AHQA Annual Meeting May 6, 2010

1. AHQA Annual MeetingMay 6, 2010 9th SoW and Beyond Presented by Jean D. Moody-Williams, RN, MPP Director, Quality Improvement Group 1

2. AHQA Annual Meeting 18th Month Evaluation Results Ongoing Monitoring 28th Month Evaluation Beneficiary Protection Redesign Current and Future Activities outside of 9th SoW Questions and Answers 2

3. Background CMS began the QIO 9th SOW in August 2008 for a three year contract. 9th SoW was different from previous contracts in that it holds QIOs accountable for meeting predefined performance targets throughout the entire course of the contract. Integral to the changes are quarterly monitoring of metrics allowing for immediate corrective action, a formal evaluation that occurs at the 18th month, immediate contract actions for QIOs that do not meet the 18th month targets and ongoing monitoring for QIOs until the next formal evaluation at the 28th month. CMS received valuable input from a number of stakeholder when developing the SoW to ensure the establishment of a contractual relationship reflective of the business needs of the organization. The objective of this presentation is to confirm that the QIO program, with input from HHS, the QIO community and other key stakeholders, has become a model of program accountability that the Department can encourage others to replicate. 3

4. Moving – the Sale We all come with different views of the same law, regulation, program and approach depending on where you sit at the time. We have to quickly understand each persons view point and try to address their need at that time. The moving process gives you an appreciation for understanding others points of view. 4

5. My View of My House 5

6. The Realtors View of the House 6

7. The Lender’s View of the House 7

8. Appraiser’s View of the House 8

9. Observations prior to the 9th SoW Evaluation of the QIO Program under previous SOWs has not been sufficiently rigorous to persuade many outside evaluators that the program is cost effective. Complete data have not always been readily available to examine all aspects of the program’s performance. The Department has not been able to rigorously demonstrate that observed quality improvement related to program tasks could be attributed to the activities of the QIOs; and Although data flow has accelerated in the 7th and 8th SOWs, use for management and midcourse adjustments is still quite limited. CMS’ strategic oversight of program has been limited with multiple uncoordinated modifications. Most of the formal evaluation is done at the end. Little to no consequence for not meeting performance goals. 9

10. 10 9th SOW Organization Beneficiary Protection (Case Review and RHQDAPU) Core Prevention Patient Safety Pressure Ulcer Reduction (Nursing Home and Hospital) Nursing Home Physical Restraints Hospital SCIP Methicillin-resistent Staphylococcus Aureus (MRSA) Nursing Homes in Need Medication Safety Sub-national Projects (Care Transitions, Focused Disparities, Chronic Kidney Disease) Reporting Hospital Data for Annual Payment Update (RHQDAPU)Reporting Hospital Data for Annual Payment Update (RHQDAPU)

11. 18th Month Evaluation Overview 32 QIOs passed all projects Results achieved by rigorous ongoing monitoring by CMS and rapid improvement by QIOs As of March 2010, CMS has requested 57 Performance Improvement Plans from 37 QIOs. Of the 57 PIPs, 49 have been closed satisfactorily with improved performance and 8 are still open. During the entire 8th SOW a total of 8 PIPs were requested from QIOs. 20 QIOs did not meet the targets for one project 1 QIO did not meet the targets for two projects 11

12. Recommendations for an Evaluation Framework Objectives—what we want to accomplish in the task QIO Activities are described that can impact the measures. Measurable performance indicators are prospectively established to be consistent with the objectives. Expectations for improvement and its trajectory are prospectively and clearly established. Timeframes for data reporting consistent with the performance indicators and monitoring needs are established. Data infrastructure is developed to provide easily accessible information for calculating the performance indicators within the timeframes established. Appropriate evaluation methods are built into the program’s tasks so that their impact on quality can be rigorously analyzed and demonstrated. 12

13. Framework Example 13

14. Framework Example 14

15. Framework Example 15

16. Framework Example 16

17. Framework Example 17

18. Framework Example – Element #7 18

19. Q7th Sneak Preview Based on review of preliminary Quarter 7 data (just received): All QIOs submitted EHR-rates for all 4 clinical measures. Approximately 90% of QIOs will be monitored based on EHR-reported rates for all 4 clinical measures for Quarter 7. Tentatively, all of the QIOs that will be monitored based on EHR-reported rates passed Quarter 7 monitoring. This includes influenza immunization monitoring. 19

20. 20 Patient Safety 18th Month Evaluation Measures, Targets, and Results Notes: QIO not participating in some components: VI not participating in NHIN NH not participating in SCIP (high performance in the state) PR, VI, and VT not participating in restraint work Target Recruitment: NH Pressure Ulcers: 1,100 (941 recruited to date—excludes NC and CA) Hospital Pressure Ulcers: 548 (424 recruited excluding NC and CA) Restraints: 1,232 (983 recruited excluding NC and CA) SCIP: 672 (569 recruited excluding NC and CA) MRSA 518 maximum (433 recruited excluding NC and CA) Notes: QIO not participating in some components: VI not participating in NHIN NH not participating in SCIP (high performance in the state) PR, VI, and VT not participating in restraint work Target Recruitment: NH Pressure Ulcers: 1,100 (941 recruited to date—excludes NC and CA) Hospital Pressure Ulcers: 548 (424 recruited excluding NC and CA) Restraints: 1,232 (983 recruited excluding NC and CA) SCIP: 672 (569 recruited excluding NC and CA) MRSA 518 maximum (433 recruited excluding NC and CA)

21. 21 Patient Safety 18th Month Evaluation Measures, Targets, and Results Notes: QIO not participating in some components: VI not participating in NHIN NH not participating in SCIP (high performance in the state) PR, VI, and VT not participating in restraint work Target Recruitment: NH Pressure Ulcers: 1,100 (941 recruited to date—excludes NC and CA) Hospital Pressure Ulcers: 548 (424 recruited excluding NC and CA) Restraints: 1,232 (983 recruited excluding NC and CA) SCIP: 672 (569 recruited excluding NC and CA) MRSA 518 maximum (433 recruited excluding NC and CA) Notes: QIO not participating in some components: VI not participating in NHIN NH not participating in SCIP (high performance in the state) PR, VI, and VT not participating in restraint work Target Recruitment: NH Pressure Ulcers: 1,100 (941 recruited to date—excludes NC and CA) Hospital Pressure Ulcers: 548 (424 recruited excluding NC and CA) Restraints: 1,232 (983 recruited excluding NC and CA) SCIP: 672 (569 recruited excluding NC and CA) MRSA 518 maximum (433 recruited excluding NC and CA)

22. MRSA IPG Reporting of Both Metrics for at Least 4 Months During Baseline 22

23. MRSA IPG Baseline Infection Rates 23

24. MRSA IPG Baseline Incidence Rate of Hospital-Onset MRSA Transmission  24 (MRSA 2: Proxy Measure for Transmission Rate established by the CDC)(MRSA 2: Proxy Measure for Transmission Rate established by the CDC)

25. 25 Patient Safety 18th Month Evaluation Measures, Targets, and Results Notes: QIO not participating in some components: VI not participating in NHIN NH not participating in SCIP (high performance in the state) PR, VI, and VT not participating in restraint work Target Recruitment: NH Pressure Ulcers: 1,100 (941 recruited to date—excludes NC and CA) Hospital Pressure Ulcers: 548 (424 recruited excluding NC and CA) Restraints: 1,232 (983 recruited excluding NC and CA) SCIP: 672 (569 recruited excluding NC and CA) MRSA 518 maximum (433 recruited excluding NC and CA) Notes: QIO not participating in some components: VI not participating in NHIN NH not participating in SCIP (high performance in the state) PR, VI, and VT not participating in restraint work Target Recruitment: NH Pressure Ulcers: 1,100 (941 recruited to date—excludes NC and CA) Hospital Pressure Ulcers: 548 (424 recruited excluding NC and CA) Restraints: 1,232 (983 recruited excluding NC and CA) SCIP: 672 (569 recruited excluding NC and CA) MRSA 518 maximum (433 recruited excluding NC and CA)

26. MRSA Record Request Several but not all hospitals have voiced concerns related to recent record requests related to HAIs. Rapid data collection efforts implemented to inform immediate policy needs. Have implemented communications efforts to address concerns. Options under consideration to accomplish needs in least burdensome manner. 26

27. 18th Month Evaluation Targets, Results, & Contract Actions: Sub-National Themes  27

28. Measures of Success Recruitment, Participation, and Training Lab Test “Utilization Measures” HgbA1c (glycemic control) Lipids (Cholesterol) Eye Examination Actual Laboratory Result Improvement 28

29. Prevention: Disparities 18th Month Evaluation  Targets and Results 29

30. Prevention: CKD 18th Month Evaluation Targets and Results 30

31. 31 Care Transitions Goals To measurably improve the quality of care for Medicare beneficiaries who transition among care settings through a comprehensive community effort; and To reduce readmissions following hospitalization and to yield sustainable and replicable strategies to achieve high-value health care for sick and disabled Medicare beneficiaries. Tasks Community/Provider Recruitment/Selection Interventions Monitoring and Reports Evaluation of Task Performance

32. Project Characteristics The unit of intervention for this initiative is the community The QIO will be judged on whether it has improved results for the population of Medicare beneficiaries in its defined community at 18 and 28 months. Focus on changes in the processes of care at a community level that engage more than one provider as well as patients, families, and community healthcare stakeholders. 14 communities participating based on the communities proposed through a competitive procurement process that was open to all QIOs. 32

33. 33 Community Characteristics The Care Transitions Theme (7.2) was awarded to 14 QIOs in 14 unique communities; these are: Tuscaloosa HRR (AL) – 48 zip codes NW Denver (CO) – 44 zip codes Miami (FL) – 20 zip codes Metro Atlanta East (GA) – 18 zip codes Evansville (IN) – 92 zip codes Baton Rouge (LA) – 81 zip codes Greater Lansing Area Community (MI) – 40 zip codes Omaha (NE) – 48 zip codes SW New Jersey – 44 zip codes Upper Capital Region (NY) – 84 zip codes Western Pennsylvania – 53 zip codes Providence (RI) – 41 zip codes Harlingen HRR (TX) – 35 zip codes Whatcom (WA) – 18 zip codes

34. 34 Community Characteristics(Care Transitions Summary) Providers: Hospitals – 70 Skilled Nursing Facilities – 277 Home Health – 316 Other - 89 Zip Codes – 666 Medicare Beneficiaries – 1,125,649 Total Number of 30-day Readmissions Avoided if 2% reduction is met: 2,585

35. Care Transitions 18th Month Evaluation Targets and Results 35

36. 36 6.1 Beneficiary ProtectionPerformance Metrics/Results

37. Beneficiary Protection Redesign 37

38. Beneficiary Protection Redesign 38

39. Other HHS Recommendations 39

40. Funds Management HHS also recommended additional items as it related to funds management as addressed below:   CMS addressed the cost items of the “Contract Oversight” section and the “Funds Management” section of the Evaluation Framework by developing systems/processes to collect, report, and analyze QIO financial data. Specifically, CMS implemented the systems/processes to ensure appropriate contract oversight and financial monitoring of cost under the 9th SOW QIO Program: CMS revised the Financial Information and Vouchering System (FIVS). The system collects detailed cost information including: Detailed monthly cost information for meetings and conferences, membership and dues, fringe benefits, and staff training costs 40

41. What Happens now that the House is Sold 41

42. Unpacking the Boxes Value Based Purchasing Selecting the Measures Determining the Performance Standards Selecting the Period of Performance Determining the methodology for determining payment reduction or incentive Applying the reduction or incentive and inquiry Technical Assistance for improvement Unintended Consequences and Program Monitoring and Evaluation 42

43. Unpacking the Boxes Health Information Technology National Quality Strategy Reduction of Disparities Prevention Conflict of Interest 43

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45. Questions and Wrap-Up QUESTIONS AND FEEDBACK THANK YOU! 45