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The CMS quality initiative: gentlemen, start your computers. (Computer Quarterly Update).

Beginning in October, the Centers for Medicare and Medicaid Services (CMS) plans to implement new national mandatory quality-of-care measures (QMs) for long-term care residents and subacute care patients. CMS intends to establish "outcomes reporting" using the new QMs. The establishment of long-term and subacute care "report cards" can be viewed as the result of CMS's extensive multiyear investment in the development of quality indicators (QIs) and QMs for the long-term care industry.

Through the efforts of the University of Wisconsin, the Hebrew Rehabilitation Center for Aged Research and Training Institute, LTCQ, Inc., Abt Associates, Inc., and others, many long-term care QIs have been developed and tested for reliability and validity. Most recently, CMS contracted with the National Quality Forum (NQF), a broadly representative organization of healthcare organizations, for its recommendations on a set of core national long-term care QMs that could be tested and implemented in all 50 states. Last year the NQF established a steering committee of national experts in long-term care quality measurement, and this committee recommended 10 national long-term-care core measures (Table 1) and 4 subacute measures (Table 2) for national adoption. All QMs are based directly on indicators reported in the Minimum Data Set (MDS) 2.0, as reported by long-term care organizations. A six-state demonstration project, which is testing six long-term care measures and three subacute care measures, is now in it s fourth month.

Although certain methodologic issues remain to be resolved--including risk adjustment of QMs, use of a Facility Admission Profile, MDS coding errors and use of quality-of-life and staffing data--CMS is moving ahead with its planned October national rollout. This means that for the first time, comparative data on quality of care in all long-term care facilities will become generally available to consumers, hospital discharge planners, case managers, policymakers, researchers, long-term care providers and many others.

In general, most long-term care facilities have not used electronic QI reporting to monitor and track their quality of care against national, regional or local benchmarks. Some organizations have subscribed to long-term care QI reporting services that provide benchmark-type reports (based on subscriber databases) on a quarterly, semiannual and annual basis. These "historical" data, however, have rarely been made available to the public. Moreover, many of the current software systems used by long-term care providers cannot produce either real-time or trended reports on MDS QIs, including the new CMS QMs; this results in individual facilities being unable to access their own QM data and, therefore, possibly having to wait for CMS or state agencies to publish their data before being able to evaluate the information and implement appropriate corrective actions.

Long-term care facilities should act now to remedy datareporting problems and institute a system to provide management reports on the CMS QMs. Facilities should take the following steps:

* Review the QI reporting tools and management reports available in the clinical software they use presently. Ensure that new CMS QMs will be available in future management reports.

* Evaluate whether QM data can be reported either on demand or at quarterly intervals using current software.

* If current software does not include MDS QI reporting functionality, consult with the IT vendor to determine its availability.

* If QI measurement reporting functionality is not available from the current software vendor, consider subscribing to one of the long-term care data-reporting services. Some of the services are now using secure Internet applications with real-time reporting capability.

* Evaluate whether the organization wants to present its quality-of-care data using comparative (benchmark) data from national, regional or local geographical areas.

* If the facility wants to use benchmark data, evaluate whether there will be staff who can download benchmark data from CMS (if CMS makes the data available online) or, instead, the facility should subscribe to one of the long-term care data-reporting services.

* Be prepared to have the facility's recent CMS QM data available for public inspection, with appropriate interpretive information to explain QM results.

The reporting of QMs and their correct interpretation are not easy tasks for long-term care facilities. In general, the most effective solution for facilities will be to adopt and use QM reporting programs provided by vendors. Additional assistance in reporting and trending comparative QM data is available through long-term care database-subscription services.

It is important to act now. While it is not entirely certain how the new CMS QMs will be used, it is clear that CMS, state Quality Improvement Organizations, state survey agencies, the Joint Commission on Accreditation of Healthcare Organizations, hospital discharge planners and case managers, and consumers will resort to QMs to evaluate resident care outcomes for specific facilities. Establishing facility-based automated reporting of QMs should become a priority.

Table 1. LTC National Core Measure Set.

* Decline in Late Loss ADLs (admission exclusion)

* Prevalence of weight loss (admission exclusion)

* Inadequate pain management (covariate adjustment)

* Prevalence of Stage 1-4 pressure ulcers (stratification)

* Prevalence of daily restraints (no risk adjustment)

* Prevalence of antipsychotic use, in absence of cause (stratification)

* Prevalence of depressive symptoms without therapy (exclusion)

* Prevalence of bladder or bowel incontinence (stratification into high and low risk)

* Prevalence of indwelling catheters (two assessments)

* Prevalence of bedfast residents (no risk adjustment)

Table 2. Subacute Care Measures.

* Post-acute care/failure to improve and manage pain (Facility Admission Profile [FAP] adjustment)

* Post-acute care/failure to improve and manage symptoms of delirium (FAP)

* Post-acute care/improvement in walking (FAP)

* Readmission to hospital (defer implementation)

Malcolm H. Morrison, PhD, is president of Morrison Informatics, Inc., a healthcare information technology and data analysis firm in Mechanicsburg, Pennsylvania. For further information, phone (800) 559-8410 or e-mail
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Author:Morrison, Malcolm H.
Publication:Nursing Homes
Geographic Code:1USA
Date:Aug 1, 2002
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