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Core Measures October 2013

Core Measures October 2013. Division of Quality and Patient Safety NewYork-Presbyterian Hospital. What are Core Measures?. Core Measures are widely agreed upon quality metrics the federal government use to assess how well hospitals care for patients

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Core Measures October 2013

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  1. Core Measures October 2013 Division of Quality and Patient Safety NewYork-Presbyterian Hospital

  2. What are Core Measures? • Core Measures are widely agreed upon quality metrics the federal government use to assess how well hospitals care for patients • Core Measures initiative by the CMS help promote higher quality and more efficient care for Medicare beneficiaries • Impact of Core Measures • Quality of Patient Care • Reputation • Reimbursement

  3. Process of Care Measures • Measures are based on both expert opinion and evidenced based practice • Measures evaluate timeliness and effectiveness of care • Measures are endorsed by National Quality Forum • The program requires hospitals to submit data for specific measures for health conditions common among people with Medicare • Hospitals that do not participate will receive a reduction of 2.0 percent in their Medicare Annual Payment Update for fiscal year 2013

  4. What is Value Based Purchasing? • Value Based Purchasing is a program implemented by CMS in 2011 to promote better clinical outcome and patient experience of care with Pay-For-Performance • CMS will pay for care that rewards better value and patient outcomes, instead of just volume of services • Financial penalties are effective 2012 for our Core Measure performance • Current performance is compared to baseline from prior year. We are rewarded for performance based on achievement and improvement score

  5. Venous Thromboembolism New Core Measure started in Q1 2013 *Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013 Green = 90% or greater and equal to or above national average Yellow = Equal to or above national average, but below 90% OR Above 90% , but below national average Red = Below 90% and below national average Data Source: CMS Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M

  6. VTE-1: Prophylaxis • Admitted patients who: • Received VTE prophylaxis, or • Have documentation why no VTE prophylaxis was given • Timeframe: • The day of/after hospital admission, or surgery end date, for surgeries that start the day of/after admission

  7. VTE-3: Overlap Therapy • Patients diagnosed with confirmed VTE who received an overlap of parenteral (IV or SubQ) anticoagulation and warfarin therapy • Overlap should be administered for at least 5 days with an INR greater than or equal to 2 prior to discontinuation of the parenteral anticoagulant, or else: • Discharged on both medications, OR • Have a documented reason for discontinuation of parenteral anticoagulation

  8. VTE-3: Overlap Therapy • Included VTE types: • Any pulmonary embolus • Proximal lower extremity veins: Inferior vena cava; Iliac, femoral, or popliteal veins

  9. VTE-5: Discharge Instructions • Patients diagnosed with confirmed VTE that are discharged to home, home care, court/law enforcement, or home on hospice care on warfarin • Written discharge instructions must address all four criteria: • Compliance issues, • Dietary advice, • Information about the potential for adverse drug reactions/interactions • Follow-up monitoring

  10. Value Based Purchasing Core MeasuresNew Performance Period: FY2015 (Q1 2013 – Q4 2013) FY14 FY15 *Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013 Green = 90% or greater and equal to or above national average Yellow = Equal to or above national average, but below 90% OR Above 90% , but below national average Red = Below 90% and below national average Data Source: CMS Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M

  11. Acute Myocardial Infarction *Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013 Green = 90% or greater and equal to or above national average Yellow = Equal to or above national average, but below 90% OR Above 90% , but below national average Red = Below 90% and below national average Data Source: CMS Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M

  12. Heart Failure *Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013 Green = 90% or greater and equal to or above national average Yellow = Equal to or above national average, but below 90% OR Above 90% , but below national average Red = Below 90% and below national average Data Source: CMS Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M

  13. Global Immunization *Q2 and Q3 2013 data preliminary; Q2finalized after 10/25/13; Q3 finalized after 1/25/2013 Green = 90% or greater and equal to or above national average Yellow = Equal to or above national average, but below 90% OR Above 90% , but below national average Red = Below 90% and below national average Data Source: CMS Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M

  14. Perinatal Care Elective Delivery New Core Measure started in Q1 2013 *Q2 2013 data preliminary and finalized after 10/25/13. Data source: CMS Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M

  15. Stroke New Core Measure started in Q1 2013 *Q2 2013 data preliminary. Data source: CMS Privileged and Confidential Information for Quality Assurance and Performance Improvement Purposes and Protected under New York Education Law Section 6527 and Public Health Law Section 2805 J, K, L, and M

  16. Areas for Improvement • VTE-3 (Overlap Therapy) • Ensure that pts with confirmed VTE who are treated with warfarin receive at least 5 days of overlap AND have INR ≥ 2 prior to stopping overlap • OR document a reason for discontinuing overlap in the “VTE Core Measures” section of the DC Summary • VTE-5 (Warfarin Discharge Instructions) • Explicitly document how to monitor warfarin post-discharge in the “Follow-Up Appointments” or “Additional Instructions” section of the DC Summary

  17. Areas for Improvement • HF-1 (Discharge Instructions) • Explicitly document follow-up appointments with MD/PA/NP name and date (specific provider name is required) • Use of "PMD” or “Primary MD” is NOT acceptable by CMS

  18. Areas for Improvement • IMM-1 (Pneumococcal Immunization) Screening Year Round • Eligible patients: • All patients 65 or older • Patients age 5-64 with a high risk condition: • DM, ESRD, COPD, Nephrotic Syndrome, CHF, HIV, Asplenia • Asthma (for pts age 19-64) • Ensure that vaccine orders are not discontinued during transfer to another level of care • IMM-2 (Influenza Immunization) Screening Sept 1-March 31 • Eligible patients: All patients age 6 months or older • Ensure that vaccine orders are not discontinued during transfer to another level of care

  19. Core Measure Education Guide • Versions for measures relevant to your area • Infonet > Quality & PtSafety > Core Measures • infonet.nyp.org/QA/Pages/coremeasures.aspx

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