LTC Trend Tracker Publications Publication Frequency Description Your Top-Line Quarterly Summary of Five-Star Your Quality Initiative Progress Semi-annual Progress on AHCA Quality Initiative Your Resident Profile Semi-annual Data to help complete required Facility Assessment Your PAC Scorecard (First release in 2019q4) Quarterly Data to share with referral partners Your AL Top-Line Quarterly Progress on NCAL Quality Initiative and data uploaded to Trend Tracker
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LTC Trend Tracker Publications
Publication Frequency Description Your Top-Line Quarterly Summary of Five-Star Your Quality Initiative Progress
Semi-annual Progress on AHCA Quality Initiative
Your Resident Profile Semi-annual Data to help complete required Facility Assessment
Your PAC Scorecard (First release in 2019q4)
Quarterly Data to share with referral partners
Your AL Top-Line Quarterly Progress on NCAL Quality Initiative and data uploaded to Trend Tracker
Survey Ra ngYour center is ranked 374th out of 617 centers in your state.For more on how your survey score was calculated and to seeif you a Special Focus Facility Candidate, see page 2
For more on your survey score, see Page 2.
Staffing Ra ngYour center’s StaffingRa ng is currently basedon2019-Q1Payroll-BasedJournal (PBJ) data. See page 3 for your ra ng breakdown and how youcan improve it.
For more on your staffing breakdown, see Page 3.
Quality Measure Ra ngThe greatest opportunity to improve your QM ra ng is on LSED Visit, where you are currently earning 15 points based ona rate of 1.92.
See your performance on all Quality Measures on Page 4.
Overall Ra ngYour Overall Ra ng Calcula on
+ 2 Stars (From your Survey Ra ng being 2 Stars)
+ 0 Stars (From your Staffing Ra ng being 2 Stars)
Your Survey Score and State RankingThe table below shows how your survey score is calculated and where it ranks within your state. Your statesurvey rank impacts whether your facility is a candidate for Special Focus Facility designa on.
Score Breakdown Deficiencies (#)Ini al Revisits Total StandardScore # Score Score Health Complaint Total
Cycle
on 2019-04-26 20 0 0 20 3 3 5Cycle
on 2017-10-19 32 1 0 32 6 2 7Cycle
on 2016-06-24 32 1 0 32 7 0 7
Weighted 3-Cycles 202 + 32
3 + 326 = 26 To have had another star
you needed a score < 23.3State Survey Rank Your center is ranked 374th out of 617Special Focus Facility In the Program? No Candidate for the Program? No
State Distribu on of Survey ScoresThe histogram below show the distribu on of survey scores within your state. The cut points to determine starra ngs is done by CMS to have a fixed percentage of buildings at each star level.
The dashed black line (- -) in the histogram represents where your survey score ranks.
State SummarySurvey Star Ra ng SNF Centers Survey Score Range
Your Registered Nurse (RN) and Total Nursing Staff (TNS) Hours per Resident Day (HPRD)
Adjusted RN HPRD =0.555Reported
0.429Expected×0.3804NationAvgExpected = 0.487
Adjusted TNS HPRD =3.411Reported
3.301Expected×3.2285NationAvgExpected = 3.319
Your Staffing Star Ra ngs (Overall Staffing= 2⋆, RN = 2⋆)Overall Staffing Star (X marks your facility)
1.049
0.731
0.508
0.317Adjusted
RNHP
RDan
dRN
Star
Rang
3.108 3.580 4.038 4.408
Adjusted Total Nursing HPRD
Average Daily Census & Days with No RN HoursCMS calculates your average daily census using MDS. Star ng in April 2019, nursing homes with4 or more days with no RN hours will receive a 1 star staffing ra ng.
2018-Q1 2018-Q2 2018-Q3 2018-Q4 2019-Q1Avg Daily Census 87.1 85.5 85.9 80.9 84.9Days with No RN Hours 0 0 0 0 0
Your Staffing Ra ng BreakdownThe data shown here is your center’s PBJ data for 2019-Q1. It led to an Overall Staffing Ra ng of 2 Stars and RNStaffing Ra ng of 2 Stars.
Your Quality Ra ng BreakdownBelow is a breakdown of how your aggregate Quality Ra ng of 2 Stars, a Short-Stay Quality Component ra ngof 1 Star, and a Long-Stay Quality Component ra ng of 3 Stars was derived.
Short-Stay Quality Ra ngNext Cut-Point
Measure Time Period Rate Points Indicator Rate PointsSS Pain 2018q2-2019q1 3.3% 100 - -SS Func onal Improvement 2018q2-2019q1 69.5% 90 70.4% 105SS ED Visit 2018q1-2018q4 13.0% 45 12.7% 60SS An psycho cs 2018q2-2019q1 2.1% 40 1.7% 60QRP Pressure Ulcer 2017q4-2018q3 2.3% 40 1.6% 60QRP Discharge to Community 2016q4-2017q3 32.5% 30 37.1% 45SS Readmission 2018q1-2018q4 33.3% 15 30.3% 30Star Ra ng Release Month Ra ng Points Next Star Ra ng Needed PointsSS QM Ra ng July 2019 1 Star (360 * (1250/900)) = 500 2 Stars 542Long-Stay Quality Ra ng
Next Cut-PointMeasure Time Period Rate Points Indicator Rate PointsLS Mobility 2018q2-2019q1 9.6% 135 8.2% 150LS An psycho cs 2018q2-2019q1 8.7% 120 7.5% 135LS Hospitaliza on 2018q1-2018q4 1.32 105 1.31 120LS Catheter 2018q2-2019q1 1.0% 80 0.5% 100LS ADL 2018q2-2019q1 16.1% 60 15.9% 75LS Pressure Ulcer 2018q2-2019q1 7.3% 60 5.8% 80LS Fall 2018q2-2019q1 4.4% 40 3.6% 60LS Pain 2018q2-2019q1 7.8% 40 6.8% 60LS UTI 2018q2-2019q1 4.2% 40 2.7% 60LS ED Visit 2018q1-2018q4 1.92 15 1.91 30Star Ra ng Release Month Ra ng Points Next Star Ra ng Needed PointsLS QM Ra ng July 2019 3 Stars 695 4 Stars 710Aggregate Quality Ra ng
Next Cut-PointStar Ra ng Release Month Ra ng Points Next Star Ra ng Needed PointsQM Ra ng July 2019 2 Stars (500 + 695) = 1195 3 Stars 1264
Notes: 1. Total Short-Stay QMpoints aremul plied by a factor of 1250/900 so short- and long-staymeasures are weightedequally in the aggregate quality ra ng. 2. Need at least 6 Long-Stay measures and 4 Short-Stay to have respec vecomponent ra ngs. 3. SS Pressure Ulcer and SS Discharge to Community are Quality Repor ng Program (QRP) measures4. Source- July 24, 2019 Release of Nursing Home Compare
Indicator Key Descrip on- Red Circle 30 or less points earned- Yellow Circle 40 - 90 points earned- Green Circle 100 or more points earned- Gray Circle Measure points imputed due to small denominator (i.e.
Not enough residents mee ng measure inclusion criteria)
The AHCA/NCAL Quality Ini a ve (2018-2021)The table below shows your center’s most current data as of July 25. For more on the ini a ve visit thiswebpage.
Short-Stay Long-Stay
MeasureBaselineRate
Goal Latest Rate MeasureBaselineRate
Goal Latest Rate
Hospitaliza ons
PointRightPro30
15.3%(2016Q2-2017Q1) <13.8% 18.5%
(2017Q4-2018Q3)
PointRightPro-
LongStay13.7%
(2016Q2-2017Q1) <12.3% 13.9%(2017Q4-2018Q3)
An psycho cs
NursingHome
Compare4.3%
(2016Q2-2017Q1) < 3.9% 2.1%(2019Q1)
NursingHome
Compare7.9%
(2016Q2-2017Q1) < 8.0% 8.7%(2019Q1)
CustomerSa sfac on
CoreQResident
TBD(Data Missing) >90.0% N/A
(Data Missing)
CoreQResident
TBD(Data Missing) >90.0% N/A
(Data Missing)
CoreQFamily
TBD(Data Missing) >90.0% N/A
(Data Missing)
Func onalImprovement
AHCASelf-Care
TBDComming Soon TBD N/A
AHCAMobility
TBDComming Soon TBD N/A
Data SourcesSurvey, Staffing, and Five-Star Quality data (pages 1-4) come from July 24, 2019 release of Nursing Home Com-pare, which is updated monthly. Quality Ini a ve data (page 5) from LTC Trend Tracker as of July 25, 2019.
Your Resident Profile: Your Resident Profile provides the information you need to begin the resident profile portions of the annualFacility Assessment required under CMS’s Requirements of Participation (§483.70(e)). The purpose of the Fa‐cility Assessment is to help a facility determine the resources required to provide person‐centered care and theservices residents need in both day‐to‐day operations and emergencies. CMS’s Quality Improvement Organiza‐tions (QIO) have provided a Facility Assessment template http://qioprogram.org/facility‐assessment‐tool. Wehave adapted the first section to provide a profile of your resident population using your most recent data.Definitions:
Episode: period of time a person is in your facility from admission to discharge or deathResident day: any day a resident was physically in your facility
More detailed information available at:https://educate.ahcancal.org/products/facility‐assessment‐elements‐phase‐ii‐48370‐administration‐tool
Resident Statistics by Year Jan 2017‐Dec 2017 Jan 2018‐Dec 2018Average Census
Hearing Loss: 17 6% 1,934 6% 18 9% 3,430 9%Your Resident Profile Continued on Next Page
*Suppressed due to CMS cell suppression policies for restricted data. Source: MDS 3.0 data Jan 2017‐Dec 2018https://www.resdac.org/articles/cms‐cell‐size‐suppression‐policy
Other Acuity IndicatorsAverage BIMS: 12.6 8.4 10.5 8.4
AssistanceAcuity and
Average ADL Score: 8.4 6.3 8.4 8.4Ethnic or Cultural Element
Preferred Language Not English: N/A* N/A* 730 3% N/A* N/A* 730 3%CulturalEthnic and
Married: 44 12% 2,930 9% 12 6% 2,655 9%*Suppressed due to CMS cell suppression policies for restricted data. Source: MDS 3.0 data Jan 2017‐Dec 2018https://www.resdac.org/articles/cms‐cell‐size‐suppression‐policy
Na onal averages based on data submi ed to LTC Trend Tracker as ofMay 31, 2019. Turnoverdata is for 2018. All othermeasures are for Q1 2019. The sample size for the na onal averagesare as follows: DCS Turnover - 129, An psycho cs - 187, Readmissions - 187, CoreQ Family -160, CoreQ Resident - 204.
If no bar appears for your community above, data is missing for the latest me period. Na-onal averages for different me periods are available within LTC Trend Tracker and can be
trended alongside your community’s data. To view turnover data within LTC Trend Tracker,your account administrator must grant you the appropriate privileges.
AHCA/NCAL RESOURCES TO KNOW
• How do I use LTC Trend Tracker as an Assisted Living? Find out with this on-demandahcancalED course.
• Have you heard about the AL Cost Calculator? It is a new, online tool available exclu-sively to members of NCAL. Check out www.ALCostCalculator.org to learn how it canbenefit your organiza on.
• The new Workforce Reserouce Center has tools to address staff stability and turnover.
The 2018-2021 AHCA Quality Ini a ve has four aims: 1) Reduce Hospitaliza ons, 2) Reduce Off-Label Use ofAn psycho cs, 3) Increase Customer Sa sfac on, and 4) Improve Func on. They align with CMS ini a ves,such as SNF Value-Based Purchasing and metrics used by managed care (see graphic below). Thus, improve-ment in these areas is not only beneficial to residents, but also to an organiza on’s opera onal viability.
Execu ve Summary
You have achieved at least one goal in 2 of the 4 focus areas. Overall, you have achieved the goal for 4 of the 9measures. The table below summarized overall progress and pages 3-4 provide detailed performance.Customer Sa sfac on CoreQ data comes from LTC Trend Tracker, where your sa sfac on vendor can uploaddata on your center’s behalf. For more on CoreQ, visit CoreQ.org.AHCA is s ll working on calcula ng the two func onal improvement measures using MDS assessments.
Short-Stay Long-StayCenters inKY Mee ngQI Goal (%)
StateAverageRate
Your Center’sRate (State Rank)
Centers inKY Mee ngQI Goal (%)
StateAverageRate
Your Center’sRate (State Rank)
Hospitaliza ons36.1% 16.1%
(2017Q1-2017Q4)
12.2% (40th)
Top 1/3
45.8% 12.5%(2017Q1-2017Q4)
9.7% (55th)
Top 1/3
An psycho cs55.1% 1.6%
(2018Q1)
0.0% (1st)
Top 1/3
45.8% 13.0%(2018Q1)
9.7% (72nd)
Middle 1/3
ResidentSa sfac on
2.6% 63.4%(2017Q4-2018Q3) N/A (N/A) 4.4% 62.3%
(2017Q4-2018Q3) N/A (N/A)
FamilySa sfac on
4.0% 77.1%(2017Q4-2018Q3) N/A (N/A)
Table Abbrevia ons and Notes: QI = Quality Ini a ve, N/A = Not Available. State ranking is Not Available ifeither the center’s data does not meet the appropriate sample size or response rate requirements, or there arefewer than 5 centers with data.
AHCA/NCAL Quality Ini a ve Resources
• Building Preven on into Every Day Prac ce- Your fellow nursing home administrators and cliniciansknow the challenges you face. Learn how they overcome these challenges in this online series.
• The AHCA/NCAL Na onal Quality Awards Program- Leverage systems thinking into providing efficient,high-quality care. For a discounted applica on fee, submit your intent to apply by November 8, 2018.The applica on deadline is January 31, 2019.
• ahcancalED!- Your one stop shop for on-demand learning and webinars.
• Share Your Story!- Have you implemented an innova ve idea or significantly improved the quality ofcare in your center? Help others learn from you by comple ng this online form, so AHCA/NCAL canwork with you to spread your best prac ces and recognize you.
Data SourcesOff-Label An psycho c data is from the August 22, 2018 release of Nursing Home Compare. Hospitaliza ondata is derived fromMDS 3.0 assessments by AHCA/NCAL and published on LTC Trend Tracker. CoreQ CustomerSa sfac on data is submi ed by users or vendors to LTC Trend Tracker and was pulled on Sep 10, 2018.