Quality Improvement Using the Quality Indicators Reducing Hospitalization Rates Keith Rapp MD, CMD Keith.Rapp@gaa-ltc.com Mary Pat Rapp PhD, RN Mprapp75@aol.com Geriatric Associates of America, PASlide 2
Objectives Describe Quality Indicators [QI] and Quality Measures [QM] Describe Medical Director/supplier parts in affecting QMs Discuss avoidability of hospitalizations from nursing offices Discuss instruments to help with decreasing avoidable hospitalizationsSlide 3
Quality Measures 1990: Development of 24 QIs in view of MDS 2.0 by the Center for Health Services Research Association [CHSRA] 2002: Nursing Home Compare www.medicare.gov Quality Measures 2005: CMS consolidated QIs & QMs Some hazard modification Not a static procedure Continuing refinement by the National Quality ForumSlide 4
Short-Stay Measures Influenza Vaccination During the Flu Season (October 1 through 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)Slide 5
Quality Measures – Chronic Care.. Requirement for help with day by day exercises has expanded Moderate to serious torment Pressure Ulcers (high and generally safe) Physical limitations Incontinence and Catheters Low hazard occupants who lost control of bladder or inside Percent with indwelling bladder catheter Residents who invest the greater part of their energy in bedSlide 6
..Quality Measures – Chronic Care Decline in capacity to move in and around their room Urinary tract contamination Worsening tension or discouragement Weight misfortuneSlide 7
Reporting of Measures with little denominators are not posted on NH Compare Post-Acute Measures with under 20 in denominator Chronic Measures with under 30 in the denominatorSlide 11
Geriatric Associates [GAA] Quality Model Pilot Started June 2002 Physician/Nurse Practitioner Collaboration on Medical DirectionSlide 12
GAA Quality Model NP in office 5 days for each week 25% NP time is contracted to office 75% of NP time spent seeing GAA pts Physician week after week or more visits Physician is Medical Director of officeSlide 13
Quality Model Work Daily stand up rounds with NF group Quality Assurance board of trustees cooperation Mentoring and instruction for staff Available for evaluation of all inhabitants Available for "uncommon ventures" Use of occupant level synopses to enhance QM/QIsSlide 14
Facility/Community Advantages Masters prepared attendant in the office 5 days/week Increased level of correspondence Increased office registration More assets at the office level Increased capacity to look after higher sharpness patients = releasing healing facility doctors with a higher solace level Lower hospitalization rates (keep the indirect access shut) Improved and increment involved with releasing Physicians and offices Enhanced following of referral assetsSlide 15
Medication Reduction Pilot Outcomes 2 units with BID dosing Over 1,500 less pills/day apportioned Improvement of other related QA/QMs Percent on at least 9 medsSlide 16
Liability OutcomesSlide 17
GAA Quality Model Outcomes at 14 Facilities Benchmarking Provider CareSlide 18
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS 9 + MEDS Privileged and Confidential - Proprietary InformationSlide 19
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS Intellectual IMPAIRMENT Privileged and Confidential - Proprietary InformationSlide 20
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS NO TOILET PLAN Privileged and Confidential - Proprietary InformationSlide 21
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS CATHETERS Privileged and Confidential - Proprietary InformationSlide 22
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS UTI Privileged and Confidential - Proprietary InformationSlide 23
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS TUBE FEEDING Privileged and Confidential - Proprietary InformationSlide 24
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS Scope Of Motion Privileged and Confidential - Proprietary InformationSlide 25
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS NO ACTIVITY Privileged and Confidential - Proprietary InformationSlide 26
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS Pressure Ulcer High Risk Privileged and Confidential - Proprietary InformationSlide 27
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS Weight Ulcer Low Risk Privileged and Confidential - Proprietary InformationSlide 28
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS ANTIPSYCHOTICS Low Risk Privileged and Confidential - Proprietary InformationSlide 29
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS ANTIANXIETY Privileged and Confidential - Proprietary InformationSlide 30
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS BLADDER Low Risk Privileged and Confidential - Proprietary InformationSlide 31
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS RESTRAINTS Privileged and Confidential - Proprietary InformationSlide 32
Management Pearls Include MDS Coordinator in QA Committee Focus on inhabitants that have up and coming MDSs Use occupant level rundown Provider documentation Root Cause examination of QM issues Understand MDS questions for pointers Obtain client manual for QMs Understand prohibitions Prioritize center One to Three activity territories for each month is sensible Responsibility should be doled out Follow up on activity things in QA meeting Sentinel occasions (drying out, impaction, okay PU) Indicators in 90 + percentileSlide 33
Reference assets http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/NHQIQMUsersManual.pdf http://www.cms.hhs.gov/NursingHomeQualityInits/10_NHQIQualityMeasures.asp Google "Quality Measures Nursing Homes"Slide 34
Improving Nursing Facility Care by Reducing Avoidable Acute Care Hospitalizations Used with consent Joseph G. Ouslander, M.D. Executive, Boca Institute for Quality Aging Boca Raton Community Hospital Mary Perloe, MS,GNP-BC Project Coordinator Georgia Medical Care Foundation 34Slide 35
Background 40% of 100 admissions to 8 LA nursing homes appraised as unseemly 1 68% of 200 admissions to 20 Georgia nursing homes evaluated as conceivably avoidable 2 1 Saliba et al, J Amer Geriatr Soc, 2000 2 CMS Special Study, 2008Slide 36
Background Common Disruptive for the occupant and family Fraught with numerous entanglements deconditioning, wooziness, incontinence/catheter utilize, weight ulcers, polypharmacy Costly Sometimes an improper and avoidable utilization of the crisis room and intense healing center Hospitalization of Nursing Home Residents 36Slide 37
Background Reducing avoidable hospitalizations speaks to a chance to enhance mind and lessen costs Some of the costs kept away from can be reinvested in the framework for nursing homes to give excellent care 37Slide 38
Percent of Potentially Avoidable Hospitalizations Georgia Medical Foundation N = 105 38Slide 39
Expert Opinion Avoiding Hospitalizations similar advantages can regularly be accomplished at a lower level of care One doctor visit may maintain a strategic distance from the exchange Better nature of care may forestall or diminish the seriousness of intense change Better propel mind arranging is essential The inhabitant\'s general condition may restrain the capacity to profit by the exchange Provider Resources Physician or NP/PA display in office no less than 3 days for each week Exam by doctor or NP/PA inside 24 hours Availability of lab tests inside 3 hours Intravenous treatment 39Slide 40
Facility Assessment Appropriate reporting instruments to guarantee that progressions of condition are accounted for properly to the ideal individual Ability to begin treatment, e.g., anti-infection agents, torment medicine in a couple of hours Ability to begin intravenous or clysis treatment for hydration inside 2 hours of the request Sufficient nursing staff scope to supervise suitable checking more than 24 hours Sufficient nursing staffing to guarantee day by day evaluation until the intense behavioral change has determined or balanced out Sufficient nursing staffing to perceive and report conceivable intricacies of treatment inside 24 hours of their ID AMDA CPG Recognition of Change in Condition 40Slide 41
A Tool Kit to Improve Nursing Home Care by Reducing Avoidable Acute Care Transfers and Hospitalizations Developed in view of the information gathered, and Expert Panel appraisals of significance and achievability Communication Tools Care Paths Advance Care Planning Tools http://www.qualitynet.org/dcs/ContentServer?cid=1181668673046&pagename=Medqic%2FContent%2FParentShellTemplate&parentName=Topic&c=MQParents 41Slide 42
Communication Tools Keeping it Simple 42Slide 43
Communication Tools *Situation, Background, Assessment, Recommendation 43Slide 44
Recognize a Change in Condition No? TELL A NURSE Yes? Adjusted from Boockvar , Kenneth et all, JAGS 48: 1086-1091,2000. S eemed like himself/herself T alked similar O verall work similar P articipated in common exercises A te similar sum N D rank similar sum W eak A gitated or anxious T ired or sluggish C onfused H elp with dressing, toileting, exchanges 44Slide 45
Associated with Hospitalizations Boockvar KS, Lachs, MS  JAGS, 51:1111-1115. Indications anticipate sickness around half of the time. Probability proportions appear there is a direct improve in the probability of infection. Be that as it may, if the signs are truant , you can be 90% constructive the individual is not sick. 45Slide 46
Change in Condition Immediate Notification Any side effect, sign or clear uneasiness that is: Sudden in onset A stamped change (i.e. more serious) in connection to common side effects and signs Unrelieved by measures effectively endorsed Sources: AMDA Clinical Practice Guideline – Acute Changes in Condition in the Long-Term Care Setting 2003. Ouslander , J, Osterweil , D
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