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VOLUME TO VALUE: CHALLENGES & OPPORTUNITIES Update on the AOTA Quality Program October 12, 2018
VOLUME TO VALUE: CHALLENGES & OPPORTUNITIES
Update on the AOTA Quality Program
October 12, 2018
The Quality Team
Sharmila Sandhu, JD Director of Regulatory Affairs
Jennifer Bogenrief, JD Assistant Director of Regulatory Affairs
Jeremy Furniss, OTD OTR/L BCG Director of Quality
Volume to Value | Quality Team Presentation to the ALC
Agenda
• Incentives for Health Systems Today
• Countdown to new Value Based Programs
• Consider Future Incentives & the Response from OT
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OT Services
⇡ staff ⇡ hours ⇡ productivity
Organization Reimbursement
⇡ Dollars
⇡ Audit Activity Incentives for Health Systems
• Hire more OT Practitioners • Maximize productivity • Focus on defensive
documentation to minimize negative audit findings
OT Services & Medicare Payment Today
Medicare is Making Changes
• An effort to change incentives for health systems
• We’ll count down changes in 4 practice areas
• These are the highlights, make sure to…
– Check out links for more info on aota.org
– Keep an eye out for new training modules
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VBP Payment changes based
on Quality Measure performance
Medicare A Quality Programs
Value Based Purchasing
QRP Public Reporting of
Quality Measure performance
Quality Reporting Program
Volume to Value | Quality Team Presentation to the ALC
IMPACT Act
• Mandated changes in Post-Acute Care, including… – Domains using standardized (uniform) data elements – Implement quality measures from five quality measure domains
using data – Development and reporting of measures pertaining to
resource use, hospitalization, and discharge to the community
• CMS created standardized data elements that can be found at https://del.cms.gov
• Section GG is one of these areas
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Section GG Self-Care Elements
• Eating
• Oral hygiene
• Toilet hygiene
• Shower/bathe self
• Upper body dressing
• Lower body dressing
• Putting on/taking off footwear
6: Independent 3: Partial/moderate assist 5: Setup or cleanup assist 2: Substantial/maximal assist 4: Supervision or touching assist 1: Dependent
Template & Education at www.aota.org/care Check out the link to the official CMS training!
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Volume to Value | Quality Team Presentation to the ALC
#4 January 1, 2020
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Home Health HH (Draft Rule)
Section GG
Yes
QRP Yes. Self-Care Measures are based on legacy data elements
VBP Demonstration (9 states)
Therapy Time
OT visits no longer contribute to payment as of Jan 1, 2020
#3 October 1, 2019
Volume to Value | Quality Team Presentation to the ALC
Inpatient Rehabilitation Facilities HH IRF
Section GG
Yes Yes. FIM™ is being replaced by GG. Used for Measures & Payment
QRP Yes. Self-Care Measures are based on legacy data elements
Yes. Self-Care & Mobility Measures based on GG
VBP Demonstration (9 states)
Not yet
Therapy Time
OT visits no longer contribute to payment as of Jan 1, 2020
Does not impact payment
#2 October 1, 2019
Volume to Value | Quality Team Presentation to the ALC
Skilled Nursing Facilities HH IRF SNF
Section GG
Yes Yes. FIM™ is being replaced by GG. Used for Measures & Payment
Yes. Used for Measures & Payment
QRP Yes. Self-Care Measures are based on legacy data elements
Yes. Self-Care & Mobility Measures based on GG
Yes. Self-Care & Mobility Measures based on GG
VBP Demonstration (9 states)
Not yet Yes. 1st Payment Adjustment 10/1/18
Therapy Time
OT visits no longer contribute to payment as of Jan 1, 2020
Does not impact payment
OT minutes no longer contribute to payment as of Oct 1, 2019
BEFORE WE GET TO #1…
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Organization Reimbursement
⇡ Dollars
⇡ Consumers d/t ⇡ QRP Measures
⇡ VBP Measures
OT Services
staff hours
Incentives for Health Systems
• Maximize staff that have an impact on quality measures
• Minimize staff that have little or no impact on quality
• Focus on collaboration and documentation that identifies value
• Identify gaps and improve care using quality measures
Future of OT Services & Medicare Payment
Examples of QRP & VBP Measures
• Functional Outcome Measure: Change in Self-Care Score (based on Section GG)
• Percent of Residents Experiencing One or More Falls with Major Injury
• Percent of Patients or Residents with Pressure Ulcers that are New or Worsened
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#1 January 1, 2019
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Quality Payment Program (QPP)
• Medicare Part B Outpatient (not facility based… yet)
• In 2019, Best performers can earn +7% to 2021 payments. Worst performers can earn -7%.
• Low Volume Threshold determines eligibility
– 60 OT NPIs mandated to participate
– 4,400 OT NPIs eligible to opt-in
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QPP Categories In 2019, OT will likely only be scored on 2 of the 4 categories:
Quality Report 6 measures
(1 outcome or high priority).
Scored based on performance.
Improvement Activities
Complete 90-days of quality
improvement using selected activities
Cost Compares the
cost of services to peers
Promoting Interoperability
Measures based on the use of certified EHR technology
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Claims 1. N-0101 Falls: Screening, Risk
assessment, and POC 2. N-0421 BMI Screen & Plan 3. N-0419 Doc Meds in Record 4. N-0420 Pain Assess & f/u 5. N-2624 Functional Outcome 6. N-0028 Tobacco Use 7. N-0418 Depression Screen & f/u 8. Q-181 Elder Maltx screen & f/u
Registry/EHR 1. N-0422 FOTO Knees
2. N-0423 FOTO Hip
3. N-0424 FOTO Foot/Ankle
4. N-0425 FOTO Lumbar
5. N-0426 FOTO Shoulder
6. N-0427 FOTO Elbow, Wrist, Hand
7. N-0428 FOTO Gen Ortho
8. N-2152 Unhealthy Alcohol Use
9. 281 - Dementia: Cognitive Assmt
10. 282 - Dementia: Functional Status Assmt
11. 283 - Dementia: Associated Behavior/Psych
12. 286 - Dementia: Safety Concerns
QPP (MIPS) Quality Measures
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Improvement Activities A few examples • Depression screening • Engagement of Patients, Family, and Caregivers in Developing a Plan of Care • Implementation of fall screening and assessment programs • Participation in Quality Improvement Initiatives • Practice Improvements that Engage Community Resources to Support
Patient Health Goals • Promote Use of Patient-Reported Outcome Tools • Tobacco use • Unhealthy alcohol use • Use of decision support and standardized treatment protocols
Volume to Value | Quality Team Presentation to the ALC
QPP.CMS.GOV
AOTA QUALITY PROGRAM
To maintain relevance…
OT practitioners must deliver high-quality services that
impact each client and
impact systems level quality measurement.
What is AOTA Doing?
• We support OTs who review, critique, and/or recommend quality measures for every program
• We develop clinical resources for practitioners www.aota.org/care | www.aota.org/profile
• We provide feedback directly to CMS
• We work with measure developers
• We are developing action oriented education
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• PCPI Primary & Preventive Care TEP • PCPI Measure Advisory Committee • AAPM&R & PCPI Measure Development • NQF Neurology Committee • NQF Serious Mental Illness Action Team • NQF Adult Medicaid Group • NQF Medicaid Scorecard • NQF Cancer Standing Committee • NQF Clinician Workgroup • NQF Admissions & Readmissions
Workgroup
• NQF Post-Acute Care Workgroup • NQF Clinician Workgroup • NQF Membership Advisory Council • CMS MSK Non-spine Cost Measure Dev • CMS MSK Cost Measure Dev • CMS Psych Cost Measure Dev • CMS Neuro Cost Measure Dev • CMS Measure Development Plan TEP • CMS Unified PAC PPS TEP • CMS IMPACT TEP (multiple) • And more…
2018 External Quality Work
There are over 20 committees/groups that include OTs just this year!
Volume to Value | Quality Team Presentation to the ALC
Areas to Address in an OT Eval 1. Occupational Profile
Occupational Performance
1. ADLs
2. IADLs
3. Fall Prevention / Fear
4. Psychosocial Skills
5. Functional Cognition
6. Vision
Our Initial Focus is the OT Eval
Volume to Value | Quality Team Presentation to the ALC
Quality Measure Examples • Readmissions
• Change in Self-Care
• Fall with major injury
• Discharge to community
• Falls: Screening, Risk Assessment, and POC
• Functional Outcome
• Depression Screen & f/u
Areas to Address in an OT Eval 1. Occupational Profile
Occupational Performance
1. ADLs
2. IADLs
3. Fall Prevention / Fear
4. Psychosocial Skills
5. Functional Cognition
6. Vision
Our Initial Focus is the OT Eval
Volume to Value | Quality Team Presentation to the ALC
Quality Measure Examples • Readmissions
• Change in Self-Care
• Fall with major injury
• Discharge to community
• Falls: Screening, Risk Assessment, and POC
• Functional Outcome
• Depression Screen & f/u
Areas to Address in an OT Eval 1. Occupational Profile
Occupational Performance
1. ADLs
2. IADLs
3. Fall Prevention / Fear
4. Psychosocial Skills
5. Functional Cognition
6. Vision
Our Initial Focus is the OT Eval
Volume to Value | Quality Team Presentation to the ALC
Questions for Practitioners
• Can we answer: “How do I, as an OT practitioner, contribute to client and system outcomes?”
• Are we familiar with Medicare quality programs— VBP, QRP, QPP? How OT contributes?
• Are we comfortable with Section GG as a measure for self-care & mobility? Are we experts?
• Can we implement a quality improvement project?
Volume to Value | Quality Team Presentation to the ALC
Slide Deck
• Visit https://bit.ly/alc18q to download the PowerPoint and PDF versions of the slide deck
• The PowerPoint version has bonus slides that include an activity using Nursing Home Compare quality measures
• Feel free to edit and use the slides in your programs
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Bonus Slides
• These slides were put together for use with students in the classroom
• Keep an eye out for additional resources & education from AOTA
• SNF Measures are included. Measures in other settings will vary.
• Here’s a great presentation from PCPI on the PDSA process discussed in these slides
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SNF VBP Measures Measure Data Status
Skilled Nursing Facility 30-Day Potentially Preventable Readmission Measure (SNFPPR) Claims Implemented
Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) Claims Implemented
Volume to Value | Quality Team Presentation to the ALC
SNF QRP Measures Measure Data Status
Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) MDS Implemented
Percent of Patients or Residents with Pressure Ulcers that are New or Worsened MDS Implemented
Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function
MDS Implemented
Discharge to Community- Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
Claims Implemented
Potentially Preventable 30-Days Post-Discharge Readmission Measure for Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
Claims Implemented
Medicare Spending Per Beneficiary – Post-Acute Care (PAC) Skilled Nursing Facility Measure Claims Implemented
Volume to Value | Quality Team Presentation to the ALC
SNF QRP Measures: FY 2020 Claims Measure
Medicare Spending Per Beneficiary (MSPB)—Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP).
Discharge to Community Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
Potentially Preventable 30-Day Post-Discharge Readmission Measure for Skilled Nursing Facility (SNF) Quality Reporting Program (QRP).
• FY 2020 begins Oct 1, 2019
• This slide includes measures calculated with claims data
• The next slide includes measures calculated with data from the Minimum Data Set (MDS)
SNF QRP Measures: FY 2020 MDS
Measure
Percent of Residents or Patients With Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678).
Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury.
Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674).
Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631).
Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634).
Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636).
Application of the IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633).
Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635).
Drug Regimen Review Conducted With Follow-Up for Identified Issues- Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP).
Activity
• Visit Nursing Home Compare
• Select a facility (in the area, from a fieldwork, etc.)
• Identify a quality measure for improvement
• Identify the ways OT can impact the measure, questions you would ask, & possible action steps
Volume to Value | Quality Team Presentation to the ALC
Visit: https://www.medicare.gov/nursinghomecompare/
Or search for “Nursing Home Compare”
Search for your SNF
here
“Stars” provide an overview meant for consumers
Click the name of your facility to get to the good stuff!
Each tabs is important. But, we are going to focus on
“Quality”
Each tabs is important. But, we are going to focus on
“Quality”
For SNF, there are 2 sets of measures—check out both!
Short-stay & Long-stay
Up to Date
• Click on current data collection period • These measures are often a few months old • New measures may not be published yet • The facility can pull current measures using
– Electronic Health Records and/or – CASPER reports (Available from a CMS portal)
Short Stay Measures
The performance of your facility is in this column.
Short Stay Measures
The average performance of your state is in this column.
Short Stay Measures
The national average performance is in this column.
Short Stay Measures
While most all of these measures relate to OT, some are directly connected!
Short Stay Measures
All of these measures are important. Measures that are worse than state or national will likely rise to the top of priorities!
Short Stay Measures
Your facility can identify the people in the measure using MDS software or CASPER report.
Short Stay Measures
• What questions might you ask for this measure? • Were the people with pressure ulcers that are new or worsened
referred to OT? – If so, what areas did the OT address in the evaluation & intervention? – If not, why not? Can this be changed?
• Identify ways in which OT may help the interdisciplinary team improve on the measure. – Is OT evaluating ADL and IADL performance for clients who are at risk
for pressure ulcers? (e.g., toileting for people with decreased independence in mobility)
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HOW CAN WE USE THIS INFORMATION TO IMPLEMENT A PDSA CYCLE?
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PDSA Cycle
Download a PDSA Worksheet from the Institue for Healthcare Improvement Plan
– State the objective or purpose – Make a prediction of what will happen and why – Develop a plan to test the change
• Who? What? When? Where?
– What data needs to be collected? – Generate a Good Idea
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PDSA Cycle
Do – Test the change on a small scale (e.g., one patient,
one unit, one shift, one hour – “1:1:1 test”)
– Document what happened – problems and unexpected observations
– Begin data analysis
– Test on a SMALL scale!
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PDSA Cycle
Study
– Complete data analysis
– Compare data to predictions
– Summarize learnings and think about meaning
– Don’t Forget to Study the results!
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PDSA Cycle
Act
– Adopt, adapt, abandon the change based on results of the test
– Prepare plan for next test
– Adjust and Do Again
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Compare Sites This process works the same way for most settings. See the sites below: • Home Health Compare
https://www.medicare.gov/homehealthcompare/search.html • Inpatient Rehabilitation Facility Compare
https://www.medicare.gov/inpatientrehabilitationfacilitycompare/ • Long Term Care Hospital Compare
https://www.medicare.gov/longtermcarehospitalcompare/ • Hospital Compare
https://www.medicare.gov/hospitalcompare/ • Physician Compare (Including OT in private practice)
https://www.medicare.gov/physiciancompare/
Volume to Value | Quality Team Presentation to the ALC
