Clinical

To receive the quality incentive point for this measure, not more than 13.35% of the facility's long-stay residents may report severe to moderate pain during the minimum data set assessment process. (The applicable percentage is based on CMS calculations using MDS 3.0. The applicable percentage was calculated so that approximately 50% of providers earn the point.  See O.R.C. 5111.244(E) and (F) for details.)

The facility's MDS score will be verified; no reporting action by the facility is needed.

Relative Advantage

Advances in pain management will not only improve the residents quality of life and increase cost savings for the facility, they will also result in:

• Improved health outcomes;
• Improved survey performance;
• Improved resident satisfaction;
• Increased resident socialization;
• Increased resident ambulation/mobilization;
• Decreased pain for residents;
• Decreased hands on care required;
• Decreased falls; and
• Decreased agitation and resident behaviors.

Compatibility

In compliance with F309 Quality of Care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Prioritizing resident comfort levels allows for the best outcome for the resident.

Simplicity

The facility should evaluate their current quality measures to determine how to improve upon pain management. The facility may consider developing a screening tool upon admission that follows the residents' care needs throughout their stay. Consider the following:

• Evaluate the existing tools the provider has in place.
• Identify pain during the admission nursing assessment.
• Evaluate the medication administration record - pain measurement/medication provided/effectiveness of pain medication.
• Validate pain tool adoption and place on medication administration book for quick reference/assessment for cognitive and cognitively impaired.
• Observe residents daily for new pain identification.
• Use a pain tracking tool consistently and proactively for screening and assessments in order to validate severity of pain, duration of pain and the residents' ability to ask for medication.
• Recognize residents' verbalization and staff recognition of nonverbal residents' pain.
• Raise awareness of pain issues, especially in confused or non-verbal residents.

Trialability

The nursing facility should determine their pain management needs, then adopt interventions on one wing or unit while evaluating the outcomes. The facility can then roll out what they have learned incrementally to the rest of the facility. Consider the following:

• Start with residents who are currently on pain medication.
• Rate pain levels for those on pain medication to identify ineffective relief.
• Conduct a survey of residents who are not on pain medication who report pain.
• Determine/develop a list of pain medication alternatives known to decrease pain.
• Use pharmacological and non-pharmacological interventions together.
• Observe residents to identify new pain or ineffective control of pain.
• Use a consistent pain tool throughout the facility.
• Educate staff in regard to consistent and proactive screening.
• Adopt a special program/protocol for pain management for residents with moderate to severe pain.
• Ensure the analgesic used is specific for the pain diagnosis, when pharmacological interventions are implemented.

Observability

Ways to observe the effects of this measure include:

• MDS 3.0 data, use of medication administration records, pain relief results in quality assurance and quality improvement data.
• Observation of residents.
• Pharmacy review and recommendations for those with ineffective relief.
• Review of PRN (as needed) pain medication.
• Review of medication administration records for documented effective pain relief.
• Individual resident review of pain meds given per standing orders.

Resources

The Advancing Excellence in America's Nursing Homes campaign's materials on Reducing Pain, includes an implementation guide, tool for tracking, webinar, fact sheets

NQF measure 677 National Quality Forum (NQF), National Voluntary Consensus Standards for Nursing Homes: A Consensus Report, Washington, DC: NQF; 2011.

Prevalence and Management of Pain, Center for Disease Control and Prevention

Pain assessments for older adults

Tools - Setting : Nursing Home Condition, PainPrimaris (Quality Improvement Organization for Missouri

Clinical Practice Guideline: Pharmacological Management of Persistent Pain in Older Persons, American Geriatrics Society

Pain Management in the Long-Term Care Setting (2003), American Medical Directors Association (AMDA) Clinical Practice Guideline

American Academy of Hospice and Palliative Medicine

American Academy of Pain Medicine

American Pain Society

Pain and Physical Symptoms Toolkit, Brown University

Hospice and Palliative Nurses Association

"Try This" series, John A Hartford Institute for Geriatric Nursing

National Initiative on Pain Control

Partners Against Pain®

Quality Improvement Organizations

Beth Israel Medical Center Resource Center for Pain Medicine and Palliative Care

Ohio Department of Health Technical Assistance Program

To receive the quality incentive point for this measure, not more than 5.73% of the facility's long-stay, high-risk residents may have been assessed as having one or more stage two, three or four pressure ulcers during the minimum data set assessment process. (The applicable percentage is based on CMS calculations using MDS 3.0. The applicable percentage was calculated so that approximately 50% of providers earn the point. See O.R.C. 5111.244(E) and (F) for details.)

The facility's MDS score will be verified. No reporting action by the facility is needed.

Relative Advantage

Health outcomes for nursing homes residents include reduction in pain and suffering, reduced risk of infection and sepsis, and Improved quality of life and dignity.

Outcomes also include savings to the health care system (wound care supplies and staff time to assess, document and treat wounds). "AHRQ estimates that the average pressure ulcer-related hospital stay extends to between 13 and 14 days and costs between $16,755 and $20,430, depending on medical circumstances." - "Positive Outcomes of Culture Change - The Case for Adoption," Tools for Change, vol.1, no 2, April 2011, the Pioneer Network

This measure also can improve survey performance (less margin for citation with fewer pressure ulcers) and satisfaction score improvement. Clinical practice, expert opinions and published literature indicate that most, but not all, pressure ulcers can be prevented (consensus statement from NPUAP

Compatibility

Achieving this measure maintains compliance with survey regulations, corporate monitoring systems and quality indicators and quality measures.

Simplicity

Reducing the number of pressure ulcers in high-risk residents requires a systemic approach to quality improvement:

• Implement clear protocols for risk assessment and skin inspection.
• Individualize care plans (with front-line staff input) based on identified risk areas.
• Implement clear protocols for risk assessment and skin inspection. Refer to these resources for help.
• Implement clear protocols for communicating care plans and risk status to front-line staff.
• Provide effective education for new staff; annual in-servicing and competency testing for nursing department.
• Increase use of consistent assignment and improved staff retention.
• Improve supervision and monitoring of hands-on care (e.g. turn schedules, incontinence care, etc.).
• Conduct root cause analysis of all facility-acquired pressure ulcers.
• Implement clear protocols for treatment of existing pressure ulcers.

Trialability

Review policies and procedures. Involve staff in improvement efforts and individualized care planning. Focus on communication and interdisciplinary involvement.

Observability

Mentor nursing facility .

Resources

The Advancing Excellence in America's Nursing Homes campaign's materials on Pressure Ulcer Reduction (LINK:  http://www.nhqualitycampaign.org/star_index.aspx?controls=pressureulcersexploregoal) includes an implementation guide, tool for tracking, webinars, fact sheets and more.

Pathway for Prediction, Prevention and Treatment of Pressure Ulcers in Nursing Homes, Ohio KePRO

Gauging Pressure Ulcers: A Nursing Home's Guide to Prevention and Treatment, Primaris

Reducing Pressure Ulcers in Nursing Homes: An Interdisciplinary Process Framework (Audio file), Advancing Excellence in America's Nursing Homes Campaign

Quick Reference Guide for Prevention, National Pressure Ulcer Advisory Panel (NPUAP)

A Handbook for Nurses, Chapter 12. Pressure Ulcers: A Patient Safety Issue, Agency for Healthcare Research & Quality Patient Safety and Quality

Pressure Points Poster, Ohio KePRO

Pressure Ulcer Staging, National Pressure Ulcer Advisory Panel (NPUAP)

Quick Reference Guides for and Treatment, National Pressure Ulcer Advisory Panel (NPUAP)

Pressure Ulcer Prevention Points, National Pressure Ulcer Advisory Panel (NPUAP)

Pressure Ulcer Scale for Healing (PUSH) Tool, National Pressure Ulcer Advisory Panel (NPUAP)

Skin Care Posters - Set I, Ohio KePRO

Skin Care Posters - Set II, Ohio KePRO

Skin Care Posters - Set III, Ohio KePRO

Skin Care Posters - Set IV, Ohio KePRO

Pressure Ulcer Quality Measure Poster, Ohio KePRO

Electronic PUSH Tool, Ohio KePRO

Pressure Ulcer-Free Calendar, Ohio KePRO

Pressure Ulcer Overview, Ohio KePRO

Positive Outcomes of Culture Change, The Pioneer Network

State Operations Manual Appendix PP, FTag 314, The Centers for Medicare & Medicaid Services.

NCHS Data Brief: Pressure Ulcers Among Nursing Home Residents, 2004, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics

To receive the quality incentive point for this measure, not more than 1.52% of the facility's long-stay residents may be physically restrained as reported during the minimum data set assessment process. (The applicable percentage is based on CMS calculations using MDS 3.0. The applicable percentage was calculated so that approximately 50% of providers earn the point. See O.R.C. 5111.244(E) and (F) for details.)

The facility's MDS score will be verified. No reporting action by the facility is needed.

Relative Advantage

Meeting this measure can lead to improved health outcomes for nursing homes residents (less risk for unintended adverse outcomes, such as pressure ulcers or contractures, less risk of injury or entrapment, and improved dignity), as indicated by:

• "Positive Outcomes of Culture Change - The Case for Adoption," Tools for Change, vol.1, no 2, April 2011, the Pioneer Network
• Physical Restraints - brochure on the adverse effects of restraint use, Ohio Department of Health
• Information on falls in nursing homes, Centers for Disease Control

Compatibility

This measure maintains compliance with survey regulations, corporate monitoring systems and quality indicators and quality measures.

Simplicity

Remember that restraints cannot be added without a physician order, and that they must be used to address a medical symptom. Adopt a "restraint keeper" policy so that plans to add new restraints must be filtered through one person (i.e. director of nursing or restorative nurse).

For residents currently in restraints, identify the common reasons restraints are used: history of falls, positioning, behaviors or other common reasons. Begin quality improvement efforts to improve outcomes in these areas. For example, revitalize your facility's fall prevention program or meet with physical/occupational therapists for seating or positioning issues. Discuss restraint reduction with medical director and physicians, families and staff; focus on the dangers of restraint use.

Commit to a restraint-free philosophy. See the Advancing Excellence in America's Nursing Homes Campaign Fact Sheet for Consumers and the Fact Sheet for Staff. See also the Ohio Department of Health Restraint Brochure.

Engage therapy department in restraint reduction for individual residents (for PT/OT/ST physical therapy, occupational therapy and speech therapy assessments, seating/positioning needs and, functional improvements).

Trialability

Ensure that all staff (i.e. floor staff, MDS coordinator, restorative, therapy, director of nursing, administrator, etc.) understand the definition of a restraint. See the CMS memo. Limit the accessibility of restraints for all front-line staff, and appoint a "Restraint Keeper" to coordinate new restraint orders.

Systematically review all existing restraints and begin to trial a reduction process. See Ohio Department of Health Restraint Guidelines. Remove for short periods of time to assess resident response. Use restraint alternatives as appropriate. Be sure all staff is aware of restraint alternatives.

Observability

In addition to the resources below, Ohio's Local Area Network for Excellence (LANE), the statewide partnership of the Advancing Excellence in America's Nursing Homes Campaign, is pleased to sponsor a free three-part webinar series to provide education on the topic of restrain reduction in Ohio's nursing homes.

Webinar #1: 

Legal Ease:  Understanding Restraint Use from a Compliance and Quality Improvement Perspective  Presented September 2012.

Speaker:  Janet Feldkamp, RN, BSN, LNHA, CHC, JD

Click here to listen to the recording:  https://www1.gotomeeting.com/register/409829624  

Review the Q&As resulting from the webinar.

Resources

Implementation Guide, Advancing Excellence in America's Nursing Homes Campaign

Interventions Table, Advancing Excellence in America's Nursing Homes Campaign

Restraint Tracking Tool, Advancing Excellence in America's Nursing Homes Campaign

Webinars and other materials on Restraints, Advancing Excellence in America's Nursing Homes Campaign

Fact sheet on restraints, Ohio KePRO

Restraint Crossword Puzzle, Ohio KePRO

Restraint Poster, Ohio KePRO

Restraint Dashboard (blank), Ohio KePRO

Restraint Dashboard (sample), Ohio KePRO

Fact sheet on fall prevention, Ohio KePRO

Handout on Behavior Management, Ohio KePRO

State Operations Manual Appendix PP, F-Tag 221, The Centers for Medicare & Medicaid Services. This regulation helps to ensure that residents are not restrained for reasons of discipline or staff convenience, or not used to treat a medical symptom.

Ohio Administrative Code, Ohio Department of Health

FDA Guide to Bed Safety

FDA Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment

To receive the quality incentive point for this measure, less than 7.78% of the facility's long-stay residents may have had a urinary tract infection as reported during the minimum data set assessment process. (The applicable percentage is based on CMS calculations using MDS 3.0. The applicable percentage was calculated so that approximately 50% of providers earn the point. See O.R.C. 5111.244(E) and (F) for details.)

The facility's MDS score will be verified. No reporting action by the facility is needed.

Relative Advantage

There are multiple advantages to decreasing urinary tract infections, including:

• Improved resident/family satisfaction
• Improved resident health
• Improved regulatory compliance
• Improved reputation of facility care in community
• Improved health outcomes as evidenced by no bacteremia or septicemia related to, or as a result of, urinary tract infections
• Improved survey results
• Better resident outcomes
• Cost savings from decreased antibiotic usage and repeat lab tests
• Improved staff morale

Compatibility

In compliance with F315 Urinary Incontinence, Residents are not catheterized unless medically necessary. Incontinent residents receive services to prevent urinary tract infections and treatment to restore bladder function as possible.

The measure may lead to increased regulatory compliance and serve as evidence of level and quality of care provided. It also may lead to increased knowledge of and ability to recognize the scope and severity of urinary tract infections. In addition, it helps meet additional regulations with the overall goal of maintaining resident's highest practicable well-being. When incorporated into care planning/assessments, standards of practice, restorative care, infection control and hydration practices and staff competencies, it leads to increased health of residents.

Simplicity

The nursing facility should evaluate their current quality assurance measures and policy and procedure to determine if any revisions are needed. The facility may also consider a screening tool to determine which individuals require increased monitoring. The nursing facility should consider:

• Proper implementation of quality measures, policies and procedures.
• Staff training, which is updated as necessary.
• Having floor nurses monitor front line staff to ensure proper peri care is given, proper hydration is offered via in room fluids and meal fluids.
• Adding programs such as restorative, bowel/bladder, hydration, skin and infection control.
• Adding risk and prevention of urinary tract infections information to new hire orientation, admission assessment for "risk" identification and staff competencies.

Trialability

The nursing facility should determine care area needs then adopt interventions on one wing or unit while evaluating the outcomes. Attempt this practice on one floor or wing of the facility, then adopt it for residents or staff that fit a profile determined by the facility. Implement and use existing quality assurance based tools, policies, procedures, staff training and make revisions as necessary.

Educate floor nurses in regard to the importance of direct monitoring of core floor staff. Enable floor nurses to give instant education and feedback during observed peri care. Enable and empower floor nurses to be part of the continual monitoring teaching process and to give positive feedback - especially in regard to newly trained STNAs.

Implement a written and accountable monitoring system to randomly spot check peri-care for all staff. This can be added to the admission/readmission and nursing assessment forms. Identify residents with current urinary tract infections on infection control forms. Identify residents with catheters or other identified risk factors for urinary tract infections, such as decreased hydration, etc.

Observability

Conduct on-site visits to observe practice. This could be another facility or within a facility where the trial practice was successful. Focus on your own facility resident success stories.

You can view this practice at selected mentor facilities who are willing to share information gathered in their quality assurance process in regard to all aspects of urinary tract infections, investigations, results, training, monitoring, etc.

Examine lab results and facility surveillance rounds for appropriate perineal, catheter care/tubing control, implementation of toileting programs and appropriate hand washing.

Make available videos or webinars on prevention of urinary tract infections. Make weekly/monthly and quality calculations for urinary tract infections by unit.

Resources

Appendix PP - Guidance to Surveyors for Long Term Care Facilities

Ohio KePRO

Facility's medical director and contracted pharmacy in-services

F315 Urinary Incontinence with corresponding interpretive guideline (urinary tract infections)

The Agency for Healthcare Research and Quality

Guideline for Prevention of Catheter-associated Urinary Tract Infection, The Centers for Disease Control and Prevention

National Kidney & Urologic Diseases Information Clearinghouse (NKKUDIC)

National Association For Continence, Charleston, South Carolina

Mayo Clinic

Ohio Department of Health Technical Assistance Program for free facility education

To receive the quality incentive point for this measure, the facility must use a tool for tracking residents' admissions to hospitals.

The nursing facility must meet the accountability measure in the period beginning January 1, 2012 and ending March 31, 2012 to be awarded points for fiscal year 2013.

Relative Advantage

Tracking residents' admissions to hospitals may reveal care practice improvement needs and lead to better relationships with referring hospital(s) to improve care transitions. CMS recommends strong relationships between care providers as seen by the Accountable Care Organization (ACO) opportunity. ACOs create incentives for health care providers to work together to treat an individual patient across care settings - including doctor's offices, hospitals and long-term care facilities.

Better use of evidence-based practices results in better patient outcomes and reduces the cost of care. Transfers to and from the hospital cause disruptions in care continuity. There are potential costs in medication stabilization, transportation and resulting transfer trauma to the resident.

Compatibility

The Quality Indicator Survey (QIS) triggers investigation in the area of hospitalization if thresholds for readmissions are exceeded in the Phase I review. The following F tags can be cited if resident care results in hospitalization:

• F272: Comprehensive Assessment;
• F274: Resident Assessment When Required;
• F279: Comprehensive Care Plan;
• F282: Care Plan Implementation by Qualified Persons;
• F309: Provision of Care and Services;
• F157: Notification of Changes;
• F241: Dignity;
• F271: Admission Orders;
• F278: Accuracy of Assessments;
• F281: Professional Standards of Quality;
• F242: Self-Determination and Participation;
• F353: Nursing Services;
• F385: Physician Supervision;
• F501: Medical Director; and
• F514: Clinical Records.

Hospitals will seek cooperation from area nursing homes to avoid the new rehospitalization penalties included in the Patient Protection and Affordable Care Act of 2010. Nursing facilities seeking to improve transitions from hospitals to nursing care will have motivated partners in their efforts.

"As pay-for-performance initiatives begin to be implemented, both hospitals and payers will be quickly looking to their clinical practitioners to develop programs to improve the transition outcomes. The key elements to the transition of care are as follows:

• Develop comprehensive discharge plans that screen for risk factors, and engage the patient/family in the self-management skills and goal setting needed to launch a successful transition of care.
• Deploy home follow-up protocols, including home chronic disease professionals, to follow the patient at home.
• Create disease-specific programs that measure the risks of a readmit, develop action plans to resolve those risks, and monitor the progress via data collection to better understand future performance."

(Paying the Price for Rehospitalizations, Robert McCoy, BS, RRT, FAARC and Dan Easley, BS)

Simplicity

A number of tracking tools are available from public and private vendor sources. Ohio KePRO's website has a list of some of the best known.

Trialability

A number of programs on care transitions have documented positive outcomes for both patients and providers.

• UPDATED:  Interventions to Reduce Acute Care Transfers (INTERACT). INTERACT was first designed in a project supported by the Centers for Medicare and Medicaid Services (CMS). This site contains implementation tools for Version 3.0 released January 2013.
• State Action on Avoidable Rehospitalizations (STAAR), the Institute for Health Care Improvement
• Care Transitions, developed by Dr. Eric Coleman

Observability

The Ohio KePRO, Ohio's Quality Improvement Organization, under contract with CMS, is working with health care providers to improve the quality of care for individuals who transition between care settings. A number of multidimensional programs for improving care transitions have documented success in patient outcomes. A description of those programs may be found in the Ohio KePRO fact sheet on the Integrating Care for Populations and Communities project.

Resources

The Advancing Excellence in America's Nursing Homes campaign has added a new goal on Reducting Hospitalizations (LINK: http://www.nhqualitycampaign.org/star_index.aspx?controls=hospitalizationsexploregoal) includes an implementation guide, tool for tracking, webinars, fact sheets and more.

"QIS System Addresses Hospital Readmissions," Andy Kramer, MD, Provider, June 2011

National Quality Forum Webinar: Reducing Readmissions through Care Transitions

The RARE (Reducing Avoidable Readmissions Effectively) Campaign

Interventions to Reduce Acute Care Transfers (INTERACT)

Health Care Leader Action Guide to Reduce Avoidable Readmissions

Readmission rates for hospitals

Transitional care processes and outcomes among adult recipients of long-term services and supports, Long Term Quality Alliance

Building Innovative Communities: Promoting Health Reform Principles through Community-based Learning and Collective Action, Long Term Quality Alliance

"Reducing Heart Failure Hospital Readmissions from Skilled Nursing Facilities," Professional Case Management, Vol. 16, No. 1, 18-24