Welcome to our Quality Measures-- Antipsychotic Medication program. I'm Melody Malone, a Quality Improvement Consultant with TMF Health Quality Institute, and I'm happy to be bringing you this program today.
Our objectives are to review the quality measure specification for both short-stay anti-psychotic medication and long-stay anti-psychotic medication, and to identify the relationship between the minimum data set, or the MDS, and the quality measure.
But here's my disclaimer. I am not an MDS expert. I'm going to always encourage you to use all of the manuals, tools, and resources you have available to you. That includes the RAI manual or the MDS manual, the MDS 3.0 Quality Measure User Manual, the Quality Measure ID manual, as well as the Five-Star Quality Rating System Technical Users' Guide. You can get to all of those resources on the cms.gov website, and also in the QAPI resources on the TMF website at the Nursing Home Network page.
I'm also going to encourage you to use the Texas MDS Program Staff. They are great resources for you, and you've got two great folks, Brian Johnson, as well as Cheryl Shiffer, and they will be more than happy to help you with your MDS and quality measure questions.
But let's jump into how are the quality measures used, and specifically, how are these two anti-psychotic quality measures used. Well, in the Texas Quality Reporting System, or the state level public reporting system, we don't have quality measure reporting yet. This is March, 2014, when I'm recording this. So, time will tell.
On the federal [INAUDIBLE] website, at Nursing Home Compare, we did see both the short-stay and the anti-psychotic quality measures, and you'll see them also on your CASPER Quality Measure Report. The anti-psychotic medications are not utilized in the Five Star Quality Rating System, or the public system, as far as rating your facility for quality measure-- five star.
There is a new quality composite measure score called the National Nursing Home Quality Care Collaborative Quality Composite Measure Score, and you're going to see in a minute that the long-stay measure's included. And then lastly, the survey process utilizes the CASPER Quality Measure Report. Therefore, your surveyors are going to see both the short-stay and the long-stay anti-psychotic quality measure.
But most importantly, your quality measure should be utilized by you to help you identify what might be a problem, to also help you look at what correlations you may see between your quality measures and resident care, to help you understand the impact of a single click on the MDS, and this also helps you see how the world views you, and I hope now you appreciate that.
But keep in mind, your quality measures are all retrospective. It's what's happened in the past, so you want to use your quality master data-- but help you propel into the future with your quality improvement efforts and collect concurrent data in your quality improvement efforts.
That National Nursing Home Quality Care Collaborative Quality Composite Measure Score comprises 13 quality measures that are all long stay, and one of them is a percent of residents who received anti-psychotic medications long stay. And we'll be doing a whole program on this score soon.
So, let's jump into both of these anti-psychotic medication quality measures and determine how they're utilized. So, I keep saying short stay, as designated by the S. A short-stay quality measure is based upon the days in facility-- the total days in facility. That includes the discharges and the re-admits, but only the real days in the facility. That's what CDIF means-- cumulative days in facility.
The short-stay quality measure includes any resident with a stay of 100 days or less. So, it's equal or less than 100 days. The anti-psychotic medication long stay equals 101 days or more. These are mutually exclusive. On any quality measure report, the resident is only classified as a short-stay resident or as a long-stay resident, based upon their total days in facility.
So when you go to look at your quality measure report-- and we're going to begin looking at your facility report-- the anti-psychotic medication is a little bit further down, and you'll see short stay and long stay. So in this case, for this facility, the short-stay anti-psychotic medication-- there was only one resident that actually triggered in the numerator-- meaning they actually had this quality measure-- out of 18 in the denominator.
And you can see the facility observed percent, 5.6%, is about both the state and the national average, which has this facility in the 85th percentile in the nation, meaning performing in the bottom 15 percentile. And for anti-psychotic medication long stay, they have 21 residents out of a possible 71, and you can see, again, they are above the state and the national average, and they're at the 80th percentile in the nation, or the bottom 20% performance-- so, potentially, a quality improvement opportunity.
Now, there's an interesting report you may or may not use called the Facility Characteristics Report. And I like this report for many reasons, but one of the interesting things is it has psychiatric diagnoses, and I think it's important to look at this in correlation to your anti-psychotic medication. It will help you see whether or not you're even capturing all of the psychiatric diagnoses for your resident.
And when you look in the Quality Measure User Manual, the diagnostic characteristics that the psychiatric diagnosis is picking up is any of the psychiatric mood disorders in MDS items I5700 through I6100, or Tourette's syndrome, or Huntington's. So, you're going to see all of that in just a little bit, but I wanted to share with you that right off the bat.
Then, when we go to the resident level quality measure report, this is when we can see what resident triggered, and we can begin looking at these correlations to see do our residents have some similar issues. So, for example, we see that many of the residents coding with an anti-psychotic medication long stay also have a fall. So, that might be an interesting correlation to look at. Some of them also have pain. Some of them also have a pressure ulcer.
So, we may begin seeing these correlations of quality measures, where the same residents are triggering for all the same quality measures. And you can also see we've got one resident in the discharge list for the short-stay anti-psychotic medication.
In order to really analyze this and determine do we have a quality improvement or not opportunity, you've got to go to your Quality Measure User Manual and identify and understand the measure specifications. Then, go to the RAI Manual and identify if your coding is accurate or not. Do we have a point and click error? Are we really understanding how these items should be coded? And do we have the ARD correct, or the assessment reference date? Then, we can determine do we have a QI opportunity.
So, let's start with the Quality Measure User Menu. We're going to begin looking at the short-stay residents who newly received an anti-psychotic medication. This measure reports the percentage of short-stay residents who were receiving an anti-psychotic medication during the target period but not on their initial assessment.
So, there's something interesting about the numerator for this one. The short-stay residents for one or more assessment in the look back scan, not including the assessment, indicates that an anti-psychotic medication was received. So, let's look at what that really means. So, the target date is-- for all assessments, except the discharge, that is the MDS ARD that you're really looking at and the last assessment in the selected date range.
But for this short-stay quality measure, it's going to look back within the entire short stay, up to 100 days or less, so that this quality measure includes all the data from all the other assessments within the target date range for that time period. So, except for the initial assessment, it's going to look at all. And since I am recording this in 2014, we're just going to look at the second numerator item, which discusses assessments of target dates on or after April 1, 2012.
And right there, what it's saying is MDS Item N0410A equals a 1, 2, 3, 4, 5, 6, or 7. So, this is the MDS item that looks at the issue of anti-psychotic medication and whether or not the resident actually had that anti-psychotic medication. Did they receive it during any of the seven days of the observation period? So, I think it's important to understand it's only a anti-psychotic medication.
So, we want to make sure one of our quality improvement opportunities will be to say did we accurately code. Did we code an anti-psychotic correctly? Do we have the medication classified correctly? Did we code for an anti-anxiety medication, but we did it as an anti-psychotic? So those-- begin looking about those as your root cause.
Back to the numerator in the quality measures specification. Note that residents are excluded from the measure if their initial assessment indicates anti-psychotic medication use or if anti-psychotic medication use is unknown on the initial assessment.
And see exclusion three below. So, look at the very bottom of our screen. The exclusion is that the resident's initial assessment indicates an anti-psychotic medication use, or anti-psychotic medication use is unknown. So again, for assessments what a date of April 1, 2012, or after, N0410A is coded as a 1, 2, 3, 4, 5, 6, or 7, or it's missing. Those are your residents in the numerator.
In the denominator, all short-stay residents who do not have exclusions and who meet all of the following conditions-- so these are going to be short-stay residents with a target assessment and an initial assessment, and the target assessment is not the same as the initial. So, this means they have at least two MDS's in the system, and they are a short-stay resident, and they do not have exclusions. Then they are going to be in the denominator.
So let's go see who has exclusions. An exclusion is going to be true if for all assessments in the look back scan-- remember, all that way back-- again, N0410A is missing. So if it's missing on all assessments, then the resident will not be in the denominator, and therefore, they can't trigger in the numerator. Or, any of the following related conditions are present on the assessment in a look back scan-- they're coded in Section I, for a diagnosis of schizophrenia, Tourette's syndrome, or Huntington's disease.
If they have any one of those conditions on any assessment, they will be excluded. Or, again, the resident initial assessment indicated an anti-psychotic medication use, or it was unknown, in Section N0410A.
So, let's look at that active diagnosis issue. So Huntington's disease, Tourette's syndrome, or schizophrenia are the three active diagnoses that exclude the resident. So, active diagnosis is a 2-step process, and this is the MDS manual item that discusses that, as well as, MDS Mentor of March, 2013, they do a great job discussing this 2-step process. So, I recommend you look at both of these in order to help you ensure you're accurately coding.
Now, let's look at long stay. Long stay's very similar. There's a few things that are different, but not that much. This measure reports the percentage of long-stay residents who are receiving anti-psychotic drugs in the target period.
Now remember, a long-stay resident has been in your facility for total days in facility of 101 or more. So their selected target, MDS, is going to be the most current MDS within your quality measure date range. And so, in this case, again, for assessments, the target date's on or after April 1, 2012. N0410A is a 1, 2, 3, 4, 5, 6, or 7.
So, if the resident is coded as having an anti-psychotic during their observation period, and they're long stay, then they can be in the numerator. The denominator, however, is all long-stay residents with the selected target assessment, except those with exclusions. So remember, if a resident doesn't qualify to be in the denominator, they cannot be in the numerator.
So, an exclusion is pretty simple. Again, it's the item is missing, or that the resident has any of the following related conditions on the target assessment unless otherwise indicated. So again, it's schizophrenia, Tourette's, and Huntington's, but I want you to notice the extra little comment on Tourette's syndrome. If, on the prior assessment, this item is not active on the target assessment, and if the prior assessment is available, then the resident would be excluded with Tourette's.
So, that's kind of a little caveat there, but the long and the short of it is if schizophrenia, Tourette's, or Huntington's are on the same MDS where the item is coded for anti-psychotic medication, then the resident would be excluded. However, if Tourette's is not active on that one but it is active on the prior one, then they would also be excluded.
So, let's talk about how many long-stay residents are excluded. There's not really a way to look at how many short-stay residents are excluded, but for long stay, there is a little way we can back into that. If you look at the denominator for anti-psychotic medication, 71, and you look at the next highest denominator-- the most high long-stay denominator you've got-- in this case, we've got three at 75-- physical restraints, falls, and falls with a major injury.
If we were to subtract 71 from 75, we're going to get 4, so that tells me we've got about 4 residents that were excluded as long-stay residents because they do have a diagnosis of schizophrenia, Huntington's, or Tourette's.
So if I really want to look at, well, how many residents may I really have in my facility on an anti-psychotic medication, period, I would do 21 in the numerator for long stay, plus 4 that are excluded. That would give me 25 long stay. Then, it's got another one in the anti-psychotic meds short stay, and any other new admissions or newly added anti-psychotic medication.
So I know right now I've got somewhere between 25, 26. So, when you're looking at your anti-psychotic medication use, you really want to look at every resident. Before your quality measure report, right now, we only look like we have 22.
So now, we want to say do we have a problem. Well, we know we were high in our facility average compared to the state and the national average. We were performing in the low 15th percentile for short stay, 20th percentile for long stay, so we really want to search for a root cause and say do we have a failure to perform at a high level.
And in doing our real root cause analysis, we can look at what our potential causes may be. Do we have point and click errors on the MDS? Did we accidentally code an anti-anxiety medication as an anti-psychotic? Or do we have a medication classification error? Someone thought an anti-psychotic was an anti-anxiety, or an anti-anxiety with an anti-psychotic. Do we have missing diagnoses? Do we have a missing diagnosis on the MDS? Do we have a missing diagnosis in the chart?
But maybe we have inappropriate use of medication. Maybe we have facility practice issues. Maybe we have medication management system issues. You would have to do a full root cause analysis to identify what's our real problem.
Well, we know what we're trying to accomplish is decreased inappropriate anti-psychotic medication use. How will we know that it changes in improvements? Well, we're going to measure our concurrent data as we go through our quality improvement project, and we can also see it show up as we cycle through the MDS cycle on our quality measures.
And what change can we make that will result in an improvement? It's going to depend upon our root cause analysis. What was our problem? Was it an MDS coding problem? Was it a medication management issue? Was it a behavior facility practice issue? And then, we're going to develop our plan, do, study, act cycle of quality improvement.
So what I'm sharing with you now is your Worksheet for Testing Change, which is nothing more than the model for improvement pushed out onto a piece of paper that allows you to really develop that robust plan for quality improvement efforts and really determine what types of change can we make that resulted in improvement, and how are we going to get our plan done.
And then, were we able to really work our plan, steadied our results, and then act and do another cycle of change with the long-term goal of reducing inappropriate anti-psychotics and developing a system where we sustain that over time? And in our QAPI resources, we have more videos on the quality improvement process.
So, for now, I think your next steps are to review the coding for all the MDS items on this quality measure. Look at your quality measure report and determine what efforts do you want to make in quality improvement. Look at your Quality Measurement User Manual for those measure specifications. Really make sure you understand the measure specification, as well as the MDS item coding.
Complete your root cause analysis and determine what is our quality improvement opportunity and begin your QI project. Check out our website for tools and resources for quality improvement efforts, as well as anti-psychotic medication reduction.
And we will have future quality measure sessions working through the entire quality measure report to help you learn the quality measure specifications in these three easy to learn sessions, and we're hoping that this will help you in your quality improvement process.
Feel free to reach out to us if we can help you in any way. Have a blessed day.