Welcome to this session on the quality measures, the percent of residents who self-report moderate to severe pain. My name is Melody Malone, a quality improvement consultant with TMF Health Quality Institute. And I'm happy to bring you this program today.
Our objectives are to review the quality measure specification for this measure. Percent of residents who self-report moderate to severe pain long-stay. Don't confuse this with this short-stay measure. And to identify the relationships between the Minimum Data Set, or the MDS, and the quality measure.
Here is my disclaimer, however. I am not an MDS expert. So I'm going to encourage you to always use the tools and resources you have available to you. That would be the Resident Assessment Instrument, or the RAI User Manual, or the MDS Manual, the MDS 3.0 Quality Measure User Manual, the Quality Measure Identification Number Reporting Module by CMS, the QMID, and the Five-Star Quality Rating System Technical Users' Guide.
You have these resources available to you on the CMS.gov website, as well as links to them in the TMF website on the Quality Measure Video page. Additionally, you've got your resources of the Texas MDS program staff. The MDS Automation and QIES Coordinator is Brian Johnson. And our MDS Clinical Coordinator is Cheryl Shiffer. I really encourage you to reach out to them. They're a great resource.
But let's delve into how this pain quality measure is really used. And it is used widely. It is part of the Texas Quality Reporting System Calculation for the public reporting website, the QRS site. You'll find it on your CASPER Quality Measure Report, as well as on the CMS Nursing Home Compare site. It is part of the Five-Star Quality Rating System on the Nursing Home Compare site, as well as it goes into the National Nursing Home Quality Care Collaborative Quality Composite Measure Score. And of course, pain is always going to be a part of our survey process.
When you're looking at your Five-Star Quality Rating System, there are nine quality measures that go into the actual Five-Star Quality Measure Calculation. Percent of residents who self-report moderate to severe pain long-stay is one of those. And of course, here's the 13 quality measures that comprise the composite score. And pain long-stay is one of those. But really, you need to be using this.
You need to identify what might be a problem in your nursing home. Search for those correlations. And understand the impact of a single click. And appreciate how the world views you. But this is all retrospective data. You're going to have to collect your data concurrently for your quality improvement efforts.
This measure is a long-stay measure, meaning that cumulative days in facility for the resident means they've been there 101 days or more. Those are days in facility. And these are mutually exclusive long-stay, short-stay. On any given report, a resident is only considered long-stay or short-stay, depending upon their cumulative days in facility.
When you look at your quality measure report for your facility, be careful not to confuse the pain short-stay with the pain long-stay measure. In this case, our highlighted long-stay measure, we can see we have 10 residents in the numerator out of 33 in the denominator, which gives us a facility observed percent of 30.3.
But we see this facility adjusted percent at 19% and have to say, hmm, what's that all about. And I'll explain that one to you. But either way, we see that either at the observed or the adjusted percent, we're quite above the state and the national average, which puts us in the bottom national percentile ranking in the country. So we probably have a quality improvement opportunity here.
To analyze this, you have to go to the Quality Measure User Manual. Identify the measure specification. Then go to the RAI Manual and determine if your coding is accurate. Then you can begin to decide, do we have a quality improvement opportunity? And if so, what is it?
So this is a very busy quality measure. This is the Quality Measure Specification. But let's go through this in detail.
So this measure captures the percent of long-stay residents who report either almost constant or frequent moderate to severe pain in the last five days or any very severe, horrible pain in the last five days. So when we're looking at the numerator, keep in mind several things, self-report and long-stay. So this is long-stay resident, 101 days or more, with a selected target assessment where the assessment meets either or both of the following two conditions.
In Condition 1, the resident reports almost constant or frequent moderate to severe pain in the last five days. Both of the following conditions must be met-- almost constant or frequent pain and at least one episode of moderate to severe pain. In Condition 2, the resident reports very severe to horrible pain at any frequency. So this is an and/or situation. The resident might meet Condition 1 or Condition 2 or both.
So let's look at Condition 1. And J0400 pain frequency, for Condition 1 in the last five days, the resident reported almost constantly or frequently pain in the last five days. In pain intensity, at 0600 on the numerical scale, they report as 05, 06, 7, 8, or 9 as their pain intensity. Or on the verbal descriptor scale, they report moderate or severe pain. So they have to have both-- the pain frequency and the pain intensity in Condition 1 at almost constantly or frequently moderate to severe pain.
In Condition 2, at pain frequency, it's any of the frequencies-- almost constantly, frequently, occasionally, or rarely-- so 1, 2, 3, or 4. Or and in the pain intensity, it's a 10. Or on the verbal descriptor scale, it's a very severe, horrible. But notice in pain frequency, if there's a dash, a blank, or a 9, in this item, all of those are considered exclusions. So if we don't answer pain frequency accurately, then we're going to have problems with our quality measure not calculating and picking up that resident who is telling us they are having very severe or horrible pain.
So that's what goes into our numerator. Remember they can have either Condition 1 or Condition 2 or both. In the denominator, it's going to be all long-stay residents with a selected target assessment, except those with exclusions. So let's walk through those.
The exclusion is going to be that the target assessment is an admission assessment, a PPF five-day, or a PPF return or readmission assessment. But that makes sense. This is a long-stay measure. So we're going to expect to see not those assessments as our target. Or the resident is not included in the numerator. So they didn't meet any of the pain conditions for the numerator.
And the following conditions are true-- the pain assessment interview was not completed, the pain presence item was not completed, the residents with pain or hurting at any time in the last 5 days at J0300 or a 1 and any of the following are true-- the pain frequency item was not completed, the pain intensity items weren't completed, or the numerical pain intensity item indicates no pain. So if we have any of these exclusions, we're going to have the resident excluded.
But notice on the right, this little issue of covariate. That's where we get to that adjusted percent for our facility percent. So let's discuss this issue of covariate in detail. But a covariate is found to increase the risk of an outcome. There are only three quality measures that have adjustments at the resident level with covariate-- percent of residency self-report moderate to severe pain long-stay is one of those.
What this really means is, if the resident has independence or modified independence in daily decision-making on the prior assessment, CMS is giving us this risk adjustment to adjust this resident's quality measure so that the overall facility has an adjustment that's actually the one that you'll see used on Nursing Home Compare and other areas as noted earlier.
So let's look at what this means. The covariate is a 1 or means that it's going to apply. If it's C1000, cognitive skills for daily decision-making, is a 0 or 1. So they're independence or modified independence. The covariate is a 1, meaning it will apply. If the summary score at C0500 is a 13, 14, or 15, that summary score is those three questions-- repetition of three words-- temporal orientation and recall.
So in either one of those cases, where it's a 1, the resident is going to have this adjustment applied. If the covariate is a 0, then that means their cognitive skills for daily decision-making at C1000 is a 2 or 3. Or if their summary score is a 0 through 12, then that will make that covariate a 0. It will not apply. The covariate will be missing if either the following are true. If C0500 is missing, if C01000 is missing or not assessed, or there's no prior assessment. If there's no prior assessments, then we would question the long-stay status anyway.
Now remember these missing non-valid values. A dash means that the item wasn't assessed, the caret, that the item was skipped, or the 99 indicates that the resident was not capable of completing the interview.
So now, when we look back at the Facility Level Quality Measure Report, and we look at that facility adjusted percent, we can say, ah. So out of the 30.3%, we're adjusted down to 19%. So, about three residents or so had that issue as independence or modify independence in cognitive daily scales. So they were making their own decisions about pain management. But we still are way above the state and the national average. And nobody wants to hurt. So we still may have our quality improvement opportunity.
So just a real quick look back at the quality measure. I know that it's busy. But now, hopefully, you feel a little better about it. But let's address this issue of pain. I think this is important. And out of the RAI manual, on page J7, we see the definition for pain. Any type of physical pain or discomfort in any part of the body. It may be localized to one area or be more generalized. It may be acute or chronic, continuous or intermittent, or occur at rest or with movement. Pain is very subjective. Pain is whatever the experiencing person says it is and an exists whenever he or she says it does.
We need to think about, as health care providers, really respecting this definition of pain. And I'm going to encourage you also to look back at the MDS Mentor of December 2013 for Chapter 2 of the MDS Manual, Setting the ARD. They do a great discussion here. And I point this out because the pain interview is a five-day look-back, which is unlike many of the other questions on the MDS. You can find that on the dads website.
And on the Resident Level Quality Measure Report, be mindful of pain long-stay versus short-stay. So when we're looking at our residents with the x, so they actually triggered. Our resident E1 has pain. But let's look at some correlations. They also are at high risk for having a pressure ulcer and have one. They also have an anti-psychotic medication, as well as a catheter. Resident H1 has pain. They also have an anti-psychotic med, depression symptoms, as well as a UTI. And resident K1 has pain and a pressure ulcer, a fall, and anti-anxiety hypnotic medication, and excessive weight loss.
So when we're looking at this, we have to say, OK, we've got two residents with a high-risk pressure ulcer and pain. So are we not medicating before we do [? one ?] treatment? We have someone who had a fall. We have two residents on anti-psychotic meds and another one on an anti-anxiety hypnotic medication. So we may have some correlations here that we need to look at. And I can tell you right now, if I had a catheter, I'd be in pain. So let's look for what's the real root cause. That's what we need to do to get to our quality improvement efforts. This is our real reason why our problem occurred. And no one wants to be in pain. So we want to figure that out.
Always start with the MDS and let's ensure we have accurate coding. Do we have a point and click error? Does everybody really understand all the components of this quality measure? And how to code it accurately on the MDS for that resident for that five-day ARD? And what about the pain problem? What's the problem with pain? Is it that our staff is not respecting the definition of pain? Do they not believe someone's in pain? Do they not have a prevention strategy mentality, only an intervention strategy mentality? What do we need to do about that? And are there correlations to other quality measures where we can identify?
Maybe one is feeding the other. For example, that anti-psychotic medication. Maybe those behaviors are really manifestations of pain. And if we address pain, not only could we eliminate their pain, but get them off that anti-psychotic medication, as well. Kind of a two for the price of one.
Once we've identified our root cause analysis, then we go into our model for improvement, which is, we've got to decide what is it that we're trying to accomplish. Decrease pain. How will we know that change is an improvement? Because we're going to measure our quality improvement data concurrently. What change can we make that will result in an improvement? Well, that depends upon your root cause analysis. Is it an MDS coding problem? Is it a staff beliefs problem? Is it a prevention versus an intervention strategy issue? What's really going on?
Then we come up with our robust plan for doing our test of change, which is going to include the who, what, when, where, how we're going to get it done. We go out and we do that, measuring along the way. Study those results. And then act upon those results. So we can get to a sustainable level of quality improvement.
The Worksheet for Testing Change is available for you in the QAPI resources to help you document your quality improvement effort so that you can really be monitoring your progress and your process of quality improvement.
So here's your next steps. I'm going to challenge you to review your coding for the MDS items for this quality measure, to review the Quality Measure User Manual specification again for this measure, to complete your root cause analysis-- nobody deserves to be in pain-- and begin a quality improvement project for pain management. And then, check out the TMF website for more tools and resources. And part of those are going to be future quality measures series that we're going to have for you that will help you and your team to move through the quality measure review and your quality improvement efforts and support you with these easy-to-learn short sessions.
We hope you'll work through that entire series and help your residents get out of pain through your quality improvement efforts.