Performance Improvement Projects Technical Assistance Nursing Home Diversion Programs Thursday, March 29, 2007 8:30 a.m.

1. Performance Improvement Projects Technical AssistanceNursing Home Diversion ProgramsThursday, March 29, 20078:30 a.m. – 10:30 a.m. Cheryl L. Neel, RN, MPH, CPHQ Manager, Performance Improvement Projects David Mabb, MS Sr. Director, Statistical Evaluation

2. Presentation Outline • PIP Overall Comments • Aggregate MCO PIP Findings • Aggregate NHDP Specific Findings • Technical Assistance with Group Activities • Study Design • Study Implementation • Quality Outcomes Achieved • Questions and Answers

3. Key PIP Strategies • Conduct outcome-oriented projects • Achieve demonstrable improvement • Sustain improvement • Correct systemic problems

4. Validity and Reliability of PIP Results • Activity 3 of the CMS Validating Protocol: Evaluating overall validity and reliability of PIP results: • Met= Confidence/High confidence in reported PIP results • Partially Met= Low confidence in reported PIP results • Not Met= Reported PIP results not credible

5. Summary of PIP Validation Scores

6. Proportion of PIPs Meeting the Requirements for Each Activity

7. Aggregate Valid Percent Met I II III IV VI VII VIII IX X V

8. NHDP Specific Findings • 20 PIPs submitted • Scores ranged from 17% to 75% • Average score was 40% • Assessed evaluation elements were scored as Met 40% of the time

9. Summary of NHDP Validation Score

10. Study Design Four Components: • Activity I. Selecting an Appropriate Study Topic • Activity II. Presenting Clearly Defined, Answerable Study Question(s) • Activity III. Documenting Clearly Defined Study Indicator(s) • Activity IV. Stating a Correctly Identified Study Population

11. Activity I. Selecting an Appropriate Study Topic - NHDP Overall Score

12. Activity I. Selecting an Appropriate Study Topic Results: • 71 percent of the six evaluation elements were Met • 29 percent were Partially Met or Not Met • None of the evaluation elements were Not Applicable or Not Assessed

13. Activity I: Review the Selected Study Topic HSAG Evaluation Elements: • Reflects high-volume or high-risk conditions (or was selected by the State). • Is selected following collection and analysis of data (or was selected by the State). • Addresses a broad spectrum of care and services (or was selected by the State). • Includes all eligible populations that meet the study criteria. • Does not exclude members with special health care needs. • Has the potential to affect member health, functional status, or satisfaction. Bolded evaluation elements show areas for improvement

14. Activity II. Presenting Clearly Defined, Answerable Study Question(s) - NHDP Overall Score

15. Activity II. Presenting Clearly Defined, Answerable Study Question(s) Results: • 28 percent of the two evaluation elements were Met • 73 percent were Partially Met or Not Met • None of the evaluation elements were Not Applicable or Not Assessed

16. Activity II: Review the Study Question(s) HSAG Evaluation Elements: • States the problem to be studied in simple terms. • Is answerable. Bolded evaluation elements show areas for improvement

17. Activity III. Documenting Clearly Defined Study Indicator(s) - NHDP Overall Score

18. Activity III. Documenting Clearly Defined Study Indicator(s) Results: • 27 percent of the seven evaluation elements were Met • 54 percent were Partially Met or Not Met • 19 percent were Not Applicable or Not Assessed

19. Activity III: Review Selected Study Indicator(s) HSAG Evaluation Elements: • Is well defined, objective, and measurable. • Are based on practice guidelines, with sources identified. • Allows for the study question to be answered. • Measures changes (outcomes) in health or functional status, member satisfaction, or valid process alternatives. • Have available data that can be collected on each indicator. • Are nationally recognized measure such as HEDIS®, when appropriate. • Includes the basis on which each indicator was adopted, if internally developed. Bolded evaluation elements show areas for improvement

20. Activity IV. Stating a Correctly Identified Study Population - NHDP Overall Score

21. Activity IV. Stating a Correctly Identified Study Population Results: • 48 percent of the three evaluation elements were Met • 52 percent were Partially Met or Not Met • None of the evaluation elements were Not Applicable or Not Assessed

22. Activity IV: Review the Identified Study Population HSAG Evaluation Elements: • Is accurately and completely defined. • Includes requirements for the length of a member’s enrollment in the managed care plan. • Captures all members to whom the study question applies. Bolded evaluation elements show areas for improvement

23. Group Activity

24. Study Implementation Three Components: • Activity V. Valid Sampling Techniques • Activity VI. Accurate/Complete Data Collection • Activity VII. Appropriate Improvement Strategies

25. Activity V. Presenting a Valid Sampling Technique - NHDP Overall Score

26. Activity V. Presenting a Valid Sampling Technique Results: • 5 out of the 20 PIP studies used sampling. • 9 percent of the six evaluation elements were Met. • 16 percent were Partially Met or Not Met. • 75 percent of the evaluation elements were Not Applicable or Not Assessed.

27. Activity V: Review Sampling Methods * This section is only validated if sampling is used. HSAG Evaluation Elements: • Consider and specify the true or estimated frequency of occurrence. (N=5) • Identify the sample size. (N=5) • Specify the confidence level to be used. (N=5) • Specify the acceptable margin of error. (N=5) • Ensure a representative sample of the eligible population. (N=5) • Ensure that the sampling techniques are in accordance with generally accepted principles of research design and statistical analysis. (N=5) Bolded evaluation elements show areas for improvement

28. Populations or Samples? All? Some? Generally, • Administrative data uses populations • Hybrid (chart abstraction) method uses samples identified through administrative data

29. Activity VI. Specifying Accurate/Complete Data Collection - NHDP Overall Score

30. Activity VI. Specifying Accurate/Complete Data Collection Results: • 25 percent of the eleven evaluation elements were Met • 66 percent were Partially Met or Not Met • 10 percent of the evaluation elements were Not Applicable or Not Assessed

31. Activity VI: Review Data Collection Procedures HSAG Evaluation Elements: • Clearly defined data elements to be collected. • Clearly identified sources of data. • A clearly defined and systematic process for collecting data that includes how baseline and remeasurement data will be collected. • A timeline for the collection of baseline and remeasurement data. • Qualified staff and personnel to collect manual data. • A manual data collection tool that ensures consistent and accurate collection of data according to indicator specifications. Bolded evaluation elements show areas for improvement

32. Activity VI: Review Data Collection Procedures (cont.) HSAG Evaluation Elements: • A manual data collection tool that supports interrater reliability. • Clear and concise written instructions for completing the manual data collection tool. • An overview of the study in the written instructions. • Administrative data collection algorithms that show steps in the production of indicators. • An estimated degree of automated data completeness (important if using the administrative method).

33. Where do we look for our sources of data?

34. Baseline Data Sources Medical Records Administrative claims/encounter data Hybrid HEDIS Survey Data MCO program data Other

35. Activity VII. Documenting the Appropriate Improvement Strategies - NHDP Overall Score

36. Activity VII. Documenting the Appropriate Improvement Strategies Results: • 15 percent of the four evaluation elements were Met • 18 percent were Partially Met or Not Met • 68 percent of the evaluation elements were Not Applicable or Not Assessed

37. Activity Seven: Assess Improvement Strategies HSAG Evaluation Elements: • Related to causes/barriers identified through data analysis and Quality Improvement (QI) processes. • System changes that are likely to induce permanent change. • Revised if original interventions are not successful. • Standardized and monitored if interventions are successful. Bolded evaluation elements show areas for improvement

38. Determining Interventions Once you know how you are doing at baseline, what interventions will produce meaningful improvement in the target population?

39. First Do A Barrier Analysis What did an analysis of baseline results show ? How can we relate it to system improvement? • Opportunities for improvement • Determine intervention(s) • Identify barriers to reaching improvement

40. How was intervention(s) chosen? • By reviewing the literature • Evidence-based • Pros & cons • Benefits & costs • Develop list of potential interventions -- what is most effective?

41. Types of Interventions • Education • Provider performance feedback • Reminders & tracking systems • Organizational changes • Community level interventions • Mass media

42. Choosing Interventions • Balance • potential for success with ease of use • acceptability to providers & collaborators • cost considerations (direct and indirect) • Feasibility • adequate resources • adequate staff and training to ensure a sustainableeffort

43. Most effective: real-time reminders outreach/detailing opinion leaders provider profiles Less effective: educational materials (alone) formal CME program without enabling or reinforcing strategies Physician Interventions: Multifaceted Most Effective

44. Patient Interventions • Educational programs • Disease-specific education booklets • Lists of questions to ask your physician • Organizing materials: flowsheets, charts, reminder cards • Screening instruments to detect complications • Direct mailing, media ads, websites

45. Evaluating Interventions • Does it target a specific quality indicator? • Is it aimed at appropriate stakeholders? • Is it directed at a specific process/outcome of care or service? • Did the intervention begin after baseline measurement period?

46. Interventions Checklist • Analyze barriers (root causes) • Choose & understand target audience • Select interventions based on cost-benefit • Track intermediate results • Evaluate effectiveness • Modify interventions as needed • Re-Measure

47. Group Activity

48. Quality Outcomes Achieved Three Components: • Activity VIII. Presentation of Sufficient Data Analysis and Interpretation • Activity IX. Evidence of Real Improvement Achieved • Activity X. Data Supporting Sustained Improvement Achieved

49. Activity VIII. Presentation of Sufficient Data Analysis and Interpretation - NHDP Overall Score

50. Activity VIII. Presentation of Sufficient Data Analysis and Interpretation Results: • 10 percent of the nine evaluation elements were Met • 18 percent of the evaluation elements Partially Met or Not Met • 72 percent of the evaluation elements were Not Applicable or Not Assessed