[PDF] - Behold the Power of Data Lonnita Belk, MBA, Manager, LTC Trend PDF Document

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3/26/2018 1

Behold the Power of Data

Lonnita Belk, MBA, Manager, LTC Trend Tracker Gautami Inamdar, Manager, LTC Trend Tracker, Lindsay B. Schwartz, Ph.D., Associate Vice President, Workforce and Quality Improvement Nebraska Health Care Association April 3, 2018

Schedule for the day

9:00am – 10:30 am Introductions and Outcome 1
10:30am – 10:45am Break
10:45am – 12:15pm Outcome 2 Presentation and activities
12:15pm – 1pm Lunch Break
1:00pm ‐ 1:15pm Wrap up of Outcome 2
1:15 – 2:15pm Outcome 3
2:15pm – 2:30pm Break
2:30 ‐ 4:15pm Outcome 3

Outcome 1

Presenters will demonstrate how to use LTC Trend Tracker,

including uploading data, running reports, scheduling reports, modifying the dashboard and downloading data

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What’s your Trendtrackability?? Poll Everywhere LTC Trend Tracker: Getting Started

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How to Register & Access LTC Trend Tracker

www.ltctrendtracker.com

LTC Trend Tracker Resource Center

LTC Trend Tracker Registration for Assisted Living Communities

Important data field in registration form for Individual Facility/Owner ALs

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Meaningful Comparatives

1) Pick Your Area

National
State
County
City
Zip Code
Congressional District
CMS Region
Core Based Statistical Area
Develop a custom peer group

2) Pick Your Peer Group

For Profit Not for Profit Chain Facility Single Facility CCRC Veterans’ Homes Bed Size All Peers

LTC Trend Tracker Data Sources

REPORT DATA SOURCE UPDATE FREQUENCY Assisted Living Quality Measures LTC Trend Tracker Users Real Time CASPER Reports Collected at time of survey Monthly CoreQ Customer Satisfaction Vendors Real Time Cost Report Full cost report as submitted to your FI/MAC Quarterly Five-Star Nursing Home Compare Monthly Quality Measures Nursing Home Compare Quarterly Hospitalization Report and Discharge to Community MDS 3.0 Quarterly Medicare Patient Days by RUG Category LTC Trend Tracker Users Monthly Turnover and Retention LTC Trend Tracker Users Real Time

Account Administrators of LTC Trend Tracker

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What is an Account Administrator?

Primary contact for each organization
Typically the administrator of a facility or community
For Multi organizations, typically someone from the corporate
ffice
FAQ: Can I have more than one?
Absolutely! However, there will be one primary account

administrator who will be the AHCA/NCAL point of contact.

What are permissions?

User Roles, Permissions and Functions Table User Roles Definition Provider Org Administrator Sets the user privileges and facilities for the organization, has access to information for the entire organization Provider Org Org Unrestricted User Has access to information for the entire organization (all centers) Provider Org Center Unrestricted User Has access to information for one or more individual center(s) Default Functions/ Permissions By User Role Definition Provider Org Account Administrator: Create/edit centers and profiles The ability to create/edit facility profiles Create/edit center groups (sub

rgs)

The ability to create/edit sub organizations Create/edit users & their permissions The ability to create/edit user permissions Create/Edit org focus tags (F & K tags) The ability to edit and change the organization-wide focus tags visible on CASPER Citation reports for the organization and all associated centers Provider Org or Center Unrestricted User: Edit Own Dashboard, Report and Peer Group selections, run all reports except Turnover and RUGs The ability to select report & dashboard options and peer groups, run reports (except Turnover and RUGs) for all centers assigned (Provider Org Center Unrestricted User) or for entire

rganization (Provider Org Org Unrestricted User)

Additional (Optional) Permissions (Assigned to Users by Account Administrator) Definition Edit Center and Profile Information Permission to modify, delete, and add facilities to organization (subject to AHCA customer service approval), edit facility profiles (name, contact info). Upload RUGs data Permission to upload, edit & download RUG data (does not include permission to view RUG reports or RUGs metrics on dashboard) Edit Turnover data Permission to upload, edit & download Turnover data View Cost Report Permission to see the Medicare cost report data NCAL Measures Upload NCAL Measures View RUGs Report Permission to view & download RUGs report, upload/edit RUGs data, and view RUGs dashboard metrics View Turnover Report Permission to view & download Turnover report, upload/edit turnover data (when option becomes available in early 2015), and view Turnover dashboard metrics

What is a User Role?

Only accessible by AHCA

Customer Service, and Account Administrators

Are modifiable
Only one user role per individual
Individual users cannot change

their user role

AHCA Customer Service will
nly change a individuals user

role when granted permission by the account administrator

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Individual User Profile Page

A new feature!
Each user can see the following:
Individual permissions
Additional permissions that have been set by their account

administrator

Name of their organization
User Role
Account Administrator contact information

Where can I see all of my buildings?

Click “Manage My Organization”
Click “Manage” under ‘Organization centers/communities’
Allows you to manage the list of centers that are “attached to”

your organization.

In this section you will also be able to perform the function of

detaching centers from your organization.

Each building is listed alphabetically
The list starts from the top if there are any non‐member

facilities

Where can I see a list of my users?

Click “Administration”
Click “Administration Home”
Allows for Account Administration to download a current listing of

their users

Each user is listed alphabetically along with their user role
Account Administrators can use this list in conjunction with the

“Manage Multiple Users/Roles” screen

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LTC Trend Tracker: Uploading Data

How to Upload Your Data

1. Download template 2. Enter Facility/Community information 3. Upload file into LTC Trend Tracker 4. Click “Submit” button, which will become available if there are no errors in the uploaded file 5. Data is ready to view immediately in those reports

How Did You Calculate…

Assisted Living Hospital Admissions: Numerator: Number of residents who spent the night in the hospital Denominator: Number of residents in AL on the last day of the month Includes both observation and admissions *From the upload spreadsheet this would be column G divided by column F

Number of residents in the AL on the last day

f the month

Number of residents who spent the night in a hospital

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How Did You Calculate…

Hospital Readmission: Numerator: Number of residents sent back to the hospital within 30 days of being admitted to AL directly from Hospital Denominator: Number of residents admitted directly from the hospital to AL Include: observation and admission stays Exclude: planned admissions or ER only visits *From the Upload spreadsheet Column J divided by Column I

Number of residents admitted directly from the hospital to AL

Number of residents sent back to the hospital within 30 days

f being admitted to AL

directly from Hospital

How Did You Calculate… Turnover

The total number of staff employed at any time in the year DIVIDED BY the total number

f staff employed
n December 31st
f the year

How Did You Calculate… Retention

The total number of staff employed for all 12 months

f the year

DIVIDED BY the total number

f staff employed
n December 31st
f the year

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Resident Transfer Date from Hospital to AL Hospital Readmission Date Resident 1 January 1 Resident 2 January 3 Resident 3 January 4 January 31 Resident 4 January 8 Resident 5 January 10 Resident 6 January 15 February 5 Resident 7 January 19 Resident 8 January 25 Resident 9 January 31 March 1 Resident 10 January 31 March 15

Hospital Readmissions:

Residents included in readmissions Resident not included in readmissions – admitted after 30 days of initial discharge

Now let’s put this in our upload Frequently Asked Questions Hospital Admissions/Readmissions

Q: Do I count ED visits? A: No, observation and admissions count only Q: Can the numerator be bigger than the denominator? A: No

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Hospital Admissions Example

The residents in your numerator (those sent to the hospital for

admission or observation) have to also be in your denominator (those residents in your AL on the last day of the month).

I have 3 Residents (Sue, Mary, and Dave) went to the hospital in

October and were in the AL on the 10/31.

October Hospital Admissions Numerator (Sue, Mary, Dave = 3)

DIVIDED by: Denominator (Sue, Mary, Dave plus all the rest of your residents in your AL on 10/31)

I have 100 total residents on 10/31, this includes Sue, Mary and

Dave so I would put 100 in residents on the last day of the month for October and 3 for hospital admissions in my upload sheet

Hospital Readmissions Example

If Sue, Mary, and Dave all came back on 10/30 they would be at

risk for the hospital readmission for 30 days out, or 11/30 to count for the OCTOBER hospital readmission measure. If all 3 went back before their 30 days, they would be counted in the October hospital readmission measure, NOT the November hospital readmission measure.

October Hospital Readmission measure – Numerator (Sue, Mary,

and Dave) – went back within 30 days DIVIDED by Denominator – (Sue, Mary and Dave) which would be 100%

How Did You Calculate…

AL Off‐Label Use of Antipsychotics: Numerator: Number of residents prescribed an off‐label antipsychotic Denominator: Number of residents in the AL on the last day

f the month

*From upload spreadsheet: Column H divided by Column F **Find list of off‐label antipsychotics in Resource center – AL Quality Measures Upload

Number of residents in the AL

n the last day of

the month Number of residents prescribed an

ff‐label

antipsychotic

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Frequently Asked Questions

Q: What does off‐label antipsychotic mean? A: this means the antipsychotic is prescribed for a diagnosis not approved by the FDA Q: How do I know what antipsychotics are off‐label? A: See the chart in the LTC Trend Tracker resource center: AL Quality Measures Upload

A Checklist for Submitting Data

Download data entry sheet – It has been updated for 2018 Enter data and make sure to save Upload data and make sure you receive the message data was uploaded successfully Go to report, run report and make sure to customize at bottom and choose monthly, hospital readmissions and off‐label use of antipsychotics as measures You will see your current month’s data If you don’t your upload wasn’t successful – see next slide

I don’t see my data

Double check the upload sheet and make sure you have the correct month and year Make sure you are using upload excel file and not download file Try to upload again and check data If it is still not there send email to help@ltctrendtracker.com explaining problem and attach your upload sheet

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LTC Trend Tracker: Reports

Report Functionalities

Save or Schedule
Save: Create a saved view of

any report for easy access

Schedule: Save a report

criteria to be delivered at any frequency

Saved & Scheduled
View a listing of your saved

and scheduled reports

Download Data
For more data savvy folks
Download raw data files
Historical upload files

Staff Turnover & Retention, AL Quality Measures, RUGs, and CoreQ

Staff Turnover & Retention RUGs

Information uploaded from LTC

Trend Tracker Participants

Allows you to compare your
rganization’s turnover and

retention rates to your peers

Information uploaded from LTC

Trend Tracker Participants

Medicare Patient Days
Number of Days/RUG Category
Information uploaded from LTC

Trend Tracker Participants

Occupancy Rate
Hospital Readmissions
Hospital Admissions
Off‐Label use of Antipsychotics

AL Quality Measures CoreQ

Information uploaded from LTC

Trend Tracker Participants or can work with satisfaction survey vendors to directly upload data

Satisfaction for AL: Families &

Residents

Satisfaction for SNF: Short‐Stay,

Long‐Stay Family & Residents

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19 reports in LTC Trend Tracker
Survey Data
Quality Measure Data

LTC Trend Tracker Reports

AL Quality Measures Report

Staff Turnover
Staff Retention
CoreQ
Hospital Admissions
Hospital Readmissions
Off‐Label Use of Antipsychotics
Occupancy Rate
Can choose time‐frame: Monthly, quarterly, 6‐month, yearly

Turnover and Retention

Information uploaded from LTC Trend Tracker Participants
Compare organization’s turnover and retention rate to your peers

for:

Administrator/Executive Director
DON/Director of Residential Care
Staff RN
LPN/LVN
CNA (Skilled Nursing Centers only)
Aide (AL only – this includes CNAs, Med Aides)
All Staff

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3/26/2018 14 How do I run a report? – Part I How do I run a report? ‐ Part II How do I run a report? – Part III

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AL Quality Measures Report

Viewing your report

Viewing historical information

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Viewing historical information cont.

LTC Trend Tracker: The Dashboards

SNF Dashboard

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Dashboards: Green Boxes

**Shown on AL & SNF Dashboards

How do I modify my Dashboard?

Dashboard and QAPI

Members use the dashboard to track performance over time
Notices that Antipsychotic data has a “red arrow”
Runs the QM report and data download
Reviews Clinical tracking systems
Determines action and follow ‐‐‐ Root Cause Analysis

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Assisted Living Dashboard Assisted Living Dashboard – How to Customize Goal Setting (AL only)

Account Administrators who have access to Assisted Living

Communities can set goals for their users.

Users are able to select their own goals on their dashboards,

but cannot modify organization goals.

Goals are set per individual community
Reflected in the table located on the dashboard

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Assisted Living Dashboard – How to Set Goals

Top‐Line

What is Your Top‐Line?

5 page outline of a facilities performance
By individual facility and not by organization
Snapshot of Five Star data including the following:
Survey Score
Staffing Rating
Quality Measures
Additional information:
Quality Awards
Quality Measures
Resources

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Page 1: Overall Five Star Rating

Snapshot of your facility’s 5‐

star rating, which is unique to your facility.

Each rating section has

includes a summary of their associated page

The calculation for your Five

Star Rating follows the CMS Technical Users Guide

Question: Should we include

more language to explain the calculation?

Page 2: Overall Survey Score

Breakdown of your overall

survey score, based on your facility’s three latest survey cycles.

The score required to add

another star is variable by state.

The next two tables have a

in‐depth look at the deficiencies that are steering the overall score.

Page 3: Current Staffing Rating

Looks at your facility’s

current staffing rating and details out how to adjust your staffing levels in order to gain a star.

“X Marks the Spot”
This is where your facility

currently rates on staffing

Arrow shows the most

efficient way to increase your staffing

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Page 4: Quality Measures

Breaks down the points your

facility is currently earning on the individual quality measures that factor into your 5‐Star quality rating.

The measures are listed from

the ones you are earning the least amount of points to the most.

You are able to earn up to

100 points per measure.

Scale for the arrows in shown in

the key

At the bottom, your facility’s

individual measures points are summed up and listed out on the nation‐wide scale that converts your points to a star rating.

Page 4: Additional Information

Summary of your facility’s

performance in the AHCA/NCAL Quality Initiative.

Within each condition, there is
ne measure and a goal for

current performance and improvement over time.

You get credit if you meet at

least one of the goals, which is indicated by a green check mark and a gold cup icon.

Each header is a link to the AHCA

website for additional information

AHCA/NCAL Resources
Data Source and Time‐Frame

Page 5: Resident Profile

Provides the information you

need to begin the resident profile portions of Components 1 and 2 of the annual Facility Assessment required under the Centers for Medicare and Medicaid Services (CMS) Requirements of Participation (§483.70(e)).The measures are listed from the ones you are earning the least amount of points to the most.

Your Resident Profile was

developed from the Resident Profile section of the QIO template.

Further information can be

found on ahcancalED.

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Five‐Star Rating & LTC Trend Tracker

What is Five‐Star and why is it important to me?

Quality rating system developed by The Centers of Medicare &

Medicaid Services (CMS)

3 components as a part of the overall Five‐Star rating:

1. Health Inspection Results 2. Staffing Data 3. Quality Measure Data

Your overall Five‐Star determines referrals
Families and residents look at star ratings when deciding where to

go

Five‐Star Quality Domain

16 measures
Type: 9 Long‐Stay & 7 Short‐Stay
Source Nursing Home Compare: 13 MDS‐based & 3 Claims‐

based

Updated every quarter
Earn between 20‐100 points for each measure based on your 4

quarter rate

Sum total of the points determines star rating [for QMs]

Star rating → Points Total→

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*Denotes claims‐based

measure. These measures are

updated every 6 months.

Converting Measure Rates to Points

Example with SS Rehospitalizations

Measure Points→ QM Rate→

Five‐Star Quality Measure (QM) Predictor Tool

This online tool helps you see how close you are to gaining or

losing points on each measure and model various scenarios

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How to access the Five‐Star QM Predictor Tool in LTC Trend Tracker

SNF Value‐Based Purchasing & LTC Trend Tracker

What is SNF Value Based Purchasing?

Protecting Access to Medicare Act of 2014 (PAMA) required CMS

to implement SNF VBP, a value‐based program that through hospital readmission measures aims to:

Link financial outcomes to quality performance…
Institute uniform policies for acute hospitals, SNFs, HHAs, IRFs

and LTCHs…

Encourage coordination across the acute‐post‐acute continuum
f care…

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Meet the SNF VBP Measures!

SNF‐RM (VBP FY 2019, FY 2020)

SNF 30‐Day All‐Cause Readmission

Measure (NQF #2510)

Calculated using Medicare FFS Part A

claims

Counts rehospitalizations during 30

day window from admission to the SNF

During & after SNF stay (if

discharged home prior to 30 days)

Excludes planned readmissions
Excludes observation stays
Risk adjusted
(Actual ÷ Predicted) x National

average

SNF PPR (VBP starting TBD)

Skilled Nursing Facility 30‐Day

Potentially Preventable Readmission Measure (NQF endorsement pending)

4 Clinical Categories (Potentially

Preventable)

1. Inadequate mgmt. of chronic

conditions

2. Inadequate mgmt. of infections
3. Inadequate mgmt. of other

unplanned events

4. Inadequate injury prevention

(does not apply when home)

SNF VBP Predictor Tool in LTC Trend Tracker

New predictor tool set to release the third week in April 2018
Tool will allow members to forecast their payment adjustment

factor before CMS officially notified providers in August

Tool can also be used to forecast performance in second year
f program (FY 2020)

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Time for a stretch!

Let’s Practice!

Activity 1: Dashboard Practice

Refer to page 6 of your training manual

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Activity 2: Report Practice

Refer to page 7 of your training manual

Activity 3: Scenario Practice

Refer to page 8 of your training manual

LTC Trend Tracker: Q&A Time!

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Outcome 2: Understand how to interpret the data contained in key reports.

Data: The Good, The Bad, and The Ugly

Who Collects Data on LTC?

Government Accountability Office (GAO)
Office of Inspector General (OIG)
Centers for Medicare and Medicaid Services (CMS)
Centers for Disease Control – National Center for Health Statistics

(NCHS)

Trade Associations (NCAL, Argentum, Leading Age, ASHA, NIC)
Hospital and Healthcare Compensation

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What People Know About You

Hospitals track your data
Yelp
Google
Facebook
Twitter
State Surveys
Health Grades
Word of mouth/reputation

Deciding What Data to Collect

Principles Guiding Measure Selection

Quality measures should
Reflect the primary goals for the population receiving care,
Be meaningful to the consumer and provider,
Risk adjust for differences in patient populations and acuity,
Be more heavily weighted for patient outcome measures than

structure or process measures, and

Help achieve better outcomes (e.g. are timely and can be used

in quality improvement efforts)

Be readily available for use now or under development to be

used in the near future.

Should not be driven by available data

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Who are you preparing the data for?

Hospital CEO
Quality Assurance/Performance Improvement Committee
Internal use
Marketing – Lonnita will fill you in on this!
Residents/Family

Improving Safety & Quality

Incidents – patient safety events that reached the patient/resident

whether or not there was harm

Near misses (or close calls) – patient safety events that did not

reach the patient/resident

Unsafe conditions – any circumstance that increases the

probability of a patient safety event

The Donabedian Model

Structure

Buildings
Staff
Financing
Equipment

Process

Screening

for pressure ulcer risk

Screening

for falls Outcomes

Number of

pressure ulcers

Falls with

injury

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A Definition Break:

Incidence is defined as the number of new cases of a disease that
ccur during a specified time in a population at risk for the

disease.

Example ‐ the number of residents with the initiation of off‐

label antipsychotic drug use in the first 90 days of assisted

living. The denominator only includes residents who have

been at the assisted living 90 days or less at the end of the target month.

Prevalence is defined as the number of persons affected in the

population at a specific time divided by the number of persons in the population at that time.

Point prevalence – number of residents with off‐label use of

antipsychotics prescribed out of the number of residents in the community on the last day of the month.

“In God we trust, all others bring data.” –

Elements of Statistical Learning

Why Data Matters

Must manage by facts, not feelings
Shows how well you are performing and areas for improvement
Without data we function in an atmosphere of blame
problems are hidden
results are excused
people are blamed
It’s a team effort! All staff are important in quality improvement.

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Show me the Data Be a Good Consumer of Data

What is your data telling you?
Make sure you understand your data before you share it
Numerators, denominators, risk adjustment, oh my!
Do NOT massage your data to get the message you want!

Rates vs. Percentages

Percentages are a form of a

proportion where the numerator is a subpart of the denominator, which is the total so the formula is: (a / (a+b) ) x 100.

Percentage of New or Returning

Residents Identified as At‐Risk Referred for Fall Prevention

Services. A community has 3 (a

+ b) new residents this month and 2 (a) of the 3 residents are assessed for fall risk within their 14th day of admission.

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Rates vs. Percentages, cont.

Rates are a form of ratio that represents the probability of an

event.

Rate may or may not be a proportion, like a percentage.
Numerator is the number of occurrences of an event during a

specified time period and the denominator is the number of persons exposed to that event in the time period.

The formula for a rate is a / (a+b)
where a = the frequency of events during a certain time period
a+b = the number at risk of the event during that time period.

Why Use Resident Days as a Denominator?

Rates with person‐time in the denominator are used when an

event can occur more than once in a target period, such as a fall. Some residents may be exposed to the risk of an event, such as a fall, for differing periods of time due to moving‐in or out of the community during the month.

Resident days are calculated by multiplying the number of

residents by the number of days they were cared for at the

community. Alternatively, it may be calculated by totaling the

daily resident census counts for the month. Typically, 1,000 resident days is used because it makes more sense to have 6.69 falls per 1,000 resident days instead of 0.006 resident falls per day.

Resident Days Example

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Who Is Better?

Huskers AL

Hospital Readmission rate: 100%
Numerator: 1
Denominator: 1

Hawkeye AL

Hospital Readmission Rate: 50%
Numerator: 5
Denominator:10

50 100 Huskers AL Hawkeyes AL

Hospital Readmissions

1 2 3 4 5 6 Huskers AL Hawkeyes AL

Hospital Readmissions

Risk Adjustment

A statistical process that takes into account the underlying health

status or other factors that could impact outcomes.

Why is this important?
Is LTC Trend Tracker data for assisted living risk adjusted? No

Why Representative Data Matters

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Sampling and Response Bias

Sample – the group of people invited to participate in your survey
Response rate – the percentage of people invited to respond to a survey that

actually returned a usable survey.

Non‐response bias – the error resulting from distinct differences between people

who responded to a survey versus the people who did not respond.

Do these matter?

How Non‐Response Bias Impacts Outcomes

Source: http://www.readexresearch.com/how‐response‐rate‐affects‐a‐survey/

An important reminder…

Source: How to Lie with Statistics, Darrell Huff

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Case Study #1: Customer Satisfaction

Interpreting Data Example

Response Rate Goal

LTC Trend Tracker: CoreQ Reports

3 CoreQ Reports Available

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LTC Trend Tracker: CoreQ Report Why did our CoreQ Score Decrease?

Look at response rate – did it decrease dramatically?
Did we change something?
Survey mode for CoreQ– telephone, in‐person, mail?
Activities, food, etc at the center/community
You need to ask more questions than just the CoreQ questions for

quality improvement efforts

Customer Relationships

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Next Steps

Meeting with residents/families
Expectations
Meeting with Staff – it’s a team sport!
Set priorities and goals (SMART ones)
Pilot programs (PDSA)
Communications is vital!
Continue to monitor progress on CoreQ

Case Study #2: Quality Improvement

Scenario

Ken, the Administrator at Haven Center is concerned about a

recent reduction in admission referrals from the local hospital.

Ken reaches out to the hospital and learns that they have noticed

Haven Center’s declining Five Star rating. He also learns that there have been concerns expressed about quality of care, specifically that patients who go to Haven Center decline unnecessarily and are unlikely to be discharged successfully out of the Center. Question: What can Ken do to investigate these concerns? Answer: Use LTC Trend Tracker!

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Where to Start?

Five Star Overall Rating Report Hospitalization Rate Report Discharge to Community AHCA Measure Report Quality Measure (All) Report

LTC Trend Tracker

Overall & Over Time Let’s Take a Look…..

Five Star Overall Rating Report

Five Star rating has declined from 5 stars to 4 stars……….why?

Five Star Overall Rating Report

Five Star rating has declined from 5 stars to 4 stars…..driven by decline in QM rating from 5 stars to 3 stars in the past year.

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Hospitalization Rate Report

Risk Adjusted Rehospitalization rate shows a steady increase from 17.2% to 20.4%.

Discharge to Community AHCA Measure Report

Risk Adjusted Discharge to Community shows a steady decline from 61.7% to 43.7%.

What’s Next?

Quality Measure (All) Report

Drill Down

Let’s Take a Look…..

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Short Stay Quality Measures Long Stay Quality Measures

Tell Me More…

QIES – CASPER

Reports – MDS 3.0 QM

Drill Down to

Resident Level

Seek to Understand
Take Action

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CASPER QM Facility Level Report

Facility Facility Comparison Group Comparison Group Comparison Group

CMS Observed Adjusted State National National Measure Description ID Data Num Denom Percent Percent Average Average Percentile SR Mod/Severe Pain (S) N001.01 18 99 18.2% 18.2% 22.8% 18.7% 5 4 SR Mod/Severe Pain (L) N014.01 2 46 4.3% 3.6% 9.9% 7.7% 3 6 Hi-risk Pres Ulcer (L) N015.01 4 70 5.7% 5.7% 4.3% 6.5% 5 1 New/worse Pres Ulcer (S) N002.01 2 161 1.2% 0.8% 0.9% 1.0% 6 9 Phys restraints (L) N027.01 82 0.0% 0.0% 0.4% 1.0% Falls (L) N032.01 42 82 51.2% 51.2% 52.1% 44.3% 6 6 Falls w/Maj Injury (L) N013.01 5 82 6.1% 6.1% 4.2% 3.3% 85 * Antipsych Med (S) N011.01 1 121 0.8% 0.8% 1.7% 2.6% 4 6 Antipsych Med (L) N031.02 14 80 17.5% 17.5% 14.9% 19.2% 5 Antianxiety/Hypnotic (L) N033.01 2 44 4.5% 4.5% 5.6% 9.8% 2 9 Behav Sx affect Others (L) N034.01 24 75 32.0% 32.0% 30.7% 23.9% 7 4 Depress Sx (L) N030.01 4 78 5.1% 5.1% 5.6% 6.2% 6 6 UTI (L) N024.01 2 81 2.5% 2.5% 4.7% 5.9% 3 Cath Insert/Left Bladder (L) N026.01 3 77 3.9% 3.7% 3.5% 3.6% 5 9 Lo-Risk Lose B/B Con (L) N025.01 21 33 63.6% 63.6% 48.2% 45.0% 83 * Excess WtLoss (L) N029.01 5 81 6.2% 6.2% 8.2% 7.7% 4 2 Incr ADL Help (L) N028.01 5 64 7.8% 7.8% 14.8% 16.0% 1 7

Num Denom Observed Pres Ulcer New Worsened (S) 4 70 5.9%

CASPER QM Resident Level Report

Resident Name Resident ID A0310A/B/F SR Mod/Severe Pain (S) SR Mod/Severe Pain (L) Hi-risk Pres Ulcer (L) New/worse Pres Ulcer (S) Phys restraints (L) Falls (L) Falls w/Maj Injury (L) Antipsych Med (S) Antipsych Med (L) Antianxiety/Hypnotic (L) Behav Sx Affect Others (L) Depress Sx (L) UTI (L) Cath Insert/Left Bladder (L) Lo-Risk Lose B/B Con (L) Excess Wt Loss (L) Incr ADL Help (L) Quality Measure Count Data C C C C C C C C C C C C C C C C C Active Residents ABEL, ABE 12121212 02/99/99 b b b b b X b b X b X b b b b b b 3 BEAN, BERTHA 23232323 99/03/99 X b b b b b b b b b b b b b b b b 1 COLUMBUS, CARMEN 34343434 02/99/99 b b b b b X b b X b b b b b b b b 2 JACKSON, JANE 33333333 04/99/99 b b b b b X X X b b b b b b Χ b X 5 JACKSON, JEFF 45454545 01/01/99 b b b b b b b b b b b b b b b b b JOHNSON, JACKIE 56565656 99/99/01 b b b b b b b b b b b b b b b b b JOHNSON, JOHN 66666666 02/99/99 b b b b b X X X b b b b b b X b b 4 KIRK, KENNETH 67676767 99/99/01 b b b b b b b b b b b b b b b b b LARSEN, LYLE 78787878 99/03/99 b b b b b b b b b b b b b b b b b LARSON, LILLY 89898989 03/99/99 b b b b b X b b X b X b b b b b b 3 MICHAELS, MERLIN 90909090 99/03/99 b b b b b b b b b b b b b b b b b NUTTE, NANCY 25252525 99/02/99 b b b b b b b b b b b b b b b b b OLIVERS,OLIVIA 36363636 01/99/99 b b b b b b b b b b b b b b b b b PETERSON, PETER 99999999 02/99/99 b b b b b X Χ b b b b b b b X b b 3

x x x x

Mystery Solved….Opportunities Revealed

Change in acuity of patients coming from hospital to SNF with increased

cognitive impairment.

Development plan for SNF staff to attain new competencies on providing quality

care for individuals with cognitive impairment.

Recognition of pain and evidence based treatment
Nonpharmacological interventions for behavioral expressions
Specialized therapy approaches
Restorative nursing
SNF and Hospital partner on improving transition of care for individuals with

cognitive impairment by sharing most important information to know the person prior to and upon admission to SNF.

More….

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Linking it to QAPI…

Use Five Star QM Rating Report with Predictor Tool to help with performance

improvement and goal setting How to get back to 5 star QM component rating:

SS Pressure Ulcers New or Worsened ‐ improve rate from 5.9% to 3%
SS Pain – improve rate from 17.1% to 11%
SS Antipsychotic – improve rate from 4.4% to 2%
LS Antipsychotic‐ improve rate from 16.7% to 14%
LS Falls with Major Injury – improve rate from 4.6% to 3%
LS ADL Decline – improve rate from 16.2% to 14%

Lunch!

Quality Initiative

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The Quality Initiative for Assisted Living

http://QualityInitiative.ncal.org March 2015‐2018

Why?

ORGANIZATIONAL SUCCESS

Staff Stability
Consistent staff assignment is

better for residents

Reduce operational costs from

constant turnover, hiring and training

Customer Satisfaction
Ensures person‐centered care
Research shows organizations do

better in other outcomes RESIDENT OUTCOMES

Hospital Readmissions
Prevent residents from returning

with higher acuity

Demonstrate your value to

referrals

Off‐Label Use of Antipsychotics
Not supported clinically for

residents with dementia (FDA)

Increases risk of death, falls with

fractures, hospitalizations and

ther complications

http://QualityInitiative.ncal.org

Ways to Get Started

Staff Stability
AHCA/NCAL’s staff turnover calculator – see how much turnover is costing you
Conduct annual staff satisfaction surveys
Empower employees with quality improvement projects
Recognize staff for excellence
Customer Satisfaction
Incorporate CoreQ into your satisfaction survey
Share results with resident and family councils
Utilize feedback, identify areas to improve

http://QualityInitiative.ncal.org

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Ways to Get Started

Hospital Readmissions
INTERACT for Assisted Living: www.pathway‐interact.com
Monitor days and times residents are being sent to the hospital
Implement consistent staff assignment, so staff can better detect changes in a

resident’s status

Make sure all residents have advanced directives in place
Off‐Label Use of Antipsychotics
Train staff to understand dementia and the disease process
Implement consistent staff assignment, so staff know residents’ preferences and

communication methods

Look for non‐pharmacologic interventions (e.g., lighting, routines, life enrichment

programs)

Help educate family members, health care partners

http://QualityInitiative.ncal.org

How to Measure?

www.LTCTrendTracker.com

AHCA Quality Initiative

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AHCA Quality Initiative

GOAL MEASURES TRACK Target Functional Improvement AHCA Self‐Care AHCA Mobility LTC Trend Tracker Improve by 15% Improve Customer Satisfaction CoreQ for SS residents CoreQ for LS residents CoreQ for LS families LTC Trend Tracker At least 90% of customers and/or families are satisfied

r achieve a 10%

improvement Safely Reduce Off‐Label use of Antipsychotics Nursing Home Compare’s Long‐Stay and Short‐Stay measure LTC Trend Tracker Nursing Home Compare Reduce off‐label use of antipsychotics to <8% for long‐stay and <1% for short‐ stay or improve by 10% Safely Reduce hospital readmissions and hospitalizations PointRight Pro30 (Short‐Stay) PointRight ProLongStay LTC Trend Tracker Reduce short‐stay hospital readmissions or long‐stay hospitalizations to <10% or improve by 10%

A note about Staff Stability and Customer Satisfaction

Workforce

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2018 AHCA/NCAL Strategic Plan Workforce Goal

Develop a resource of workforce education and recruitment programs for use by state affiliates and member providers

Recruitment: Advertise

Utilize alternative advertising: community bulletins, apartments, online
Sponsor local sports teams in your community
List your jobs with your AHCA/NCAL State Associations and AHCA/NCAL’s LTC

Career Center

Utilize mailing lists from licensing agencies
Advertise with universities, community colleges, and vocation schools
Utilize mobile recruiting like magnetic signs on community vans
Place a link on your website

Recruitment: Offer Incentives

Including career growth and on the job training
Promote opportunities for growth
Offer career ladders and lattices
Promote temporary to career paths for employees

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Recruitment: Thinking outside the box

Support current employees – good employees enlist good

employees

Host employee networking events
Offer incentives for referrals both inside and outside
Build a presence in your Broader community
Hold ESL classes in your community
Combine marketing with your employment search to let people

know you are hiring during tours

Ask state for program waivers for younger individuals to

work/volunteer at community

Host workshops covering topics like resume writing and

interviewing skills

Recruitment Jeni’s Example

Founder – Jeni Britton Bauer
Employees – refers to employees as team and ambassadors
“Scooping ice cream is physically and emotionally rigorous activity.

It’s important to me that – in addition to serving with grace and confidence – everyone who spends at least one season with us goes away with a clear understanding of the powerful lessons they just picked up. These become college essays or applications, resumes, and leadership in the next era of life – even and especially, if they move up in our company. Our ambassadors become Jedi’s of emotion, facial expressions, and body language, they learn that “flavor is everything” and by “flavor” I mean CHARACTER, they learn what it means to “put your name on it” and other lessons about teamwork and community. I should know, I spent 10 years behind the counter daily. I use those lessons

everyday. “

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Staff Stability: Interviewing

Employee Participation in interviews
Select 3‐6 high performing employees who want to be peer‐

reviewers (pilot the program in 1 department)

Train selected staff on how to conduct interviews using

behavioral‐based questions (make sure they know about questions not to ask)

Department leader should pre‐screen candidates then identify

those coming in for a peer interview

Have employee selection team members ask preselected

question(s) and rate candidate’s responses then make a recommendation

Staff Stability: Behavioral‐Based Interviews

This interviewing technique is based on how the interviewee

acted in the past as the ideas is that this influences future behavior.

Resource: AHCA/NCAL’s workforce toolkit at

qualityinitiative.ahca.org

Some suggested questions from the Studer Group follow

Staff Stability – Reviews

30, 60, and 90 Day Reviews
Provides opportunity to identify where new hires need help and

development is needed

Helps maintain employee morale. Early feedback is important
Helps reduce new employee frustration
Allows employee know where they stand

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Staff Stability: Peer Mentoring

Designing a Peer Mentoring Program
Job description
Mentor Compensation
Management buy‐in
Organizational orientation to mentor’s role
Mentor selection
Mentor training
Mentor oversight and support
Mentor to mentee matching
Mentee orientation

See Introducing Peer Mentoring by PHI available at qualityinitiative.ncal.org

Staff Stability: Training

Training is vital for employees to succeed
Must provide continuous training
Ask employees what they need training on
Bring training to the community, so all staff can participate
Great resources via NALA, NCAL, and other organizations

Helping employees find meaning

Surveys confirm meaning is top for Millennials
Less than 50% of people see their work as a calling
Work can be meaningful even if it is not your calling
Strategies
Connect with end user
Reframe task as opportunities to help others
Reminder of organizational goal or mission
JFK and the Janitor

Emily Esfahani Smith, 2017 “How to Find Meaning in a Job That Isn’t Your Calling” Harvard Business Review https://hbr.org/2017/08/how‐to‐find‐ meaning‐in‐a‐job‐that‐isnt‐your‐true‐calling

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Staff Stability: Recognition

Recognition is important to everyone and can help retain good

staff

According to Forbes, companies that regular recognize employees
utperform those that don’t.
Forbes top 5 best practices for employee recognition
Recognize people based on specific results and behaviors
Implement peer‐to‐peer recognition
Share recognition stories
Make the programs easy and frequent
Coordinate with company’s values or goals

Source: Forbes http://www.forbes.com/sites/joshbersin/2012/06/13/new‐research‐unlocks‐ the‐secret‐of‐employee‐recognition/

Examples from the Grocery Store Staff Stability: Resources

LTC Trend Tracker –Turnover

and Retention Upload

Introducing Peer Mentoring

in Long‐Term Care Settings

AHCA/NCAL Toolkit: 4 Key

Strategies to Retain New Hires and Reduce Employee Turnover

Cost of Turnover Calculator
Staff Stability toolkit (available

in the AHCA/NCAL Bookstore)

NCAL Guiding Principles of

Leadership

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Staff Stability: Achieving this Goal

See how much turnover is costing with turnover calculator
Start tracking your staff turnover with LTC Trend Tracker
Conduct annual staff satisfaction surveys
Empower employees to participate in QI projects
Implement consistent assignment

Leadership Matters! Get out of your Box!

Quality Initiative: Customer Satisfaction

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The Customer Experience

Providing a consistent customer journey
Creating a customer‐centric culture
Building and improving your customer experience is a

marathon and not a sprint

Mindset Model

The Arbinger Institute: Mindset Model

MINDSET

PRACTICES

CURRENT RESULTS

Customer Satisfaction

What are people saying about your center/community?
CoreQ will likely be included in Five‐Star in the future as well

as other CMS programs

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What is CoreQ?

Quality measure developed to assess customer satisfaction in

both Skilled Nursing Care Center and Assisted Living provider settings.

SNF‐related measures are NQF endorsed
AL measures are being submitted to NQF this year
There are five CoreQ measures:
Short‐Stay Discharges Satisfaction – recommended by CMS for

the SNF Quality Reporting Program

Long‐Stay Resident Satisfaction
Long‐Stay Family Satisfaction
Assisted Living Resident Satisfaction
Assisted Living Family Satisfaction

What are the Core Questions?

The three core questions are:

1. In recommending this facility to your friends and family, how would you rate it overall? 2. Overall, how would you rate the staff? 3. How would you rate the care you receive? [ADDITIONAL QUESTIONS]

SS ONLY: How would you rate how well your discharge needs

were met?

AL ONLY: Overall, how would you rate the food?
Questions are answered using Likert scale (1‐5): Poor, Average,

Good, Very Good, Excellent

Vendor Contact Align Neil Gulsvig – ngulsvig@align30.com A Place for Mom Jaime Andersen – JaimeA@aplaceformom.com Bivarus, Inc. Libby Frei – lfrei@bivarus.com Brighton Consulting Group Lisa Jesse – lisajesse@bcgdata.net Cortex Health, Inc. Riley Adamson – riley@cortexhc.com The Doug Williams Group, Inc. Frank Sanabria – frank@thedougwilliamsgroup.com Healthcare Academy Judy Hoff, MA – jhoff@healthcareacademy.com Holleran Aggie Marciniak – amarciniak@holleranconsult.com inQ Experience Surveys Rich De Jong – RDeJong@symbria.com Lighthouse Care Updates Kevin Goedeke – kevin@lighthouseupdates.com Market Research Answers (CareSat) Jill Rosso – jill.rosso@marketresearchanswers.com Nexus Health Resources, Inc Ryan Sparks – rsparks@NexusHealth.com NRC Health Rich Kortum – RKortum@nrchealth.com Pinnacle Brady Carlsen – brady.carlsen@pinnacleqi.com Providigm/abaqis Peter Kramer – pkramer@providigm.com Sensight Surveys Lyn Ackerman Ph.D. – lynn@sensightsurveys.com ServiceTrac Michael Johnson – Michael.Johnson@practicemax.com

Vendors Who Have Added CoreQ

Nicholas Castle, Ph.D., University of Pittsburgh is willing to administer only the CoreQ if you don’t have a vendor for a fee. Contact him at CastleN@Pitt.edu

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Customer Satisfaction: How to Achieve this Goal

Ensure your customer satisfaction survey vendor has added CoreQ

to your resident/family surveys

Ask your customer satisfaction vendor to upload your CoreQ data

to LTC Trend Tracker

Make sure to utilize additional questions from your vendor for

quality improvement efforts

Track your progress through CoreQ reports available in LTC Trend

Tracker

ALs can use the goal setting function in the AL dashboard to

monitor progress

Learn More About CoreQ!

Coreq.org

Hospital Admissions/Readmissions

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INTERACT for AL: Communication with Hospital

Assisted Living Capabilities – lists what your community can

do, great to use with hospitals and other providers

Hospital Transfer Form – vital information
AL to Hospital Transfer Data list – key important elements
Hospital to AL transfer form

INTERACT: Communication

Stop & Watch
SBAR for nurses and for caregivers:
Situation
Background
Appear
Review

INTERACT Advance Care Planning

Advance Care Planning Communication Guide
Identifying residents appropriate for hospice
Comfort care interventions
Deciding about going to the hospital
Education on CPR for Residents and Families
Education on Tube Feeding for Residents and Families

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INTERACT – Engaging Hospitals

Transitions in care require 2 partners
Information is only useful when it is used by receiver
If safe and appropriate, be ready to accept resident back
Use RCA to review transfers to see what could be improved
n – include feedback from hospital
Important for changing landscape of health care

Working with Hospitals

Create a list of hospitals your community sends and receives

residents from

Identify “readmission champion” for each hospital and have

points of contact

Host community care transitions coalition for community
State goals of community to reduce avoidable hospital

transfers, admissions, and readmissions

Assessment After Hospital Admission

Complete assessment of resident after hospital admission
Screen for hospital readmission risk
Repeat move‐out criteria after assessments or

hospitalizations

Communicate resident’s change in health conditions with

resident and family

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Have a Protocol for Talking About about Decline and Death

Don’t assume the resident’s physician has effectively

communicated with the resident or the family

Be caring and supportive, but factual
Set realistic expectations for the future
Identify what the resident/family’s outcome expectations are

given the circumstances. Is everyone in agreement?

Document those conversations
Develop the care plan moving forward.

Hospital Readmissions: Resources

LTC Trend Tracker
CHATs – Communicating Health Assessments by Telephone
INTERACT for Assisted Living
INTERACT for Skilled nursing

Off‐Label Use of Antipsychotics

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Antipsychotic Medications

Abilify (Aripiprazole)
Saphris (Asenapine)
Clozaril Fazaclo (Clozapine)
Fanapt (Iloperidon)
Zyprexa (Olanzapine)
Invega (Paliperidone)
Seroquel (Quetiapine)
Risperdal (Risperidone)
Geodon (Ziprasidone)
Haldol (Haloperidol)
Loxitane (Loxapine)
Navane (Thiothixene)
Orap (Pimozide)
Compazine (Prochlorperazine)
Mellaril (Thioridazine)
Moban (Molindone)
Prolixin (Fluphenazine)
Stelazine (Trifluoperazine)
Thorazine (Chlorpromazine)S

Convention (Generic) Atypical (Generic)

FDA approved diagnoses

Schizophrenia
Bi‐polar Disorder
Irritability associated with Autistic Disorder (Aripiprazole &

Risperidone)

Treatment Resistant Depression (Olanzapine)
Major Depressive Disorder (Quetiapine)
Tourettes (Orap)
When prescribed to a patient without an FDA approved diagnosis;

considered off‐label use, which is allowed by FDA and Medical Boards

Common Off‐label uses

Dementia with behavior difficulties
Agitation
Aggression
Wandering
Acute Delirium
Depression
Obsessive‐compulsive disorder
Psychotic symptoms (e.g. hallucinations, delusions) with

neurological diseases

Parkinson’s disease
Stroke

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Effectiveness in Dementia

Antipsychotic effect takes 3‐7 days
Acute response most likely due to sedating properties, not

antipsychotic effect

In RCTs, recipients do a little bit better than placebo but the effect

beyond 3 months is unclear and:

Not everyone who receives the meds improves
A large number of people getting the placebo improve
The net effect is that 10 to 20 people out of 100 who receive the

medication improve due to the medication

Associated with Adverse Outcomes

Off‐label use of antipsychotics in nursing facility residents is

associated with increase in:

Death (heart failure or pneumonia) 1.6 x greater than placebo
Hospitalization (40% increase)
Falls & fractures
Venothrombotic events
Conventional antipsychotics are worse than atypical antipsychotics

Effectiveness with Low Doses

Low dose Risperidone (<1 mg/d): small positive effect but also increased risk of

adverse events

Low dose Olanzapine (5 mg/d): no positive effect but does have increase risk of

adverse events

Low dose Aripiprazole and Quetiapine: effectiveness unknown, but Quetiapine at

normal dose has no evidence of effectiveness

Source: Cochrane Review 2012; Meta‐analysis 16 RCTs in dementia

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FDA Black Box Warning

Issued in 2005
Warning: Increased Mortality in Elderly Patients with

Dementia‐Related Psychosis

Elderly patients with dementia‐related psychosis treated

with antipsychotic drugs are at an increased risk of death. [Name of Antipsychotic] is not approved for the treatment

f patients with dementia‐related psychosis.

Antipsychotics: Achieving the Goal

Focus on non‐pharmacologic approaches for preventing the

frustrations that can lead to challenging behavior and for addressing resident’s behavioral expressions when they do occur

Using a positive physical approach, engaging residents in

meaningful activity, and using therapeutic strategies for catastrophic events can make a real difference for residents with dementia.

Environmental changes : reducing noise, improving lighting, and

allowing flexible scheduling.

Alzheimer’s Association Dementia Care Practice Recommendations

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Practice Recommendations for Person‐ Centered Care

Know the person living with dementia
Recognize and accept the person’s reality
Identify and support ongoing opportunities for meaningful

engagement

Build and nurture authentic, caring relationships
Create and maintain a supportive community for individuals,

families, and staff

Evaluate care practices regularly and make appropriate changes

Practice Recommendations for Detection and Diagnosis

Making information about brain health and cognitive aging readily

available to older adults and their families

Know the signs and symptoms of cognitive impairment
Listen for concerns about cognition, observe for signs and

symptoms of cognitive impairment, and note changes in cognition that occur abruptly or slowly over time

Develop and maintain routine procedures for detection of

cognition and referral for diagnostic evaluation

Use brief mental status to test to detect cognitive impairment
Encourage older adults whose physician has recommended a

diagnostic evaluation to follow through on the recommendation

Support better understanding of a dementia diagnosis

Practice Recommendations for Person‐ Centered Assessment and Care Planning

Perform regular, comprehensive person‐centered assessments

and timely interim assessments

Use assessment as an opportunity for information gathering,

relationship‐building, education, and support

Approach assessment and care planning with a collaborative team

approach

Use documentation and communication systems to facilitate the

delivery of person‐centered information between all care providers

Encourage advance planning to optimize physical, psychosocial,

and fiscal well‐being and to increase awareness of all care options, including palliative care and hospice.

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Practice Recommendations for Medical Management

Take a holistic, person‐centered approach to care and embrace a

positive approach to support residents and family that encourages individuals’ ongoing medical care to their well‐being and quality of life.

Seek to understand the role of medical providers in the care of

persons living with dementia and the contributions that they make to care.

Know about common comorbidities of aging and dementia and

encourage persons living with dementia and their families to talk with the person’s physician about how to manage comorbidities at home or in residential care settings

Encourage non‐pharmacologic interventions for BPSD

Practice Recommendations for Medical Management, cont.

Understand and support the use of pharmacological interventions

when they are necessary for the person’s safety, well‐being and quality of life.

Work with the person living with dementia, the family, and

physician to create and implement person‐centered plan for possible medical and social crises

Encourage persons living dementia and their families to start end‐
f‐life care discussions early.

Practice Recommendations for Information, Education, & Support for Individuals Living with Dementia and their Caregivers

Provide education and support early in the disease to prepare for

the future

Encourage care partners to work together and plan together
Build culturally sensitive programs that are easily adaptable to a

special population

Ensure education, information, and support programs are

accessible during times of transition

Use technology to reach more families in need of education,

information, and support

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Practice Recommendations for Care of BPSD

Identify characteristics of the social and physical environment that

trigger or exacerbate BPSD

Implement non‐pharmacological practices that are person‐

centered, evidence‐based, and feasible in the care setting

Recognize that the investment required to implement non‐

pharmacological practices differs across care settings.

Adhere to protocols of administration to ensure that practices are

used when and as needed, and sustain in ongoing care

Develop systems for evaluating effectiveness of practice and make

changes as needed

Practice Recommendations for Support of ADLs

Support for ADL function must recognize the activity the individual’s

functional ability to perform the activity and the extent of cognitive impairment

Follow person‐centered care practices when providing support for all

ADL needs

When providing support for dressing, attend to dignity, respect, and

choice; the dressing process; and the dressing environment

When providing support for toileting, attend to dignity and respect; the

toileting process; the toileting environment; and health and biological considerations

When providing support for eating, attend to dignity, respect and choice;

the dining process; the dining environment; health and biological consideration; adaptations and functioning; and food beverage and appetite

Practice Recommendations for Staffing

Provide a thorough orientation and training program for new staff,

as well as ongoing training

Develop systems for collecting and disseminating person‐centered

information

Encourage communication, team work, and

interdepartmental/interdisciplinary collaboration

Establish an involved, caring and supportive leadership team
Promote and encourage residents, staff, and family relationships
Evaluate systems and progress routinely for continuous

improvement

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Practice Recommendations for Supportive and Therapeutic Environment

Create a sense of community within the care environment
Enhance comfort and dignity for everyone in the care community
Support courtesy, concern, and safety within the care community
Provide opportunities for choice for all persons in the care

community

Offer opportunities for meaningful engagement to members of

the care community

Practice Recommendations for Transitions in Care

Prepare and educate persons living with dementia and their family

caregivers about common transitions in care

Ensure complete and timely communication of information

between, across, and within settings

Evaluate the preferences and goals of the person living with

dementia along the continuum of transitions in care

Create strong interprofessional collaborative team environments

to assist persons living with dementia and their care partners/caregivers as they make transitions

Initiate/Use evidence‐based models to avoid, delay, or plan

transitions in care

Guiding Principles for Dementia Care

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A Person‐Centered Approach

A continuous, relationship‐based process…
Listening
Paying attention
Trying things
Seeing how they work
Changing as needed
Consider – What works for you?

Meaningful Life & Engagement

Activity Materials – should be adult in nature
Art – including painting, sculpture, photography
Spending time with children of various ages
Music that is pleasant and familiar (Music & Memory)
Pets
Social Interaction/Solitude
Spirituality/Religion
Touch such as massage
From: Dementia Care: The Quality Chasm 2013

Engaging Activities

Find out what the person liked/likes
Including past hobbies
Activities may need to be modified
A cook can still help stir, pour ingredients already measured, knead bread
A carpenter can put together items that are larger (easy to see) that don’t require

nails or glue

Puzzles – large pieces with defined edges and not many pieces (less than 25)
Music & Memory Program

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Staff & Family

Are all staff trained on dementia care?
How often do staff repeat the dementia training?
Virtual Dementia Tour
Do staff observe each other when interacting with dementia

residents and provide constructive feedback?

Do staff work on how they communicate with residents with

dementia so they know how to be clear?

Do staff understand the side effects and effectiveness of

antipsychotics in dementia?

Addressing any family issues/concerns

Dementia & Behavior Redefined Alzheimer’s and the Brain

Normal Brain Brain with Advanced Alzheimer’s

Picture from Alzheimer’s Association: http://www.alz.org/alzheimers_disease_4719.asp

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Primary Challenge is Changing Beliefs

Most health care professionals and families believe
(1) “Dementia behaviors” are abnormal & need to be treated.
(2) Antipsychotics medications are effective.
For any technical change to be successful, must first achieve

adaptive change that addresses beliefs

Education is necessary but not sufficient

What would you do if…?

Scenario 1: You are asleep in a chair at home when suddenly you are woken up by a person you have never seen before trying to undress you.

Make sense of the situation – what’s going on here?
How do you feel?
What do you do?

What would you do if…?

Scenario 2: You are feeling bored and restless at home, so you decide to go out for a walk. But you find that your front has been locked and a stranger appears and tells you to go and sit down.

Make sense of the situation – what’s going on here?
How do you feel?
What do you do?

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Immediate Strategies: Persons Currently on Antipsychotics

No role for PRN only
Evaluate use >12 weeks, consider GDR
Attempt discontinuation for those on low doses
Critically evaluate new admissions on antipsychotics – When

started? Why? What can we do about it?

Create process for critical & timely review of new Rxs, especially

started on evenings, nights and weekends

Educate families about dementia, use of antipsychotics and

alternatives

Intermediate Strategies: Preventing New Rxs Whenever Possible

Build on your early successes – celebrate the wins!
Review data & benchmark against top performers
Put a stake in the ground:
Set a goal of providing drug‐free care for persons with

dementia

Communicate that goal to all staff, to families, to key partners
Educate staff & families on:
Understanding of behavior as communication
Experiential model of dementia
Person‐centered approaches to care
Implement consistent assignment

Longer‐Term Strategies for Sustainable Change

Build on your continuing successes – keep celebrating the wins!
Focus on quality improvement processes and systematic changes:
Improve staff stability
Seek out mentors – learn from other facilities
Continue to enhance person centered care through changes to

environment, staffing, scheduling, facility routines & processes…

Engage staff in identifying solutions & leading change

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Questions to ask before Prescribing/Requesting

What did you do to try and figure out why the resident was doing

<fill in the blank>?

What is resident trying to communicate to us about their <fill in

blank>?

What is reason for resident doing <fill in blank>?
Unacceptable answer (Dementia or sun‐downing)
What did you try before requesting medications?

Think about the Environment

Is it too loud?
Is it too bright or not light enough?
Is the environment cluttered?
How do residents find their way to their room, the dining room, or
ther important places?
Is it hard to get around or easy to maneuver?
Think about resident rooms/layout

The Environment: Try this!

Take 10 minutes to sit in an area of your assisted living/residential

care facility, close your eyes for a few minutes. What sounds do you hear? Is it loud? Are there a lot of different sounds coming from different places? Open your eyes. What do you see? Is it really bright and hard to see or too dark and hard to make out

bjects? Is the area cluttered and hard to get around?
Repeat this activity during the night.

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Antipsychotics: Resources

AHCA/NCAL Quality Initiative Websites
Consumer Fact Sheet
15 ways to use the Consumer Fact Sheet
Alzheimer’s Association Dementia Care Practice Recommendations
NCAL Guiding Principles of Dementia Care
IA‐ADAPT https://www.healthcare.uiowa.edu/igec/iaadapt/
The National Dementia Initiative White Paper ‐ http://www.ccal.org/national‐

dementia‐initiative/white‐paper.shtml

Functional Outcomes Goal

Two measures:
AHCA’s Self‐Care
AHCA’s Mobility
NQF endorsed measures based on MDS Section GG

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You have your data now what?

Slide used with permission from Dr. Sheryl Zimmerman

Value of LTC Trend Tracker for Marketing Yourself

Who Collects Data on LTC?

Government Accountability Office (GAO)
Office of Inspector General (OIG)
Centers for Medicare and Medicaid Services (CMS)
Centers for Disease Control – National Center for Health Statistics

(NCHS)

Trade Associations (NCAL, Argentum, Leading Age, ASHA, NIC)
Hospital and Healthcare Compensation

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Ways to Change the Narrative

Earned Media
Paid Media
Social Media
Online Reviews

Utilizing LTC Trend Tracker Data & Marketing

Publicly reported data means your data is available for all who are

interested.

Modify your peer group to local peers & reference THIS data when

marketing your facility.

Control the narrative by drilling down into key reports based on

feedback from referral agencies.

Examples of key reports: Discharge to Community,

Hospitalization, Quality Measure, Five Star Rating.

Use key reports IN CONJUNCTION with internal reporting &

perform RCA to see the impact of your care improvements.

Earned Media

Build a relationship with your local press
Pay attention to what’s important to the reporter you’re trying to

pitch

Highlight special programs, community events, or unique

individuals

Think of an interesting hook

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Paid Media

TV, radio, print
Billboards
Advertorials
Online
Paid search
Display ads on third‐party websites
Social media

Establish a Social Media Plan

1. Identify your audience 2. Identify which sites to join (you and your consumers will use) 3. Identify dedicated staff to manage your accounts 4. Set SMART goals 5. Brainstorm possible content 6. Create a schedule to post content, follow others 7. Reputation Management: check your mentions and reviews consistently; respond appropriately 8. Monitor your progress on your goals

Engage, Engage, Engage

Social media is a discussion
Appeal to/identify with your

audience

Too promotional is boring
Engage like a friend, not like a

business

Use images and multimedia
Use features of the platform
Encourage sharing
Don’t just focus on your account –

engage with others

Tag/Retweet/Like/Mention

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Quick Tips

Facebook

Use photos and videos
Tell stories
Timing is everything
75% of the engagement on a

post happens in first 5 hours

Connect like a friend, not a

business

Twitter

Use photos
Use 1 or 2 hashtags
Keep it mobile friendly
It doesn’t hurt to ask for a

retweet

Social Media & Marketing: The Good, The Bad, & The Ugly

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BrightLocal: 2017 Consumer Review Survey

(October 2017)

97% of consumers read online reviews for local businesses in

2017, with 12% looking for a local business online every day

85% of consumers trust online reviews as much as personal

recommendations

Positive reviews make 73% of consumers trust a local business

more

49% of consumers need at least a four‐star rating before they

choose to use a business

68% of consumers left a local business review when asked ‐ with

74% having been asked for their feedback

Online Review Sites

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Responding to Negative Comments

Stay calm
Respond (privately)
Introduce yourself.
Thank them for the comment/feedback.
Apologize.
Acknowledge their complaint, and explain what you’ve done to

address the problem.

Don’t be too defensive.
Invite them to return.
Respond (publicly)
It’s not an opportunity to nitpick the comment, but to demonstrate

to would‐be customers that you’re on top of your customer service.

Do not violate HIPAA with specific information about the resident.

Final Thoughts

The press are not the enemy.
Make a plan, set goals.
Keep it short, simple and jargon‐free.
Get your residents and their family members involved – tell THEIR

story, not yours.

Don’t forget the human element.

Don’t Forget to Have Fun

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AHCA/NCAL’s National Quality Award Program

Established in 1996
Based on the Baldridge Performance Excellence Framework
3 Levels:
Level 1: Bronze Award – Commitment to Quality
Level 2: Silver Award – Achievement in Quality
Level 3: Gold Award – Excellence in Quality
Organizations must achieve the award at each level to continue to

the next level

AHCA/NCAL National Quality Award Program

Quality Award Program & the Baldridge Criteria

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Why Should My Organization Apply?

Performance Improvement
Program criteria assists organizations with preparation for

regulatory demands such as CMS’ QAPI & RoP.

Superior Outcomes
Silver and Gold recipients have superior performance in

quality outcomes such as 30‐day hospital readmissions,

ccupancy rating, and operating margin.
Esteemed Recognition
Receipt of an award is an opportunity to establish recognition
n both a local and national level.

Silver and Gold vs the Nation: Quality Metrics Silver and Gold vs the Nation: Overall Five-Star Rating

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Silver and Gold vs the Nation: Business Advantage

Bronze Award Basics

The Bronze Application is most importantly a statement of priorities for a center
Many criteria questions use the term “Key” = Most Important
You may have a clear picture of what’s most important (key), but others in the

center may not

This comprehensive understanding creates an unwavering focus on key

performance requirements and results

Evaluated on a criteria met/not met basis

Silver Award Basics

Silver award recipients demonstrate effective systems and positive results, indicating

they are most likely to keep moving forward on their quality journey, rather than sliding back

Criteria span the 7 Baldrige categories – results are required at the silver level
Examiners determine each applicant’s level of criteria implementation using

established scoring guidelines

All applicants receive a personalized feedback report in each section of the criteria

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Gold Award Basics

Builds upon Silver application; Responsive to full Baldrige Criteria
Higher scoring threshold than Silver
Examiners determine applicant’s level of criteria implementation using established

scoring guidelines

Potential award recipients are visited onsite by a team of Examiners
All applicants receive a personalized feedback report in each section of the criteria

Helpful Resources

Website: educate.ahcancal.org Bronze Criteria Series: educate.ahcancal.org/products/2017‐ bronze‐criteria‐series Website: www.ltctrendtracker.com Email: help@ltctrendtracker.com Website: www.ahcancal.org/qualityaward Email: qualityaward@ahca.org Website: www.ahcapublications.org Phone: 800‐321‐0343

Quality Improvement

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QAPI – it’s for Assisted Living

Learn and apply the skills of QAPI
particularly root cause analysis
action planning and
team‐based performance improvement.
For more information & resources, visit

http://www.ahcancal.org/quality_improvement/QAPI

Root Cause Analysis

A structured method used to analyze adverse events
Initially developed in industrial incidents, now widely used in

health care settings

Identify underlying problems that increase the likelihood of errors

while avoid focusing on the individual

Follow a protocol including data collection and reconstruction of

even in question

Multidisciplinary team should analyze events to identify how and

why event occurred to learn from and eliminate latent errors

Source AHRQ PSNET: http://psnet.ahrq.gov/primer.aspx?primerID=10

Root Cause Analysis Tools

Fishbone (Ishikawa) diagram
5 whys
Pareto chart
Flow charts
Cause and effect diagraming
Many more!

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Root Cause Analysis Tools

Fishbone (Ishikawa) diagram
5 whys
Pareto chart
Flow charts
Cause and effect diagraming
Many more!

Practice the 5 Whys

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Flow Charts

Beginning & End Decisio n Point Task/Activity Process Flow

A Quick Exercise

List the steps to make a peanut

butter and jelly sandwich using a flow chart

Some Take Aways from PB&J Exercise

Clear communication is important
Process vs systems
Pay attention to details
Be flexible – look at situations in different ways
Don’t make simple things complicated

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Implementation: Plan, Do, Study, Act

Re‐administer the instrument/measure Continuous quality improvement Administer the instrument/measure Meet with staff, residents, families Jointly plan for change Modify efforts (if necessary)

Slide used with permission from Dr. Sheryl Zimmerman

PDSA: Plan

Step 1: Plan Plan the test or observation, including a plan for collecting data.

State the objective of the test.
Make predictions about what will happen and why.
Develop a plan to test the change. (Who? What? When? Where? What data

need to be collected?)

From the Institute for Healthcare Improvement http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx

PDSA: Do

Step 2: Do Try out the test on a small scale.

Carry out the test.
Document problems and unexpected observations.
Begin analysis of the data.

From the Institute for Healthcare Improvement http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx

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PDSA: Study

Step 3: Study Set aside time to analyze the data and study the results.

Complete the analysis of the data.
Compare the data to your predictions.
Summarize and reflect on what was learned.

From the Institute for Healthcare Improvement http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx

PDSA: Act

Step 4: Act Refine the change, based on what was learned from the test.

Determine what modifications should be made.
Prepare a plan for the next test.

From the Institute for Healthcare Improvement http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx

PDSA: An Example

Reducing hospital admissions/readmissions: Stop & Watch

Plan: Ask 1 aide to use the Stop & Watch Tool
Do: Aide uses Stop & Watch Tool with residents
Study: Stop & Watch tool was able to identify issue early for 1 resident and nurse

was able to intervene early

Act: Aide will continue to use the Stop & Watch tool and work with other aides

to implement

From the Institute for Healthcare Improvement http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx

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Let’s Practice PDSA with PB&J

Plan – instructions for PB&J
Do – Made PB&J
Study – what happened?
Act – what could we do differently, let’s make another!

“To Err is Human…

To forgive is divine” – Alexander Pope

“Swiss cheese model”

Sources: Reason, J. (2000). Human error: models and management. British Medical Journal, 320.

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Factors that may Lead to Latent Errors

Institutional/regulatory
Organizational/Management
Team environment
Staffing
Task‐Related
Patient Characteristics

System Changes

Every system is designed to achieve

the results it gets

To improve results focus on systems

not individuals

Person versus Systems Approach

Person Approach

Focus is on person
Naming, blaming, shaming
Improvement approach:

Poster campaigns, writing procedures, disciplinary measures, litigation, Retraining

Systems Approach

Focus is on the

environment/conditions staff work in

Making a fault tolerance in the

system

Improvement approach:

improving the system (teams, environment, conditions, tasks)

Sources: Reason, J. (2000). Human error: models and management. British Medical Journal, 320. and Dennison, Himmelfarb, C. Complexity in Healthcare: A systems Approach Imprves Safety, Johns Hopkins University, 2014

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What Happens in a Punitive Environment?

Errors are still made
Errors are not reported
Can’t learn from errors
Repeat of errors
Turnover

Culture Change

Past (and possibly current) – blame the individual (punitive)
Not focused on how we can learn from errors
Create an environment where employees feel engaged and

empowered to report errors, near misses, and unsafe situations

Everyone is part of the team and everyone’s voice is important

It Takes a Village…

Teamwork training is vital and so is communication
Team Strategies and Tools to Enhance Performance and Patient

Safety (TeamSTEPPS) is evidence‐based system aimed at

ptimizing outcomes by improving communications.
TeamSTEPPS for Long‐Term Care:

http://www.ahrq.gov/professionals/education/curriculum‐ tools/teamstepps/longtermcare/index.html

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Your Next Steps

Make quality improvement part of your culture
Think about systems
Identify key metrics and start collecting data
Utilize what AHCA/NCAL has developed for you
Register for LTC Trend Tracker and start uploading data!
Find your quality champions in each department and utilize them

and finally…..

It doesn’t have to be complicated…

What’s your Trendtrackability Now?

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Poll Everywhere

Key Takeaways

Senior living providers must be able to demonstrate value
Be able to show improved quality and outcomes
Use LTC Trend Tracker to track and trend performance in quality

measures over time

Ability to communicate and collaborate with other providers and/or

managed care plans

Understand the data you are sharing
Be able to tell your story with data

Contact

ltctrendtracker.com help@ltctrendtracker.com

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