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The Proposed QIO 9th Statement of Work: A Content Overview

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The Proposed QIO 9th Statement of Work: A Content Overview

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    1. The Proposed QIO 9th Statement of Work: A Content Overview Roland A. Grieb, MD, MHSA Health Care Excel Medical Director, Indiana Medicare Quality Improvement Organization (QIO) May 1, 2008

    3. Objectives Review the background and history leading to the 9th SOW Recognize the changes in the framework of accountability for QIOs in the 9th SOW Discuss the goals and themes for the 9th SOW

    4. Background Medicare QIO program created by statute in 1982 Focus to improve quality, safety, and efficiency of health care services delivered to Medicare beneficiaries Medicare contractors hired to work with health care providers including home health agencies, hospitals, nursing homes (NH), and physicians’ offices Goal to improve health care services by assuring the right care for every patient, every time

    5. Background (continued) Improving the Medicare Quality Improvement Organization Program, 2006 Institute of Medicine (IOM) report to Congress Focus more on quality improvement and performance measurement Prioritize program resources so that QIOs can help providers who demonstrate the most need, or who face significant challenges delivering quality care Strengthen organizational structure and governance of the QIOs Strengthen management of the QIO Program by CMS Strengthen the evaluation system for the QIO program

    6. Background (continued) Nursing Homes: Federal Actions Needed to Improve Targeting and Evaluation of Quality Improvement Organizations, 2007 Government Accountability Office (GAO) report Increase the number of low-performing nursing homes that QIOs assist intensively Direct QIOs to focus intensive assistance on those quality-of-care areas in which nursing homes most need improvement Collect more complete and detailed data on the methods QIOs are using to assist nursing homes and the impact that these methods have on quality of care Identify a broader spectrum of publicly reported quality measures to evaluate changes in nursing home quality.

    7. 9th SOW: History Priorities of the Secretary of the Department of Health and Human Services (DHHS) Recommendations from external stakeholders What do QIOs do well? What can we measure well? What is important? What interventions are backed by evidence? Recommendations from the QIO community and DHHS Workgroup 1: QIO/CMS Community Workgroup 2: DHHS CMS The Assistant Secretary for Planning and Evaluation (ASPE) Assistant Secretary for Resources and Technology (ASRT) Agency for Healthcare Research and Quality (AHRQ) Centers for Disease Control and Prevention (CDC) Office for Civil Rights (OCR) Office of the General Council (OGC) Office of the Secretary (OS) Workgroup 1: QIO/CMS Community Workgroup 2: DHHS CMS The Assistant Secretary for Planning and Evaluation (ASPE) Assistant Secretary for Resources and Technology (ASRT) Agency for Healthcare Research and Quality (AHRQ) Centers for Disease Control and Prevention (CDC) Office for Civil Rights (OCR) Office of the General Council (OGC) Office of the Secretary (OS)

    8. 9th SOW: Overarching Design Principles More effective management Measurement accountability Relevance to CMS and DHHS Value-Driven Health Care (VDHC) Disparities Reduction Health Information Technology (HIT) Careful evaluation with attribution Background: The Quality Improvement Organization Program was created by statute in 1982 to improve the quality, safety and efficiency of health care services delivered to Medicare beneficiaries.  QIOs are Medicare contractors hired to work with health care providers like home health agencies, hospitals, nursing homes and physicians’ offices to improve health care services by assuring the right care for every patient, every time.   In an IOM report to Congress published in 2006 titled Improving the Medicare Quality Improvement Organization Program, the IOM called on CMS to: Focus more on quality improvement and performance measurement; Prioritize program resources so that QIOs can help providers who demonstrate the most need or who face significant challenges to providing quality care; Strengthen organizational structure and governance of the QIOs; Strengthen management of the QIO Program by CMS; and Strengthen the evaluation system for the QIO program.   In a GAO report issued in 2007 titled Nursing Homes: Federal Actions Needed to Improve Targeting and Evaluation of Quality Improvement Organizations, the GAO recommended that CMS, among other actions: Increase the number of low-performing nursing homes that QIOs assist intensively; Direct QIOs to focus intensive assistance on those quality-of-care areas on which nursing homes most need improvement; Collect more complete and detailed data on the methods QIOs are using to assist nursing homes and the impact that these methods have on quality of care; and Identify a broader spectrum of publicly reported quality measures to evaluate changes in nursing home quality.   In particular, the GAO suggested CMS redirect its QIO resources so that the program helps nursing homes with the greatest need for assistance in implementing quality improvement initiatives.   Responding to those concerns, CMS is focusing additional efforts to ensure that the QIOs provide Medicare beneficiaries – and the Medicare program – with the highest value of services in their efforts to improve the quality of care among health care providers who serve people with Medicare.  Background: The Quality Improvement Organization Program was created by statute in 1982 to improve the quality, safety and efficiency of health care services delivered to Medicare beneficiaries.  QIOs are Medicare contractors hired to work with health care providers like home health agencies, hospitals, nursing homes and physicians’ offices to improve health care services by assuring the right care for every patient, every time.   In an IOM report to Congress published in 2006 titled Improving the Medicare Quality Improvement Organization Program, the IOM called on CMS to: Focus more on quality improvement and performance measurement; Prioritize program resources so that QIOs can help providers who demonstrate the most need or who face significant challenges to providing quality care; Strengthen organizational structure and governance of the QIOs; Strengthen management of the QIO Program by CMS; and Strengthen the evaluation system for the QIO program.   In a GAO report issued in 2007 titled Nursing Homes: Federal Actions Needed to Improve Targeting and Evaluation of Quality Improvement Organizations, the GAO recommended that CMS, among other actions: Increase the number of low-performing nursing homes that QIOs assist intensively; Direct QIOs to focus intensive assistance on those quality-of-care areas on which nursing homes most need improvement; Collect more complete and detailed data on the methods QIOs are using to assist nursing homes and the impact that these methods have on quality of care; and Identify a broader spectrum of publicly reported quality measures to evaluate changes in nursing home quality.   In particular, the GAO suggested CMS redirect its QIO resources so that the program helps nursing homes with the greatest need for assistance in implementing quality improvement initiatives.   Responding to those concerns, CMS is focusing additional efforts to ensure that the QIOs provide Medicare beneficiaries – and the Medicare program – with the highest value of services in their efforts to improve the quality of care among health care providers who serve people with Medicare. 

    9. The QIO Program Has Been Re-designed Framework for Accountability Content The QIO 9th Statement of Work: Content The 9th SOW is a completely re-designed program GOALS: to help providers • Prevent Illness • Decrease Harm to Patients • Reduce Waste in Healthcare 9th Statement of Work Redesign: • Supports the Secretary of DHHS’s Priorities • Emphasizes Achieving Value and Efficiency in Health Care • Increases Competition • Responds to Criticism of earlier QIO contracts Overview:  On January 22, 2008, the Centers for Medicare & Medicaid Services (CMS) released the 9th Statement of Work (SOW) for Medicare’s 53 Quality Improvement Organizations (QIOs).  The 9th SOW is focused on improving the quality and safety of services for beneficiaries.  It provides CMS additional tools to better manage the QIOs by linking the work completed by the organizations to measurable outcomes reviewed and measured during the entire length of the three-year contract.  Responding to concerns from the Institute of Medicine (IOM), the Government Accountability Office (GAO), and Congress, and in an effort to improve oversight of the QIOs, CMS is channeling additional efforts and resources to ensure the QIOs provide Medicare beneficiaries with the highest value in their efforts to improve the quality of care among health care providers.  As part of the contract requirements, QIOs will center their improvement efforts on Protecting Beneficiaries, Care Transitions, Patient Safety and Prevention.  Each program has measurable criteria, close monitoring and performance improvement plans to gauge each QIOs performance under the contract.  Under the 9th SOW, QIOs must work with a variety of health care providers during the three-year contract beginning August 1, 2008.  By starting the contract period for all QIOs simultaneously, CMS will be better equipped to ensure the QIOs meet their contract requirements.  Also, the QIOs will have to meet periodic milestones to further ensure they are serving the needs of beneficiaries. In addition, the QIOs will help Medicare promote value-driven health care, support the adoption and use of interoperable health information technology and reduce health disparities in their communities.  The QIO 9th Statement of Work: Content The 9th SOW is a completely re-designed program GOALS: to help providers • Prevent Illness • Decrease Harm to Patients • Reduce Waste in Healthcare 9th Statement of Work Redesign: • Supports the Secretary of DHHS’s Priorities • Emphasizes Achieving Value and Efficiency in Health Care • Increases Competition • Responds to Criticism of earlier QIO contracts Overview:  On January 22, 2008, the Centers for Medicare & Medicaid Services (CMS) released the 9th Statement of Work (SOW) for Medicare’s 53 Quality Improvement Organizations (QIOs).  The 9th SOW is focused on improving the quality and safety of services for beneficiaries.  It provides CMS additional tools to better manage the QIOs by linking the work completed by the organizations to measurable outcomes reviewed and measured during the entire length of the three-year contract.  Responding to concerns from the Institute of Medicine (IOM), the Government Accountability Office (GAO), and Congress, and in an effort to improve oversight of the QIOs, CMS is channeling additional efforts and resources to ensure the QIOs provide Medicare beneficiaries with the highest value in their efforts to improve the quality of care among health care providers.  As part of the contract requirements, QIOs will center their improvement efforts on Protecting Beneficiaries, Care Transitions, Patient Safety and Prevention.  Each program has measurable criteria, close monitoring and performance improvement plans to gauge each QIOs performance under the contract.  Under the 9th SOW, QIOs must work with a variety of health care providers during the three-year contract beginning August 1, 2008.  By starting the contract period for all QIOs simultaneously, CMS will be better equipped to ensure the QIOs meet their contract requirements.  Also, the QIOs will have to meet periodic milestones to further ensure they are serving the needs of beneficiaries. In addition, the QIOs will help Medicare promote value-driven health care, support the adoption and use of interoperable health information technology and reduce health disparities in their communities. 

    10. Framework for Accountability Clinical themes built on a business model Focus resources Allocate the most resources to the most capable organizations (introduce competition and reward good contractor behavior) Measure important parameters continuously during contract management Interventions linked to measurable outcomes Outstanding measurement system Standardized set of interventions, built on 8th SOW base QIOs need to link interventions to outcomes Continuous monitoring by CMS Central Office and Regional Offices

    11. Framework for Accountability (continued) “Attribution” carefully considered Well-defined measure set with continuous, high-quality data CMS chooses participants with specified criteria Use of “matched control groups,” when possible More ability to control for confounding variables Use of standardized interventions, disseminated with help of support contractors, linked to measures Careful management of partnerships

    12. Evaluation Contract Evaluation Table of Measures Mid-point evaluation (18 months) Program Evaluation Independent, outside evaluation contractor Independent report on the QIO program is a final deliverable (2011) Attribution of success to QIO interventions Continuous Contract Evaluation • 9th SoW contract will contain frequent, pre-determined performance metrics that must be met by all QIOs. • Failure to meet interim performance requirements will result in consequences to the contractor. • Failure to meet specific 18-month performance goals may result in the need for the QIO to obtain expertise from subcontractor or consultant. Continuous Contract Evaluation • 9th SoW contract will contain frequent, pre-determined performance metrics that must be met by all QIOs. • Failure to meet interim performance requirements will result in consequences to the contractor. • Failure to meet specific 18-month performance goals may result in the need for the QIO to obtain expertise from subcontractor or consultant.

    13. Our Shared Goal To help providers accomplish the following objectives Prevent illness Decrease harm to patients Reduce waste in health care

    14. 9th SOW: Content 4 Themes Prevention Patient Safety Care Transitions/Patient Pathways Beneficiary Protection 9th Statement of Work Themes: o Beneficiary Protection (case review) o Prevention o Patient Safety o Care Coordination/Patient Pathways Cross-Cutting Themes *Promoting the use of Health Information Technology & Electronic Health Records (EHRs), *Reducing Health Care Disparities, and *Emphasizing Value in Health Care 9th Statement of Work Themes: o Beneficiary Protection (case review) o Prevention o Patient Safety o Care Coordination/Patient Pathways Cross-Cutting Themes *Promoting the use of Health Information Technology & Electronic Health Records (EHRs), *Reducing Health Care Disparities, and *Emphasizing Value in Health Care

    15. 9th SOW: Content 4 5 Themes Prevention Patient Safety Care Transitions/Patient Pathways Beneficiary Protection Evaluation

    16. 9th SOW: Levels of Understanding 4 Themes (+ Evaluation) 10 Components 44 Final Measures 59 Total Measures 15 18-month and 44 28-month (Final) Measures 200 to 300 Detailed Measures Schedule of Deliverables

    17. 9th SOW: Component Level Prevention (3) Core Chronic Kidney Disease (CKD) Focused disparities Patient Safety (6) Pressure Ulcers Physical Restraints SCIP (Surgical Care Improvement Project) MRSA (Methicillin Resistant Staphylococcus Aureus) Drug Safety Nursing Homes in need of quality improvement (QI) assistance Care Transitions (1) Beneficiary Protection (1)

    18. Prevention Theme Emphasize evidence-based and cost-effective care Interventions to prevent and/or slow disease progression Focus on early testing, effective, and timely interventions Three areas of focus Core Measures CKD Disparities Prevention: QIOs will work with consumers, physicians and other caregivers to refine care delivery systems to make sure patients get the right care at the right time, particularly patients from underserved populations.  Health care disparities, including geographic disparities, are significant and increasing in the Medicare population.  In the 9th SOW, QIOs will be focusing on reducing health care disparities for Medicare beneficiaries with diabetes.  The QIOs will be using evidence-based methods to improve primary care physicians’ adherence to recommended national clinical standards of diabetes care. The organizations will also work closely with physicians and physician practices to encourage the use of secure and interoperable electronic health records.  These practices will all report regularly from their electronic health records systems the practices’ adherence to recommended guidelines for adult immunization of the Medicare population, as well as two cancer screening tests (colorectal carcinoma screening and mammography). QIOs will work to help improve vaccination rates for flu and pneumonia, increase the early identification and reduce the progression of chronic kidney disease, encourage the use of colorectal cancer screening and mammography, and support provider adoption of secure and interoperable electronic health records.  They will analyze the impact that their prevention efforts have on the number of Medicare claims submitted for vaccinations, urine tests to detect kidney malfunction, and cancer screening tests, as well as the number of prescriptions filled for kidney patients for certain types of drugs for high blood pressure that may help to prevent the progression of the disease. Prevention: QIOs will work with consumers, physicians and other caregivers to refine care delivery systems to make sure patients get the right care at the right time, particularly patients from underserved populations.  Health care disparities, including geographic disparities, are significant and increasing in the Medicare population.  In the 9th SOW, QIOs will be focusing on reducing health care disparities for Medicare beneficiaries with diabetes.  The QIOs will be using evidence-based methods to improve primary care physicians’ adherence to recommended national clinical standards of diabetes care. The organizations will also work closely with physicians and physician practices to encourage the use of secure and interoperable electronic health records.  These practices will all report regularly from their electronic health records systems the practices’ adherence to recommended guidelines for adult immunization of the Medicare population, as well as two cancer screening tests (colorectal carcinoma screening and mammography). QIOs will work to help improve vaccination rates for flu and pneumonia, increase the early identification and reduce the progression of chronic kidney disease, encourage the use of colorectal cancer screening and mammography, and support provider adoption of secure and interoperable electronic health records.  They will analyze the impact that their prevention efforts have on the number of Medicare claims submitted for vaccinations, urine tests to detect kidney malfunction, and cancer screening tests, as well as the number of prescriptions filled for kidney patients for certain types of drugs for high blood pressure that may help to prevent the progression of the disease.

    19. Core Prevention Goal is to use Electronic Health Records (EHRs) to report and improve the following Colorectal Cancer (CRC) Screening Mammography Screening Influenza Vaccination Pneumococcal Vaccination Target will be clinical offices with EHR capability

    20. Disparities Reduction Emphasize preventive care for population with diabetes Based on evidence collected in research trials and a special study in the 8th SOW—“Every Diabetic Counts” Will be awarded to a subset of QIOs, based on population and need

    21. Disparities in the Prevention Theme Cross-cutting across the theme Collect data on all measures for race, ethnicity, and zip code Analytic report on disparities findings and its impact

    22. CKD Optional competitive task awarded to a subset of QIOs CKD goals Timely testing to reduce rate of kidney failure due to diabetes Slow progression of kidney disease in hypertensive persons with diabetes Angiotensin Converting Enzyme (ACE) inhibitor Angiotensin Receptor Blocking (ARB) agent Arteriovenous fistula (AVF) placement and maturation, where medically appropriate, for individuals starting hemodialysis

    23. 9th SOW: Measure Level Prevention (10 measures) Core Mammography screening CRC screening Influenza vaccination Pneumococcal pneumonia vaccination Focused disparities: Diabetes A1C rates Lipid examination rates Eye exam rates

    24. 9th SOW: Measure Level (continued) CKD Screening for nephropathy ACE/ARB therapy to prevent progression AV fistula rate (new dialysis patients)

    25. Patient Safety Freeing patients from the risk of harm, injury, or loss resulting from their interaction with the health care delivery system Components of Patient Safety Pressure Ulcers—Nursing Homes and Hospitals Physical Restraints—Nursing Homes SCIP—Hospitals MRSA—Hospitals Drug Safety—Physician Offices, Nursing Homes, Home Health, Hospitals Nursing Homes in need of assistance with quality improvement (QI) efforts Patient Safety: QIOs will build on current efforts and best practices of other QIOs to reduce avoidable pressure ulcers and use of physical restraints in nursing homes to improve the quality of care for beneficiaries in these facilities. Surgical care improvement, reducing the incidence of drug-resistant staph infections in hospitals, and improving drug safety are also key elements in the new SOW. QIOs will help specific facilities—nursing homes and hospitals—in need of improvement on specific quality measures posted at Nursing Home Compare and Hospital Compare at http://www.medicare.gov/ or http://www.hospitalcompare.hhs.gov/ respectively.  Under the 9th SOW, QIOs will concentrate their efforts on facilities with the greatest opportunity for improvement in each individual measure.  CMS has identified these hospitals and nursing homes, and has published this list on its website as part of the 9th SOW proposal solicitation process.   By posting information about these facilities, CMS strengthens its commitment to increasing the transparency of information available to consumers in the healthcare market by providing the public with the information needed to make informed choices about health care.  More importantly, CMS addresses one of the IOM’s key recommendations for improving the QIO Program—prioritizing program resources so QIOs can help providers who demonstrate the greatest need to partner with QIOs to improve the quality of care available to beneficiaries.  In addition to those facilities identified by CMS, QIOs will also have the opportunity to choose 15 percent of facilities based on the QIOs’ own criteria, which will also be part of their 9th SOW proposals.  CMS expects many QIOs will select these facilities based on other criteria; for example, facilities that have already made great improvement or can share “best practices” in the required measures.  “Best practices” may be management or technical approaches to patient care that have been shown to either result in improvement in quality, or the sustained attainment of benchmark performance in any particular measure.  Patient Safety: QIOs will build on current efforts and best practices of other QIOs to reduce avoidable pressure ulcers and use of physical restraints in nursing homes to improve the quality of care for beneficiaries in these facilities. Surgical care improvement, reducing the incidence of drug-resistant staph infections in hospitals, and improving drug safety are also key elements in the new SOW. QIOs will help specific facilities—nursing homes and hospitals—in need of improvement on specific quality measures posted at Nursing Home Compare and Hospital Compare at http://www.medicare.gov/ or http://www.hospitalcompare.hhs.gov/ respectively.  Under the 9th SOW, QIOs will concentrate their efforts on facilities with the greatest opportunity for improvement in each individual measure.  CMS has identified these hospitals and nursing homes, and has published this list on its website as part of the 9th SOW proposal solicitation process.   By posting information about these facilities, CMS strengthens its commitment to increasing the transparency of information available to consumers in the healthcare market by providing the public with the information needed to make informed choices about health care.  More importantly, CMS addresses one of the IOM’s key recommendations for improving the QIO Program—prioritizing program resources so QIOs can help providers who demonstrate the greatest need to partner with QIOs to improve the quality of care available to beneficiaries.  In addition to those facilities identified by CMS, QIOs will also have the opportunity to choose 15 percent of facilities based on the QIOs’ own criteria, which will also be part of their 9th SOW proposals.  CMS expects many QIOs will select these facilities based on other criteria; for example, facilities that have already made great improvement or can share “best practices” in the required measures.  “Best practices” may be management or technical approaches to patient care that have been shown to either result in improvement in quality, or the sustained attainment of benchmark performance in any particular measure. 

    26. Components Pressure Ulcers—Hospitals 20% of pressure ulcers identified in nursing home residents originate outside the nursing home (acute care hospitals) Cross-setting efforts are needed to reduce incidence of pressure ulcers Hospital-acquired conditions/present on admission requirements Mean length of stay is 13.14 days compared to 4.83 days SCIP Two new measures added for the 9th SOW SCIP Cardiac 2—Perioperative beta blocker SCIP Infection 7—Colorectal surgery patients with post-operative normothermia

    27. Components (continued) MRSA 94,000—Annual life-threatening infections 19,000—Annual deaths 250—Deaths per day Drug safety measures Drug-drug interactions Potentially inappropriate medications Physical Restraints Reduce use of physical restraints in nursing homes to improve the quality of care for beneficiaries in these facilities

    28. Components (continued) Nursing Homes in need of assistance with QI efforts Based on evaluation, in conjunction with CMS Survey and Certification QIOs will perform a root cause analysis to identify factors leading to suboptimal performance Action plan will be implemented involving QI efforts Improvement in quality measures (Pressure ulcers (PrU) and physical restraints) Nursing home satisfaction with QIO technical assistance

    29. 9th SOW: Measure Level Patient safety (14 measures) MRSA 1 (infection rate) MRSA 2 (transmission rate) PrU 1 (high risk, NH) PrU 2 (hospital, acquired) Physical restraints (NH) SCIP Infection 1,2,3,4,6,7 SCIP Venous thromboembolism (VTE) 1,2 SCIP Cardiac 2

    30. SCIP Measures Infection 1—Prophylactic antibiotic received within one hour prior to surgical incision 2—Prophylactic antibiotic selection for surgical patients 3—Prophylactic antibiotics discontinued within 24 hours after surgery end time 4—Cardiac surgery patients with controlled 6 A.M. postoperative serum glucose 6—Surgery patients with appropriate hair removal 7—Colorectal surgery patients with immediate postoperative normothermia

    31. SCIP Measures (continued) VTE 1—Surgery patients with recommended venous thromboembolism prophylaxis ordered 2—Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery Cardiac 2—Surgery patients on beta blocker therapy prior to admission who received a beta blocker during the perioperative period

    32. Care Transitions/ Patient Pathways The QIO work under the Care Transitions (Patient Pathways) Theme aims to measurably improve the quality of care for Medicare beneficiaries who transition among care settings, through a comprehensive community effort. These efforts aim to reduce readmissions following hospitalization and to yield sustainable and replicable strategies to achieve high-value health care for sick and disabled Medicare beneficiaries. Care Transitions: The Care Transitions theme is designed to help improve coordination across the continuum of care. In particular, promote seamless transitions from the hospital to home, home health care, or skilled nursing care. Some QIOs will also work to help reduce unnecessary readmissions to hospitals of Medicare beneficiaries that may increase risk or harm patients and cost the Medicare program.  Under Care Transitions, CMS will look to QIOs to implement projects that effectuate process improvements that address issues in medication management, post-discharge follow-up, and plans of care for patients who move across healthcare settings.  The QIOs will lead projects that focus on designing: 1) changes that impact a hospital or a community at-large; 2) changes that impact processes of care for patients with specific diseases (such as heart failure or pneumonia); and 3) changes that target specific reasons for re-hospitalizations. Care Transitions: The Care Transitions theme is designed to help improve coordination across the continuum of care. In particular, promote seamless transitions from the hospital to home, home health care, or skilled nursing care. Some QIOs will also work to help reduce unnecessary readmissions to hospitals of Medicare beneficiaries that may increase risk or harm patients and cost the Medicare program.  Under Care Transitions, CMS will look to QIOs to implement projects that effectuate process improvements that address issues in medication management, post-discharge follow-up, and plans of care for patients who move across healthcare settings.  The QIOs will lead projects that focus on designing: 1) changes that impact a hospital or a community at-large; 2) changes that impact processes of care for patients with specific diseases (such as heart failure or pneumonia); and 3) changes that target specific reasons for re-hospitalizations.

    33. Interventions Aim of QIO work under Care Transitions Theme Improve Medicare beneficiary transitions from hospitals to other care settings through a comprehensive community effort Three general strategies of intervention Hospital and community system-wide Interventions that target specific diseases or conditions Interventions that target specific reasons for readmission

    34. Continuity Assessment Record and Evaluation (CARE) Develop a uniform assessment instrument to measure and compare Medicare beneficiaries’ health and functional status across settings, over time Develop and test the instrument’s usefulness in a three-year demonstration starting in 2008 Uniform assessment instrument Standardized data collection vehicle Internet-based, interoperable Rapid communication of critical information

    35. 9th SOW: Measure Level Care Transitions (10 measures) Four types of re-hospitalization rates Two patient assessments of hospital discharge performance using the Hospital Consumer Assessment of Healthcare Providers and Systems (H-CAHPS) One physician visit post discharge, before re-admission (within 30 days) Two measures with CARE instrument One measure of adoption of interventions

    36. Beneficiary Protection Statutorily Mandated Case Review Activities Are the items and/or services reasonable and medically necessary Do the quality of services meet professionally recognized standards of care Are services being provided in the appropriate and most economical setting Protecting Beneficiaries: Under the 9th SOW, QIOs will continue to carry out statutorily mandated review activities, such as: ·      Reviewing quality of care provided to beneficiaries; ·      Reviewing beneficiary appeals of certain provider notices;   ·      Reviewing potential anti-dumping cases (under the Emergency Medical Treatment and Active Labor Act); and ·      Implementing other quality improvement activities. In the 9th SOW, QIOs will be increasing their efforts to link case review activities to improvements in the quality of care, specifically by developing quality improvement activities focused on system-wide changes.  These activities will be aimed at using the data available from these case review activities to determine potential problems in quality of care, and then designing programs aimed at helping providers to address these problems.  Protecting Beneficiaries: Under the 9th SOW, QIOs will continue to carry out statutorily mandated review activities, such as: ·      Reviewing quality of care provided to beneficiaries; ·      Reviewing beneficiary appeals of certain provider notices;   ·      Reviewing potential anti-dumping cases (under the Emergency Medical Treatment and Active Labor Act); and ·      Implementing other quality improvement activities. In the 9th SOW, QIOs will be increasing their efforts to link case review activities to improvements in the quality of care, specifically by developing quality improvement activities focused on system-wide changes.  These activities will be aimed at using the data available from these case review activities to determine potential problems in quality of care, and then designing programs aimed at helping providers to address these problems. 

    37. Mandatory Review Activities Utilization review Quality of care review Review of beneficiary appeals of certain provider notices (Grijalva, Benefits Improvement and Protection Act of 2000 (BIPA), Weichardt) Review of potential Emergency Medical Treatment & Labor Act (EMTALA) cases

    38. Other Case Review Activities Quality Improvement Activities (QIAs) Alternative Dispute Resolution (ADR) Sanction activities Collaboration with CMS contractors Transparency through reporting Quality data reporting Communication

    39. 9th SOW: Measure Level Beneficiary Protection (four measures) Timely completion of case reviews Beneficiary satisfaction with complaint process Completion of satisfaction survey Percent of QIA completion, based upon confirmed quality of care complaints and concerns

    40. Ways to Think of the 9th SOW Levels 4 Themes to 59 Measures, and beyond Topic-oriented, not setting oriented Cross-cutting themes (HIT, disparities, and VDHC) Outcomes oriented (44 Final Measures) Patient-centered 245,000 more patients screened for CKD 40,000 fewer pressure ulcers 20,000 more adult immunizations provided What will change? (Old work compared to new work) What will not be automatic? (National compared to sub-national tasks)

    41. Old Work Compared to New Work Theme by Theme Prevention Mammography Influenza vaccination Pneumococcal pneumonia vaccination Colorectal cancer screening CKD Focused disparities reduction Prevention: QIOs will work with consumers, physicians and other caregivers to refine care delivery systems to make sure patients get the right care at the right time, particularly patients from underserved populations.  Health care disparities, including geographic disparities, are significant and increasing in the Medicare population.  In the 9th SOW, QIOs will be focusing on reducing health care disparities for Medicare beneficiaries with diabetes.  The QIOs will be using evidence-based methods to improve primary care physicians’ adherence to recommended national clinical standards of diabetes care.   The organizations will also work closely with physicians and physician practices to encourage the use of secure and interoperable electronic health records.  These practices will all report regularly from their electronic health records systems the practices’ adherence to recommended guidelines for adult immunization of the Medicare population, as well as two cancer screening tests (colorectal carcinoma screening and mammography).   QIOs will work to help improve vaccination rates for flu and pneumonia, increase the early identification and reduce the progression of chronic kidney disease, encourage the use of colorectal cancer screening and mammography, and support provider adoption of secure and interoperable electronic health records.  They will analyze the impact that their prevention efforts have on the number of Medicare claims submitted for vaccinations, urine tests to detect kidney malfunction, and cancer screening tests, as well as the number of prescriptions filled for kidney patients for certain types of drugs for high blood pressure that may help to prevent the progression of the disease. Prevention a. CORE QIOs will work with physician offices to improve utilization of preventive services. – Adult Immunization – Cancer Screening Builds on 8th SOW activity to encourage adoption of EHRs in physician offices (Doctors Office Quality-Information Technology - DOQ-IT & DOQ-IT University) b. Disparities • Disparity reduction will be part of the entire contract, but also • Focused Disparity Reduction Project: – QIO work will address proper preventive care for the diabetic population • HbA1C test according to guidelines • Diabetic retinopathy eye exams according to guidelines • Lipid testing according to guidelines c. Chronic Kidney Disease (CKD) • Increase the detection and decrease the progression of Chronic Kidney Disease (CKD) • QIOs will work with the health care community to: – Ensure timely testing to increase the detection and treatment of early stage CKD – Slow disease progression by use of angiotensin converting enzyme (ACE) inhibitor and/or angiotensin receptor blocking (ARB) agent – Encourage the appropriate use of arteriovenous (AV) fistulas for dialysis accessPrevention: QIOs will work with consumers, physicians and other caregivers to refine care delivery systems to make sure patients get the right care at the right time, particularly patients from underserved populations.  Health care disparities, including geographic disparities, are significant and increasing in the Medicare population.  In the 9th SOW, QIOs will be focusing on reducing health care disparities for Medicare beneficiaries with diabetes.  The QIOs will be using evidence-based methods to improve primary care physicians’ adherence to recommended national clinical standards of diabetes care.   The organizations will also work closely with physicians and physician practices to encourage the use of secure and interoperable electronic health records.  These practices will all report regularly from their electronic health records systems the practices’ adherence to recommended guidelines for adult immunization of the Medicare population, as well as two cancer screening tests (colorectal carcinoma screening and mammography).   QIOs will work to help improve vaccination rates for flu and pneumonia, increase the early identification and reduce the progression of chronic kidney disease, encourage the use of colorectal cancer screening and mammography, and support provider adoption of secure and interoperable electronic health records.  They will analyze the impact that their prevention efforts have on the number of Medicare claims submitted for vaccinations, urine tests to detect kidney malfunction, and cancer screening tests, as well as the number of prescriptions filled for kidney patients for certain types of drugs for high blood pressure that may help to prevent the progression of the disease. Prevention a. CORE QIOs will work with physician offices to improve utilization of preventive services. – Adult Immunization – Cancer Screening Builds on 8th SOW activity to encourage adoption of EHRs in physician offices (Doctors Office Quality-Information Technology - DOQ-IT & DOQ-IT University) b. Disparities • Disparity reduction will be part of the entire contract, but also • Focused Disparity Reduction Project: – QIO work will address proper preventive care for the diabetic population • HbA1C test according to guidelines • Diabetic retinopathy eye exams according to guidelines • Lipid testing according to guidelines c. Chronic Kidney Disease (CKD) • Increase the detection and decrease the progression of Chronic Kidney Disease (CKD) • QIOs will work with the health care community to: – Ensure timely testing to increase the detection and treatment of early stage CKD – Slow disease progression by use of angiotensin converting enzyme (ACE) inhibitor and/or angiotensin receptor blocking (ARB) agent – Encourage the appropriate use of arteriovenous (AV) fistulas for dialysis access

    42. Old Work Compared to New Work Theme by Theme (continued) Patient Safety Pressure ulcers (New: hospital setting) Physical restraints SCIP Drug safety Focused MRSA work Patient Safety: QIOs will build on current efforts and best practices of other QIOs to reduce avoidable pressure ulcers and use of physical restraints in nursing homes to improve the quality of care for beneficiaries in these facilities.   Surgical care improvement, reducing the incidence of drug-resistant staph infections in hospitals, and improving drug safety are also key elements in the new SOW.   QIOs will help specific facilities—nursing homes and hospitals—in need of improvement on specific quality measures posted at Nursing Home Compare and Hospital Compare at www.medicare.gov or www.hospitalcompare.hhs.govrespectively.    Under the 9th SOW, QIOs will concentrate their efforts on facilities with the greatest opportunity for improvement in each individual measure.  CMS has identified these hospitals and nursing homes, and has published this list on its website as part of the 9th SOW proposal solicitation process.   By posting information about these facilities, CMS strengthens its commitment to increasing the transparency of information available to consumers in the healthcare market by providing the public with the information needed to make informed choices about health care.  More importantly, CMS addresses one of the IOM’s key recommendations for improving the QIO Program—prioritizing program resources so QIOs can help providers who demonstrate the greatest need to partner with QIOs to improve the quality of care available to beneficiaries.  In addition to those facilities identified by CMS, QIOs will also have the opportunity to choose 15 percent of facilities based on the QIOs’ own criteria, which will also be part of their 9th SOW proposals.  CMS expects many QIOs will select these facilities based on other criteria; for example, facilities that have already made great improvement or can share “best practices” in the required measures.  “Best practices” may be management or technical approaches to patient care that have been shown to either result in improvement in quality, or the sustained attainment of benchmark performance in any particular measure.  Patient Safety: QIOs will build on current efforts and best practices of other QIOs to reduce avoidable pressure ulcers and use of physical restraints in nursing homes to improve the quality of care for beneficiaries in these facilities.   Surgical care improvement, reducing the incidence of drug-resistant staph infections in hospitals, and improving drug safety are also key elements in the new SOW.   QIOs will help specific facilities—nursing homes and hospitals—in need of improvement on specific quality measures posted at Nursing Home Compare and Hospital Compare at www.medicare.gov or www.hospitalcompare.hhs.govrespectively.    Under the 9th SOW, QIOs will concentrate their efforts on facilities with the greatest opportunity for improvement in each individual measure.  CMS has identified these hospitals and nursing homes, and has published this list on its website as part of the 9th SOW proposal solicitation process.   By posting information about these facilities, CMS strengthens its commitment to increasing the transparency of information available to consumers in the healthcare market by providing the public with the information needed to make informed choices about health care.  More importantly, CMS addresses one of the IOM’s key recommendations for improving the QIO Program—prioritizing program resources so QIOs can help providers who demonstrate the greatest need to partner with QIOs to improve the quality of care available to beneficiaries.  In addition to those facilities identified by CMS, QIOs will also have the opportunity to choose 15 percent of facilities based on the QIOs’ own criteria, which will also be part of their 9th SOW proposals.  CMS expects many QIOs will select these facilities based on other criteria; for example, facilities that have already made great improvement or can share “best practices” in the required measures.  “Best practices” may be management or technical approaches to patient care that have been shown to either result in improvement in quality, or the sustained attainment of benchmark performance in any particular measure. 

    43. Old Work Compared to New Work Theme by Theme (continued) Care Transitions (entire program) Beneficiary Protection Increasing linkage of case review to quality of care Emphasis on improved efficiency in the case review process Care Transitions: The Care Transitions theme is designed to help improve coordination across the continuum of care. In particular, promote seamless transitions from the hospital to home, home health care, or skilled nursing care.   Some QIOs will also work to help reduce unnecessary readmissions to hospitals of Medicare beneficiaries that may increase risk or harm patients and cost the Medicare program.  Under Care Transitions, CMS will look to QIOs to implement projects that effectuate process improvements that address issues in medication management, post-discharge follow-up, and plans of care for patients who move across healthcare settings.  The QIOs will lead projects that focus on designing: 1) changes that impact a hospital or a community at-large; 2) changes that impact processes of care for patients with specific diseases (such as heart failure or pneumonia); and 3) changes that target specific reasons for re-hospitalizations. Protecting Beneficiaries: Under the 9th SOW, QIOs will continue to carry out statutorily mandated review activities, such as: ·      Reviewing quality of care provided to beneficiaries; ·      Reviewing beneficiary appeals of certain provider notices;   ·      Reviewing potential anti-dumping cases (under the Emergency Medical Treatment and Active Labor Act); and ·      Implementing other quality improvement activities.   In the 9th SOW, QIOs will be increasing their efforts to link case review activities to improvements in the quality of care, specifically by developing quality improvement activities focused on system-wide changes.  These activities will be aimed at using the data available from these case review activities to determine potential problems in quality of care, and then designing programs aimed at helping providers to address these problems.  Care Transitions: The Care Transitions theme is designed to help improve coordination across the continuum of care. In particular, promote seamless transitions from the hospital to home, home health care, or skilled nursing care.   Some QIOs will also work to help reduce unnecessary readmissions to hospitals of Medicare beneficiaries that may increase risk or harm patients and cost the Medicare program.  Under Care Transitions, CMS will look to QIOs to implement projects that effectuate process improvements that address issues in medication management, post-discharge follow-up, and plans of care for patients who move across healthcare settings.  The QIOs will lead projects that focus on designing: 1) changes that impact a hospital or a community at-large; 2) changes that impact processes of care for patients with specific diseases (such as heart failure or pneumonia); and 3) changes that target specific reasons for re-hospitalizations. Protecting Beneficiaries: Under the 9th SOW, QIOs will continue to carry out statutorily mandated review activities, such as: ·      Reviewing quality of care provided to beneficiaries; ·      Reviewing beneficiary appeals of certain provider notices;   ·      Reviewing potential anti-dumping cases (under the Emergency Medical Treatment and Active Labor Act); and ·      Implementing other quality improvement activities.   In the 9th SOW, QIOs will be increasing their efforts to link case review activities to improvements in the quality of care, specifically by developing quality improvement activities focused on system-wide changes.  These activities will be aimed at using the data available from these case review activities to determine potential problems in quality of care, and then designing programs aimed at helping providers to address these problems. 

    44. Matching the Scope to Resources Available National Implementation Sub-national Implementation CKD Focused Disparities Care Transitions Theme Special Projects 9th SoW Contract Structure: Core QIO Work • National Work (all QIOs) – Beneficiary Protection – Core Prevention (Adult Immunization & Cancer Screening) – Patient Safety (as determined by need) • Sub-national Work (select QIOs) – CKD (Prevention Theme) and Care Coordination/Patient Pathways (entire Theme) • Must be the designated QIO in the State to conduct this work. • Prevention: Disparities Focus (33 QIOs based on State need)9th SoW Contract Structure: Core QIO Work • National Work (all QIOs) – Beneficiary Protection – Core Prevention (Adult Immunization & Cancer Screening) – Patient Safety (as determined by need) • Sub-national Work (select QIOs) – CKD (Prevention Theme) and Care Coordination/Patient Pathways (entire Theme) • Must be the designated QIO in the State to conduct this work. • Prevention: Disparities Focus (33 QIOs based on State need)

    45. National Compared to Sub-national First, consider the new work Care Coordination: Sub-national CKD: Sub-national Pressure Ulcer Work (in hospitals): National Focused MRSA Work: National

    46. National Compared to Sub-national (continued) Review of old work Cancer Screening and Adult Immunization: National Focused Disparity Reduction: Sub-national Patient Safety Work: National Beneficiary Protection Work: National

    47. Special Initiative/Project Funding Projects essential to the following goals Advance quality improvement and beneficiary protection work with a focus on implementation in the 10th SOW Advance 9th SOW efforts Management objectives CMS will more aggressively prioritize and manage special projects and results (higher efficiency) Track and maintain project results and evaluation Obtain results in time for 10th SOW Implementation (minimum one year in advance) Link all projects to overall measurement strategy

    48. Sample of 9th SOW Proposed Special Projects Use of EHR to improve access and quality of care for minority health Use of electronic prescribing technology to eliminate Adverse Drug Events (ADEs), reduce polypharmacy, and increase rate of generic medication prescription Preventive and chronic care quality improvement initiatives in Medicare Advantage Programs

    49. Cross-Cutting Priorities in 9th SOW Reducing Health Care Disparities Promoting use of HIT Value-Driven Health Care

    50. The CMS Strategy to Reduce Health Care Disparities Data Find affected individuals Providers Sensitize providers (continued work from the 8th SOW) Interventions Use proven interventions, develop effective partnerships, and help CMS programs be responsive to need Messaging Get the message out

    51. HIT Potential benefits of broad use of HIT Improve health care quality Prevent medical errors Reduce health care costs Increase administrative efficiencies Decrease paperwork Expand access to affordable care Improve tracking of chronic disease management http://www.hhs.gov/healthit/ Health information technology (Health IT) allows comprehensive management of medical information and its secure exchange between health care consumers and providers. Health information technologies can be tools that help individuals maintain their health through better management of their health information. Health IT will help consumers gather all of their health information in one place so they can thoroughly understand it and share it securely with their health care providers so they get the care that best fits their individual needs. Health IT can help to improve public health one individual at a time by building partnerships between health care consumers and providers across the country. Health information technology (Health IT) allows comprehensive management of medical information and its secure exchange between health care consumers and providers. Health information technologies can be tools that help individuals maintain their health through better management of their health information. Health IT will help consumers gather all of their health information in one place so they can thoroughly understand it and share it securely with their health care providers so they get the care that best fits their individual needs. Health IT can help to improve public health one individual at a time by building partnerships between health care consumers and providers across the country.

    52. Value-Driven Health Care Four Cornerstones Interoperable HIT Measure and publish quality information Measure and publish price information Promote quality and efficiency of care (e.g., Value-Based Purchasing) http://www.hhs.gov/valuedriven/ Four Cornerstones The Executive Order is intended to ensure that health care programs administered or sponsored by the federal government build on collaborative efforts to promote four cornerstones for health care improvement: Interoperable Health Information Technology (Health IT Standards): Interoperable health information technology has the potential to create greater efficiency in health care delivery.  Significant progress has been made to develop standards that enable health information systems to communicate and exchange data quickly and securely to protect patient privacy.  Additional standards must be developed and all health care systems and products should meet these standards as they are acquired or upgraded.   Measure and Publish Quality Information (Quality Standards): To make confident decisions about their health care providers and treatment options, consumers need quality of care information.  Similarly, this information is important to providers who are interested in improving the quality of care they deliver.  Quality measurement should be based on measures that are developed through consensus-based processes involving all stakeholders, such as the processes used by the AQA (multi-stakeholder group focused on physician quality measurement) and the Hospital Quality Alliance. Measure and Publish Price Information (Price Standards): To make confident decisions about their health care providers and treatment options, consumers also need price information.  Efforts are underway to develop uniform approaches to measuring and reporting price information for the benefit of consumers.  In addition, strategies are being developed to measure the overall cost of services for common episodes of care and the treatment of common chronic diseases.  Promote Quality and Efficiency of Care (Incentives): All parties - providers, patients, insurance plans, and payers - should participate in arrangements that reward both those who offer and those who purchase high-quality, competitively-priced health care.  Such arrangements may include implementation of pay-for-performance methods of reimbursement for providers or the offering of consumer-directed health plan products, such as account-based plans for enrollees in employer-sponsored health benefit plans. Four Cornerstones The Executive Order is intended to ensure that health care programs administered or sponsored by the federal government build on collaborative efforts to promote four cornerstones for health care improvement: Interoperable Health Information Technology (Health IT Standards): Interoperable health information technology has the potential to create greater efficiency in health care delivery.  Significant progress has been made to develop standards that enable health information systems to communicate and exchange data quickly and securely to protect patient privacy.  Additional standards must be developed and all health care systems and products should meet these standards as they are acquired or upgraded.   Measure and Publish Quality Information (Quality Standards): To make confident decisions about their health care providers and treatment options, consumers need quality of care information.  Similarly, this information is important to providers who are interested in improving the quality of care they deliver.  Quality measurement should be based on measures that are developed through consensus-based processes involving all stakeholders, such as the processes used by the AQA (multi-stakeholder group focused on physician quality measurement) and the Hospital Quality Alliance. Measure and Publish Price Information (Price Standards): To make confident decisions about their health care providers and treatment options, consumers also need price information.  Efforts are underway to develop uniform approaches to measuring and reporting price information for the benefit of consumers.  In addition, strategies are being developed to measure the overall cost of services for common episodes of care and the treatment of common chronic diseases.  Promote Quality and Efficiency of Care (Incentives): All parties - providers, patients, insurance plans, and payers - should participate in arrangements that reward both those who offer and those who purchase high-quality, competitively-priced health care.  Such arrangements may include implementation of pay-for-performance methods of reimbursement for providers or the offering of consumer-directed health plan products, such as account-based plans for enrollees in employer-sponsored health benefit plans.

    53. Support for QIOs before and during the 9th SOW: Quality Improvement Organization Support Contractors (QIOSC)

    54. QIOSC-like Entities Currently in Preparation Core Functions 1. Beneficiary Protection 2. Patient Safety 3. Prevention a. Core b. Disparities c. CKD 4. Care Transitions

    55. What’s in it for Beneficiaries? 245,000 more patients screened for CKD 39,616 fewer pressure ulcers in NH 3,687 fewer pressure ulcers in hospitals 23,610 fewer physical restraints in NH 7,875 fewer antibiotic-resistant infections 14,252 lives saved from postoperative complications in hospitals

    56. Summary 9th SOW now planned Measurement system (final and interim), support system structure, list of possible special studies Evaluation strategy has been worked out in advance with quantitative targets and some control groups Higher degree of competition has been introduced (sub-national deployment) Monitoring now has greater transparency and involves both DHHS and Office of Management and Budget (OMB) regularly through contract

    57. Summary (continued) Interventions are linked to measures Independent outside evaluation contractor will be engaged from the beginning Final independent program evaluation report at end of contract New management strategies will be applied to continuous contract oversight, encouraging high performance throughout the contract period New contract responsive to all external stakeholders

    58. Our goals are to prevent illness, decrease harm to patients, and reduce waste in health care

    59. QUESTIONS? Roland A. Grieb, MD, MHSA rgrieb@inqio.sdps.org (812) 234-1499 Extension: 221 This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization (QIO) for Indiana, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-IN-GENE-08-17 03/14/2008

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