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Information for this presentation was taken from the following conference materials.Centers for Medicare
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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 DHHSs 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 Medicares 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 DHHSs 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 Medicares 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 SOWEvery 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 UlcersNursing Homes and Hospitals
Physical RestraintsNursing Homes
SCIPHospitals
MRSAHospitals
Drug SafetyPhysician 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 facilitiesnursing homes and hospitalsin 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 IOMs key recommendations for improving the QIO Programprioritizing 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 facilitiesnursing homes and hospitalsin 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 IOMs key recommendations for improving the QIO Programprioritizing 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 UlcersHospitals
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 2Perioperative beta blocker
SCIP Infection 7Colorectal surgery patients with post-operative normothermia
27. Components (continued) MRSA
94,000Annual life-threatening infections
19,000Annual deaths
250Deaths 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
1Prophylactic antibiotic received within one hour prior to surgical incision
2Prophylactic antibiotic selection for surgical patients
3Prophylactic antibiotics discontinued within 24 hours after surgery end time
4Cardiac surgery patients with controlled 6 A.M. postoperative serum glucose
6Surgery patients with appropriate hair removal
7Colorectal surgery patients with immediate postoperative normothermia
31. SCIP Measures (continued) VTE
1Surgery patients with recommended venous thromboembolism prophylaxis ordered
2Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery
Cardiac
2Surgery 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 instruments 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 facilitiesnursing homes and hospitalsin 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 9thSOW, 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 IOMs key recommendations for improving the QIO Programprioritizing 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 facilitiesnursing homes and hospitalsin 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 9thSOW, 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 IOMs key recommendations for improving the QIO Programprioritizing 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 9thSOW, 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 9thSOW, 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. Whats 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
