Improving the Quality Measures: Percent of Residents Who Lose Too Much Weight (Long Stay)
Measure Description This measure captures the percentage of long-stay residents who had a weight loss of 5% or more in the last month or 10% or more in the last two quarters who were not on a physician prescribed weight-loss regimen noted in an MDS assessment during the selected quarter.
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Numerator Long-stay nursing home residents with a selected target assessment which indicates a weight loss of 5% or more in the last month or 10% or more in the last 6 months who were not on a physician prescribed weight-loss regimen (K0300 = [2]).
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Denominator Long-stay nursing home residents with a selected target assessment except those with exclusions.
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Exclusions 1. Target assessment is an OBRA admission assessment (A0310A = [01]) or a PPS 5-day assessment (A0310B = [01]).
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Exclusions 2. Weight loss item is missing on target assessment (K0300 = [-]).
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How to Make Improvements 1. Refer to RAI Manual Appendix C: Nutritional Status and for residents who trigger evaluate: • Current eating pattern • Functional problems that affect their ability to eat • Cognitive, mental status, and behavioral concerns that can interfere with eating • Communication problems • Dental/oral problems
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How to Make Improvements • • • • •
Other diseases and conditions that can affect appetite or nutritional needs Abnormal laboratory values Medications Environmental factors Input from the 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/wp-content/uploads/2015/03/NHChangePackage-032615-Final-508.pdf
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Resources •
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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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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-C2-16-12 011916
