Welcome to this Quality Measure video on the Percent of Residents Who Lose Too Much Weight. I'm Melody Malone, a quality improvement specialist with TMF Health Quality Institute, and I'm happy to bring you this program today. So we'll review the Quality Measure specification for this measure, the percent of residents who lose too much weight-- it's a long stay measure. We'll identify the relationship between the MDS, or the Minimum Data Set assessment, and the Quality Measure specification. Here's my disclaimer. I am not an MDS expert, so I'm always going to encourage you to use all the tools and resources you have available to you. That includes the RAI manual, or the Resident Assessment Instrument User Manual, the Quality Measure User Manual, the Five-Star Quality Rating System Technical Users' Guide, and the Centers for Medicare & Medicaid, or CMS, MDS video training series. You can find links to all of these resources on our website, and they are also available to you on the CMS website at cms.gov. So let's identify how this measure, the percent of residents who lose too much weight, is used. You will find this on your CMS Casper Quality Measure reports. I'm going to show you that in a few minutes. We also see it on the CMS Nursing Home Compare website, so publicly reported. However, it is not one of the measures currently-- I'm recording this in 2019-- where it's included in the Five-Star Quality Rating System. It is included in this survey process, and the surveyors have access to all of your MDS data. And their computer system creates quality measures for them as well. But this needs to be used by you to help you identify what might be a problem in your facility, to help you search for correlations to other quality measures, to understand the impact of a single click on the MDS, but also to appreciate how the world views you. This is all retrospective data. So you've got to be working on your activities proactively to improve your data. So this measure is a long stay measure, which means the cumulative days in facility are equal to or greater than 101 days. Short stay and long stay measures are mutually exclusive on any given quality measure report. So this cumulative days in facility includes discharges and readmit, but it only counts the actual days in the facility. So let's look at your CMS Casper Facility Level Quality Measure Report. You will find this measure excessive weight loss down towards the bottom, and I encourage you, when you go to look in your quality measure specification manual, to search it by the CMS ID number that you see there-- N029.01. That will help you get right to that measure specification, easy. So in this case, for this facility, they had one resident trigger in the numerator out of 51 in the denominator that could have triggered for a facility at 0% and 2.0. There is no risk adjustment for this measure. So the adjusted percent is the same as the observed. But you can see, this facility is far below the state average at 6.5, even better, below the national average of 7.7. And they're in the high national percentile ranking of 11. This is a closer-to-zero-is-better measure, so higher in the national percentile in this case means closer to zero. So at 11th in the country, it's pretty darn good. In order to analyze the measure, you need to go to the Quality of Measure User Manual, identify the measure of specifications, then go to the RAI manual so you can determine if coding is accurate. We want to see, do we have a point-and-click error, or do we have issues with those who code the MDS, or understanding the ARD. It's a great place for us to start. Then we can determine what is our quality improvement opportunity, or do we even have one? So let's look at the Quality Measures Specification manual and look at this measure-- again, CMS ID number N029.01. So this measure captures the percent of long-stay residents who had a weight loss of 5% or more in the last month or 10% or more in the last six months who were not on a physician-prescribed weight loss regimen, as noted on their MDS during the selected quarter. So that not-on-a-physician-prescribed weight loss regimen is a critical point. So when we look at the numerator, it basically repeats that. So it's long-stay residents, so we know they've been in the building 101 days or more, that have a 5% or more weight loss in one month or 10% or more in the last six months who were not on a physician-prescribed weight loss regimen, as noted at MDS item K0300 equals a 2. So this is an OR question. So they had a 5% weight loss at one month or a 10% weight loss at six months. So you got to keep in mind, it's really two questions in one. So that's who triggers in the numerator. Let's look at who's in the denominator, which is all long-stay residents with a selected target assessment, except those with exclusions. So let's look at exclusions. The first one is that the target assessment, the target MDS, is an OBRA Admission assessment. Well, that kind of makes sense. This is a long-stay resident. It means they've been there 101 days or more. Or a PPS 5-day, so it's going to exclude those two. They still have the old Medicare Readmission Return assessment listed in the manual. We know that one doesn't exist anymore. The next exclusion is a prognosis of a life expectancy less than six months is noted at MDS item J1400 as a 1 or the prognosis item is missing, as noted by a dash at J1400. We don't want missing data on our MDSes So that second half of the exclusion isn't really something you want to shoot for. Or another exclusion is if the resident is receiving hospice care at MDS item 00100K2 is a 1 or, again, if that hospice item is missing in that MDS item, as noted by a dash. And then the last exclusion is that the weight loss item is missing completely at K0300 is a dash. So really, we don't want that exclusion. So prognosis less than six months, hospice-- those are good exclusions when appropriate. So let's talk about this issue of the physician-prescribed weight loss regimen. You're going to find the definition for this on page K-5 in your RAI manual. The definition includes that it's a weight loss reduction plan ordered by the resident physician with the care plan goal of weight reduction. It may employ a calorie-restricted diet or other weight loss diet and exercise. It also includes planned diuresis, and it's important, again, that the weight loss is intentional. So let's look at the MDS item itself. Remember, it is one MDS item but it is two questions. It's a weight loss of 5% or more in the last month or 10% or more in the last six months. When we check two, or yes, not on a physician prescribed weight loss regimen, that's when the resident could be in the numerator if they do not have exclusions. So let's talk about this 5% or 10% thing. So on page K-4 in the RAI manual, it defines this 5% weight loss in 30 days. So they start with the resident's weight closest to 30 days ago, and multiply it times 0.95, or 95%. That resulting figure represents a 5% loss from the weight of 30 days ago. So if the resident's current weight is equal to or less than the resulting figure, the resident has lost more than 5% of their body weight. So let's do a math example. So their weight 30 days ago was 100 pounds. We're going to multiply that times 0.95 to get that 95%, which actually, in this case, equals 95. The resident's weight today is 94. Therefore, 94 is less than 95. The resident has experienced a 5% weight loss in 30 days. Let's talk about 10% weight loss in 180 days, again, on page K-4 in your RAI manual. So you start with the resident's weight closest 180 days ago and multiply it times 0.90, or 90%. The resulting figure represents a 10% weight loss from the weight 180 days ago. So if the resident's current weight is equal to or less than the resulting figure, the resident has a loss of 10% or more body weight. So here's our example. Same resident, weighed 100 pounds 180 days ago. So 100 pounds times 0.90 would give us 90 pounds. Her weight today is 94. So 94 is more than 90, therefore she has not experienced a 10% weight loss in 180 days. But remember, this is one MDS item but two questions. So she qualified in one but not in the other. She qualified at her 5% loss but not in the other. So I encourage you to go look at the MDS Mentor on the HHS website, and look at setting the ARD, keeping in mind that the look-back period for this question is both 30 and 180 days. So when you go look to identify who are the residents that are triggering in the numerator, you go look at your Casper Report, your resident level quality measure report. In this case, this facility only had one, and the resident was in the discharge list. So we see resident S in the discharge list with excessive weight loss and therefore, they are triggering and will continue to trigger until six months after discharge. So now that we know our data, and we understand how the measure is calculated, we've determined-- or we've got to determine, do we have a problem? So we want to do a root cause analysis to identify what is our issue, how did we not meet expectations? There could be lots of reasons why. I always encourage you to begin with MDS accuracy. Do we have a point-and-click error? Do we have accuracy for coding? Was it the 5%? Was it the 10%? Did we not get the math right? And is everybody coding to the one ARD? Once you figure that out, then what's the reason for the excessive weight loss? And are there correlations to any other quality measures, like you might identify that everyone with a weight loss also has had a fall, or has a decline in ADLs, or some other quality measure. So once you do that, then it's time to go to the model for improvement. And let's start with asking our three questions. So what are we trying to accomplish? Decrease inappropriate weight loss. How will we know that a change is an improvement? We're going to track our quality measured data. And what change can we make that will result in improvement? Depends upon what you found in your root cause analysis. Once you determine that, you'll come up with your Plan, Do, Study, Act cycle for quality improvement and run multiple cycles of PDSAs in order to get to your improvement. I encourage you to document your performance-improvement projects. And we have a worksheet for testing change on our website that you can use, so I invite you to download this tool if you don't have anything. So here's your next steps. Review the coding for the MDS items for this quality measure and, again, review the measure specification so you really understand how the MDS causes this measure to trigger. Complete your root cause analysis and begin your quality improvement project, then check out our resources on our website for tools and resources. You can also reach out and contact us. We have an email address at NHnetwork@tmf.org, and we have our website, which is tmfnetworks.org. So once you join the website, please be sure to join the nursing home network, and that'll get you right to our resources and tools. I hope this has helped you out today.