Welcome to this session on the Quality Measure, the Percent of Residents Whose Need for Help with Activities of Daily Living has Increased. I'm Melody Malone, a quality improvement consultant with TMF Health Quality Institute, and I'm happy to bring you this program today.
We will be reviewing the Quality Measure Specification for this measure, the Percent of Residents Who Need Help with ADL activities, or Activities of Daily Living, has Increased Long Stay, and identify the relationship between the minimum data set items and this Quality Measure Specification. But here's my disclaimer. I am not an MDS expert. I am going to encourage you to always use the tools and resources that you have available to you.
That includes the Resident Assessment Instrument User Manual, or the RAI Manual, the MDS 3.0 Quality Measure User Manual, the Quality Measure ID Reporting Module, as well as the Five-Star Quality Rating System Technical User's Guide. You can reach all those resources from the tmfqin.org website, as well as the cms.gov website.
I'm also going to encourage you to reach out to our wonderful Texas MDS program staff. They include Brian Johnson, who is the MDS Automation and QIES Coordinator, and Cheryl Shiffer, the MDS Clinical Coordinator. I think you'll find them to be very helpful, so please reach out to them.
So let's look at how is this ADL Quality Measure used. Well, it is on the Texas Quality Reporting System website, which is the state public reporting website. It is also on the federal public website, which is the Nursing Home Compare site. And you will find it on your CASPER Quality Measure Report as well.
It is also in the Five-Star Quality Rating System, which uses nine quality measures to calculate the Five-Star. And it is one of the measures that comprises the National Nursing Home Quality Care Collaborative Quality Composite Measure Score. And of course, decline in ADLs is reviewed as part of the survey process.
So when looking at the Five-Star Quality Rating System, I mentioned that there were nine Quality Measures utilized to calculate the Five-Star as of today. I'm recording this in September of 2014. So percent of residents whose need with ADLs has increased is one of the long-stay measures utilized. It is also part of that National Nursing Home Quality Care Collaborative Quality Composite Measure Score, which is made up of 13 long-stay Quality Measures.
But really, this measure, along with all of the Quality Measures and the composite score, needs to be utilized by you to help you identify what might be a problem in your nursing home, to help you search for correlations between the Quality Measures, to understand the impact of a single click on your MDSs, and to also appreciate how the world views you.
But remember, all of this is retrospective information. As you make your quality improvement efforts, you'll want to collect concurrent data so you can track your quality improvement efforts.
But let's get into how is this measure calculated. Well, first of all, it's important to understand that it is a long-stay measure, which means that the cumulative days in facility is equal to or greater than 101 days. Every Quality Measure is stratified into either long-stay or short-stay, never the same on the same report. So it's a mutually-exclusive issue.
A resident is either considered a long-stay resident or a short-stay resident on any given Quality Measure Report. So decline in ADLs is a long-stay measure. The resident's been there 101 days or more.
When you look at your Quality Measure Report, you will see this item on your Quality Measure Report. So in looking at this report, we see that for this facility, the Quality Measure of Increase for ADLs Long Stay. The numerator, meaning the number of residents that triggered for the problem, is 13, out of all that could have triggered, or the denominator, of 60, for a facility-observed percent of 21.7.
There is no adjustment for this measure. So it's still 21.7 is considered the adjusted percent against the state and the national average. So you'll see that this facility is performing a little bit worse than the state and the national average for a national percentile ranking of 74.
So they're in the bottom performance. Because remember where Quality Measures are concerned, the closer to zero in the numerator, the better. So we would want to look at, why are we having so many residents with an increase in help for ADLs?
So in order to analyze that and determine that, we need to go to the Quality Measure User Manual and identify the measure specification. Then go to the MDS Manual, and that will help us identify potential problems, such as do we have a point and click error? Are we not coding the items correctly? Maybe we're not coding it correctly to the ARD, or the Assessment Reference Day.
Once we look at all of that, then we can determine, do we have a quality improvement opportunity? And even more specifically, what is our quality improvement opportunity?
So let's do just that. This is the Quality Measure User Manual page for the numerator for the Activities of Daily Living has Increased Long Stay. Now, this utilizes two MDSs. So it's comparing a more current MDS to a prior MDS.
So let's look at this in detail. So this measure is long-stay residents with both a selected target assessment and prior assessment that indicate the need for help with Late Loss ADLs has increased when you're comparing the target assessment to the prior assessment.
Now, the four Late Loss ADL items are self-performance bed mobility, self-performance transfers, self-performance eating, and self-performance toileting. Now, each one of those G items noted, like G0110A1, self-performance bed mobility, that is the actual MDS item.
So that shows you how every one of those MDS items pulls over to help create this Quality Measure. So it's utilizing these four Late Loss ADLs when compared to a prior assessment from the target assessment. So it's very important that we understand this is Late Loss ADLs self-performance.
So this is looking at two separate conditions, and we're going to go through these in detail. So when one of these conditions are met, the resident is into the numerator, meaning they triggered for the decline. So let's go into detail about what this says.
And I want you to notice that note. The note reads that for each of these four ADL items, if the value on the MDS is equal to 7 or 8 on either the target or the prior assessment, then the item gets recoded to equal 4 to allow for the comparison.
So let's go through these two conditions. The first condition, at least two of the following are true. And the way you read this is the little t means the target assessment, meaning the most current MDS. t minus 1 refers to the prior assessment.
So in each case of bed mobility, if on the target assessment, meaning the current assessment, it has gone up one level in coding-- so on the MDS if it goes from a 1 to a 2, or a 2 to a 3, 3 to a 4-- then from the prior assessment, which means that it went up more than 0, wasn't the same, then it's going to trigger if there's at least two of these Late Loss ADLs self-performance.
So bed mobility on the target is greater than 0 increase in coding for that ADL, it's going to trigger from the prior, so bed mobility, transfers, eating, or toileting.
The second condition is only one of these areas has increased but more than one point on the MDS. So bed mobility target assessment has gone up more than one MDS coding point in self-performance for that ADL. So bed mobility, or transfers, or eating, or toileting in condition two means it's gone up more than one MDS coding point.
So let me review this again. Condition one, at least two of these ADLs have increased in MDS coding points by more than 0. So it might be bed mobility and transfer. It might be transfer and eating. It might be eating and toileting, or any combination. Two have gone up more than 0. But in condition two, only one has to go up more than one MDS coding point.
So let's go back to these coding instructions. And I am going to refer you to your RAI Manual to ensure that you understand full MDS coding. But remember in our instructions for the Quality Measure, if the MDS item coding is a 7 or an 8, so the activity occurred only once or twice during the observation period for a code 7, or code 8, the activity did not occur at all, those are going to get changed down to 4 to allow for comparison.
So I think it's very important when you're looking and if you're trying to figure out why is someone triggering in the numerator, keep in mind if they were a 7 or an 8, the system coded them as a 4 on either the prior or the target MDS for this Quality Measure.
So let's do two examples. We're going to do the example of numerator condition one where at least two of the following are true, which means that two ADL codes are greater than 0 on the target assessment from the prior. So that means they worsened in ADL performance.
So in our example, our first ADL, bed mobility at MDS item G0110A1, on the target is a 1, and on target minus 1, or the prior, it was a 0. So bed mobility went up by one point, which is greater than 0. And eating, at MDS item G0110H1, on the target assessment is a 2, and on the prior assessment, target minus 1, is a 0.
So it actually went up two points. Two ADL codes went up, greater than 0. So it really doesn't matter the combination, but two were greater than 0 in change. So there was a change greater than 0.
But numerator condition two is at least one ADL code goes up greater than 1 on the target from the prior. So in this example, transfer, at G0110B1 on the MDS, the target is now 3, and target minus 1, or the prior, was a 1. So it went up two points. But notice in this condition, only one has to go up for that numerator to be triggered.
The denominator, who gets into the denominator? Well, the denominator for this Quality Measure is all long-stay residents. Remember, they are mutually exclusive, and you're building 101 days or more, and with a selected target and prior assessment, except those with exclusions.
So let's take a quick look at the exclusions. So an exclusion would be that all four of these Late Loss ADLs were total dependence on the prior assessment as indicated by each one being either a 4, a 7, or an 8, so bed mobility and transfers and eating and toileting. So all four of the Late Loss ADLs have to be coded on the prior assessment at a 4, 7, or 8. OK? So that makes sense?
Three of the Late Loss ADLs indicate the dependence on the prior assessment, as in number one. And the fourth Late Loss ADL indicates extensive assistance, a value of 3 on the prior. So the resident will be excluded there.
If the resident's in a coma on the target assessment, so that would be the current assessment. The prognosis of life expectancy is less than six months on the target assessment, hospice care on the target assessment, or the resident's not in the numerator and any of these items were missing, indicating-- I'm sorry, is a dash indicating that it wasn't assessed on the prior assessment.
So the thing to think about the exclusion, remember, that's going to exclude the resident out of the denominator. So if any one of these items occur, the resident's going to be excluded out of the denominator, which means they also will be excluded out of the numerator.
All right. I know that ADL coding is challenging. I'm going to encourage you to use your MDS Manual, the RAI Manual, as well as the MDS Mentor for September of 2011. There are two discussions there on Section G, Coding of ADLs, and then a focus on the ADL item of eating.
I'm also going to encourage you to go to the MDS Mentor for December, 2013 with a discussion from the HHSC OIG Utilization Review Staff on Activities of Daily Living. And remember, on the CMS MDS training site, there is a Section G video training that can help you understand further how to accurately code Section G.
Once you have all your coding down, and you know your coding's accurate, and you want to really ensure we're doing everything that we can for our residents, now we want to come and look at our Resident Level Report and identify if anybody is triggering for ADLs. And remember, we had quite a few people triggering. We were above the state and the national average.
So here we have someone on our resident list, noted with an X, for triggering an increase for ADLs. However, this resident, Resident F1, also is triggering for antipsychotic medications, for a fall, and also for pain. So we really have to say to ourself, is there any kind of a correlation between these four Quality Measures?
So did the fall cause the pain? Did the antipsychotic medication contribute to the resident complaining of being in pain, because we're giving them an antipsychotic medication instead of addressing their pain? Is their pain causing their decline in ADLs?
You really are going to have to investigate for this resident, and every resident that is having a decline in ADLs, what is going on for that resident so you can ensure that you're accurately moving forward in your quality improvement efforts.
So when you look at this Quality Measure and you identify, are we coding accurately or not, do we have care at the bedside issues or not, what's really going on, that's your search for your root cause in your quality improvement efforts.
And once you've completed that root cause analysis, you can then determine what is it that's really going on and where do we need to focus our quality improvement efforts. So is it MDS coding problems? Is it true decline in ADL issues?
Then you can move on to your model for improvement. What are we trying to accomplish? Decrease the decline in ADLs in our residents. How will we know that it changes in improvement? Because you're going to measure concurrent data in your quality improvement efforts.
And then what change can we make that result in an improvement? That depends upon your root cause analysis. Is it an ADL coding problem? Is it a true decline in ADLs? Is there any of those other correlations, to pain, to falls, to antipsychotic medication? Is there a trend in that that we can really pull out and utilize? Then you'll create your robust plan-do-study-act cycle and go through your quality improvement efforts.
So here's a worksheet for testing change. It's available for you in the TMF website under the QAPI Resources to utilize and document your quality improvement efforts, which we encourage you to do so you guys can become a learning organization.
Here's your next steps. Review the coding for this MDS item for the MDS items themselves and also the User Manual for the measure specification so you can really understand this again. Complete your root cause analysis and identify, why do we have residents that are having increases in need for help with their ADLs? And begin your quality improvement project.
Check out our website for tools and resources. And let us know what more you need. And remember, we have other Quality Measure video series that can help you and your staff to learn more about each one of the Quality Measures on your CASPER Quality Measure Report, as well as flu and pneumonia.
Let us know how we can help you in your quality improvement efforts. And we look forward to hearing your successes.