Guest Columns

Be thankful ... for QAPI details?!

Steven Littlehale
Steven Littlehale

It's the time of year when we reflect and give thanks. With all the rapid changes in post-acute care, providers can be thankful for the Quality Assurance and Performance Improvement regulations detailed in the Reform of Requirements for Long-Term Care Facilities: Proposed Rule.

 Thankful? Yes, thankful! We have been waiting five years since the passing of the Affordable Care Act of 2010 for the QAPI compliance details. Providers have been relying on the Centers for Medicare & Medicaid Services' draft guide QAPI at a Glance to learn about QAPI: The five elements providing overall structure to the program supported by 12 action steps. It's like saying you need to bring pumpkin pie to dinner, but you don't know how many you're feeding or if you need gluten-free crust! Without all the details, you can't be sure which action steps to take.

In the details of the proposed rule for participation, we see some requirements that were expected — and some surprises. It's not surprising that quality programs would have increased emphasis on rehospitalization and infection control. These can be disastrous for the person and are costly outcomes that are better off avoided.  A surprise was the requirement to present QAPI plans to the state agency surveyor on the first annual recertification survey after the effective date of the regulation.

Additional financial and human resources are expected whenever major regulatory changes unfold, and the QAPI requirements are no exception. CMS estimates QAPI implementation as the third-costliest program in the rule, estimating each SNF will spend $7,500 the first year and $3,000 in Year 2 and beyond. Considering the much higher estimated costs for other proposed changes, the QAPI regulations might stick.

So what's all the fuss really about? Post-acute providers have been quality-improvement focused for years. In 2003, the Office of the Inspector General reported that between 1997 and 2001, 99% of SNFs held QA&A meetings at the required frequency and with mandated attendees. The change comes with the now-regulated review of data to prioritize problems and opportunities and take data-driven action. The essential task at hand is to raise your competence in the interpretation and use of data. Thankfully, those investment dollars are well spent! Improve your outcomes by following QAPI and other successes will fall into place. (Think preferred networks, choice referrals, etc.)

You'll discover that in order to achieve compliance, you'll utilize basic descriptive statistics like mean, median, and mode and give careful consideration to your comparative benchmark. Take rehospitalization as an example, starting with your adjusted rate: Are you better or worse than your peers? Who are your peers; are you looking at your performance within your local market or comparing yourself to the nation?

Once you establish your benchmark group, a comparison to its median will reveal if you have a competitive advantage or a PIP! Once you know that, set goals to move from where you are today to the top quartile of performance. Top performers in fiscal 2019 will see in their Medicare rates a return of the withheld funds under PAMA; make it your QAPI goal to be a top performer!

CMS is still digesting the 8,000-plus comments received on the proposed rule and once the final regulation has been published, nursing homes will have one year to develop and implement their QAPI plan. 

As you think about what you are most thankful for, be thankful that QAPI standards align with value- based payment systems and use this process to rise above the median and distinguish yourself as a top-performer in post-acute care! Believe me, you'll be thankful you did.

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.

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