In the long term care profession, understanding the differences between Quality Measure (QM) exclusions outlined by the Centers for Medicare & Medicaid Services (CMS) and clinical standards of practice can be challenging.
For example, a nurse assessment coordinator (NAC) states, “CMS only allows two diagnoses for an indwelling catheter: uropathy and neurogenic bladder.” Although the NAC has identified the two diagnoses that can exclude a resident from the QM for indwelling catheter, he or she fails to recognize the other appropriate clinical indications for use.
The ability to distinguish between these two components is essential for ensuring proper care delivery and careful reporting in nursing home facilities. This article highlights the key distinctions between QM exclusions and clinical standards of practice and how putting the resident at the center of the care decisions can guide the NAC in the right direction.
Quality Measure Exclusions
When discussing QM exclusions, CMS does not mandate specific indications for medical interventions, such as the use of indwelling catheters. Instead, CMS identifies certain diagnoses or conditions that are beyond the control of the facility and, therefore, should not count against the facility for quality measurement. For instance, CMS outlines several QM exclusion criteria related to the long-stay indwelling catheter measure, including admission assessments or the 5-day assessment, missing catheter status, and specific diagnoses, such as neurogenic bladder and obstructive uropathy.
Here's another example: The long-stay QM for residents receiving an antipsychotic medication excludes residents who have missing data for antipsychotic medication use or a diagnosis of schizophrenia, Tourette’s syndrome, or Huntington’s disease from triggering this measure.
However, facility teams must recognize that CMS does not limit the facility to using these exclusionary diagnoses as the only appropriate diagnosis for the clinical condition. Teams must work with the primary physician to identify the clinical indication for each resident, regardless of the impact on the QMs.
Clinical Standards of Practice and Clinical Indications
Contrary to QM exclusions, clinical standards of practice offer guidelines for appropriate indications and the use of medical interventions like indwelling catheters in long term care settings. These standards aim to optimize resident care while minimizing risks and complications.
The Centers for Disease Control and Prevention’s (CDC) Guideline for Prevention of Catheter-Associated Urinary Tract Infections lists clinical guidelines for appropriate catheter use.1 Examples of correct indications for indwelling urethral catheter use according to this guideline are acute urinary retention, perioperative needs, wound healing assistance, prolonged immobilization, and end-of-life comfort care. Conversely, inappropriate uses of catheters are substituting them for nursing care, unnecessary urine collection, or prolonged postoperative usage without suitable indications.
Regarding clinical indications for antipsychotic medications, many conditions, in addition to those that exclude the resident from the antipsychotic QM, may still warrant a physician to prescribe an antipsychotic medication. One guideline for this decision comes from a StatPearls article2 that identifies several additional indications for antipsychotic medication use: acute mania, major depressive disorder with psychotic features, delusional disorder, severe agitation, borderline personality disorder, dementia and delirium, substance-induced psychotic disorder, Parkinson’s disease, Lesch-Nyhan syndrome, and pervasive developmental disorder.
Focusing on Resident Well-Being and Investigating QM Triggers for Accurate Reporting and Interventions
Although nursing home facilities must strive for continuous quality improvement, resident-centered care must be prioritized. By focusing on resident well-being and addressing the underlying causes of QM triggers, facilities can achieve more precise Minimum Data Set (MDS) assessments, care plans, and QM reporting.
To ensure the well-being of the resident, the team must identify current and active diagnoses correctly. In some instances, the medical record does not provide the details to support coding the specific diagnosis or the use of a medical device. Facility teams should query the physician to ensure the diagnoses represent the resident’s conditions accurately.
Consider a resident with prostate cancer who has an indwelling catheter for urine output due to his enlarged prostate that is likely causing obstructive uropathy. But the resident does not have this diagnosis in the medical record. Querying the physician in this situation will improve the accuracy of the medical record, support the use of the medical device, ensure an appropriate care plan, and lead to better QM reporting by appropriately excluding the resident.
CMS acknowledges that facilities have residents who trigger for different measures, and based on the resident population, they may do better in some measures than others. CMS does not expect facilities to prevent all residents from triggering any of the measures because clinical conditions require interventions like an indwelling catheter or antipsychotic medication administration. Therefore, the care team should focus on ensuring the appropriateness and the need for such interventions in individual resident care plans.
Unfortunately, some facility staff may feel pressured to seek out a diagnosis from the provider, even if the medical record does not support the diagnosis, just to improve QM outcomes. This type of practice prompted CMS to initiate the schizophrenia coding audits in January 2023. The QSO-23-05-NH memo stated,
CMS is concerned that some nursing homes have erroneously coded residents as having schizophrenia, which can mask the facilities’ true rate of antipsychotic medication use. Therefore, CMS will conduct offsite audits of schizophrenia coding and, based upon the results, adjust the quality measure star ratings for facilities whose audit reveals inaccurate coding.3
Regardless of QM outcomes, facility teams must always ensure the accuracy of diagnosis coding and not lead the physician to state a vague or imprecise diagnosis to change outcomes.
Aligning Quality Measures with Resident-Centered Care
The disparity between QM exclusions and clinical standards of practice highlights the importance of holistic resident care in long term care facilities. Facility teams must ensure the diagnoses and the MDS represent the resident fairly. This accuracy will result in a care plan that is resident-centered and QM outcomes that represent the resident’s care in the facility.
Consider a resident who has an indwelling catheter to promote healing for a Stage 3 pressure ulcer to the coccyx. Although this resident will trigger the indwelling catheter QM, the facility team must recognize that the catheter is medically appropriate and clinically indicated. The resident-centered care plan would reflect the catheter as an intervention to keep the skin dry while the wound is healing. The MDS, care plan, and QMs must all align to accurately represent the resident and the care provided.
Ultimately, the goal remains the same: to promote the highest practicable physical, mental, and psychosocial well-being of every resident in long term care. Through careful consideration of appropriate QM exclusions and clinically indicated practices based on the resident’s needs, goals, and preferences, the facility team can ensure QM and MDS accuracy while providing resident-centered care.
Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, is curriculum development specialist at the American Association of Post-Acute Care Nursing (AAPACN).
References
1. Gould, C.V., Umscheid, C.A., Agarwal, R.K., Kuntz, G., Pegues, D.A., & Healthcare Infection Control Practices Advisory Committee. (2019). Guideline for prevention of catheter-associated urinary tract infections 2009. Centers for Disease Control and Prevention.
2. Chokhawala, K., & Stevens, L. Antipsychotic medications. [Updated 2023 Feb 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK519503/#
3. Centers for Medicare & Medicaid Services. (2023). Updates to the nursing home Care Compare website and Five Star Quality Rating System: Adjusting quality measure ratings based on erroneous schizophrenia coding, and posting citations under dispute. https://www.cms.gov/files/document/qso-23-05-nh-adjusting-quality-measure-ratings-based-erroneous-schizophrenia-coding-and-posting.pdf