Welcome to this session on the Quality Measure: The Prevalence of Antianxiety Hypnotic Use. I'm Melody Malone, a Quality Improvement Consultant with TMF Health Quality Institute, and I'm happy to bring this program to you today.
The objectives are to review the Quality Measures specifications for the prevalence of antianxiety hypnotic use, long-stay, and we'll identify the relationship between the Minimum Data Set, or the MDS and this Quality Measure.
But here's my disclaimer. I am not an MDS expert, so I'm going to encourage you to always use the RAI Manual or the Resident Assessment Instrument User's Manual, the MDS 3.0 Quality Measures User's Manual, the Quality Measure ID Reporting Module, as well as the Five-Star Quality Rating System Technical User's Guide.
You can find all of these resources on the TMFQIN.org website, as well as the CMS. gov website.
I'm going to also encourage you to reach out to the Texas MDS Program Staff. We have Brian Johnson, who is our MDS Automation and QIES Coordinator, and Cheryl Shiffer, who is our MDS Clinical Coordinator.
So let's start looking at how is this quality measure used. The Antianxiety Hypnotic Use measure. We do not find it as one of the measures on the Texas Quality Reporting System, or the state public website. Nor is it reported on the Five Star Quality Rating System, or is it part of the National Nursing Home Quality Care Collaborative Quality Composite Measure Score.
You will find it, however, on your Casper Quality Measure Report, and it is going to be on Nursing Home Compare, which is the CMS public website at the federal level for nursing homes. But it's not one that goes into the Five Star Quality Rating calculation. And of course, the Survey Process will use this measure.
But really, you need to be using this measure, to help you identify, what might be a problem to help you search for correlations between your MDS items and your quality measures, to help you understand the impact of a single click under MDS, and also to appreciate how the world views you.
But all of this is retrospective. You need to be utilizing your quality measure data and your quality improvement data in a go-forward way to help you work through your quality improvement process.
So let's look at prevalence of antianxiety hypnotic use. This is a long stay measure, which means that cumulative days in facility is equal to or greater than 101 days. Now this issue of long-stay measure versus short-stay.
They are mutually exclusive. So on any given quality measure report, a resident is only considered a long-stay resident or a short-stay resident based upon days in facility. A long-stay is equal to or greater than 101 days.
On our Quality Measure Report, you will find this listed as Antianxiety Hypnotic long-stay, or L. In our case today, this facility has 11 residents in the numerator. Meaning 11 residents are triggered for this use, out of a denominator of 56.
And we can see their Observed Report percent at 19.6, against a state average and the a average that's lower, which puts them in the low national percentile ranking at 85. So they're ranked at the 85th percentile in the country.
And remember, in quality measures, the closer to zero, the better. So we're only 15 percentile points away from the bottom. So maybe some quality improvement opportunities.
But in order to determine that, we need to go to the Quality Measure User's Manual, identify the measure's specifications, then go to the RAI Manual to help us identify whether or not we have accurate coding. And then we can determine whether or not we have a quality improvement opportunity.
So let's go and do that. But let's start with this word "prevalence." The Merriam Webster dictionary online defines prevalence as the percentage of a population that is affected with a particular disease at a given time. But Mosby's Medical Dictionary, I think, speaks to us in a better way. It reads , the number of all new and old cases of a disease or occurrences of an event during a particular period.
So when we're looking at this Quality Measures User's Manual and identifying about this particular measure, this measure is reporting in a percentage of long-stay residents. So remember, 101 days or more who are receiving an antianxiety medication or hypnotic medication, but do not have evidence of psychotic or related conditions in the target period.
So that's where this issue of prevalence comes in-- into this target period. So in this case of this long-stay measure, in looking at the numerator, we see that there was something dealing with before March 31st of 2012. So since I'm recording this in 2014, I'm only going to deal with the questions about issues regarding assessments of target dates on or after April 1st, 2012.
So in this measure, all long-stay residents with the selected target assessment with any of the following conditions are true. So antianxiety medication, add MDS item NO410B. Or if hypnotic medications were received, add NO410D. Any of the days of the observation period. So that's what that 1, 2, 3, 4, 5, 6, or 7 refers to.
So when looking at, did the resident receive an antianxiety medication any day during the observation period, or a hypnotic medication any day during that observation period. Those are going to be the residents in the numerator.
But let's look at the denominator. It's all long-stay residents with the selected target assessment, except those with exclusions. Well, let's look at exclusions. Well, so if the resident didn't qualify for the numerator, and any of the following is true-- so for residents of target date on or after April 1st of 2012, either one of the medication items-- antianxiety or hypnotic medications are not assessed. And that's what the dash means.
Or the second exclusion is that any of the following related conditions are present on the target assessment, meaning the same assessment in which the resident qualified in the numerator, potentially, unless otherwise indicated.
So if the resident has any of the following diagnoses, they would be considered excluded. So their excluded out the denominator, then they're excluded out of the numerators. They're not going to count in the quality measure.
So if they have a diagnosis checked off as schizophrenia, psychotic disorder, manic depression, bipolar disease, Tourette's syndrome, Huntington's disease, hallucinations, delusions, anxiety disorder, or post traumatic stress disorder, if any of those conditions are present on the target assessment, the resident is excluded.
But you'll notice for both Tourrette's and post traumatic stress disorder, there is an additional notation. And what this is saying to us is, if Tourrettte's or post traumatic stress disorder were noted on the prior assessment, if the item isn't active on the target assessment, and if a prior assessment is available, that resident will be excluded. So if it wasn't on this most current MDS, and it was on the prior one for both Tourrette's or post traumatic stress disorder, then the resident is considered excluded.
So let's look at this MDS items a little bit. So an N0410, it's an and/or question here. Did the resident receive an antianxiety medication any number of the days of the observation period, or did they receive a hypnotic medication. So they may receive one, or the other, or both. And then depending upon the exclusions, they'll be in the numerator.
So let's look at this issue of the exclusion diagnoses. It includes Huntington's disease and Tourrette's It also includes those diagnoses in the psychiatric mood disorder, except depression. Depression is not an exclusion.
But remember, both Tourrette's and post traumatic stress disorder have that extra note that, if it was on the prior assessment, it's going to be an exclusion if it's not active on the target assessment if a prior assessment is available.
In The MDS Mentor of March 2013, there's a great discussion on this 2-step process of coding diagnoses, and I refer you to that item.
But remember, there's even more exclusion definitions that are included in section E0100, Potential Indicators of Psychosis, which include hallucinations and delusions. So if either one of those are checked, again, the resident will be excluded in the denominator, excluded in the numerator.
So the hallucination is the perception of the presence of something that is not actually there. It may be auditory or visual, or involve smell, taste, or touch.
And a dilution is a fixed, false belief not shared by others that the resident holds even in the face of evidence to the contrary.
And you can find this in your MDS RAI Manual at page E1. And these are behaviors observed, and/or thoughts expressed.
So in looking at how this item is coded, or how these items are coded, again, I'm going to refer you to The MDS Mentor item for Setting the ARD article. That's in the December 2013 edition. And you can find all the mentors on the DADS website.
So let's look at this again. So even though it appears to be very busy, it really is fairly clear. If the resident received an antianxiety medication or a hypnotic medication, and they do not have one of the exclusionary diagnoses, then they will trigger in the numerator.
If they do have one of the exclusion diagnoses, or if Tourrette's or post traumatic stress are active on a prior assessment, then the resident will be excluded from the denominator, which excludes them from the numerator, and they will not trigger.
So in looking at your Resident Level Quality Measure Report, you can identify those residents that are triggering for this quality measure, as noted by the X. So let's take a look at some of these.
So resident B1 also has a fall, and a high risk pressure ulcer. Resident D2 has an antipsychotic medication, and resident K1 has excessive weight loss, a fall, a high risk pressure ulcer, and moderate to severe pain long stay.
So we do have a few correlations. We've got a couple of falls. We've got a couple of pressure ulcers. So we may have something going on with our residents from a correlation standpoint, above and beyond just the fact that they don't have diagnoses excluding them.
This brings us to our quality improvement effort in searching for the root cause. This is what helps us to identify what's really going on, why do we have a quality improvement opportunity at all, and what might it be. It's when our performance doesn't meet expectations.
So as you're doing that root cause analysis on your Antianxiety Hypnotic Medication Quality Measure, I always encourage you to begin looking for errors on the MDS first. Is it a point and click error, or do we have an accuracy of coding error. Maybe we're not capturing the proper diagnoses. Maybe we're not capturing the medication during the correct observation period.
And then, if we are using the antianxiety or the hypnotic medication, why? What's the reason, if we don't have a diagnosis that might be supporting it? Or do we have a diagnosis that might be supporting it, and we're not getting it on the MDS?
So there's lots of reasons for your root causes. Once you've identified your root cause analysis, then you go on to your Model for Improvement. So what are we trying to accomplish? Decrease the inappropriate use of antianxiety and hypnotic medication.
How will we know that a change is an improvement? We're going to have to track our data concurrently. Our quality improvement efforts concurrently, because the quality measure isn't very current, when you think about it from the standpoint of MDS timing. So you're going to want to track your data concurrently.
What change can we make that result in an improvement? That will depend upon your root cause analysis. Was it an MDS point and click error? Was it an MDS accuracy error? Do we truly have inappropriate medications at the bedside?
Then you'll go into your Plan, Do, Study, Act cycle. So when you're looking at that, you're going to develop a very robust plan. Who's going to do what by when? How are we going to get it done? What's our measurement strategy?
And then go out and actually do the plan. Collect your data. Study those results. And then act upon those results.
So this worksheet for testing change is just a method for you to document your quality improvement effort. It's just a model for improvement pushed out onto a piece of paper. And we encourage you to document your quality improvement effort, so you learn from your quality improvement.
So here's my suggestion. Review the coding for each one of these MDS items for the quality measure. Use your Quality Measure User's Manual measure specifications to help you understand this measure fully. Then complete your root cause analysis, and begin your quality improvement project.
And check out our website for tools and resources. We hope that you'll use the quality measure video series we've created for you to help you and your team learn more about the quality measures, and to move through your quality improvement efforts to help you achieve your goals.
Feel free to reach out to us and let us know how we can help you in the future.