

Key Levers – the Vision for Quality Reporting Engage Patients and Providers Measures development begins from a person-centered

perspective. Involve patients and caregivers in measure development and

public reporting efforts. Involve first - line health care professionals on the front line who are

involved in measure development, implementation, and data feedback processes.

Strengthen/Facilitate Interoperability Ongoing, timely information is provided to health care professionals. Data collection and exchange is low burden. Quality measure data is fed into planning and implementation of

quality. improvement initiatives. Optimize Public Reporting Relevant, actionable data is accessible to a variety of audiences. Patients and caregivers have access to data

Key Levers – the Vision for Quality Reporting Aligned Measure Portfolio An enterprise - wide strategy for measure selection focuses on

patient - centered, outcome, and longitudinal measures.

Infrastructure supports development of health IT enabled measures.

Aligned Quality Reporting and Value - based Purchasing Aligned and streamlined policies and processes for quality

reporting and value-based purchasing programs.

CMS demonstration programs have flexibility to test innovative models while maintaining a desired end state of alignment with legacy of CMS programs.

Meaningful Measures: Promote Effective Communication & Coordination of Care

Meaningful Measure Areas: Medication Management.Admissions and Readmissions to Hospitals.Transfer of Health Information and

Interoperability.

Meaningful Measures: Promote Effective Prevention & Treatment of Chronic Disease

Meaningful Measure Areas: Preventive Care.Management of chronic conditions. Prevention, treatment and management of

mental health Prevention and treatment of opioid and

substance use disorders Risk-adjusted mortality.

Meaningful Measures: Work With Communities to Promote Best Practices of Healthy Living

Meaningful Measure Areas:Equity of care.Community engagement.

Meaningful Measures: Make Care Affordable

Meaningful Measure Areas: Appropriate use of healthcare. Patient-focused episode of care. Risk-adjusted total cost of care.

Meaningful Measures: Make Care Safer by Reducing Harm Caused in the Delivery of Care

Meaningful Measure Areas:Healthcare-associated infections.Preventable healthcare harm.

Meaningful Measures: Strengthen Person & Family Engagement as Partners in their Care

Meaningful Measure areas:Care is personalized and aligned with patient’s

goals. End of life care according to preferences. Patient’s experience of care. Patient reported functional outcomes.

Getting to Measures That Matter

The meaningful Measures initiative: Aligns with existing quality reporting programs and helps programs to

identify and select individual measures. Allows clinicians and other healthcare providers to focus on patients

and improve quality of care in ways that are meaningful to them. Intends to capture the most impactful and highest priority quality

improvement areas for all clinicians including specialists. Is used to guide rulemaking, measures under construction lists, and

impact assessments. Will move payment toward value by focusing everyone’s efforts on the

same specific quality areas.

Meaningful Measures Website Go to:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/MMF/Shareable-Tools.html

Measures for HHA’s with the IMPACT Act New Measure domains 1/1/2019: Functional Status

Incidence with major falls

Transfer of health information

Other measure domains:

Skin integrity 1/1/2017

Medication reconciliation 1/1/2017

Medicare spending per beneficiary 1/1/2017

Discharge to community 1/1/2017

Potentially preventable hospital readmissions 1/1/2017

OASIS-D Is Here!

OASIS-D became effective 1/1/2019.Changes with OASIS-D included 28 removed

items, 7 changed items 2 new sections (J & GG)Changes to wording with some item’s stem

and specific-response instructions, skip patterns and collection time points.

Standardizing Function at the Item/Assessment Level

Each PAC has an assessment tool that can standardize function at the assessment level.

Inpatient Rehab facilities (IRF) have the Patient Assessment Instrument (PAI)

Skilled Nursing Facilities (SNF) have the Minimum Data Set (MDS)

Long-term Care Hospitals have Continuity Assessment Record & Evaluation (CARE) Data Set – (LCDS)

Home Health Agencies have Outcome & Assessment Information Set (OASIS)

The IRF-PAI, MDS, OASIS, and LCDS each have an item with function – for example, eating, that can be compared across all four settings after standardization.

Standardized Patient Assessment Data Elements (SPADEs)

SPADEs:

Question and response options that are identical in all 4 PAC assessment instruments.

Identical standards and definitions apply.

The move toward standardized assessment data elements facilitates cross-setting data collection, quality measurement, outcome comparison, and interoperable data exchange.

Resources and QRP Reports Provider Preview Reports

Automatically generated and saved into your provider’s shared folder in CASPER.

Displays agency - level results that will be posted on the Compare websites.

Two Provider Preview Reports: Home Health Compare Provider Preview Report.

Quality of Patient Care Star Ratings Provider Preview Report.

Provider Preview Reports are available 3 months in advance of the HHC refresh

Provider Preview Reports (cont.1)

Important Notes: Please review your agency’s data.

Providers may email homehealthqualityquestions@cms.hhs.gov for questions related to the reports.

The order of the measures may not represent the order in which they will be displayed on the Compare websites.

The titles of the measure(s) are not the consumer language titles that will appear on the Compare websites.

The crosswalk between these titles is available on the Compare websites

Provider Preview Reports (cont. 2)

All corrections must be made prior to the applicable quarterly data submission deadline (quarterly freeze date), which falls approximately 135 days after the end of each calendar year quarter as noted on the Review and Correct Reports.

There is a 30 - day preview period prior to public reporting, which begins the day reports are issued to providers via their CASPER system folders.

Providers will not have the opportunity to request the correction of underlying publicly reported data if the data correction deadline has passed.

CMS QIES Systems for Providers website

How to Obtain Reports

How to Obtain Reports (cont.1)

How to Obtain Reports (cont. 2)

On-Demand QM reports

Agency - Level Reports: Agency Patient - Related

Characteristics (Case Mix) Report.

Outcome Report. Potentially Avoidable

Event Report. Process Measures Report.

Patient - Level Reports: Agency Patient - Related

Characteristics (Case Mix) Tally Report.

Outcome Tally Report. Potentially Avoidable

Event: Patient Listing Report.

Process Tally Report.

Review and Correct Report

User - requested, on - demand CASPER report. Confidential to providers. Provides agency - level quarterly and cumulative performance

rates for Outcome and Assessment Information Set (OASIS) -based publicly reported quality measures (QMs).

Presents aggregate performance for the most recent four full quarters, as data are available.

Available for providers to run with updated data weekly (until the data correction deadline).

Only observed (raw) data are provided; risk - adjusted rates are not shown.

Data collection Periods

Calendar Year Data Collection Quarter Data Collection/ Submission QRP(Quality Episode End Dates) Quarterly Review and Correction Periods* Quarter 1 January 1 to March 31 April 1 to August 15

Quarter 2 April 1 to June 30 July 1 to November 15

Quarter 3 July 1 to September 30 October 1 to February 1

Quarter 4 October 1 to December 31 January 1 to May 15

• *Data correction deadlines are for data that are used to calculate the publicly reported measures and are not applied to the confidential QM reports.

Quality Measure (QM) reports User - requested, on - demand CASPER reports. Include process and outcome quality measure result data at

the patient and agency levels. Provide confidential feedback to agencies on their

performance. Result data are risk - adjusted where applicable. Include all data submitted from OASIS assessments with a

target date within the requested reporting period, regardless of their submission date.

Include claims - based measure data at the agency - level. QM reports may be helpful to providers as they provide a

snapshot of performance for quality improvement processes based on data submitted and results risk-adjusted, as applicable. They may be used for HHA internal quality improvement purposed, such as QAPI.

Changes to the Agency Patient-Related Characteristics (case mix)Report Measure Removals: Numerous measures cannot be calculated

due to item removals in OASIS-D. Examples: Prior Conditions, Patient Diagnostic Information,

Reasons for Hospitalization. Measure Additions: Added due to new/revised OASIS - D items. Examples: Functional Abilities (calculated using OASIS - D

Section GG), Health Conditions/Falls (calculated using OASIS-D Section J).

Measure Updates: Home Care Diagnoses were updated to match ICD - 10 coding categories.

The Integumentary Section of this report was updated to include revised pressure ulcer/injury terminology and new measures for unstageable pressure ulcers/injuries.

Changes to Outcome Report Change in report title from “Risk Adjusted Outcome Report” to “Outcome

Report” as not all outcome measures will be risk - adjusted. Measures on the report were reorganized by: Risk Adjustment Status (risk adjusted or non - risk adjusted). Type (end result outcome, utilization, resource use). Source (OASIS - based or claims - based). Removal of measures: Acute Care Hospitalization (OASIS - based). Emergency Department Use with Hospitalization (OASIS - based). New Footnote: “Measure results for ‘Percent of Residents or Patients with

Pressure Ulcers That Are New or Worsened’ will be frozen as of the October 2019 Home Health Compare (HHC) refresh and will include quality episodes ending January 2018 – December 2018

Home Health Compare

The public HHC website provides: Access to quality measure results (tailored for the public).

The ability to search for a home health agency by geographic location (city, State, ZIP Code).

https://www.medicare.gov/homehealthcompare/search.html

Home Health Compare (cont.)

New quality measures were added to HHC on January 1, 2019: Assessment-based measures: Percent of Residents or Patients with

a Pressure Ulcers that Are New or Worsened (Short Stay) (NQF#0678).

Drug Regimen Review Conducted with Follow - Up for Identified Issues.

Claims-based measures: 1. Medicare Spending Per Beneficiary – Post Acute Care HH QRP. 2. Discharge to Community – Post Acute Care HH QRP.

More Resources Refer to the CASPER Reporting User's Guide for detailed information.

Welcome to the CMS Quality Improvement and Evaluation System (QIES) Systems for Providers web page.

The guide is also available for download in the following location:

Home Health Agency (HHA) Providers – Reference & Manuals page on the QIES Technical Support Office (QTSO) website https://qtso.cms.gov/providers/home-health-agency-hha-providers/reference-manuals

OASIS Education Coordinators:

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/OASIS-Coordinators.html

Resources (cont.)

Quality Measures and OASIS Data Collection Guidance: Home Health Quality Reporting Program: HomeHealthQualityQuestions@cms.hhs.gov.

Medicare Prospective Payment System Payment Policy Mailbox: HomeHealthPolicy@cms.hhs.gov.

Data Submission & CASPER: QTSO Help Desk:

Telephone: (800) 339 - 9313.

Email: help@qtso.com.

Website: https://qtso.cms.gov/.

Questions??? Five more webinars on Quality: June 20, 2019 OASIS D changes for Home Health July 18, 2019 Health conditions– falls August 22, 2019 Changes in skin integrity – pressure ulcer/injury September 18, 2019 Functional abilities, self-care ang goals October 17, 2019 Drug regimen review and follow up for identified

issues marciac@nehca.org P: 402-435-3551 ext. 510