Medicare Advantage Quality Improvement Project Medicare Advantage Industry Training

1. Medicare Advantage Quality Improvement ProjectMedicare Advantage Industry Training Jaya Ghildiyal and Vanessa Sammy Medicare Drug and Health Plan Contract Administration Group April 11, 2012

2. Objectives • Identify requirements of the Quality Improvement (QI) Program • Identify requirements of a Quality Improvement Project (QIP) • Describe how QIPs improve health outcomes and quality of care

3. Objectives -2- • Describe the role of the Regional Office Account Managers • Describe the QIP submission process • Describe the QIP reporting tool

4. Presentation Overview: Part I • QI Program Overview • Background on QIP Required Topic • Partnership for Patients Initiative • Overview of QIP Development & Evaluation • Case Studies • Discussion • Brief break/Stretch

5. Presentation Overview: Part II • Role of the Regional Office (RO) Account Managers • QIP Reporting & Submission Process • Plan, Do, Study, Act (PDSA) Framework • Review QIP Reporting Tool • Wrap up & Questions

6. Quality Improvement (QI) Program Overview

7. Quality Improvement (QI) Program • 42 Code of Federal Regulations (CFR) § 422.152 • Applies to all MAOs, including SNPs • Serves to integrate and coordinate all of the assessment tools and reporting requirements • Seven components of the QI Program

8. Components of the QI Program 1. Chronic Care Improvement Program (CCIP) • Meets requirements at 42CFR §422.152(c) • Addresses populations that CMS identifies by reviewing current quality performance 2. Quality Improvement Projects (QIPs) • Meets requirements at 42CFR §422.152(d) • Expected to favorably affect health outcomes and enrollee satisfaction • Address areas identified by CMS

9. Components of the QI Program -2- 3. Develop and maintain a health information system 4. Encourage providers to participate in CMS and Health &Human Services (HHS) QI initiatives 5. Contract with an approved Medicare CAHPS vendor to conduct the Medicare CAHPS satisfaction survey

10. Components of the QI Program -3- 6. Include a program review process for the formal evaluation of the QI Program that addresses at least the following areas on an annual basis: • Impact • Effectiveness 7. Take remedial action to correct problems identified using ongoing quality improvement

11. Defining Quality

12. BACKGROUND

13. Background • Identified need to improve reporting tools for both the CCIPs and the QIPs • Follow the QI cycle of Plan, Do, Study, Act • More focused on interventions and outcomes • Participate in national health initiatives • CCIPs must be clinical • QIPs may be clinical or non-clinical

14. Background -2- • CMS is involved in several important Department of Health & Human Services (HHS) Initiatives • Want to ensure that our beneficiaries enrolled in the Medicare Advantage (MA) program have the opportunity to benefit from these initiatives

15. QI Program Alignment with HHS Initiatives • Aligning the MA QI program with the HHS quality initiatives: • Partnership for Patients QIP • Million Hearts Initiative CCIP • The Quality Improvement Project is an important tool ,

16. Required Quality Improvement Project • In 2011, HEDIS® introduced a new measure on plan all-cause readmission rates • In 2012, CMS is requiring a QIP focused on decreasing hospital readmissions • Supports the national HHS initiative—Partnership for Patients

17. PARTNERSHIP FOR PATIENTS INITIATIVE

18. Goals of Partnership for Patients • Prevent patients from getting injured or sicker during their care • By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010  • Achieving this goal would mean approximately 1.8 million fewer injuries to patients with more than 60,000 lives saved over three years

19. Goals of Partnership for Patients -2- • Help patients heal without complication • By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010 

20. Goals of Partnership for Patients -3- • Help patients heal without complication • Achieving this goal would mean more than 1.6 million patients would recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge

21. Key Components of Partnership for Patients • Hospital Engagement Networks • Comprised of 26 State, Regional, National and Hospital System Organizations • Required to support hospitals in making patient care safer • Improving Care Transitions • Care transitions are an opportunity for improvement

22. Hospital Readmission Rates • At any given time, about one in every 20 patients acquires an infection that results from his or her hospital care • On average, one in seven Medicare beneficiaries is harmed in the course of his or her care, costing the government an estimated $4.4 billion every year Source: Partnership for Patients

23. Hospital Readmission Rates -2- • Nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days • That’s approximately 2.6 million seniors at a cost of over $26 billion every year Source: Partnership for Patients

24. Joining the Partnership Join the Partnership for Patients at: http://www.healthcare.gov/compare/partnership-for-patients/join/index.html

25. OVERVIEW OF QIP DEVELOPMENT & EVALUATION

26. Steps To Developing a QIP Identify the potential target of opportunity Synthesize information about optimal practice Synthesize information about current practice Identify reasons for discrepancy between current and optimal practice Source: PrabithaVarkey. Medical Quality Management: Theory & Practice. Jones & Bartlett publishers, 2010.

27. Steps To Developing a QIP -2- Develop a strategy for practice improvement Assess effectiveness & cost-effectiveness of the practice improvement strategy Determine whether the practice improvement strategy should be implemented and how it can be improved

28. Areas of Focus for the QIP • The focus of the QIP can be to yield improvements in any or all of the following areas: • Functional • Clinical • Satisfaction • Costs

29. Areas of Focus for the QIP • Functional • Physical Function • Mental Health • Social Role • Other (e.g., pain, health risk) • Satisfaction • Health Care Delivery • Perceived Benefit • Clinical • Mortality • Morbidity • Complications • Costs • Direct Medical • Indirect Social Source: PrabithaVarkey. Medical Quality Management: Theory & Practice. Jones & Bartlett publishers, 2010.

30. QUALITY IMPROVEMENT PROJECTCASE STUDY

31. Identify the Potential Target of Opportunity • Developing the focus of the QIP (may be clinical or non-clinical): • Pressure ulcers are among the most frequent of hospital-acquired conditions and the MAO has identified this as a recurring reason cited for hospital readmissions

32. Synthesize Information About Optimal Practice • Rationale for Selection: • Evidence based guidelines inform us that pressure ulcers in Stages III and IV put patients at significant risk for infection that can potentially result in death

33. Synthesize Information About Current Practice • Developing the Target Goal: • The MAO has identified the target population and believes that enhanced post-discharge follow-up and patient education regarding wound care can prevent 50% of pressure ulcers from exacerbating and leading to complications that cause hospital readmission

34. Synthesize Information About Current Practice -2- • The goal is to ensure that members of the target population and their caregivers understand instructions for wound self-care, recognize symptoms that signify potential complications requiring immediate attention, and make and keep follow-up appointments with their primary care physicians (PCP)

35. Identify Reasons for Discrepancy Between Current & Optimal Practice • Planning the Intervention: • The MAO identified that, after hospital discharge, members of their target population were not currently scheduling follow-up appointments with their PCPs to monitor pressure ulcers

36. Develop A Strategy For Practice Improvement • Doing the Intervention: • The MAO chose to send discharged patients and their caregivers educational materials on the importance of scheduling follow-up appointments with PCPs to monitor pressure ulcer wounds

37. Assess Effectiveness of the Practice Improvement Strategy • Studying the Intervention: • The MAO found that the interventions were able to reduce 25% of the most dangerous pressure ulcer complications that lead to hospital readmission

38. Determining How Practice Improvement Strategy Can Be Improved • Developing Next Steps: • The MAO found that the interventions were able to reduce 25% of hospital readmissions caused by dangerous pressure ulcer complications, but fell short of the target goal of a 50% reduction in pressure ulcer-related readmissions

39. Determining How Practice Improvement Strategy Can Be Improved -2- • After further review, the MAO decided to adjust its original intervention to include additional actions focused on increasing members’ PCP visits for follow-up monitoring of pressure ulcers • In addition to mailing information on the importance of follow-up with their PCP, the MAO started making phone calls to patients and caregivers to remind/assist them with scheduling follow-up appointments

40. DISCUSSION

41. Brief Break/Stretch

42. WORKING WITH CMSREGIONAL OFFICE (RO) ACCOUNT MANAGERS (AMs)

43. Regional Office (RO) Account Managers (AMs) • Will provide day-to day monitoring of the QI Program • Provide technical assistance (TA) to health plans to improve their overall QI program • Review and approve the Plan Sections of the CCIPs and the QIPs

44. QIP SUBMISSION PROCESS

45. CY 2011 QIP Submissions • The QIPs are based on their quality improvement projects from CY 2011 • Reported through HPMS using the new template • Submitted from May 1-15, 2012 • Scored by a contractor

46. CY 2012 QIP Submissions • The QIPs submitted later this Spring are based the planned quality improvement project for CY2012 • Reported through HPMS using the new template • Submitted in two sections • Plan section due June 11-July 31 • Do-Study-Act sections will be required to be submitted in early 2013

47. CY 2012 QIP Submissions -2- • MAOs must work with the AMs to have the Plan section approved • Plans cannot begin QIP without the AMs approval • AMs will review and approve/deny the CY2012 QIP “Plan” Section by July 31 • Completed within HPMS using new template

48. QIP REPORTING PROCESS

49. Plan-Do-Study-Act (PDSA) Quality Model • “Plan” Identify the potential target of opportunity, plan the project • “Do” Implementation of the project • “Study” Data collection and analysis • “Act” Next Steps

50. Quality Improvement PDSA