MDS Alert

Published on Sun Aug 24, 2008 PDF

Hint: Having this information for consumers will soon become more important than ever.

Come December, the Centers for Medicare & Medicaid Services plans to implement a five-star rating program for nursing homes to give consumers an easier way to size up their quality. And now is the time to figure out how to tell the "rest of the story" about your facility's outcomes and services -- beyond the number of stars that CMS gives it on the agency's Nursing Home Compare website.

How you'll be graded: CMS will assign a facility one to five stars based on its survey performance over the past three years, its scores on a subset of the publicly reported quality measures, and staff information already reported on the agency's NHC website. CMS has yet to announce which QMs it will use.

The problem: Even a great facility can have a bad survey. And a leading-edge facility can actually look bad on certain QMs if it admits a lot of high-acuity residents with serious pressure ulcers or pain, as examples. And, as studies have shown, the sheer numbers of staff don't always add up to better care.

A bright idea: CMS should rate facilities in ways that truly reflect quality, said Terry Sullivan, executive director of the of Illinois Council on Long Term Care in a recent Open Door Forum on the five-star rating system and in a letter to CMS shared with Eli. Sullivan cited a number of "more proactive indicators of quality available to CMS from collected MDSs." Experts note that facilities could calculate their own measures using these and other MDS items for internal quality improvement and to tout their successes to consumers and surveyors. For instance, try keeping track of the following:

• The number of restorative services per resident (MDS section P3). An active restorative care program underscores a facility's commitment to reverse chronic conditions of aging and improve a resident's involvement in living, wrote Sullivan in his letter to CMS.

• Improvement in ADLs (MDS sections G1 and G9). ADL improvement is another good measure that correlates to provision of restorative in Section P3, Sullivan tells Eli.

• Healed pressure ulcers. (MDS section M3). Sullivan notes that facilities specializing in aggressive wound management will always have a greater number of pressure ulcers than facilities that admit healthier populations. "The true measure of quality in this critical benchmark care area is not just the absence of pressure ulcers; it is the history of resolved pressure ulcers," he states in his letter to CMS.

Also: Pressure ulcer prevention services (MDS sections M5 and M6) are another benchmark indicator of quality, added Sullivan.

You can track pressure ulcer healing in various ways, counsels Nathan Lake, RN, BSN, MSHA, director of clinical design for American HealthTech based in Jackson, MS. For example, you can use the National Pressure Ulcer Advisory Panel's PUSH tool, which allows you to measure a wound's progress, he notes. (For a copy of the PUSH tool, see MDS Alert, Vol. 5, No. 9 in the Online Subscription System archives. If you haven't yet signed up for this free service, call customer service at 1-800-508-2582.)

Good idea: Track the incidence of pressure ulcers or those that developed in house versus the facility's overall prevalence of pressure ulcers; the latter includes both pressure ulcers that developed in house and ones the facility inherited from other settings, said Steven Levenson, MD, CMD, in a webinar presentation on pressure ulcers sponsored by Advancing Excellence in Nursing Homes.

• Reduction in pain (MDS section J2a or J2b). Assessing, and then reducing, either the frequency or intensity of pain, is another mark of quality, Sullivan told CMS.

Cast a wider net: A facility can fine-tune its measures to give a clearer picture of its pain management efforts. For example, include coding combinations at J2 that won't trigger the pain QMs. Those coding combinations would encompass moderate pain less than daily, and mild pain daily, suggests Christie Teigland, PhD, director of Health Informatics and Research for the New York Association of Homes & Services for the Aging/EQUIP for Quality. "Doing so captures people whose pain should also be addressed," says Teigland. "And it can also preempt triggering of the pain QMs as residents' pain worsens if not managed appropriately."

Teigland notes that most MDS software allows you to pull out how you coded various MDS items. So you could also, for example, pull out residents with dementia and look at their pain scores. "Our validated definition of dementia includes residents with a dementia or an Alzheimer's disease diagnosis checked in Section I on any current or previous MDS assessment ... or an ICD-9 code for dementia or a Cognitive Performance Scale score of 4, 5 or 6 ... ." (To review how the CPS is calculated, see the April 2006 MDS Alert in the Online Subscription System.) You may find that the dementia residents have zero pain reported even though they have cancer, arthritis and other painful conditions, Teigland says. By identifying these residents, you can use a pain assessment tool designed for this population.

• Services coded in Section P. "Five-star hotels provide the extra level of amenities and services that you would not normally find," Sullivan pointed out. Examples of services coded in P1a that can set a facility apart include ventilators, Alzheimer's dementia special care units, hospice care, respite care, and training in skills required to return to the community.

Mental health services coded in P2 include a special behavior symptoms evaluation program and group therapy.

Another idea: Your facility can use a dining observation assessment tool to assess whether residents are eating enough and getting quality dining assistance, including social interaction. For details, see "Dining Observation Tool Measures Amount, Quality Of ADL Assistance" in MDS Alert (Vol. 6, No. 5) and watch the CMS webinar on how to enhance the quality of dining assistance at cms.internet streaming.com. Also see p. 106 of this issue for a list of quality indicators that can be developed by using the dining observation tool presented in the webinar.

Monitor this outcome: The facility could provide more staffing of different types to help during meals and snack-times and look at the effect on its unintended weight- loss QI, Lake suggests.