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New York State 2016 Nursing Home Quality
Initiative Results and 2017 Proposals
New York State Department of Health
February 24, 2017
2
NHQI Status Updates
3
2015 and 2016 NHQI Status Updates
• 2015 NHQI
o 2015 NHQI State Planning Amendment was approved by CMS on December 19, 2016
• 2016 NHQI
o Facility-specific results for feedback were released on the Health Commerce System in
January 2017
o Final results were released on the Health Commerce System in February 2017
o Quintile ranking and continued top performer list was released on the Department’s
Medicaid Redesign Team website in February 2017
o Downloadable data was released on Health Data NY in February 2017
4
2016 NHQI
Methodology
5
2016 NHQI Structure
Quality Component: 70 points
Percent of Long Stay High Risk Residents With Pressure Ulcers*
Percent of Long Stay Residents Who Received the Pneumococcal Vaccine
Percent of Long Stay Residents Who Received the Seasonal Influenza Vaccine
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
Percent of Long Stay Residents Who have Depressive Symptoms
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowels or Bladder
Percent of Long Stay Residents Who Lose Too Much Weight*
Percent of Long Stay Antipsychotic Use in Persons with Dementia (PQA)
Percent of Long Stay Residents Who Self-Report Moderate to Severe Pain*
Percent of Long Stay Residents Whose Need for Help with Daily Activities Has Increased
Percent of Long Stay Residents with a Urinary Tract Infection
Percent of Employees Vaccinated for Influenza
Rate of Staff Hours per Day (new measure)
Percent of Contract/Agency Staff Used
*denotes risk adjustment by NYS
Compliance Component: 20 points
NYS Regionally Adjusted Five-Star Quality Rating for Health Inspections
Timely Submission of Nursing Home Certified Cost Reports
Timely Submission of Employee Influenza Immunization Data
Efficiency Component: 10 points
Number of Potentially Avoidable Hospitalizations per 10,000 Long Stay Days*
6
Scoring Details - Quality Component
Quintile 1: 5 points
Quintile 2: 3 points
Quintile 3: 1 point
Quintiles 4 and 5: 0 points
Two measures were awarded 5 or 0 points based on threshold values:
1. Percent of Contract/Agency Staff Used (5 points for a rate of less than 10%)
2. Percent of Employees Vaccinated for Influenza (5 points for a rate of 85% or higher)
11 measures were eligible for improvement points based on the previous year’s
quintile
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Percent of Long Stay High Risk Residents With Pressure Ulcers
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
Percent of Long Stay Residents Who have Depressive Symptoms
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowels or Bladder
Percent of Long Stay Residents Who Lose Too Much Weight
Percent of Long Stay Residents Who Self-Report Moderate to Severe Pain
Percent of Long Stay Residents Whose Need for Help with Daily Activities Has Increased
Percent of Long Stay Residents with a Urinary Tract Infection
Percent of Long Stay Residents who Received the Seasonal Influenza Vaccine
Percent of Long Stay Residents who Received the Pneumococcal Vaccine
Percent of Long Stay Antipsychotic Use in Persons with Dementia
2015 Performance
2016 Performance
•
•
•
•
Quintile
1
2
3
4
5
1 (best)
5
5
5
5
5
2
3
3
4
4
4
3
1
1
1
2
2
4
0
0
0
0
1
5
0
0
0
0
0
If 2015 NHQI performance was in the third quintile,
and 2016 NHQI performance was in the second
quintile, the facility received 4 points. This is 3 points
for attaining the second quintile and 1 point for
improvement from the previous year’s third quintile.
7
Scoring Details – Quality Component
Rate of Staff Hours Per Day
•
•
•
•
•
•
Replaced CMS Five-Star Quality Rating for Staffing
Awarded points based on the quintile method
Benchmarking rates using 2014 data were reported to nursing homes with the 2015 NHQI
Hours reported
o Full time hours worked for RNs, LPNs, and Aides: Schedule 5A of the nursing home cost report
o Contract hours paid for RNs, LPNs, and Aides: Schedule O – Quality of the nursing home cost report
Days reported from Bed Capacity Patient Days schedule of the nursing home cost report
Hours and days expected are computed by counting resident days at MDS 3.0-generated RUGIII category, and
utilizing CMS Time Staff Measurement Study
(Annual hours reported on cost
report / Annual days reported on
cost report)
(Annual hours expected from
MDS RUG distribution / Annual
days expected from MDS)
Statewide
reported
average
Rate of staff
hours per
day
8
Scoring Details – Compliance and Efficiency
Components
Compliance Component
• NYS Regionally Adjusted Five-Star Quality Rating for Health Inspections
o Used CMS health inspection survey scores as of April 2016 to calculate cut points for each region in the state
o Regions include the Metropolitan Area, Western New York, Capital District, and Central New York
o Within each region, the top 10% of nursing homes received five stars, the middle 70% received four, three, or two stars, and the
bottom 20% received one star
o Each nursing home was awarded a Five-Star Quality Rating based on the cut points calculated from the health inspection survey
scores within its region
o 10 points for 5 stars, 7 points for 4 stars, 4 points for 3 stars, 2 points for 2 stars, 0 points for 1 star
• Timely Submission of Nursing Home Certified Cost Reports – 5 points
• Timely Submission of Employee Influenza Immunization Data – 5 points
Efficiency Component
• Potentially Avoidable Hospitalizations
o Quintile 1: 10 points
o Quintile 2: 8 points
o Quintile 3: 6 points
o Quintile 4: 2 points
o Quintile 5: 0 points
9
2016 NHQI Results
2016 NHQI Measure Statistics
10
1st
Quintile
Measures
Higher Rate is Better
Statewide
Average
P100 (max)
2nd
Quintile
P80
3rd
Quintile
P60
4th
Quintile
P40
5th
Quintile
P20
P0 (min)
2016 2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 2015
50.1
49.3
86.2
89
60
60
53
52
46
45
39
38.9
9
19
Percent of long stay residents who received the pneumococcal vaccine
82
83.6
100
100
92
93
87
88
81
83
74
75
24
33
Percent of long stay residents who received the seasonal influenza vaccine
83
84
100
100
92
91
87
87
83
83
77
78
47
50
3.4
3.5
12.5
9.9
3.1
3.2
2.8
2.8
2.5
2.6
2.3
2.3
0
0
Overall score
Rate of staff hours per day
Measures
Lower Rate is Better
Percent of long stay high risk residents with pressure ulcers
Percent of long stay low risk residents who lose control of their bowel or bladder
Percent of long stay residents experiencing one or more falls with major injury
Percent of long stay residents who have depressive symptoms
Percent of long stay residents who lose too much weight
Percent of long stay residents with dementia who received an antipsychotic medication
Percent of long stay residents who self-report moderate to severe pain
Statewide
Average
P0 (min)
P20
P40
P60
P80
P100 (max)
2016 2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 2015 2016 2015
7.2
7.2
0
0
4.9
4.8
6.2
6.3
7.5
7.6
9.4
9.5
20.7
17.2
46.6
45.8
4
6
33
30
44
41
54
51
62
61
100
98
2.6
2.7
0
0
1.2
1.2
2.2
2
3
2.9
4.3
4.1
9.4
16.9
11.6
11.7
0
0
0.9
1.2
2.8
3.2
6.2
7.2
18.2
20.2
98
94.8
6.2
6
0.4
0.3
4.2
3.8
5.5
5.2
6.7
6.4
8.2
8
16.2
16.7
12.8
14
0
0
7
9
11
12
14
15
18
20
50
51
5.6
6.5
0
0
1.4
1.5
3.1
3.7
6.1
6.7
10.2
11.6
22.2
34.7
13.5
14.3
2
3
9
9
12
12
15
15
19
19
35
39
Percent of long stay residents with a urinary tract infection
4.2
5.4
0
0
2.4
2.8
3.4
4
4.7
5.7
6.6
7.6
20.3
21.5
Number of potentially avoidable hospitalizations per 10,000 long stay days
6.4
6.3
0
0
4
3.9
5.7
5.3
7.2
6.7
9.2
8.6
31.1
18.6
Percent of long stay residents whose need for help with daily activities has increased
11
Quality Component – Employee Vaccination
Measure
• Statewide employee influenza vaccination average decreased from 86% in the 2014-2015 influenza
season to 85% in the 2015-2016 influenza season
Measurement year
NHQI year
Statewide Average
2012
2013
51%
2013
2014
86%
2014
2015
86%
2015
2016
85%
12
Quality Component – Improvement Results
• Facilities received one point for improvement if the 2016 NHQI quintile for a measure was an improvement from the
2015 NHQI quintile
• 11 measures were eligible for improvement points based on the previous year’s quintile
• 95% of facilities received at least one improvement point (compared to 93% in 2015 NHQI)
Number of
Improved Quality
Measures
Percent Facilities
2015 NHQI
2016 NHQI
1
22
15
2
26
23
3
25
24
4
13
20
7
13
93
95
5 or more
Total
13
Compliance Component and Deficiencies
Compliance
• Timely Submission of Nursing Home Certified Cost Reports – 5 points
o 99.3% (N=585) of facilities submitted by the designated deadlines (compared to 97.3% in 2015 NHQI)
• Timely Submission of Employee Influenza Immunization Data – 5 points
o 95.2% (N=561) of facilities submitted by the May 1, 2016 deadline (compared to 97.5% in 2015 NHQI)
Deficiencies
• Measurement period of July 1, 2015 - June 30, 2016
• 4% (N=22) of facilities received a J, K, or L deficiency, compared to 3% (N=16) in 2015 NHQI
Number (%) of facilities with a J, K, or L deficiency in 2016 NHQI compared to 2015, by Quintile
NHQI
year
Quintile
1
Quintile
2
Quintile
3
Quintile
4
Quintile
5
Total facilities
with a deficiency
Total
facilities
2015
0
0
5 (<1)
4 (<1)
7 (1)
16 (3)
594
2016
1 (<1)
4 (<1)
3 (<1)
5 (<1)
9 (2)
22 (4)
589
14
CMS Methodological
Changes
15
CMS Methodological Changes – Addition of New Measures
• In April 2016, CMS introduced six new quality measures on the CMS Nursing Home Compare
website (four short stay, two long stay)
• In July 2016, CMS began phasing five of the six quality measures into the Five-Star Quality Rating
System
• Phase-in periods in July 2016 and January 2017, increasing the weight of the new measures over
time1
• New long stay measures using MDS data:
1.
Percentage of long stay residents whose ability to move independently worsened
o
Purpose is to assess long stay residents who experienced a decline in their ability to move around
their room and in adjacent corridors over time2
2.
Percentage of long stay residents who received an antianxiety or hypnotic medication
o
Purpose is to encourage nursing facilities to reexamine their prescribing patterns in order to
encourage practice consistent with clinical recommendations and guidelines2
1 Centers
for Medicare & Medicaid Services. (August 1, 2016). CMS Five-Star Quality Rating System: Technical User’s Guide Revised August 1, 2016.
Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/usersguide.pdf
2 Abt
Associates. (March 3, 2016). Further Improvements to the Nursing Home Compare Five-Star Quality Rating System [PowerPoint slides].
Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/Improvements-NHC-April-2016.pdf
16
CMS Methodological Changes – Additional Functional Status
Measure
•
•
•
•
Percentage of residents whose ability to move independently worsened (new measure #451)
Percentage of residents whose need for help with activities of daily living has increased (established measure #401)
Both measures capture a decline in functional status and independence
NYS DOH compared the new measure to the established measure to assess similarities and differences
Comparison between Measures
Numerator
Denominator
Established Measure (#401)
Bed Mobility, Transfer, Eating, Toileting
Same (target and prior assessment)
New Measure (#451)
Locomotion on Unit (moving around room and adjacent corridor)
Same (target and prior assessment)
Exclusions
Risk-adjusted
Same
No
Same
Yes^; Eating*, Toileting*, Transfer*, Walking in corridor*, Severe
cognitive impairment*, Age, Gender, Vision, Oxygen use
^If any covariate is missing, the resident is excluded from the measure
*Covariate is taken from prior assessment
Measure Statistics using CMS Nursing Home Compare Data (Four-quarter Average, Q2 2015 – Q1 2016)
Measure #401
Measure #451*
N Facilities
612
609
Minimum
0
0
Maximum
40.3
50.2
Mean
14.2
16.6
*Measure statistics generated from the risk-adjusted rates, as CMS does not provide numerator and denominator
Median
13.5
15.3
17
CMS Methodological Changes – Additional
Antianxiety/Hypnotic Medication Measure
• Denominator is all long stay residents
• Numerator is the number of long stay residents who received antianxiety or hypnotic
medications for at least one day during the past seven days
• Excludes residents at end of life and residents with missing data
• Currently not included in the Five-Star Quality Rating System due to concerns about its
specificity and appropriate star rating cut points2
• At this time, NYS DOH does not have plans to incorporate the new functional status or
the antianxiety/hypnotic medication quality measures into the NHQI
2 Abt
Associates. (March 3, 2016). Further Improvements to the Nursing Home Compare Five-Star Quality Rating System [PowerPoint slides].
Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/Improvements-NHC-April-2016.pdf
18
CMS Methodological Changes – Specification
Modifications
Element
Number of
quarters used
Denominator size
CMS Five-Star Quality Rating System, July 2016
Four quarters of data are used to calculate quality
measures (previously used three quarters of data)
Minimum denominator for calculating quality measures is
20 summed across four quarters (previously was 30)
NYS DOH NHQI*
Four quarters of data are used to calculate quality
measures
Non-risk-adjusted measures
• Minimum denominator is 30 summed across four
quarters
Risk-adjusted measures
• Minimum denominator is 30 per quarter
Non-risk-adjusted measures
• If the denominator is < 30 the measure is suppressed
Handling small
denominators
If a denominator is < 20 and the facility meets other
criteria, CMS will impute the rate using a combination of
the facility’s data and the statewide average
*NYS DOH will continue to use current methods in NHQI
Risk-adjusted measures
• If one quarterly denominator is < 30, the statewide
quarterly average is used in its place
• If two or more quarterly denominators are < 30, the
measure is suppressed
19
CMS Methodological Changes – Modifications to
Influenza Vaccination Measure Specifications
• New measurement period for influenza vaccination measures was introduced with the release of the MDS 3.0 Quality
Measures User’s Manual version 9.0, effective October 1, 2015
• Measurement period is October 1 of the prior year through June 30 of the target year3
• Captures influenza vaccine status for a resident who was in the facility during any part of the most recent influenza
season3
• Affects the following quality measures:
o Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
o Percent of Long Stay Residents Who Received the Seasonal Influenza Vaccine (used in NHQI)
o Percent of Long Stay Residents Who Were Offered and Declined the Seasonal Influenza Vaccine
o Percent of Long Stay Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal
Influenza Vaccine
International. (August 15, 2015). MDS 3.0 Quality Measures USER’S MANUAL (v9.0 08-15-2015) Effective October 1, 2015.
Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-Users-Manual-V90.pdf
3 RTI
20
2017 NHQI and Other
Topics
21
2017 NHQI Structure
No changes are proposed by NYS DOH
Quality Component: 70 points
Percent of Long Stay High Risk Residents With Pressure Ulcers*
Percent of Long Stay Residents Who Received the Pneumococcal Vaccine
Percent of Long Stay Residents Who Received the Seasonal Influenza Vaccine (following CMS specifications, 10/1/2015 – 6/302016)
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
Percent of Long Stay Residents Who have Depressive Symptoms
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowels or Bladder
Percent of Long Stay Residents Who Lose Too Much Weight*
Percent of Long Stay Antipsychotic Use in Persons with Dementia (PQA)
Percent of Long Stay Residents Who Self-Report Moderate to Severe Pain*
Percent of Long Stay Residents Whose Need for Help with Daily Activities Has Increased
Percent of Long Stay Residents with a Urinary Tract Infection
Percent of Employees Vaccinated for Influenza
Rate of Staff Hours per Day
Percent of Contract/Agency Staff Used
*denotes risk adjustment by NYS
Compliance Component: 20 points
NYS Regionally Adjusted Five-Star Quality Rating for Health Inspections
Timely Submission of Nursing Home Certified Cost Reports
Timely Submission of Employee Influenza Immunization Data
Efficiency Component: 10 points
Number of Potentially Avoidable Hospitalizations per 10,000 Long Stay Days*
22
MDS Section S – current question
• MDS 3.0 Item ID S7000, Dental Care, effective October 1, 2014
1. Routine dental care since last assessment (planned)
2. Emergent dental care since last assessment (unplanned)
9. None of the above
• Intent of question is to use the responses to develop a quality measure for dental care
Frequency and Percent of Responses to Item S7000, Quarter 4 2014 – Quarter 4 2015 MDS Assessments
Q4 2014
Q1 2015
Q2 2015
Q3 2015
2015
Average
Q4 2015
Response
N
Routine
Percent
N
Percent
N
Percent
N
Percent
N
Percent
Percent
36,823
16
29,910
13
33,330
14
29,088
13
28,560
16
13
Emergent
None of
the above
Missing
response
2,502
1
1,893
1
2,204
1
1,854
1
1,937
1
1
185,819
82
189,318
85
200,705
85
189,088
85
194,783
82
84
1,735
1
2,914
1
331
0
2,133
1
9,498
1
2
Total*
226,879
100
224,035
100
236,570
100
222,163
100
234,778
100
100
*Total row is the number of MDS assessments that should have a response to S7000
(not number of unique people)
23
MDS Section S – future questions
• Two new questions below were approved by CMS in November 2016
• MDS effective date of October 1, 2017
• Capturing residents who are receiving comfort care, MDS 3.0 Item ID: S6500
• Question was added to capture residents in facilities that do not have designated hospice units but provide end-of-life care
(possible adjustment to long stay weight loss measure)
In the last 14 days, has the resident received comfort care? Comfort care consists of medical care and treatment provided with the
primary goal of reducing suffering. Food and fluids are offered by mouth; medication, turning in bed, wound care, and other measures are
used to relieve suffering; and oxygen, suctioning, and manual treatment of airway obstruction are used as needed for comfort.
0 = No
1 = Yes
- = Not assessed
• Discharge to hospital, healthcare proxy involvement, MDS 3.0 Item ID: S0185
• Question was added to capture residents who are sent to the hospital at family or healthcare proxy request, although the facility
staff do not feel hospitalization is medically necessary (possible adjustment to PAH measure)
If this is a discharge assessment (A0310F = 10 or 11) and the resident is being discharged to an acute hospital (A2100 = 03), is the
discharge to hospital due to the request of the resident’s healthcare proxy, and against the opinion of the nursing home?
0 = No
1 = Yes
- = Not assessed
24
Measure Exploration - Potentially
Preventable Readmissions
•
•
•
NYS DOH continues to research existing standardized efficiency measures on the
nursing home population
Tested the feasibility of Potentially Preventable Readmission (PPR) measures on the
nursing home population
Reviewed multiple methodologies and tested two methods
1. 3M Potentially Preventable Readmission measure algorithm
o Measure was tested using 2013 measurement year
2. CMS Potentially Preventable 30-Day Readmission measure, in alignment with
the Improving Post-Acute Care Transformation (IMPACT) Act
o Measure was tested using 2014 measurement year
25
Measure Exploration – 3M PPR Measure
•
PPR software created by 3M Health Information Systems identifies hospital admissions clinically
related to an initial admission within a specified time period
Denominator is the number of all at-risk admissions
•
Algorithm identifies admissions that do not qualify as at-risk and excludes them from the
denominator
Numerator is the number of admissions that were followed by a PPR chain
o PPR chain is a sequence of PPRs that are all clinically-related to the initial admission
Result is interpreted as number of PPRs per 100 hospitalizations
•
•
•
3M PPR Statistics for Long Stay Nursing Home Residents, 2013 Measurement Year
N Facilities
629
Statewide
Average
12.8
Median
11.1
Minimum
0
Maximum
33.3
N (%) Facilities
with Insufficient
Denominator Size
201 (32%)
26
Measure Exploration – CMS Potentially Preventable 30-Day
Readmission Measure
•
•
•
•
•
CMS developed this PPR measure as part of the IMPACT Act
Denominator is the number of all at-risk admissions
o At-risk admission is defined as any hospital admission that could possibly be followed by a
readmission
Numerator is the number of readmissions that occur 1-30 days after the at-risk admission
o Readmissions must be unplanned and considered to be potentially preventable, as
determined by principal diagnosis and procedure codes
Readmission window of 15-30 days was also examined by DOH
Result is interpreted as a percentage
CMS PPR Statistics for Long Stay Nursing Home Residents, 2014 Measurement Year
Readmission
Window
N
Facilities
Statewide
Average
1-30 days
592
8.4
15-30 days
592
3.3
Minimum
Maximum
N (%) Facilities
with Insufficient
Denominator Size
6.7
0
33.3
175 (30%)
2.4
0
21.4
175 (30%)
Median
27
Measure Exploration – PPR Measure Issues
•
Insufficient denominator sizes
o
•
Diagnoses overlap between PPR and PAH
o
•
Uncertainty regarding the appropriate window of time to attribute a readmission to the care received in the
nursing home vs. the care received in the hospital
Limitations to measure modification
o
•
PAH measure includes residents who never went to the hospital, while the PPR measures exclude them
Readmission timeframe
o
•
Many of the diagnoses included in the PPR measures are also included in the PAH measure
Not accounting for the healthy population
o
•
In both measures, 30% or more of facilities had a denominator of less than 30 and would not have a result if
the measures were used
3M PPR measure algorithm is proprietary software and there is limited ability to modify the measure
At this time, NYS DOH does not have plans to incorporate these measures into the NHQI
28
Thoughts and Suggestions
• Future areas of focus, developments, or changes in the industry
29
Questions/Comments
Methodology
Office of Quality and Patient Safety
(518) 486-9012
[email protected]
Rate Adjustments
Division of Finance and Rate Setting
[email protected]