Welcome to this session on the Quality Measure-- The Percent of Residents Who Have Depressive Symptoms. I'm Melody Malone, a quality improvement consultant with TMF Health Quality Institute, and I'm happy to bring this program to you today.
Our objectives are to review the quality measure for this measure, the percent of residents who have depressive symptoms-- long stay. And we're going to identify the measure specification for the quality measure and its relationship to the minimum data set.
But I am not MDS expert. I'm going to encourage you to always use the tools and resources that you have available to you. They include the RAI manual, or the Resident Assessment Instrument User Manual, the Quality Measure 3.0 User Manual, the Quality Measure ID Reporting Module, and the Five-Star Quality Rating System Technical User Guide. You can find all of these resources on the TMF website as well as the cms.gov website.
Additionally, I'm going to encourage you to reach out to our Texas MDS program staff. They include Brian Johnson, the MDS Automation and QIES coordinator, and Cheryl Shiffer, the MDS clinical coordinator.
So let's get into how is this quality measure, depressive symptoms, used? It is used in a variety of ways on both the Texas Quality Reporting System public website and the CMS Nursing Home Compare public website. So both the state and the federal public reporting show this measure. You will find this also on your CASPER quality measure report. It is used in the survey process, as well as it is part of the National Nursing Home Quality Care Collaborative Quality Composite Measure Score.
However, this quality measure is not one of the quality measures that goes into the Five-Star Quality Rating System to calculate your quality measures star rating. It is on the federal website, it just is not part of that calculation.
And in the 13 measures of the Quality Composite Measure Score, percent of residents who have had depressive symptoms is one of these measures. But this really needs to be used by you. You should always be utilizing your quality measures to help you identify what might be a problem, to help you identify correlations in different quality measures, and to understand the impact of a single click on your MDS. And remember, this is how the world views you. We just discussed all that. But this is all retrospective information. You can use your quality measure data to jump-start your quality improvement efforts and propel you to higher levels of quality of care.
But let's talk about this measure and how is this measure calculated. Well, percent of residents who have depressive symptoms is a long stay quality measure. Long stay means that their total days in facility, or cumulative days in facility, is 101 days or more.
This is mutually exclusive to short stay. So a resident, on any given quality measure report, is either long stay or short stay. They are not both on any one same report. In this case, this measure is a long stay measure, meaning cumulative days in facility 101 days or more.
When you look at your quality measure report, you can find this measure listed as depressed symptoms-- long stay. That's what the L means. In our case, today, this facility the resident in the numerator was two, out of a denominator of 64. So they had two residents demonstrating depressive signs and symptoms out of 64 who could have, for a facility observed percent of 3.1, which is better than the state and national average.
But you'll notice the national percentile ranking is only in the 49th position. And remember quality measures, the closer to 0, the better. So they still have a little ways to go.
In order to analyze this, we would have to look at the Quality Measure User Manual specification and the MDS Manual so we can identify do we have a true quality improvement opportunity at the bedside, or do we have coding accuracy issues?
So let's do just that. So let's look at the Quality Measure User Manual Measure Specification for this measure, which reports the percent of long stay residents who have symptoms of depression during the two-week period preceding the MDS 3.0 target assessment date.
Now, that two weeks is critical. That's a different lookback period than many of the MDS items. So that is oftentimes a great place for us to start, is to ensure that we're accurate coding that observation period.
So this is a long stay message. And let's look at the numerator. So the numerator is all long stay residents with the selected target assessment where the target assessment meets either of the following two conditions. So there are two conditions. If they meet one of these conditions, they will be in the numerator. So let's break down these two conditions.
So Condition A, the resident mood interview must meet both part one and part two. So part one is that in MDS Item D0200A2, "The resident demonstrates little interest or pleasure in doing things half or more of the days over the last two weeks." So day 7 to day 14, they're demonstrating little interest or pleasure. Or they are "Feeling down, depressed, or hopeless half or more of the days over the last two weeks" at MDS item D0200B2.
But remember, it said Condition A, they've got to meet both Part One and Two. So either one of those in Part One is half the story.
Now Part Two is the second half. "The resident interview total severity score indicates the presence of depression" at MDS Item D0300, meaning they scored a 10 to a 27.
So let's go look at these MDS items. So the resident mood interview-- symptom frequency is between 7 and 14 days. So half or nearly every day, they demonstrated little interest or pleasure in doing things or feeling down, depressed, or hopeless.
And they've got to meet Part Two, which is the resident mood interview. So in the resident mood interview, they scored between a 10 and a 27. But you'll notice that you have to enter a 99 if they're unable to complete the interview. That's going to become more important in a few minutes.
So Condition A, they must meet both Part One and Part Two of the resident mood interview. But Condition B is the staff assessment of the resident mood. And again, they must meet Part One and Part Two. So let's look at these.
So Part One, "The resident has little interest or pleasure doing things half or more of the days over the last two weeks" as reported in the staff assessment at D0500A2. Or "Feeling or appearing down, depressed, or hopeless half or more of the days of the last two weeks" at D0500B2.
So we've got both conditions again in Part 1, but based upon the staff assessment. And then Part Two is the staff assessment total severity score-- indicates the presence of depression at MDS item D0600 is a score of 10 to 30.
So again, let's look at these MDS items for the staff assessment-- D0500, symptom frequency, is 7 to 14 days they demonstrated little interest or pleasure in doing things or feeling or appearing down, depressed, or hopeless. And the staff assessment of the resident mood scored between 10 to 30 at D0600. So again, the resident must meet both Part 1 and 2, either Condition A or B.
Now, remember we've got the denominator, as well. So the denominator is all long stay residents with the selected target assessment except those with exclusions. And the exclusions include that the resident is comatose or that status is missing at B0100, or the resident is not included in the numerator, meaning they did not meet any of the depression symptom conditions for the numerator, and they have skipped or items that were not assessed at D0200A2 or B2 or D0300. And remember I mentioned that 99, when the resident interview was not able to be completed. So if all of these conditions are true for A, then the resident would be excluded.
And then for B, the same thing. If these items are skipped or not assessed, then the resident would not be included in the denominator.
So I want to point out, though, let's keep in mind this quality measure is a two-week lookback. So I'm going to call your attention to the MDS Mentor of December, 2013, where they have a discussion on setting the ARD, which is addressed in Chapter Two of the MDS manual. So I encourage you to read this Mentor again as you're reviewing this quality measure, and one of your first opportunities may be to look at are we accurately coding for that two-week lookback.
Now, when you go to your resident level quality measure report, you can identify if you have any residents triggering for this quality measure. We know we saw in the report that we had two. So we see we have one that we can see on this page, as denoted by the x.
So now that we know we have residents that are triggering for depression, we want to search for that real root cause and identify why do we have residents that are demonstrating signs and symptoms of depression. So that real root cause helps us search for those levels of performance that did not meet our expectations.
Now, we can have a variety of reasons. There could be errors on the MDS. So maybe we've got point and click errors. We meant to click one item, and we clicked something else.
Or we have an accuracy of coding issue. Whoever's completing the MDS items may not understand. Remember, we've got a two-week lookback as well as all of these resident interview and staff assessment of the resident.
And then, of course, what's the reason for depression? And have we really identified that issue?
All of that leads us to our model for improvement. So what are we trying to accomplish? Decrease depression in our residents.
How will we know that a change is an improvement? Well, we can track on our quality measure record, but we also want to track our activities concurrently, since we know it takes an MDS cycle for that quality measure to catch up.
What change can we make that will result in an improvement? That depends upon your root cause analysis. And once you complete that, then you can go into your plan, do, study, act cycle.
So you're going to develop your plan for working on this issue, whether it's an MDS coding problem or an ARD understanding. Or, if you're going to actually assess and work with residents with depression, you'll come up with a measurement strategy, go out and work your plan and collect your data, study those results, and then act upon those results, so that you can get to a sustainable level of quality improvement.
We have for you the worksheet for testing change that is available. It's just the model for improvement pushed out onto a piece of paper, and it helps you to write a very robust plan, do, study, act cycle. And we encourage you to document your PDSA cycles and your quality improvement effort so you can become a learning organization.
But here's your next steps. I'm going to encourage you to review the coding for the MDS items for this quality measure. Go back to that Quality Measure User Menu and review those measure specifications again. Then complete your root cause analysis, and begin your quality improvement project. And we encourage you to check out our website for tools and resources.
And in future quality measure sessions, you're going to be able to work through the entire quality measure series to help you improve your quality efforts at the bedside for your residents. And it will also help you support your efforts to train your staff.
Feel free to reach out to us if we can help you at all. Give us a call.