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Nursing Home Value Based Purchasing Demonstration

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					Nursing Home Value-Based Purchasing
           Demonstration

      LTC Provider Association Meeting

              December 8, 2010
Overview

• Objective: To improve the quality of care furnished to all Medicare
  beneficiaries in nursing homes

• Approach
    – Assess the performance of participating nursing homes based on four quality of
       care domains:
        • Nurse staffing (30 percent)
        • Hospitalization rates (30 percent)
        • MDS Outcomes (20 percent)
        • Survey deficiencies (20 percent)
    – Participants with the highest performance scores or the most improvement in their
       performance will be eligible for a payment.




                                                                                 2
Demonstration Features

• Demonstration includes all Medicare beneficiaries residing in nursing
  homes
    – Residents in a Part A stay and residents receiving only Part B services

• Demonstration will be budget neutral with respect to Medicare
    – Improvements in quality must result in a “savings” pool that can be used
      to fund the payments.
    – No payments will be made unless there are savings.

• Each host State is a separate “laboratory” in which to test the VBP
  concept.




                                                                          3
Performance Payments

• A participant will be eligible for a performance payment if it is either:
    – In the top 20 percent in overall performance; or
    – In the top 20 percent in terms of overall improvement

• Those in the top decile will receive more than those in the second
  decile.

• Participants with both high performance and improvement will receive
  the higher of the two payments.

• Performance payments weighted based on the number of resident
  days for residents who are Medicare beneficiaries.




                                                                        4
Status of NHBP Demonstration

• Demonstration began July 1, 2009 with 182 participating nursing
  homes:
    – Arizona: 41    New York: 79    Wisconsin: 62

• Currently there are 177 participants:
    – Arizona: 38    New York: 78    Wisconsin: 61

• CMS has presented aggregate information on baseline period (pre-
  demonstration) performance to the participants.




                                                                    5
MDS 3.0 Issues

• Long Stay Measures
   – NQF endorsement
   – Measure specifications
   – Initial reporting period

• Short Stay Measures
   – Discharge assessments




                                6
Value-Based Purchasing Program

• Section 3006 of the ACA requires the Secretary to develop a plan for
  a VBP program for SNFs and HHAs

• Plan shall consider:
    – Selection of quality measures
    – Reporting, collection and validation of quality data
    – Structure of payments
    – Methods for public disclosure

• Report to Congress due October 1, 2011




                                                                  7
 Staffing

• Nurse staffing data are required as a condition of demonstration
  participation:
    – Census, Payroll, Agency staff data

• NHVBP uses payroll data to calculate staffing and turnover levels.
    – Demonstration participants submitted payroll data for a three month period
        (January-March 2009) prior to the start of the demonstration.
    – This base period data will be used to measure changes in staffing levels that
        occurred during the demonstration.

• Measures:
    –   Registered nurse/ Director of nursing (RN/DON) hours per resident day
    –   Total licensed nursing hours (RN/DON/licensed practical nurse) per resident day
    –   Certified nurse aide (CNA) hours per resident day
    –   Nursing staff turnover rate



                                                                                      8
Calculating Staffing Measures

• Staffing levels:
    – Hours per resident day are calculated based on productive hours and
       resident census data reported by nursing homes
    – Adjusted for differences in the time period covered by payroll and
       resident census data
    – Staffing measures presented today are not case-mix adjusted, but the
       baseline and demonstration will use case-mix adjusted measures.

• Turnover:
    – Turnover determination considers both productive and non-productive
       hours.
    – Turnover is calculated as (# terminated/average employment), where
       average employment is the average number of employees across the
       payroll periods used in the turnover calculation.


                                                                           9
Average Staffing Levels by State- Baseline




Note: Data are for the first quarter of 2009

                                               10
Wisconsin: Distribution of Staffing Levels- Baseline




Note: Data are for the first quarter of 2009

                                                       11
Average Turnover Levels by State and Job Type-
Baseline


               12.0%



                              10.0%
               10.0%


                                             8.4%
                                      7.8%
               8.0%
     Percent




                                                                                        6.0%
               6.0%                                                                            5.6%   5.7%


                                                                  4.3%
                                                           4.1%          4.1%
                                                                                 3.9%
               4.0%
                                                    3.1%
                       2.4%

               2.0%




               0.0%
                                Arizona                    New York                     Wisconsin

                                                     DON    RN     LPN     CNA
 Note: Data are for the first quarter of 2009

                                                                                                             12
Wisconsin: Distribution of Turnover by Facility-
Baseline




Note: Data are for the first quarter of 2009

                                                   13
MDS-Based Quality Measures

• NHVBP uses a subset of already-developed and validated MDS-
 based quality measures (QMs).
   – Measures cover a broad range of functioning and health status in
      multiple care areas.
   – Measures selected based on reliability, extent to which measure is under
      the facility‟s control, statistical performance, and policy considerations.

• For long-stay measures, we use the same specifications as for the
 measures on the CMS Nursing Home Compare web site and the 5-
 star rating system.
   – Only difference is that Nursing Home Compare and the 5-Star rating
      system use data for three quarters, while our baseline period and
      demonstration years include a full year.

• Short-stay measures selected for the demonstration are not posted on
 Nursing Home Compare; Abt calculates performance using MDS
 assessments.

                                                                             14
Measures

• Chronic care (long-stay) residents: Use five of the QMs posted on
  Nursing Home Compare:
    – % of residents whose need for help with daily activities has increased;
    –   % of residents whose ability to move in and around their room got worse;
    –   % of high-risk residents who have pressure ulcers;
    –   % of residents who have had a catheter left in their bladder; and
    –   % of residents who were physically restrained.

• Post-acute care (short-stay) Residents:
    – % of residents with improving level of Activities of Daily Living (ADL)
        functioning;
    – % of residents who improve status on mid-loss ADL functioning; and
    – % of residents experiencing failure to improve bladder incontinence.

                                                                            15
MDS Performance Measures: Wisconsin- Baseline

 Quality Measure        N      Mean         Std        Min             Median               Max
                              percent       Dev      percent           percent            percent
 ADL Decline           60     0.16        0.06       0.04             0.15               0.35
 High risk             60     0.09        0.05       0.01             0.09               0.23
 pressure ulcer


 Catheter              60     0.06        0.03       0.01             0.05               0.15
 Decreased             60     0.12        0.05       0.05             0.11               0.27
 mobility
 Restraints            60     0.01        0.02       0.00             0.00               0.08
 ADL                   58     0.11        0.08       0.00             0.10               0.34
 improvement
 Mid-Loss ADL          58     0.10        0.07       0.00             0.09               0.31
 improvement
 Failure to            59     0.55        0.13       0.25             0.53               0.84
 improve
 incontinence



Note that, for all of the performance measures except ADL improvement and Mid-Loss ADL improvement,
a higher percent is associated with worse performance.



                                                                                                      16
Long-Stay Quality Measures: State Means- Baseline




                                                17
Short-Stay Quality Measures: State Means- Baseline




                                                 18
Distribution of Baseline QM Points: Wisconsin- Baseline




                                                  19
State Survey Inspections

 • Methodology is like that used on the Nursing Home Compare 5-Star
   Rating System, except that only one survey cycle is considered.

 • Baseline performance on state survey inspections is based on the
   number, scope, and severity of deficiencies identified during the most
   recent survey conducted prior to the start of the demonstration, along
   with associated complaint surveys. Repeat revisits are also
   considered.

 • Results presented here are for the baseline period and will be
   considered in calculation of nursing home improvement.




                                                                    20
Scoring Rules: Weights for Different Types of
Deficiencies


                                                                               Scope
    Severity
                                                         Isolated         Pattern            Widespread
    Immediate jeopardy to resident health or             J                K                  L
    safety                                               50* (75)         100* (125)         150* (175)
    Actual harm that is not immediate jeopardy           G                H                  I
                                                         20               35 (40)            45 (50)
    No actual harm with potential for more than          D                E                  F
    minimal harm that is not immediate jeopardy          4                8                  16 (20)
    No actual harm with potential for minimal            A                B                  C
    harm                                                 0                0                  0
    Note: Figures in parentheses indicate weight for deficiencies that are for substandard quality of care.
    Shaded cells denote deficiency scope/severity levels that constitute substandard quality of care if the
    requirement which is not met is one that falls under the following federal regulations: 42 CFR 483.13
    resident behavior and nursing home practices; 42 CFR 483.15 quality of life; 42 CFR 483.25 quality of
    care.
    * If the status of the deficiency is “past non-compliance” and the severity is Immediate Jeopardy, then
    the weight associated with a „G-level” deficiency (i.e. a weight of 20) is assigned.
    Source: Centers for Medicare & Medicaid Services




                                                                                                              21
Wisconsin: Baseline Survey Weight




                                    22
Wisconsin: Baseline Points for State Survey Inspections




                                                  23
Hospitalizations

• Includes potentially avoidable hospitalizations:
    – CHF, electrolyte imbalance, respiratory infection, UTI, sepsis for short stays; also
       includes anemia for long stays.
    – These are conditions that are prevalent in the nursing home population and
       considered to be sensitive to the quality of nursing home care.

• Includes hospitalizations that occur within 3 days of discharge from the
  nursing home.

• Excludes re-hospitalizations that occur within 1 day of hospital discharge.

• Measures will be risk-adjusted.
    – Note that the results presented here are not risk-adjusted, as we are still working
       on calculation of risk-adjusted baseline rates.

• Managed care enrollees are excluded from analysis.

                                                                                   24
Definition of Short and Long Stay Episodes

• Separate measures are used for short and long-stays:
    – Short stayers: rate of hospitalizations per nursing home stay.
    – Long stayers: number of hospitalizations per 100 resident days.

• Episode:
    – A series of contiguous stays (nursing home, hospital, community) that
      begins with the resident in the nursing home
    – Episode ends when a resident dies, resides at least 30 days in the
      community, or is admitted to another nursing home

• Short stay episode:
    – Resident spends less than 90 days of the episode in the nursing home

• Long stay episode:
    – Resident is in the nursing home at least 90 days during the episode

                                                                           25
Hospitalization Rates by State and Stay Type




                                               26
Facility-Level Distribution: Wisconsin Short-Stay-
Baseline




                                                     27
Facility-Level Distribution: Wisconsin Long-Stay-
Baseline




                                                    28
Questions/Discussion




                       29

				
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