2 New Claims-Based Quality Measures Affecting Your 5 Star Rating

APRIL 2016 - Thanks in large part to the Protecting Access to Medicare Act, CMS is placing a large focus on readmission measures, especially in nursing homes.

Wait, I thought they were already doing that?

Well, fortunately for us, CMS thinks we can do better – remember all that QAPI training? - and the focus is about to get even broader in scope. Starting this July, there will be two new claims-based quality measures affecting the QI/QM component of the 5 Star Rating. For the sake of efficiency, I’ll discuss these two measures together, as they really do go hand-in-hand.

Percentage of short-stay residents who were re-hospitalized after a nursing home admission:
• Looks at the first 30 days of admission to a nursing facility (NF) following an inpatient hospitalization (for both new admits and those previously in a nursing home);
• Includes occurrences taking place after NF discharge (if still within 30 days of initial hospital discharge);
• Counts both unplanned observation stays and actual hospital admissions;
• Excludes planned readmissions and hospice patients
        • The exclusion of hospice patients is a head-scratcher for me – isn’t the purpose of hospice to create an option for people to remain in their “home” during the dying process?

Percentage of short-stay residents who have had an outpatient emergency department visit:
• Follows the same 30-day timeframe as the re-hospitalization measure;
• Includes all outpatient emergency department (ED) visits except those leading to inpatient admissions (which would fall under the re-hospitalization measure)

Did you know that a 2010 CDC study looking at nursing home residents that had an ED visit within 90 days of admission found that 40% of these visits were preventable? Furthermore, they found that residents with potentially preventable ED visits took more medications than other residents. 56% took 9 or more medications. So how can you prevent hospital visits? And more specifically, how can GrandView Pharmacy help you prevent hospital visits?

It’s critical to first determine which types of readmissions to focus on. The Center for Healthcare Quality and Payment Reform suggests there are 3 broad categories that preventable readmissions fall into:

1. Readmissions for complications or infections arising directly from the initial hospital stay, e.g., if a surgery patient develops a surgical site infection or other complication and has to return after discharge.

2. Readmissions because of poorly managed transitions during discharge, e.g., if a patient or a caregiver does not receive clear instructions from the hospital about the types of medications to take or what to do or not do during recuperation.

3. Readmissions because of a recurrence of a chronic condition that led to the initial hospitalization, e.g., an exacerbation of asthma, congestive heart failure, or chronic obstructive pulmonary disease.

Readmissions in the first category and many readmissions in the second category can be viewed as primarily the responsibility of the hospital, and most of these readmissions occur quickly; typically within 15-30 days. But data analyses show that the largest volume of readmissions occurs among patients with chronic disease.(Source)

With this in mind, GrandView Pharmacy’s uniquely designed IMPACT (Integrated Management for Post-Acute Care Transitions) program is aimed at reducing hospital and nursing home readmissions. We start by having a Certified Geriatric Pharmacist (CGP) conduct a comprehensive, immediate medication regimen review for the resident ensuring the medications taken at home, in the hospital and the orders they have arrived at the facility with, are appropriate, accurate and complete. Our review and reconciliation uses a proprietary check sheet to ensure all aspects of resident’s medication profile are addressed, while any required lab monitoring is ordered. The pharmacist also validates all therapies have supporting diagnoses and all diagnoses have supporting therapies. This seems like “common sense”, but it often finds serious gaps in a resident’s pharmacotherapy and addresses it immediately, before adverse events can take place. If the nursing home participates in the Criteria for Optimized Senior Medication Outcomes (COSMO) program, the pharmacist applies the relevant protocols to the resident’s profile to ensure evidence-based, best practice is observed. COSMO is much more than a drug formulary, like many pharmacies promote, as it leverages evidence-based national and international guidelines and protocols, for a variety of disease states, and applies consistent standards to drug therapy, instead of relying solely on the knowledge and expertise of each different prescriber.

We then provide the resident access to a cutting-edge technological advancement in clinical pharmacy- pharmacogenomic testing, which we’ll discuss in the next blog.

References and Resources:

Learn Morewww.chqpr.org/readmissions.html

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