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CMS Policy Updates and Priorities

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  • Alice Bonner
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  • Author Footnotes
    1 Alice Bonner, PhD, RN, GNP, is director of the Centers for Medicare & Medicaid Services Division of Nursing Homes. Kathleen M. Wilson, PhD, is the former deputy director of the Division of Nursing Homes and currently is an associate executive director of the American Urological Association.
    Kathleen M. Wilson
    Footnotes
    1 Alice Bonner, PhD, RN, GNP, is director of the Centers for Medicare & Medicaid Services Division of Nursing Homes. Kathleen M. Wilson, PhD, is the former deputy director of the Division of Nursing Homes and currently is an associate executive director of the American Urological Association.
    Search for articles by this author
  • Author Footnotes
    1 Alice Bonner, PhD, RN, GNP, is director of the Centers for Medicare & Medicaid Services Division of Nursing Homes. Kathleen M. Wilson, PhD, is the former deputy director of the Division of Nursing Homes and currently is an associate executive director of the American Urological Association.
      Over the past 2 years, the Centers for Medicare & Medicaid Services has engaged in a partnership with stakeholder groups including AMDA. This enables us to hear from frontline clinicians and providers, consumers and their families, and it informs policy decisions that affect the lives of people living in nursing homes.
      Below is a brief overview of some of CMS's current, high-priority initiatives.

      QAPI

      This fall, CMS will be launching a national Quality Assurance and Performance Improvement (QAPI) initiative by releasing several tools and resources on the website http://go.cms.gov/Nhqapi. The tools are designed to help nursing homes prepare to meet Affordable Care Act requirements. Section 6102(c) of that law directs CMS to establish standards and provide technical assistance to nursing homes on the development of best practices relating to QAPI.
      Among these tools is QAPI at a Glance, a step-by-step guide to understanding and implementing QAPI in the nursing home environment. Over the next year, CMS will also make other tools available to nursing homes for implementing and refining their QAPI program.
      The tools and resources will help medical directors lead and manage quality improvement in several ways, according to CMS nurse consultant Debra Lyons, RN. In particular, the tools will guide medical directors in:
      • Creating a culture that encourages active involvement in QAPI by all care providers, especially those directly involved in delivery of care.
      • Improving the collection, analysis, and interpretation of data.
      • Creating a structured systems approach to identifying opportunities for continuous performance improvement and accountability toward achieving this goal.
      • Placing emphasis on balancing resident choice and protecting residents from harm.
      Beginning in the fall of 2013, CMS will launch the next phase of QAPI by releasing more tools and resources, including training materials that can be used to educate providers and build effective teams around QAPI.

      Hand in Hand

      The Hand in Hand training series will be disseminated to all nursing homes in the nation by sometime next month. The training materials, mandated by the Affordable Care Act, ensure that direct caregivers, such as nursing assistants, receive regular training on caring for residents with dementia and on preventing abuse. The training series is one option that emphasizes person-centered care for people with dementia and the prevention of abuse. The Hand in Hand training materials consist of an orientation guide and six 1-hour, video-based modules, each of which has a DVD and an accompanying instructor's guide.
      Although Hand in Hand targets nursing assistants, it has real value for anyone who cares for this population, including administrative and medical staff members. For this training to be most effective, it is important to use a facility-wide approach to educate and create an environment of individualized care.
      Person-centered care refers to individualized care that is focused on optimizing function and quality of life within the context of a person's wishes and goals. It is one requirement in the Nursing Home Reform Law that aims to attain or maintain the “highest practicable physical, functional, and psychosocial outcomes” by considering each resident's individual preferences, needs, strengths, and lifestyle. Person-centered care is at the heart of Hand in Hand training.
      While current nursing home regulations require annual training for nursing assistants on dementia care and abuse prevention, nursing homes are not required to use Hand in Hand specifically. Facilities may select either Hand in Hand or other available training tools and resources.

      New Interpretive Guidelines

      CMS has also continued to update the “State Operations Manual, Appendix PP: Interpretive Guidelines for Long Term Care.” The changes are based on advances in knowledge and practice in the fields of palliative and end-of-life care, oral feeding, and medication management. F tag 155 rights regarding advance directives, treatment options, and experimental research and F tag 309 rights to quality of life at the end of life have been expanded. F tag 322 on nasogastric tubes and F tag 321 on feeding tubes have been combined under F tag 322. When these tags were originally written, most oral feeding was through nasogastric tubes, but newer types of feeding tubes and alternative feeding methods have evolved.
      Upcoming revisions to guidance on F tag 329 on unnecessary medications and F tag 309 on quality of care will address dementia care. The unnecessary medications guidance, last updated in 2006, expands on the existing section to address appropriate use of antipsychotic medications in nursing home residents. F tag 309 pulls together the requirements from many other tags to address care for residents with dementia. As part of the guidance, CMS will include a surveyor worksheet on dementia care that facilitates implementation of the investigative protocol. Surveyor training is also being developed with an anticipated rollout before the end of 2012.
      The interpretive guidelines are part of the agency's Partnership to Improve Dementia Care, which has set a national goal of reducing antipsychotic medication use among long-stay nursing home residents by 15% by the end of 2012. CMS, professional associations, quality-improvement organizations, ombudsman, advocacy organizations, and others are taking steps to achieve this goal of improved care. Coalitions of those and other organizations have formed in most states and are coming together to support this vital work. AMDA state chapters have played a critical role in the development and implementation of several state coalitions and continue to provide input, education, and outreach as part of that state-level work.
      For a list of websites and contacts for these CMS programs, see this column online at www.caringfortheages.com, under “Views” and “Public Policy.”
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