CMS Releases Report on Focused Dementia Care Survey Pilot
The Centers for Medicare & Medicaid Services (CMS) has published findings from the Focused Dementia Care Survey Pilot. Included in this S&C memo, CMS has outlined how it will expand the focused dementia survey process across the nation, inviting States to conduct such surveys in FY2015 on a voluntary basis. The expansion will involve a more intensive, targeted effort to improve surveyor effectiveness in citing poor dementia care and the overutilization of antipsychotic medications, and broaden the opportunities for quality improvement among providers
A little background on where this all began. In 2012, CMS launched the National Partnership to Improve Dementia Care which includes stakeholders from regulatory entities, providers, advocacy groups and professional organizations. The primary goal of this partnership is a commitment to finding ways to implement practices which will enhance quality of life for residents while promoting goal directed, person centered care for each individual. There are numerous components related to this partnership. One component is to expand the approach of non-pharmacological care and reduce antipsychotic medication use in long-stay nursing home residents. According to the CMS, “By late CY 2014, nursing homes in the U.S. had achieved a 19.4 percent reduction in antipsychotic drug use.” The new goal is to achieve a 30 percent reduction in the use of antipsychotic medications nationally, by the end of 2016. An additional component is the MDS and Dementia Care focused survey processes. These processes focus on a review of a facility’s dementia care processes, both at a resident level and organization level.
As we know, in February 2015 CMS added two quality measures of antipsychotic use – affecting provider quality measure score and their individual 5 Star Rating. These measures coupled with our organizations outcome data will continue to be reviewed during the offsite and onsite tasks for our annual, complaint and revisit survey processes. It is time for us as leaders to assess their readiness for the expansion of the Focused Dementia Care and MDS Survey process as well as alignment with the components of the National Partnership to Improve Dementia Care.
To read more about the expansion of the Dementia focused survey process read, “Final Report: Centers for Medicare & Medicaid Services (CMS) Focused Dementia Care Survey Pilot 2014.”
Prepare. Plan. Implement.
1. Assess your organization’s readiness
– Review your organization’s current practices and compare to industry initiatives, best practices and standards for dementia care. This should also include your organization’s employee orientation process, care delivery processes!
2. Review current data
– Specifically review admission, readmission as well as antipsychotic utilization! Compare your data to industry benchmarks for performance improvement needs.
3. Redesign your internal and external education plans
– Include targeted staff, family, stakeholder training related to: the new consumer; your organization’s dementia care culture; roles and responsibilities of your team members; non pharmacological approaches; and more!
4. Conduct targeted root cause analysis for performance gaps
– Include findings and action steps into your QAPI program to monitor outcomes and celebrate success
Resources:
- Centers for Medicare and Medicaid Services. “Final Report: Centers for Medicare & Medicaid Services (CMS) Focused Dementia Care Survey Pilot 2014.” March 27, 2015.
- Centers for Medicare and Medicaid Services. ” National Partnership to Improve Dementia Care in Nursing Homes.“