ALASKA STATE HOSPITAL & Leiza NURSING HOME … · 12/4/2018 · Leiza Johnson, BSN, RN, CDP....
Transcript of ALASKA STATE HOSPITAL & Leiza NURSING HOME … · 12/4/2018 · Leiza Johnson, BSN, RN, CDP....
Leiza Johnson, BSN, RN, CDP
Nursing Home Quality Improvement Specialist
Mountain-Pacific Quality Health
ALASKA STATE HOSPITAL & NURSING HOME ASSOCIATION
CHIEF NURSE EXECUTIVE MEETING
DECEMBER 2018
Serves as the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Alaska
Five offices: Alaska, Hawaii, Montana, Wyoming and Guam
Contracted by the Centers for Medicare & Medicaid Services (CMS) to achieve the triple aim: 1) better care 2) better population health 3) lower costs
We have expert staff who facilitate various quality improvement projects across the state
MOUNTAIN-PACIFIC QUALITY HEALTH
ROLE OF THE QIN-QIO
Drive recognition of quality improvement
Provide technical assistance
Provide tools and resources
Share best practices (learning & action
networks)
Partnering with statewide stakeholders
to align efforts
Enhance quality of health care delivery
STRONGDYNAMIC
DIVERSEEXPERIENCED
THE ALASKA TEAM
Sharon ScudderState Director, Alaska
Leiza JohnsonNursing Home Task Lead
Lori ChikoyakAntimicrobial Stewardship
Miranda BurzinskiQuality Reporting
Preston GrooganQuality Reporting
Kyla NewlandAdverse Drug Events
Coleman CutchinsCare Coodination
Cathy ColwellDiabetes Self-Management
CURRENT INITIATIVES FROM CMS AND MOUNTAIN-PACIFIC STAFF
Quality Reporting(Hospitals & Outpatient –
QPP, MIPS, eCQI)
Improving Coordination of
Care
Improving Antimicrobial Stewardship
Reducing Disparities with
Diabetes
Miranda Burzinski
Coleman Cutchins
Lori Chikoyak
Cathy Colwell
Reducing Adverse Drug Events (ADEs)
Improving Cardiac Health
Improving Adult Immunization
Rates
Improving Long-Term Care
Coleman Cutchins &
Kyla Newland
Kyla Newland
Coleman Cutchins
LeizaJohnson
ALASKA LANDSCAPENURSING HOMES
Establish collaborative of nursing homes to work with the QIN-QIO on quality improvement initiatives In Alaska, this collaborative is called the Alaska Nursing
Homes Together (ANHT) group. CMS established goals for this work: Enrollment target: 35% of all Alaska nursing homes Antipsychotic use reduction target: Reduction in rate (RIR) from baseline targets established of 3%,
9%, 15% and >15% each year (3% RIR by March 2016, etc.) Note: Alaska has failed this measure the past four quarters.
Composite score of <6 target: Rolling targets of 15%, 25%, 45% and 50% of nursing home
partners achieving target by established dates (2016, 2017, 2018)
LEIZA JOHNSONNURSING HOME PROJECT
Represents quality indicators selected to characterize nursing homes’ performance
Includes 13 QMs summed to get overall composite score
Data pulled from nursing home’s Minimum Data Set (MDS) submission
When setting QI targets, CMS recognized best nursing homes had composite score of <6, so this was established as the goal
DEFINING THECOMPOSITE SCORE
SO HOW ARE WE DOING?
PROJECT GOALS:RECRUITMENT
ANHT Collaborative:Exceeded goal!CMS set rolling
targets for recruitment: 6%... 35% of homes to participate with QIN-QIO
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CMS set rolling goals for recruited nursing homes to improve overall composite score 2016 – 15% of homes to have
score of < 6 2017 – 25% of homes to have
composite score of < 6 2018 – 45% of homes to have
composite score of < 6 2019 – 50% of homes to have
composite score of < 6
PROJECT GOALS:COMPOSITE SCORE
Note: At beginning of project, there were only 17 licensed nursing homes in Alaska.
ANHT Collaborative:Exceeded goal!
< 6:11 NHs
> 6:7 NHs
CMS set rolling targets for reduction in rate (RIR):
PROJECT GOALS: ANTIPSYCHOTIC REDUCTION
Goal:
2016 2017 2018 2019
3% 9%(10.02)
15%(9.36)
>15%
Alaska: Baseline = 11.02 11.59 11.34
PROJECT GOALS: ANTIPSYCHOTIC REDUCTION
We are NOT meeting contract goal(s) –Root cause analysis to evaluate failure.
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CMS GOAL ACTUAL
20172018
Stakeholder support –ASHNHA! Long-term care ombudsman, Health Facilities Licensing & Certification (“the State”), Alzheimer’s resource of Alaska, University of Alaska Anchorage, others
Alaska Nursing Homes Together (ANHT) interest/engagement
Collaboration between organizations for common goals/cause
“Small state” mentality – willingness to help
Nursing home community in Alaska – friends and colleagues
REASONS FOR SUCCESS
THANK YOU FOR YOUR TIME!
Developed by Mountain-Pacific Quality Health, the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Montana, Wyoming, Alaska, Hawaii and the U.S. Pacific Territories of Guam and American Samoa and the Commonwealth of the Northern Mariana Islands, 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-MPQHF-AK-C2-18-65