THE FINAL RULE, VALUE BASED PURCHASING, AND OTHER HOT TOPICSBHS Clinical Services Group

September 2015

OBJECTIVES

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

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 re-hospitalizations

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

THE PROPOSED FINAL RULE

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 (COMMENTS DUE WITH EXTENDED DEADLINE TO OCTOBER 14, 2015

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…!

PAYMENT AND QUALITY

Protecting Access to Medicare Act PAMA

Improving Medicare Post-Acute Care Transformation IMPACT

Value Based Purchasing VBP

Payroll Based Journal PBJ

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

PAC REFORM

“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

“IMPACT ACT OF 2014” - PART 1

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 2

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)

Red Txt specified by CMS in 2016 Proposed rules for SNF, IRF & LTCH

ESTIMATED TIMELINE FOR SNF VBP IMPLEMENTATION

16

Oct 2018

Withhold Starts

Post withhold in Proposed

Rule

Collect Data

July 2016

Measurement Period

Analyze Data

Oct 2016

Oct 2017

Oct 2019

Oct 2015

SNF comments

SNF NATIONAL REHOSPITALIZATION RATES

At risk for full 2% penalty

Likely to receive2% back

WHERE DO WE FOCUS?

All Policies involve re-hospitalizations:

HRRP program financially penalizes hospitals with high 30 day re-admission 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 re-hospitalization 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)

5 Star Guide

WHERE DO WE FOCUS?

QM’s with Highest Impact on VBP: Pain

Pressure Ulcer

Satisfaction

Falls with Major Injury

Re-hospitalization

Discharge to Community

FY 2016 PROPOSED RULE

Specifies three measures New or worsening pressure ulcers

Based on MDS SNF short stay pressure ulcer measure

Falls with injury Based on MDS SNF long stay falls measure

Functional assessment at admission and discharge with goals 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

5 STAR OVERALL SCORING METHODOLOGYStep 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?

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

KEY COMPONENTS OF A SUCCESSFUL TRANSITION

Nurse Transition Coordinator

Alignment with referral sources

Warm hand offs

Patient goal setting

Advanced Care Planning

Patient / care giver education

Medication Reconciliation at each transition

“Bed-side Care Conferences

On-going progress towards goal discussions

“Real” discharge planning

Appointment set up

Transportation

Socio-economical factors

Follow-up calls

Patient satisfaction interview process

KEY COMPONENTS FOR SUCCESSFUL TRANSITIONS

Cost of Care By co-morbids?

Length of Stay (LOS)

St Catherine University possible grant

Importance of Partnering Transparency

Shared Risk

Removing Barriers

Alignment with referral sources

Interoperability

Admission Criteria (Capacity)

Alignment of brands (e.g. type of dressings)

NURSE TRANSITIONS COORDINATOR

ADVANCE CARE PLANNING TO REDUCE RE-HOSPITALIZATIONS

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”

TARGET INDIVIDUALS AT HIGH RISK

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

RISK ADJUSTMENT VARIABLES USED

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

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

FACTORS ASSOCIATED WITH LOW REHOSPITALIZATIONS

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

1Young Y et al. Clinical and Nonclinical Factors Associated with potentially preventable hospitalizations among nursing home residents in NYS. JAMDA 2011;12:364-371.

COMPETENCY BASED TRAINING: KSA

Knowledge

Skill

Attitude

Educate

Train

Practice

CLINICAL CAPACITY

Clinical Needs of the Center

Competency Based Training

Critical thinking via Simulation

RAISING CAPACITY OF THE CARE CENTER

Assess Referral Source Needs

Create Admission

Criteria

Assess Gap Between

Admission Criteria and Current Skill

Level

BUILDING CRITICAL THINKING

• Reduce HF Hospitalizations

Educate

• Red Flag Warning Signs

Train• Practice

Interventions Using Expected Scenarios

Practice

DATA DRIVEN DECISIONS

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: CMS SNF RM VS POINTRIGHT PRO 30

POINTRIGHT PRO 30

MDS based

All payer

30 day window During SNF stay only

All cause readmission

Observation included

Includes elective admits

CMS SNF-RM

Part A claims only

Part A SNF FFS

30 day window During & after SNF stay

All cause readmission

No observations

Excludes elective admits

DATA: AHCA DEVELOPED PAC MEASURES

PointRight Pro 30 Rehospitalization* (now available)

Discharge Back to the Community (now available)

Length of Stay (now available)

Improvement in Functional Status* (now available)**

Mobility (based on CARE tool)

Self-Care (based on CARE tool)

Customer Satisfaction*** (now available)

Long Stay Hospitalization (Oct 2015)

Unintended Healthcare Outcomes (Mar 2016)

* NQF endorsed measures** Requires use of CARE tool linked with MDS admission data*** Requires use of AHCA CoreQ satisfaction questionnaire

VALUE OF QUALITY AWARD

Silver & Gold recipients have better Survey Scores and fewer deficiencies

Quality Measures

5 Star Ratings

Rehospitalization rates

Staff Retention & less turnover

Occupancy

ACTIONS

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

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

TIPS ON HOW TO SUCCEED IN CCJR

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