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

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) March 20, 2008

2. Information for this presentation was taken from the following conference materials. Centers for Medicare & Medicaid Services (CMS)  Quality Improvement Organization (QIO) 9th Scope of Work (SOW) Pre-Proposal Conference January 28, 2008 Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland

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, 2007Government 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 Statement of Work: History • Priorities of the Secretary of Health and Human Services • 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 Department of Health and Human Services (DHHS)

8. 9th Statement of Work: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

9. The QIO Program Has Been Re-designed • Framework for Accountability • Content

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

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

14. 9th Statement of Work: Content4 Themes • Prevention • Patient Safety • Care Transitions/Patient Pathways • Beneficiary Protection

15. 9th Statement of Work: Content4 5 Themes • Prevention • Patient Safety • Care Transitions/Patient Pathways • Beneficiary Protection • Evaluation

16. 9th Statement of Work: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 Less detail More detail

17. 9th Statement of Work: Component Level • Prevention (3) • Core • Chronic Kidney Disease (CKD) • Focused disparities • Patient Safety (5) • Pressure Ulcers • Physical Restraints • SCIP (Surgical Care Improvement Project) • MRSA (Methicillin Resistant Staphylococcus Aureus) • Drug Safety • 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 • Chronic Kidney Disease • Disparities

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. Chronic Kidney Disease (CKD) • Optional competitive task • Will be awarded to a subset of QIOs • CKD Proposal is to be included in overall response to the QIO 9th SOW

23. Chronic Kidney Disease Goals • Timely testing to reduce rate of kidney failure due to diabetes • Slow progression of kidney disease in 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

24. 9th Statement of Work: 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

25. 9th Statement of Work: Measure Level (continued) • CKD • Screening for nephropathy • ACE/ARB therapy to prevent progression • AV fistula rate (new dialysis patients)

26. 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 • Nursing Homes in need of assistance with quality improvement (QI) efforts

27. 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 • SCIP Cardiac 2—Perioperative beta blocker • SCIP Infection 7—Colorectal surgery patients with post-operative normothermia

28. Components (continued) • Methicillin Resistant Staphylococcus Aureus (MRSA) • 94,000—Annual life-threatening Infections • 19,000—Annual Deaths • 250—Deaths per day • 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

29. Components (continued) • Drug safety measures • Drug-drug Interactions • Potentially inappropriate medications • Nursing Homes in need of assistance with QI efforts • Improvement in quality measures (Pressure ulcers (PrU) and physical restraints) • Nursing home satisfaction with QIO technical assistance

30. 9th Statement of Work: 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 VTE 1,2 • SCIP Cardiology 2

31. 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.

32. 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/community system wide • Interventions that target specific diseases or conditions • Interventions that target specific reasons for readmission

33. 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

34. 9th Statement of Work: Measure Level • Care Transitions (10 measures) • 4 types of re-hospitalization rates • 2 patient assessments of hospital discharge performance using the Hospital Consumer Assessment of Healthcare Providers and Systems (H-CAHPS) • 1 physician visit post discharge, before re-admission (within 30 days) • 2 measures with CARE instrument • 1 measure of adoption of interventions

35. 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

36. 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

37. 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

38. 9th Statement of Work: Measure Level • Beneficiary Protection (4 measures) • Timely completion of case reviews • Beneficiary satisfaction with complaint process • Completion of satisfaction survey • Percent of QIA completion

39. Ways to Think of the 9th Statement of Work • 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)

40. Old Work Compared to New WorkTheme by Theme • Prevention Mammography Influenza vaccination Pneumococcal pneumonia vaccination Colorectal cancer screening Chronic kidney disease Focused disparities reduction

41. Old Work Compared to New WorkTheme by Theme (continued) • Patient Safety • Pressure ulcers (New: hospital setting) • Physical restraints • SCIP • Drug safety • Focused MRSA work

42. Old Work Compared to New WorkTheme by Theme (continued) • Care Transitions (entire program) • Beneficiary Protection • Increasing linkage of case review to quality of care • Increasing awareness of complaint process among beneficiaries • Emphasis on improved efficiency in the case review process

43. Matching the Scope to Resources Available • National Implementation • Sub-national Implementation • CKD • Focused Disparities • Care Transitions Theme • Special Projects

44. 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

45. 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

46. 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

47. Sample of 9th Statement of Work 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

48. Cross-Cutting Priorities in 9th SOW • Reducing Health Care Disparities • Promoting use of Health Information Technology • Value-Driven Health Care

49. 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

50. Health Information Technology • 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/