1 Keith Rapp MD, CMD Keith.Rapp@gaa-ltc.com Mary Pat Rapp PhD, RN Mprapp75@aol.com Geriatric Associates of America, PA.

1

Keith Rapp MD, CMD Keith.Rapp@gaa-ltc.com

Mary Pat Rapp PhD, RNMprapp75@aol.com

Geriatric Associates of America, PA

2

Describe Quality Indicators [QI] and Quality Measures [QM]

Describe Medical Director / provider roles in impacting QMs

Discuss avoidability of hospitalizations from nursing facilities

Discuss tools to assist in reducing avoidable hospitalizations

3

1990: Development of 24 QIs based on MDS 2.0 by the Center for Health Services Research Association [CHSRA]

2002: Nursing Home Compare www.medicare.gov

Quality Measures 2005: CMS merged QIs & QMs Some risk adjustment Not a static process

◦ Continuing refinement by the National Quality Forum

4

Influenza Vaccination During the Flu Season (October 1 thru March 31)

Assessed and Given Pneumococcal Vaccination (Looks back 5 years)

Delirium (Looks back 7 days) Moderate to Severe Pain (Looks back 7 days) Pressure Sores (Looks back 7 days)

5

Need for help with daily activities has increased

Moderate to severe pain Pressure Ulcers (high and low risk) Physical restraints Incontinence and Catheters

◦ Low risk residents who lost control of bladder or bowel

◦ Percent with indwelling bladder catheter Residents who spend most of their time in

bed

6

Decline in ability to move in and around their room

Urinary tract infection Worsening anxiety or depression Weight loss

7

Reporting of Measures Measures with small denominators are not

posted on NH Compare

◦ Post-Acute Measures with less than 20 in denominator

◦ Chronic Measures with less than 30 in the denominator

8

9

10

11

Physician/Nurse Practitioner Collaboration on Medical Direction

12

NP in facility 5 days per week◦25% NP time is contracted to facility

◦75% of NP time spent seeing GAA pts

Physician weekly or more visits Physician is Medical Director of facility

13

Daily stand up rounds with NF team Quality Assurance committee participation Mentoring and education for staff Available for assessment of all residents Available for “special projects”

◦ Use of resident level summaries to improve QM / QIs

14

Masters trained nurse in the facility 5 days/week Increased level of communication Increased facility census More resources at the facility level Increased ability to care for higher acuity patients =

discharging hospital physicians with a higher comfort level

Lower hospitalization rates ◦ (keep the backdoor closed)

Improved and increase in relationships with discharging Physicians and facilities

Enhanced tracking of referral resources

15

2 units with BID dosing

Over 1,500 less pills/day dispensed

Improvement of other associated QA/QMs

Per

cent

on

9 or

mor

e m

edic

atio

ns

16

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

2001 2002 2003 2004 2005

Other GAA

2002 9 requests 0 requests

2004 13 requests 4 requests

2005 3 requests 0 requests

Totals: 25 4

17

GAA Quality Model Outcomes at 14 Facilities

Benchmarking Provider Care

18

Privileged and Confidential - Proprietary Information

ALL GAA Quality ModelsHOUSTON/CENTRAL TEXAS9 + MEDS

19

Privileged and Confidential - Proprietary Information

ALL GAA Quality Models HOUSTON/CENTRAL TEXASCOGNITIVE IMPAIRMENT

20

Privileged and Confidential - Proprietary Information

ALL GAA Quality Models HOUSTON/CENTRAL TEXASNO TOILET PLAN

21

Privileged and Confidential - Proprietary Information

ALL GAA Quality Models HOUSTON/CENTRAL TEXAS

CATHETERS

22

Privileged and Confidential - Proprietary Information

23

Privileged and Confidential - Proprietary Information

24

Privileged and Confidential - Proprietary Information

25

Privileged and Confidential - Proprietary Information

26

Privileged and Confidential - Proprietary Information

ALL GAA Quality Models HOUSTON/CENTRAL TEXAS

Pressure Ulcer High Risk

27

Privileged and Confidential - Proprietary Information

28

Privileged and Confidential - Proprietary Information

ALL GAA Quality Models HOUSTON/CENTRAL TEXAS ANTIPSYCHOTICS Low Risk

29

Privileged and Confidential - Proprietary Information

ALL GAA Quality Models HOUSTON/CENTRAL TEXAS

ANTIANXIETY

30

Privileged and Confidential - Proprietary Information

31

Privileged and Confidential - Proprietary Information

ALL GAA Quality Models HOUSTON/CENTRAL TEXAS

RESTRAINTS

32

Management Pearls Include MDS Coordinator in QA Committee Focus on residents that have upcoming MDSs

◦ Use resident level summary◦ Provider documentation

Root Cause analysis of QM issues◦ Understand MDS questions for indicators◦ Obtain user manual for QMs◦ Understand exclusions

Prioritize focus◦ One to Three action areas per month is reasonable

Responsibility needs to be assigned Follow up on action items in QA meeting

◦ Sentinel events (dehydration, impaction, low risk PU)◦ Indicators in 90 + percentile

33

http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/NHQIQMUsersManual.pdf

http://www.cms.hhs.gov/NursingHomeQualityInits/10_NHQIQualityMeasures.asp

Google “Quality Measures Nursing Homes”

34

Used with permission

Joseph G. Ouslander, M.D.

Director, Boca Institute for Quality AgingBoca Raton Community Hospital

Mary Perloe, MS,GNP-BCProject Coordinator

Georgia Medical Care Foundation

34

35

Background

40% of 100 admissions to 8 LA nursing homes rated as inappropriate1

68% of 200 admissions to 20 Georgia nursing homes rated as potentially avoidable2

1Saliba et al, J Amer Geriatr Soc, 20002CMS Special Study, 2008

36

Common Disruptive for the resident and

family Fraught with many complications

◦ deconditioning, delirium, incontinence/catheter use, pressure ulcers, polypharmacy

Costly Sometimes an inappropriate and

avoidable use of the emergency room and acute hospital

Hospitalization of Nursing Home Residents

36

37

Reducing avoidable hospitalizations represents an opportunity to improve care and reduce costs

Some of the costs avoided can be reinvested in the infrastructure for nursing homes to provide high quality care

37

38

Georgia Medical FoundationN = 105

38

39

The same benefits can often be achieved at a lower level of care

One physician visit may avoid the transfer

Better quality of care may prevent or decrease the severity of acute change

Better advance care planning is necessary

The resident’s overall condition may limit the ability to benefit from the transfer

Provider Resources Physician or NP/PA present in

facility at least 3 days per week

Exam by physician or NP/PA within 24 hours

Availability of lab tests within 3 hours

Intravenous therapy

39

40

Appropriate reporting mechanisms to ensure that changes of condition are reported appropriately to the right person

Ability to start treatment, e.g., antibiotics, pain medication in a few hours

Ability to start intravenous or clysis therapy for hydration within 2 hours of the order

Sufficient nursing staff coverage to oversee appropriate monitoring over 24 hours

Sufficient nursing staffing to ensure daily assessment until the acute behavioral change has resolved or stabilized

Sufficient nursing staffing to recognize and report possible complications of treatment within 24 hours of their identification

AMDA CPG Recognition of Change in Condition40

41

A Tool Kit to Improve Nursing Home Care by Reducing Avoidable Acute Care Transfers and Hospitalizations

Developed based on the data collected, and Expert Panel ratings of importance and feasibility

Care Paths

Communication Tools

Advance Care Planning Tools

http://www.qualitynet.org/dcs/ContentServer?cid=1181668673046&pagename=Medqic%2FContent%2FParentShellTemplate&parentName=Topic&c=MQParents

41

42

Keeping it Simple

42

43

Target Audience Tools

Certified Nursing Assistants Early Warning Assessment (“STOP AND WATCH”)

All nursing home licensed nursing staff SBAR* Communication (general) SBAR Communication Templates related to specific conditions

o Acute mental status changeo Fevero Pneumonia/Lower Respiratory Illnesso Dehydrationo UTIo CHF

Communicating acute changes in status – file cards by the telephone

Primary care physicians, nurse practitioners, physician assistants

SBAR Communication Templates related to specific conditions Communicating acute changes in status – file cards by the telephone

Emergency room and acute care hospital staff Transfer checklist

Administrative nurses, medical director Unplanned acute care transfer review

*Situation, Background, Assessment, Recommendation43

44

Seemed like himself/herselfTalked the sameOverall function the sameParticipated in usual activities

Ate the same amountNDrank the same amount

WeakAgitated or nervousTired or drowsyConfusedHelp with dressing, toileting, transfers

No?

Yes?

Adapted from Boockvar, Kenneth et all, JAGS 48: 1086-1091,2000.

TELL A NURSE

44

45

Boockvar KS, Lachs, MS [2003] JAGS, 51:1111- 1115.•Symptoms predict illness about 50% of the time. •Likelihood ratios show there is a moderate increase in the likelihood of disease.•However, if the signs are absent, you can be 90% positive the person is not ill.

0

10

20

30

40

50

60

Symptom

Lethargy

Weakness

DecreasedAppetiteAgitation

Falls

45

46

Immediate Notification

Any symptom, sign or apparent discomfort that is:

1.Sudden in onset2.A marked change (i.e. more severe) in relation to usual symptoms and signs3.Unrelieved by measures already prescribed

Sources:AMDA Clinical Practice Guideline – Acute Changes in Condition in the Long-Term Care Setting 2003.Ouslander, J, Osterweil, D, Morley, J. Medical Care in the Nursing Home. McGraw-Hill, 1996

46

47

Conditions that usually warrant transfer to the hospital:

Acute abdominal pain with vomiting Chest pain not due to stomach pain,

musculoskeletal pain, and not relieved with antacids or nitroglycerin

Fall with pain and signs of fracture Hypertension with systolic BP over 230 mmHg

and chest pain or signs of stroke Vomiting blood and low blood pressure and

tachycardia Respiratory distress with rate over 28 and not

relieved with oxygen, nebulizers, or suctioning

47

48

Labored breathing / shortness of breath New or worsened cough New or increased sputum production New or increased findings on lung exam

◦ Rhonchi: sputum◦ Wheezes: restricted airway◦ Crackles: fluid

Chest pain with inspiration or coughing

http://www.qualitynet.org/dcs/ContentServer?cid=1211554364427&pagename=Medqic%2FMQTools%2FToolTemplate&c=MQTools48

49

Lungs◦ Asthma◦ Chronic obstructive

pulmonary disease◦ Infection

Viral [influenza] Bacterial

Pulmonary embolism

Heart◦ Congestive heart

failure Atrial fibrillation Myocardial infarction

49

50

Physician/NP/PA Notification Resident unable to eat and

drink Temp over 102ºF (38.9ºC)

or less than 96.8ºF (36ºC) Apical heart rate more than

100 Respiratory rate > 30/min BP less than 90 systolic Oxygen saturation less than

90% Call urgently Diabetes mellitus

◦ Finger stick glucose◦ Less than 70 or more than

400

Consider hospital transfer

Results of chest radiograph show an infiltrate or pneumonia

Critical values in blood count or metabolic panel◦ WBC over 12, 000 or

less than 4000

*Suspect sepsis if there are two or more signs from red bolded parameters 50

51

Before Calling Physician/NP/PA Assess the resident Check vital signs Check pulse oximetry and/or

finger stick blood glucose if indicated

Read recent progress notes and nurses notes

Be Ready to Report Advanced directives, code status,

do not hospitalize, do not use IVs or subcutaneous fluids, do not use artificial nutrition

Allergies Medications, especially warfarin

[Coumadin]

S Situation I am calling about __________ He/she has signs/symptoms of pneumonia: Shortness

of breath, new/worse cough, new/increased sputum, fever, change in lung sounds, chest pain with breathing or with cough, other

B Background Diagnoses New medications, started oxygen, gave nebulizer Able to eat/drink [yes or no] Vital signs, pulse oximetry

A Assessment I think he/she has pneumonia Vital signs are stable, unstable

R Recommendation Chest radiograph Maybe a CBC or BMP Possibly start antibiotic now, IM and/or PO Monitor every _____ hrs Transfer to the hospital [yes/no]

51

52

Quality Improvement Measures

52

53

53

54

IF Temperature is more than102º F

Respiratory rate more than 25/minute

ORIF Temperature is more than

100º F or less than102º F Cough AND

◦ Pulse greater than 100/minute◦ Delirium◦ Chills◦ Respiratory rate more than

25/minute

IF temperature is normal AND resident has COPD

Increased cough or increased sputum

IF afebrile [no COPD] New cough Purulent sputum AND Respiratory rate more than

25/minute or deliriumIF infiltrate on chest radiograph AND Respiratory rate over 25 Productive cough Temperature over 100º F

54

55

The LVN/LPN/RN assesses the resident each shift for 3 days or until the symptom resolves

At a minimum, the LVN/LPN/RN assesses:- How the resident feels- Vital signs and pulse oximetry- Level of alertness, aggressive, combative behaviors- Appetite and fluid intake

55

56

Resident-Family-Facility-Provider Partnership

56

57

CureRestoration/RehabilitationMaintenanceComfort

57

58

Demographics Staff on duty Urgency of the transfer Resources not available Pretransfer treatment Factors associated with transfer decision

◦ Physician orders◦ Medical Instability◦ Directives

Authorizing person for transfer Diagnoses at time of transfer

58

59

CNA says resident “different”, more confused, tired, back pain, slept in chair last night. Resident says she feels okay. “Something is wrong, she is sharp as a tack.”

History: No past history of dyspnea or chest pain, no cardiac history, no diabetes, usually capable of making her own decisions. No cardiopulmonary resuscitation, wants hospitalization.

Did not sleep well last night, acetaminophen [Tylenol] did not relieve pain, slept in her chair because of coughing, non-productive, no fever reported. She has not fallen.

Normally she eats well, today says stomach is upset, she’s nauseated, and did not eat breakfast or lunch. No change in bowel or bladder pattern, confirmed by nurse aide.

Two days ago had one urinary incontinent episode which is unusual for her. She says she knew she had to go but was just too weak and out of breath. No burning, or frequency. In talking with her today she loses track of the conversation, “I’m not eating, but I don’t like waffles anyway. Didn’t we have waffles yesterday?”

59

60

Should the nurse contact the physician/NP? What do you expect the nurse to report?

What is the urgency of her condition? orders do you anticipate? nursing interventions do you expect? is your rationale?

60

61

A 76 year old with a history of COPD complains of weakness. He is not on oxygen at the nursing home. He is more short of breath than usual, and has a cough. He tells you he always has a cough. He denies fevers, chills, rigors, or chest pain. His wife and the nurses aide tell you he is weaker, more short of breath and seems confused. He has not been eating or drinking as much for several days. Advanced Directives: Code status undetermined, does want hospitalization.

Past medical history: COPD, osteoarthritis mostly in the knees

Medications: Albuterol and ipatropium via metered dose inhalers, both 2 puffs 4 times a day. Acetaminophen for knee pain twice a day.

61

62

Vital signs: BP lying 132/72, pulse 80 and regular, sitting BP 110/60, pulse 90, standing unable to obtain due to unsteadiness, sensation of falling. Respirations 24, temperature 99.9 orally, weight 140 [3 pounds less than last week].

HEENT: Mouth and throat dry Skin: Axilla dry Lungs: Decreased breath sounds over usual exam, course rhonchi in right base Heart: Regular rhythm, no cyanosis Neurological: Weak, but equal strength bilaterally in arms and legs Mental Status: Alert, rambling speech, easily distracted Gait and Balance: Cannot stand as he was too unsteady 

The white blood cell count is normal, with a left shift The chest radiograph shows a small infiltrate on the right base.

The nursing staff and his wife would like him transferred to the hospital. The facility has RNs on the skilled unit 24 hours/day and they do start and maintain IVs. The NP is in the building daily Monday – Friday and the resident can be seen by the NP daily for 3 days before the weekend.

62