Improving the Vaccination Long Stay Quality Measures 1
Objectives Become familiar with the QM specifications Understand how MDS coding triggers the QM Tips for Improvement 2
Critical Resources: Methodology and scoring for all 3 Domains 3 Identifies how each QM is triggered! Instructs on RAI coding timing and reporting
Definition-Long Stay Long stay - cumulative days in facility (CDIF) is 100 days as of the end of the target period Only days within the facility count towards CDIF 4
Vaccination QMs Flu and Pneumonia Vaccine Quality Measures are used in: 5 Star Preview Reports from CASPER Publicly reported on Nursing Home Compare Nursing Home Quality Care Collaborative Composite Measure Score 5
CASPER 5 STAR Preview Report 6
Facility STATE AVERAGE NATIONAL AVERAGE Percentage of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine. Higher percentages are better. 100.0% 97.0% 94.5% Percentage of long-stay residents assessed and given, appropriately, the pneumococcal vaccine. Higher percentages are better. 99.2% 95.6% 93.4% 7
Influenza Vaccination 8
Influenza Measure Specifications in QM Users Manual 9
MDS Coding of Influenza Vaccine 10
Influenza MDS coding 11 Did resident have Influenza vaccine during the current or most recent influenza season? If answering yes: Resident is counted into numerator data This will not count against you If answering No: What is reason? -Received outside of this facility -Not Eligiblemedical contraindication* -Offered and declined Resident is counted into numerator data This will not count against you If answering No: What is reason? -not offered -inability to obtain influenza vaccine due to a declared shortage -None of the above Resident will NOT count in the numerator bringing down your facility s percent in this QM Exclusions: Resident s age on target date of selected influenza vaccination assessment is 179 days or less This takes resident out of numerator and denominator data
Annual Influenza Checklist Centers for Disease Control and Prevention (CDC) www.cdc.gov Association for Professionals in Infection Control (APIC) www.apic.org 12
Vaccination Tips 1. Once the influenza vaccination has been administered for the current influenza season, this value is carried forward until the new influenza season begins. 2. Assess on admission-document if/when resident had vaccination 3. Resident has the right to decline-make sure to have good documentation of this so it can be captured on the MDS 4. Give as appropriate/don t give if resident has allergy to eggs, the vaccine, or any of the components to the vaccine 5. Recommended annual influenza vaccination from October through March and/or as physician orders Early Fall is optimal vaccination period 13
Pneumococcal Vaccination Measure Specification in QM User s Manual 14
MDS coding of Pneumococcal Vaccine 15
Pneumonia MDS coding Is resident up to date on pneumococcal vaccination? 1. Pneumococcal vaccine is up to date 2. Offered and declined 3. Not eligible -medical contraindication Resident will be counted in the numerator Not offered Resident will NOT be counted in the numerator National goal is 90% immunization among nursing home residents. Examples of medical contraindications include: anaphylactic hypersensitivity to components of the vaccine; bone marrow Transplant within the past 12 months; or receiving a course of chemotherapy within the past two weeks 16
Pneumococcal Vaccination Tips Assess on admission for records of the Pneumococcal Vaccine (PCV13 & PPSV23) Search for records of vaccinations Transferring organizations, PCP, State Immunization systems, resident/family, etc. If status is uncertain-consult with Physician Ok to give Influenza vaccine and Pneumococcal Vaccination at the same time- Give in separate syringes and in separate injection sites Don t give if resident is allergic to any of the vaccine s components. Resident has right to decline-make sure to get documentation so this can be coded on MDS 17
Pneumococcal Vaccinations https://www.cdc. gov/mmwr/previ ew/mmwrhtml/m m6337a4.htm 18
Reviewing Vaccination QMs Why are you not getting 100%? Could there be a coding error Misunderstanding of the Quality Measures Lack of or incomplete vaccination screening 19
Tips for Improvement Assess everyone on Admission/readmission for vaccination records Perform chart audits to ensure there is documentation for vaccinations in EVERY chart Track residents vaccinations Use EMR system Written record in chart Excel Spreadsheets Templates State specific databases 20
Contact Information Kari Caughron, RN Quality Improvement Facilitator 515-267-6227 Kari.caughron@area-d.hcqis.org Lisa Bridwell Senior Quality Improvement Facilitator lisa.bridwell@area-d.hcqis.org 630-928-5831 Nell Griffin Quality Improvement Facilitator nell.griffin@area-d.hcqis.org 630-928-5813 21 This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QIN-02/23/17-02/23/17-11968