Nursing Home Quality Initiative-Spring 2007

IN THIS ISSUE

Nursing Home Quality Measures in the 8th Scope of Work
High-Risk Pressure Ulcers
Depression/Mood Worsening
Chronic Pain
Physical Restraints
Flow Diagram: Pressure Ulcer Care Process Framework
Useful References and Web Sites
Stay in Touch

Nursing Home Quality Measures in the 8th Scope of Work

IPRO, the Medicare Quality Improvement Organization (QIO) for New York State, works with all nursing homes in the state on the Nursing Home Quality Initiative (NHQI) to improve the quality of care for New York's nursing home residents.

The NHQI is a Centers for Medicare & Medicaid Services (CMS) program under which QIOs work with nursing homes to adapt and enhance proactive continuous quality improvement (CQI) programs.

New York State nursing homes performed remarkably well during the CMS 7th Scope of Work. New York ranked as one of two high performing states in the nation.

The CMS 8th Scope of Work began in August 2005 and continues through July 2008.

The nursing home Quality Measure (QM) clinical topic areas being addressed in the 8th Scope of Work are:

percent of chronic care residents who have moderate to severe pain
percent of residents who were physically restrained
percent of high-risk residents with pressure ulcers
percent of residents who have become more depressed or anxious

While working with the state's nursing homes, IPRO's QI team noted similarities that appeared to contribute to some negative clinical outcomes and increased QM rates. The self-assessment process revealed that lack of essential follow-through with consistent, uniform, and standardized processes of care contributed to negative outcomes. This newsletter includes care process frameworks specific to each clinical topic and references to additional resource materials available at no charge on IPRO's NHQI Web site, www.ipro.org/nhqi

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High-Risk Pressure Ulcers

New York State has had a difficult time improving scores on the High Risk Pressure Ulcer Quality Measure. After much investigation and discussion, our QI team identified three areas that prompt further internal individualized review:

MDS Section G1A (bed mobility and transfer)
Pressure Ulcer Data Tracking
Nosocomial Pressure Ulcer Investigation

MDS section G1A:

Any of the following three criteria categorizes residents as high-risk for developing pressure ulcers:

The resident is Comatose (B1=1)
The resident has a diagnosis of Malnutrition (13a-e=260, 261, 262, 263.0, 263.1, 263.2, 263.8 or 263.9)
The resident has Impaired transfer or bed mobility (G1a (A) or G1b (A)=3,4, or 8

Section G1A (bed mobility and transfer) is one that defines the facility's "at risk" population for developing pressure ulcers. To ensure that all residents in the facility are accurately categorized in the "high" or "low" risk grouping, it is imperative that you look at your internal systems and assess whether there is a process in place that captures and documents significant information to correctly evaluate your resident population.

To assist nursing homes with interpreting the Pressure Ulcer QM, adequately capturing all "at risk" residents and supporting documentation, our QI team has compiled additional information, materials, and resources for your review and use in your quality improvement program at www.ipro.org/nhqi

Pressure Ulcer Data Tracking Tool.We recognize that nursing homes have access to a vast amount of data; however, the information may be excluded in quality improvement practice. As part of our statewide approach to PU prevention and treatment, and enhancement of QI activities, IPRO has developed a Microsoft Excel pressure Ulcer Data Tracking Tool.

The Pressure Ulcer data base tool is useful for monitoring every pressure ulcer in the facility, tracking pressure ulcers by site, stage, days to heal, admissions, and nosocomials. Reports are available as well as bar graphs that can be sorted as appropriate by unit, floor, assignment, or special care populations (i.e. dialysis, ventilatordependent residents, etc.) We are confident you will find the tool useful and helpful in identifying opportunities for improvement in your facility.

Nosocomial Pressure Ulcer Investigation. Clearly, each facility is in large part in control of preventing nosocomial pressure ulcers. As a component of a continuous Quality Improvement program we recommend initiating a "No Blame" investigative review of the facility's systems and care processes. Incorporate all staff, shifts, and departments in the nosocomial investigative review and utilize the information on the pressure ulcer DTT to ensure successful preventative outcomes. The pressure ulcer care process framework on page 5 is provided for your review and use. Feel free to visit our Web site at www.ipro.org/nhqi for additional tools and information to enhance your Pressure Ulcer prevention and management quality improvement program. Please contact the IPRO NHQI team if you have any questions, and to share your thoughts as you tackle this clinical topic.

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Depression/Mood Worsening

The Depression/Mood Worsening Quality Measure is new in the 8th Scope of Work. The incidence measure reflects the percent of longterm residents whose mood scale score (MSS) increases from the prior to the target MDS assessment. Identifying depression and anxiety can be difficult in elderly residents because the signs may be confused with the normal aging process, a side effect of medication, or the result of a medical condition. Additional information about this clinical condition, as well as quality improvement strategies, can be found on our Web site www.ipro.org/nhqi and on the Medicare Quality Improvement Community Web site at www.medqic.org. To help understand the QM and what goes into calculating the MSS, IPRO has developed a Mood Scale Score (MSS) worksheet and instruction sheet to aid in correctly recognizing and treating residents whose mood has worsened. To ensure that resident's moods are accurately assessed and treated, and quality of life is maximized, share information and discuss changes in the resident's mood and care plan as an interdisciplinary team.

Please take the time to review all the materials on the IPRO NHQI Web site and begin using the material to enhance your QI efforts.

During the CMS 7th Scope of Work, New York State's greatest improvement was in the Chronic Pain Quality Measure. This success is reflected in the 2nd Quarter 2004 Chronic Pain QM data. Unfortunately, maintaining these gains has been difficult for many facilities. To see if you are one of the facilities at risk of losing gains made in the 7th Scope of Work, please visit the STAR (Setting Targets-Achieving Results) Web site (www.nhqi-star.org). View your facility's Chronic Pain QM data to see if the QM has risen since the 2nd Quarter of 2004. Facilities with successful Pain Management programs have identified the following criteria as crucial to their success:

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Chronic Pain

During the CMS 7th Scope of Work, New York State's greatest improvement was in the Chronic Pain Quality Measure. This success is reflected in the 2nd Quarter 2004 Chronic Pain QM data.

Unfortunately, maintaining these gains has been difficult for many facilities. To see if you are one of the facilities at risk of losing gains made in the 7th Scope of Work, please visit the STAR (Setting Targets-Achieving Results) Web site (www.nhqi-star.org). View your facility's Chronic Pain QM data to see if the QM has risen since the 2nd Quarter of 2004.

Facilities with successful Pain Management programs have identified the following criteria as crucial to their success:

Standing Orders
It is recommended that the management of chronic care pain incorporate around-the- clock standing orders for pain medication. Assess the use of PRN medications for your chronic care residents. Those frequently needing PRN pain medication would most likely benefit from a review of the standing order regimen or the addition of a standing order to the treatment plan. Also, assess residents who under utilize PRN pain medications, but are still triggering the Chronic Pain QM. Such residents may have difficulty asking for pain medications when needed. These residents may also benefit from an around the-clock regimen. The World Health organization (WHO) analgesic ladder is a helpful resource for managing residents' pain. You can find it on the IPRO NHQI Web site(www.ipro.org/nhqi Tools: Pain Management).

Assessing pain
All staff members should be educated as to the verbal and non-verbal signs and symptoms of pain. Non-verbal signs of pain identify pain in residents who are unable to communicate, and enhance the identification of pain in residents who can communicate. Standardized pain screening and comprehensive pain assessment will lead to better pain management. Synchronizing the interpretation of the pain scales (e.g. 0-5 or 0-10) used at your nursing home with the MDS section J2b = 1 mild, = 2 moderate, or = 3 excruciating, will enhance the accuracy of MDS coding.

MDS Coding
The coding of MDS item J2a and J2b should reflect the success of the individual resident's pain management program. This success is reflected in the comfort achieved by the medications and pain-alleviation procedures outlined in the resident's care plan. One common error entails recording the highest level of pain in J2b that is based on the level/strength of medication used to achieve the resident's comfort. Make sure to refer to the RAI Manual or contact the New York State RAI Coordinator (mds2@health.state.ny.us) with any questions you may have on this clinical topic or others.

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Physical Restraints

The Physical Restraint QM refers to the percent of residents with daily physical restraints. The benefits of refraining from the use of physical restraints are well documented in long-term care literature. They include improvement in residents' quality of life, greater autonomy, use of fewer anti-psychotic medications, less skin breakdown, and fewer serious injuries due to falls. (Enhanced QM Resource Manual).

Remember some basic information from the CMS RAI Manual version 2.0 pertaining to physical restraints:

Prior to restraining a resident, there must be a determination of the presence of a specific medical symptom that requires the use of the restraint, and how the use of the restraint would treat the medical symptom, protect the resident's safety, and assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well being. Medical symptoms that warrant the use of restraints must be documented in the resident's medical record, ongoing assessments, and care plans.

When a restraint is initiated, it does not mean that it remains forever. Refer to the RAI Manual, which prompts you to ask the following questions:

Why is the resident restrained?
What type(s) of restraint is used?
During what time of day is each type(s) used?
Where is the resident restrained (i.e., own room in bed, chair in hall)?
How long is the resident restrained each day?
Under what circumstances is the resident restrained (i.e., when left alone, after family leaves, when eating)?
Who suggested that the resident be restrained (i.e., staff, family, resident)?

Re-think your restraint use protocol. If restraints are used primarily to "prevent falls," think about the complications associated with restraint use and explore alternatives for preventing falls. To help assess falls in your facility, IPRO has developed a Falls Tracking Tool and Report. The report converts the information collected on your incident report into a database that can be reviewed to identify areas for improvement. Restraint elimination tools on the IPRO Web site www.ipro.org/tools include:

Alternatives to Restraints Guide
Individualized Wheelchair Seating: For Older Adults
Activity Boxes individualized for resident
Falls Management Program

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Flow Diagram: Pressure Ulcer Care Process Framework

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Useful References and Web Sites

Enhanced Quality Measure Resource Manual Version 5.0, updated February 2006: www.medqic.org or provider.ipro.org/index/qi_nursinghome_medu
www.ipro.org/nhqi
IPRO NHQI Tools providers.ipro.org/index/Tools2
- 2007 Pain Management Training Module
- 2007 NHQI Pressure Ulcer Prevention and Management Training Module
- 2007 Restraint Elimination Training Module
- Depression Management Training Module
Medqic www.medqic.org
National Pressure Ulcer Advisory Panel (NPUAP) www.npuap.org