Nursing homes looking to best utilize QAPI, or the quality assurance and performance improvement program, should think beyond the obvious clinical compliance and care benefits to residents.
QAPI is usually seen as a way to reduce falls or tighten up medication management, but operators can do a lot more with the data besides using it for clinical compliance. In fact, QAPI is helping operators turnaround recently acquired properties, launch new business lines successfully, and even help with reimbursement.
Take for example iCare’s case. Through QAPI, the organization developed an improvement plan for its case mix index (CMI) scores, mostly since the state in which iCare operates is fairly new to CMI. However, The performance improvement program ended up being about so much more than CMI, said Donna Farr, president of Touchpoints Therapy and vice president of quality assurance and performance improvement at Connecticut-based iCare Health Network.
“What was interesting is, we started it and we improved our CMI scores, which is what was intended. We then got hit with some audits and it shifted our whole focus again, and that’s when the true QAPI started,” said Farr.
The team began identifying areas in which they were lacking, in turn affecting reimbursement and quality of care at iCare’s buildings.
This was no small task, with about 50% of its residents being under the age of 65, she said.
“The whole QAPI evolved and is continuing to evolve and change. But the benefit of it is we have seen much better assessment of our patients, better documentation, all that has led to better quality of care for our residents,” added Farr. “We’re seeing better outcomes, better reimbursement.”
Farr spoke about QAPI at Skilled Nursing News’ RETHINK conference in Chicago, along with Leslie Zimmerman-Black, regional director of clinical services, management division for Mission Health Communities and Katie Hughes, regional nurse consultant for Allure Healthcare Services.
QAPI and acquisition turnarounds, other successes
And besides improving reimbursement, QAPI data has assisted in making sure recently acquired facilities not only to get up to par with standards, but attain operational efficiencies.
At Allure, two recent acquisitions were proving challenging from a staffing and financial perspective – the buildings were so overstaffed that the certified nursing aide (CNA) to patient ratio was one to six, posing complications for leadership, said Hughes.
“The buildings were not profitable. The buildings were so overstaffed that there was absolutely no way that you were going to unburden yourself unless you started peeling back layers,” said Hughes. “When you take on an acquisition, you’ve got to start peeling back the layers on how you can ensure that quality of care exists; make the staff agreeable and have them buy into the new way that things are going to be run without a picket or people quitting.”
In this instance there were no layoffs, and staff were reallocated. Staff were finally feeling more comfortable with their changed shifts, and CNA staff to patient ratios were brought to one to nine, and finally one to 11.
Considering the adjustment to have more patients per CNA, there was a brief period when falls began to rise, Hughes said.
“As you can imagine, the falls started happening,” she said. “During our weekly risk meeting, we would be reviewing between seven and 11 falls. You know that you’re doing a root cause analysis in the charts, and you know that it is not within the chart where you’re going to find your answer.”
Allure started adding the building scheduler and a few other ancillary members to figure out adequate staffing and brainstorm about how to reduce falls as part of the QAPI meeting. Once that input was added, the building was able to go 16 days without a fall, coming from 14 to15 falls per week.
Meanwhile, Mission Health’s QAPI success story has to do with a behavioral health facility they started working with, and when clinical teams came in, the amount of reportable incidents between residents and between residents and staff was nonstop and very overwhelming, said Zimmerman-Black.
“We just couldn’t keep up with it. So what we did was, every day the administrator, [Director of Nursing], a group of us started getting together to try to figure out what in the world is going on here,” she said of Mission Health’s QAPI.
Medication management ended up being a core issue, along with Medicaid reimbursement issues, staff training and having a lot of agency staff at the time. Structured activities helped too. In some cases residents simply had to be transitioned out of the building that were causing too much hostility among residents and staff at Mission Health.
“We explored what kind of activities, what kind of structure can we offer these people, to keep them occupied, and then tracking and trending the issues. What are the hot button issues that are happening? Why are these people getting into fights? That took some time, and we were able to really make a turnaround in that building,” said Zimmerman-Black.
Better data collection, analysis
CMS has stated that nursing homes need to have a data collection and monitoring system as it relates to QAPI.
Nursing home clinical staff might be looking at data from months ago, or data that has been filtered in some way and so is not helpful in root cause analysis, said Zimmerman-Black. Partnering with companies that can parse real time data is crucial if a QAPI requires a quick turnaround for an event involving wound care really pinpoints what can be changed.
Farr said simply having data sorted with some sort of technology service, so it’s useful data, is invaluable.
“A facility was having difficulty [with rehospitalizations], and it took too long to get the data we wanted,” said Farr. “The data we finally did extract pinpointed when the hospitalizations were happening – what shift, which nurse, we got right down to the APRN, the nurse, the doctor, the time, the date. Once we had that data, it was a much easier fix.”
Hughes added that data collection partnerships with hospital systems can boost collaboration and in turn quality outcomes.
“We do calls every Friday with a lot of our major hospital systems so that we can show what we’ve done on our side to be preventative, and they can show on their side,” Hughes said. “Sometimes we’re at a stalemate where we both think we did everything right, or we both know we did everything wrong, but opening up that communication line, I think, really helps.”
Companies featured in this article:
Allure Healthcare Services, Centers for Medicare & Medicaid Services, CMS, iCare Health Network, Mission Health Communities