Measure Description Numerator - Lake Superior Quality Innovation ...

Improving the Quality Measures: Percent of Residents Who Self-Report Moderate to Severe Pain (Long Stay)

Measure Description This measure captures the percent of long-stay residents who report either: 1. Almost constant or frequent moderate to severe pain in the last 5 days or 2. Any very severe/horrible pain in the last five days

1

Numerator Long-stay residents with a selected target assessment where the target assessment meets either or both of the following two conditions:

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Numerator Condition #1: Resident reports almost constant or frequent moderate to severe pain in the last 5 days Both of the following conditions must be met:

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Numerator 1.1 Almost constant or frequent pain (J0400=1,2) 1 or 2

And and

1.2 At least one episode of moderate to severe pain (JO600A=(05,06,07,08,09) or J600B= (2,3)

05-09

2 or 3

4

Numerator Condition #2: Resident reports very severe/horrible pain of any frequency (JO600A= (10) or JO600B=(4)

10 4

5

Denominator All long-stay nursing home residents with a selected target assessment, except those with exclusions

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Exclusions 1. The target assessment is an admission assessment, or a PPS 5-day assessment (A0310A=(01) or A0310B= (01)

01

01

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Exclusions 2.

The resident is not included in the numerator (the resident did not meet the pain symptom conditions for the numerator) and any of the following conditions are true:

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Exclusions 2.1 The pain assessment interview was not completed (J0200=0, - , ᴧ)

0, - , ᴧ

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Exclusions 2.2 The pain presence item was not completed (J0300= (9, - , ᴧ)

9, - , ᴧ

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Exclusions For residents with pain or hurting at any time in the last 5 days (J0300= (1), any of the following are true: 2.3.1 The pain frequency item was not completed (J0400= (9 , - , ᴧ)

9, - , ᴧ

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Exclusions 2.3.2 Neither of the pain intensity items was completed (J0600A=(99 ,-, ᴧ) and J0600B=(9 ,-,ᴧ)

99, ,ᴧ

9, - , ᴧ

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Exclusions 2.3.3 The numeric pain intensity item indicates no pain (J0600A=(00)

0 0

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How to make improvements 1. Refer to RAI Manual Appendix C: Care Area Assessments/Pain and for each resident who triggers for pain review • The diagnosis/conditions that may cause them pain • The characteristics of their pain • The frequency and intensity of their pain • Their non-verbal indicators of pain

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How to make improvements 1. • • • •

Refer to RAI Manual Appendix C (cont.) The effects of pain on their function Associated signs and symptoms of their pain Other considerations Input from resident and/or family/representative

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How to make improvements 2. Analyze your findings for each resident and document: • A description of the problem; • The causes and contributing factors • The risk factors related to the care area 3. Develop and implement an individualized plan of care based on analysis

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The Change Package: Strategies of High-Performing Nursing Homes Provide exceptional compassionate clinical care that treats the whole person by striving to prevent problems:

Download the Change Package: https://www.lsqin.org/wpcontent/uploads/2015/03/NH-ChangePackage032615-Final-508.pdf

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Resources •

•

MDS 3.0 RAI Manual: https://www.cms.gov/Medicare/Quality-InitiativesPatient-AssessmentInstruments/NursingHomeQualityInits/MDS30RAI Manual.html MDS 3.0 QM User’s Manual: https://www.cms.gov/Medicare/Quality-InitiativesPatient-AssessmentInstruments/NursingHomeQualityInits/NHQIQualit yMeasures.html

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Resources

Principles of Pain Assessment and Management in Older Nursing Home Patients https://youtu.be/VZwkohNDvnA Pain: Assessment & Management https://youtu.be/AJC5L5Z-YI0

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Contact the Lake Superior Quality Innovation Network Michigan: MPRO Kathleen Lavich 248-465-7399 [email protected]

Minnesota: Stratis Health Kristi Wergin 952-853-8561

[email protected]

Wisconsin: MetaStar Liz Dominguez 608-441-8266 [email protected]

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This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-C2-16-22 012716