Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) can serve as key partners for directors of nursing services (DNSs) in their efforts for quality improvement. With all that DNSs are responsible for, every DNS should be aware of the resources that QIN-QIOs offer.
QIN-QIOs are key drivers of the National Nursing Home Quality Care Collaborative (NNHQCC), a national learning activity with the following aims, according to CMS: Ensure every nursing home resident receives the highest quality of care; Instill quality and performance improvement practices; Eliminate healthcare-acquired conditions; and Improve resident satisfaction by improving their care and environment.
“In every nursing facility, the DNS is an integral part of the day-to-day quality improvement (QI) efforts to instill change within their organizations,” acknowledges the CMS official. “Every DNS desires to create a culture of resident safety within their facility. A culture of resident safety is composed of many elements, beginning with the DNS’s need to engage in ongoing learning with local, state, and national colleagues.”
QIN-QIOs are eager to provide support to more nursing homes. An official with the Centers for Medicare & Medicaid Services (CMS) tells DNS Navigator, “Our goal is to engage more than 11,000 nursing homes by April 1, 2017.” Here are critical areas that the QIN-QIOs can help with and key reasons to pick up the phone:
The upcoming Skilled Nursing Facility Quality Reporting Program (SNF QRP) and SNF Value-Based Purchasing (SNF VBP) program will both have a direct impact on Part A SNF PPS payments. In addition, the Five Star Quality Rating System on Nursing Home Compare is already impacting census (and the bottom line) at many facilities. Most Medicare Advantage plans seek to partner with providers that have a 3-star minimum rating, and innovative payment models such as the Comprehensive Care for Joint Replacement (CJR) model and some accountable care organizations (ACOs) influence SNF referrals by allowing a waiver of the Part A three-day qualifying hospital stay when providers have a 3-star rating.
“One way or another, Medicare payment is being linked back to quality measures (QMs) in all of these programs,” points out Pamela Longmire, RT, BAS, the lead nursing home QI specialist for Montana at Mountain-Pacific Quality Health, the QIN-QIO for Montana, Wyoming, Alaska, and Hawaii, as well as the jurisdictions of Guam, American Samoa and Saipan.
While the QMs used in these programs differ in terms of focus and technical specifications, the QIN-QIOs target quality improvement from a systems perspective that should benefit provider quality across all three QM programs, suggests Longmire. “With CMS moving to value-based Medicare payment, facility performance right now is going to affect facility payment in the future. Providers need to get their quality standards as high as possible now by instituting systemic quality improvement so that their future payments aren’t negatively impacted.”
Prep for survey
While the growing link between payment and quality is crucial, it’s not the only reason to work with the QIN-QIOs. DNSs may also want to get involved if they’re concerned that quality issues could result in less-than-stellar survey results, suggests Longmire. “In fact, the state survey agency, the long-term care ombudsman and adult protective services have all passed my contact information to facilities in need.”
“The QIN-QIOs are a good resource for improving quality, which also improves surveys,” she says. “QIOs are nonthreatening. Nothing we do is regulatory, so I am never going to go into a nursing home and say, ‘You’ve got all of these insufficiencies. I’m going to write you a tag, and you had better get me a plan of correction.’ I never come with a slap to your hand. I always come with my hand outstretched and ask, ‘How can I help you make your facility successful?’’’
Identify and address facility-specific quality issues
The work of the QIN-QIOs centers around 13 publicly reported long-stay QMs that represent interrelated systems of care. “We focus on reductions for 11 of the measures: falls with major injury, urinary tract infections, pressure ulcers, bowel and bladder incontinence, physical restraints, moderate to severe pain, increased assistance with the activities of daily living, weight loss, depression, antipsychotic medications, and catheters inserted or left in the bladder,” says Longmire. “The two measures we are trying to increase instances of, are flu and pneumonia vaccinations.”
The NNHQCC measures progress using what’s called the QM composite score, which is derived from those 13 QMs. The composite score can be updated more frequently than the Five Star system so providers can see their progress closer to real time and examine quality from a systems perspective.
“Mountain-Pacific gives nursing homes an easy-to-understand proxy report that lets them see where they are performing as an individual home in 11 of the 13 measures (the two vaccinations are excluded from this report). It also shows where the state is performing on average, and where CMS would like to see them performing,” says Longmire. “So DNSs just have to pick up a piece of paper to quickly see, ‘Here’s where we are performing well, and here’s where we need improvement.’”
Every QIN-QIO offers some version of this report. For example, Telligen, the QIN-QIO for Illinois, Iowa, and Colorado and Mountain-Pacific, offer an Excel-based Composite Score Calculator that helps providers both identify areas for improvement and model ways to achieve a lower composite score. Note: The higher the score, the lower the quality. CMS wants nursing homes nationwide to have a composite score of 6.0 or less.
In addition to working with nursing homes on those 13 QM areas, QIN-QIOs can help with the following:
- QAPI. The Patient Protection and Affordable Care Act of 2010 mandated that CMS require nursing homes to develop, implement, and maintain a Quality Assurance and Performance Improvement program. That requirement is coming closer to implementation since CMS proposed programmatic standards for QAPI in the July 16, 2015, proposed rule for the reform of requirements for long-term care facilities (i.e., the Medicare/Medicaid conditions of participation).“ To help foster understanding and implementation of the QAPI principles and practices put forward by federal regulations, QAPI serves as the framework for the NNHQCC,” says the CMS official. For example, Mountain-Pacific has offered four on-site workshops on QAPI and provides ongoing QAPI support.
- Staffing. “Mountain-Pacific helps nursing homes with staffing issues using innovative culture-change models, and we work with leadership to help them reduce turnover,” says Longmire. “Consistent assignment is key in reducing turnover and building bonds between the resident and their care partner. The end result is a higher quality of life for both the resident and their care partner.”
- Clostridium difficile infection (CDI). The NNHQCC has established a new initiative to decrease the national rate of CDI in nursing homes, notes the CMS official. “Engaging in this effort will assist participating facilities to learn antibiotic stewardship principles and practices. The goal is to establish a national and baselines of CDI in each state, and to reduce CDI rates in participating facilities and each state.” Note: CMS also proposed a requirement that nursing homes have an antibiotic stewardship program that includes antibiotic use protocols and a system for monitoring antibiotic use in the July 16, 2015, proposed reform rule.
Recognize the value QIN-QIOs offer
Working with QIN-QIOs saves providers a lot of time, money, and stress, says Longmire. “The QIN-QIOs are here to offer assistance to help improve the DNS’s workload—and ultimately to improve the experience and the care that residents receive. Across the nation, we support DNSs with onsite trainings and webinars, tools, educational material, and easy-to-understand data reports. They don’t have to use their own time and resources to create training programs from scratch because we provide and teach them the best practices.”
Providers also don’t have to pay for nationally respected speakers because the QIN-QIOs bring in that outside expertise. Earlier this year Mountain-Pacific, hired G. Allen Powers, MD, a board-certified internist, geriatrician, and author who was vital to the creation of CMS’ Hand-In-Hand materials. “Mountain-Pacific provided an all-day workshop in Montana with Dr. Power, as well as a three-part webinar focusing on the drawbacks of our current approach to dementia and why it has been so difficult for homes to eliminate antipsychotic drug use,” says Longmire. “He introduced new methods centered on enhancing well-being, which displayed how this shift brings striking insights about the shortcomings of our current approach.”
QIN-QIOs also have varied staff resources available to help nursing homes, points out the CMS official. These can include a wide range of QI specialists, such as nurses, physicians, analysts, and pharmacists.
In other words, the QIN-QIOs “pick up the time slack and the financial slack for providers, all-the-while improving the quality of care and quality of life for their residents—and reducing provider overhead because overhead goes down as quality improves,” says Longmire. “So it’s really a win for them to join. They are getting 100 percent assistance at absolutely no cost to them.”
Don’t get hung up on the time factor
Facilities that have lower QMs and need more help do have to invest more time to move their QMs, Longmire acknowledges. “However, the beauty of this program is that you consider your areas needing improvement and choose where you want to begin. Once a facility signs up, they receive that handy proxy report that shows their performance. Then I can sit down with the DNS and find out what they want to work on. Our work is always based on their needs.”
In addition, the overall time commitment is not burdensome because “providers don’t have to report back to us,” says Longmire. “We have access to all of their data, so they don’t have to take the time to gather data and generate reports to show their performance.”
The time commitment also can vary somewhat from state to state depending on “the format of the NNHQCC implemented in each state,” adds the CMS official.
“There is a website specifically designated for the QIO program,” says the CMS official. “Please go to: www.qioprogram.org. At the top of the landing page, there is a ‘Locate your QIO’ button. Click the button, and it will take you directly to the state-specific contact information.”
DNSs can then contact their QIN-QIO to discuss participating in the NNHQCC, suggests the official. “Execution of a NNHQCC participation agreement is required.”
Learn what extras your QIN-QIO may offer
The QIN-QIO experts across the country bring their own unique skill sets and approaches that sometimes can provide even more added value to the nursing homes they work with. In Montana, Longmire often provides resources that are outside the scope of services that Mountain-Pacific is evaluated on by CMS. For example, she has helped Montana providers find resources and training on Payroll-Based Journal (the new electronic staffing data submission system that is required effective July 1).
“When new regulations are implemented and nursing home staff stress about meeting the needs of something like Payroll-Based Journal, it’s hard for them to concentrate on these QMs,” notes Longmire. “I will link them to training and help so they can understand what they need to do to meet the regulation. While my primary concern is the 13 QMs, I understand the stresses of everyday life in the nursing home. Consequently, I try to funnel information on other issues to them so they can focus on improving their quality in these areas.”
In addition, Mountain Pacific allowed Longmire to become a certified trainer in Positive Approach to Care, a dementia education program emphasizing interpersonal dynamics that was developed by dementia education specialist Teepa Snow. “To get her into a facility, a provider would pay about $8,000,” says Longmire. “But as a certified trainer, I can take this care practice to the nursing homes in Montana at no cost to them. That’s a significant benefit.”
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