Prepare to Report: HBIPS Measures for IPF QRP

Prepare to Report: HBIPS CoreMeasures9:00 – 10:00 a.m.Alyssa KeefeVice President, Federal Regulatory AffairsCalifornia Hospital AssociationElizabeth Stallings, RN, BSNChief Operating OfficerJohn Muir Behavioral Health CenterPrepare to Report: HBIPSMeasures for IPF QRPAlyssa Keefe, VP, Federal Regulatory Affairs, CHAElizabeth Stallings, COO, John Muir BehavioralHealth CenterCHA’s 7 th Annual Behavioral Health Care SymposiumDecember 4, 20121

Presentation Objectives• To review the CMS Requirements for InpatientPsychiatric Facility Quality Reporting Program (IPF QRP)• To review The Joint Commission (TJC) and CMS CoreMeasure definitions and implementation process• To identify challenges and learning from ongoing processchange and outcome tracking• To review criteria and operational plan for implementationof CMS measures (effective October 1, 2012)• To identify immediate next steps for hospitals• Discussion — Q and AStatutory AuthoritySection 3401 ofthe ACA requiresHHS Secretaryimplement aquality reportingprogram for IPFsfor FFY 2014• Reduce Annual PaymentUpdate (APU) by 2.0percentage points for nonreporters• Measures endorsed byconsensus based entity5Program ImplementationTimeline• 2010 — CMS established Technical Expert Panel (TEP) to reviewIPF measures• December 2011 — HHS releases measures for input prior torulemaking• April 2012 — CMS issued the FY 2012 IPPS/LTCH proposed ruleestablishing the parameters of the IPF QRP• Inpatient Psychiatric Facility Prospective Payment System(IPF PPS) — Rate Update Notice Only• August 2012 — CMS issued the final rule, making minormodifications, codifying the program in regulation Federal Register, Vol. 77 No. 170, pages 52644-53660 www.calhospital.org/regulatorytracker62

Who Must Report?• All freestanding inpatient psychiatric facilities paid under theMedicare Inpatient Psychiatric Facility Prospective PaymentSystem (IPF PPS)• All distinct part psych units paid under the IPF PPS Some units bill patients under IPPS only, best to check withyour billing department regarding billing for Medicare FFSpatients• Who Is Currently Reporting?As of October, 487 hospitals currently reporting nationwide408 of 487 are free standing79 of 487 are acute care hospitals with psyche units7Six Quality Measures Requiredfor FFY 2014 and 2015• HBIPS-2: Hours of Physical Restraint Use (NQF #0640)• HBIPS-3: Hours of Seclusion Use (NQF #0641)• HBIPS-4: Patients discharged on multiple antipsychoticmedications (NQF #0552)• HBIPS-5: Patients discharged on multiple antipsychoticmedications with justification (NQF #0560)• HBIPS-6: Patients for whom a post discharge care planwas created (NQF #0577)• HBIPS-7: Patients for whom care plan was transmitted tonext care provider (NQF #0558)8HBIPS National and CaliforniaDataMeasureNationwideAverageNationTop 10%CaliforniaAverageCaliforniaTop 10%Hours of Physical Restraint Use per 1000Patient Hours Overall Rate 0.394743 0.002179 0.426988 0.020922Hours of Seclusion Use Overall Rate 0.330995 0 0.489787 0Patients Discharged on MultipleAntipsychotic Medications Overall Rate 0.113252 0.021176 0.085501 0.038316Source: www.qualitycheck.org, Data reported from April 2011-March 2012 and updated November 2012.N= 3193

HBIPS National and CaliforniaDataMeasureNationwideAverageNationTop10%CaliforniaAverageCaliforniaTop 10%Multiple Antipsychotic Medicationsat Discharge Overall Rate 0.414431 0.941176 0.36413 0.836765Post Discharge Continuing CarePlan Created Overall Rate 0.926125 1 0.906662 1Post Discharge Continuing CarePlan Transmitted Overall Rate 0.846881 0.997797 0.794487 0.996988Source: www.qualitycheck.org, Data reported from April 2011-March 2012 and updated November 2012.N= 311011CMS Reporting Requirements• Data collection required for all patients, not justMedicare patients• Sampling instructions part of measurespecifications• Patient level data not required for CMSsubmission — aggregate data only• If no patients for a measure, must still reportZERO to CMS• No CMS conducted data validation at this time124

Important Dates to RememberPaymentDetermination(FY)Reporting Period forServices Provided(CY)Data SubmissionTimeframePublic Display(CY)FY 2014(6 months)October 1, 2012 –March 31, 2013July 1, 2013 –August 15, 20142014FY 2015(9 months)April 1, 2013 –December 31, 2013July 1, 2014 –August 15, 20142015FY 2016(12 Months)January 1, 2014 –December 31, 2014July 1, 2015 –August 15, 20152016• Attestation required by August 15 of each reporting year• Hospital data review and preview period is scheduled forSeptember 20 – October 19 for each reporting year13Learn More• www.jointcommission.org• Measure specification manual• www.qualitynet.org• Tools to assist in reporting — forthcoming• Web based tool to submit data — forthcoming• CMS Contractor — Telligen• IPFQR Support Help Desk (6 am – 3 pm PT)Phone: (888) 961-6425E-mail: IPF-PCHQRSupport@telligen.org 14Behavioral Health Core Measures forTJC and CMS ReportingElizabeth Stallings, RNChief Operating OfficerDecember 4, 20125

John Muir Health Background• John Muir Behavioral Health Center (JMBHC) is a freestanding73 bed inpatient psychiatric facility treatingadults, adolescents, and children for the full range ofpsychiatric and chemical dependency diagnoses• JMBHC provides the full continuum of care providingservices to about 150 patients daily• JMBHC piloted TJC measures in 2007 and hascontinually monitored the Hospital Based InpatientPsychiatric Measures for 5 years• JMBHC began implementation of the CMS measures inOctober of this year16Structure + Process = OutcomeJohn Muir Health TimelineStructure• Gap analysis to compare standards to current practice• Vendor selection for data collection• Resources, staffing, chart abstractor with knowledge of data elementsProcess• Implementation of Core Measures in all acute behavioral units in 2007• Content Expert and in chart abstractor to assure accuracy, generate audit reports,provide feedback and teaching for OFIs (Hired November 2012)• Aligned Core Measures compliance to evaluation goals and medical staff indicatorsOutcome• Monitored each measure for continuous improvement• October 1, 2012 implemented CMS measures tracking17Approved Measures TJC and CMSSetMeasureID #ApplicableToMeasure NameHBIPS - 1 TJC Only Admission screening for violence risk, substance use,psychological trauma history and patient strengths completedHBIPS - 2 TJC & CMS Hours of physical restraint useHBIPS - 3 TJC & CMS Hours of seclusion useHBIPS - 4 TJC & CMS Patients discharged on multiple antipsychotic medicationsHBIPS - 5 TJC & CMS Patients discharged on multiple antipsychotic medications withappropriate justificationHBIPS - 6 TJC & CMS Post discharge continuing care plan createdHBIPS - 7 TJC & CMS Post discharge continuing care plan transmitted to next level ofcare provider upon discharge186

HBIPS 1 — Risk Assessment(not a current CMS measure)1. Patient Strengths — must include a minimum of twostrengths2. Psychological Trauma History3. Screening for substance use within the past 12months — must list use of drugs or alcohol within thepast 12 months4. Risk for Violence to Self or Others — screening mustinclude the past 6 months19HBIPS 2 — Restraints• The total number of hours that hospital based inpatientswere held in physical restraint (personal and mechanical)• Measure start and stop times for ALL restraint events• Joint Commission’s Ratio Measure:o # of minutes of event converted to hours/# of patientdays X 24 hours X 1000 hours = ratio per 1000 hours• CMS Ratio Measure: CMS to measure in hours20HBIPS 3 — Seclusion• The total number of hours that all hospital basedinpatients were held in locked seclusion• Measure start and stop times for locked seclusion events• Ratio Measure:o # of minutes of event converted to hours/# of patientdays X 24 hours X 1000 hours = ratio per 1000 hours217

John Muir Behavioral Health Center2740 Grant Street, Concord, CA 94520Seclusion & Restraint OrderSeclusion / Restraint OrderType of Restraint Seclusion Notify Parent/Guardian of all minors for Physical HoldSeclusion/Restraint 4 Pont Velcro Restraint Name of Parent/Guardian: Prone Position (pt’s in prone position requires _________________________an order)Date & Time: Other (describe):_________________________ Minor is Ward of the Court Adult patient requesting family notification (patient mustrequest this in writing).Reason for Seclusion or RestraintTime Initiated: ____________________ Time Discontinued: ____________________ Danger to self Danger to others:Behavior(s) Observed Requiring Seclusion or RestraintDescribe:Time Limit Duration Age (8 years old and under – 1 hour) Age (9 – 17 years old – 2 hours) Age (18 years old and older – 4 hours)22Seclusion & Restraint Order — ContinuedCriteria to Discontinue Seclusion or Restraint Verbally contracts for safety to self /others. No longer demonstrates risk for danger to self and others. Responds to redirection Responds to alternatives Other (describe):Less Restrictive Alternatives Tried Before Seclusion / Restraint Self time out Offered diversionary or physical activities Verbal reminders / de-escalation / limit setting Psychosocial interventions Medications offered Reality orientation / Oriented to surroundings Provided companionship / supervision (1:1) Environment modified Assisted with: Food, Fluid, Pain,Comfort, Toileting needs Other (describe):Seclusion / Restraint Check List Treatment plan complete Treatment planning meeting complete for greater than 2 episodes of S/R in 24 hours Patient debriefing complete. Nurse Manager notified of S/R episode greater than 2 in 24 hours.Name of Doctor RN Signature Date: Time:Physician Signature: Date: Time:Seclusion & Restraint OrdersPatient Identification23Seclusion & Restraint Renewal OrderSeclusion / Restraint Renewal OrderChild Unit – Age 8 and under, requires renewal after 1 hour.Reason for continued Seclusion or Restraint: Danger to self: __________________________________________________________________________________ Danger to other: _________________________________________________________________________________ Other: _________________________________________________________________________________________ Seclusion lasting 4 hours requires MD / NP evaluation. Restraint lasting 4 hours requires MD / NP evaluation.MD/NP contacted: _________________________________ Date: _______________ Time: _______________MD order for seclusion / restraint: _______________________ Date: _______________ Time: _______________Adolescent Unit – Age 9-17 years of age, requires renewal after 2 hours.Reason for continued Seclusion or Restraint: Danger to self: __________________________________________________________________________________ Danger to other: _________________________________________________________________________________ Other: _________________________________________________________________________________________ Seclusion lasting 4 hours requires MD / NP evaluation. Restraint lasting 4 hours requires MD / NP evaluation.MD/NP contacted: _________________________________ Date: _______________ Time: _______________MD order for seclusion / restraint: _______________________ Date: _______________ Time: _______________Adult Unit – Age 18 years and older, requires renewal after 4 hours.Reason for continued Seclusion or Restraint: Danger to self: __________________________________________________________________________________ Danger to other: _________________________________________________________________________________ Other: _________________________________________________________________________________________ Seclusion lasting 8 hours requires MD / NP evaluation. Restraint lasting 8 hours requires MD / NP evaluation.MD/NP contacted: _________________________________ Date: _______________ Time: _______________MD order for seclusion / restraint: _______________________ Date: _______________ Time: _______________John Muir Behavioral Health Center Seclusion & RestraintPatient Identification2740 Grant Street, Concord, CA 94520 Renewal Orders248

HBIPS 4 — Number of Patients Dischargedon 2+ Antipsychotics• Patients discharged on two or more antipsychoticmedications• Rationale: Antipsychotic polypharmacy can lead togreater side effects, often without improving clinicaloutcomes• Measured in rate• Paired with HBIPS 5 for justification for use25HBIPS 5 — Appropriate Justification forMultiple Antipsychotics• For patients discharged on 2 or more antipsychotics,there must be one of the following 3 justifications listed:1. Three or more failed trials of monotherapy(Medications in failed trials must be listed)2. Plan to taper to monotherapy or cross-taper inprogress (Medications must be listed.)3. Augmentation of Clozapine (List what medicationwill augment Clozapine)26Challenges and SolutionsChallenges• M.D. practice• Documentation clarity for complianceSolutions:• Rationale as to research for the measure• Updated physician orders for specificity of this measurewith lines for medication list• Blinded monthly reports for compliance included inOPPE data279

2829HBIPS 6 — Complete Continuing CarePacket Created• Must include:1. Discharge diagnosis2. Reason for hospitalization3. Recommendation for the next level of care4. List of patient’s medications, including dosage andrationale for each medication• Measured in rate with all elements documented3010

Challenges and SolutionsChallenges• Indication for each medication on discharge instructionlist, including OTC, supplements, etc.• If any elements fall out of HBIPS 6, HBIPS 7automatically falls outSolutions• Developed discharge order template with the physicianspecific elements• Revised medication reconciliation process and forms31323311

HBIPS 7 — Complete Continuing CarePacket Transmission to Next Level of Care• Measure Definition: Post discharge continuing care plantransmitted to next level of care provider upon dischargeo Must have all elements listed in HBIPS 6o Must be sent to the medication provider (if patient ison no medications, may be therapist)o Must be sent within 5 days of discharge (we do upondischarge so we don’t lose track)34OutcomesReport Generation• Graphs• Control Charts• Scorecards• Targets — internally and externally• Annual Performance Improvement Plan353612

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SummaryResources• Content expert for chart abstraction with validity andreliability• Vendor selection with system interface and education fordata entry40Immediate Next Steps forHospitals and Units Determine if you have to report as part of the IPF QRP Register on Quality Net (www.QualityNet.org)Choose a QNet administrator — main point of contactComplete a Notice of Participation Investigate ORYX vendorsDoes your current vendor support HBIPS? Evaluate CMS provided tools and determine what willwork best for your organization Review measure specifications in detail Mark the calendar with reporting deadlines Listen, learn, ask questions 41What’s Next?• CMS TEP to discuss additional measures forfuture years• CMS National Provider Call Scheduled forDecember 6 at Noon PT, Register Online• IPF PPS Proposed and Final Rules will likelylay out future program changes• Proposed Rule — April• Final Rule — August4214

Contact InformationElizabeth Stallings, COOPhone: (925) 674-4101Email: liz.stallings@johnmuirhealth.comAlyssa Keefe, Vice PresidentPhone: 202-488-4688Email: akeefe@calhospital.orgThank YouAlyssa Keefe(202) 488-4688akeefe@calhospital.orgElizabeth Stallings, RN, BSN(925) 674-4102liz.stallings@johnmuirhealth.com15