Transcript ENTERPRISE DATA CENTER TRANSITION STRATEGY

Medicare Advantage Quality Improvement Project
Medicare Advantage Industry Training
Jaya Ghildiyal
and
Vanessa Sammy
Medicare Drug and Health Plan Contract Administration
Group
April 11, 2012
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Objectives
• Identify requirements of the Quality Improvement (QI)
Program
• Identify requirements of a Quality Improvement Project
(QIP)
• Describe how QIPs improve health outcomes and quality of
care
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Objectives -2• Describe the role of the Regional Office Account Managers
• Describe the QIP submission process
• Describe the QIP reporting tool
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Presentation Overview: Part I
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QI Program Overview
Background on QIP Required Topic
Partnership for Patients Initiative
Overview of QIP Development & Evaluation
Case Studies
Discussion
Brief break/Stretch
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Presentation Overview: Part II
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Role of the Regional Office (RO) Account Managers
QIP Reporting & Submission Process
Plan, Do, Study, Act (PDSA) Framework
Review QIP Reporting Tool
Wrap up & Questions
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Quality Improvement (QI)
Program Overview
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Quality Improvement (QI) Program
• 42 Code of Federal Regulations (CFR)
§ 422.152
• Applies to all MAOs, including SNPs
• Serves to integrate and coordinate all of the assessment
tools and reporting requirements
• Seven components of the QI Program
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Components of the QI Program
1. Chronic Care Improvement Program (CCIP)
• Meets requirements at 42CFR §422.152(c)
• Addresses populations that CMS identifies by reviewing
current quality performance
2. Quality Improvement Projects (QIPs)
• Meets requirements at 42CFR §422.152(d)
• Expected to favorably affect health outcomes and enrollee
satisfaction
• Address areas identified by CMS
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Components of the QI Program -23. Develop and maintain a health information system
4. Encourage providers to participate in CMS and Health
&Human Services (HHS) QI initiatives
5. Contract with an approved Medicare CAHPS vendor to
conduct the Medicare CAHPS satisfaction survey
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Components of the QI Program -36. Include a program review process for the formal evaluation
of the QI Program that addresses at least the following
areas on an annual basis:
• Impact
• Effectiveness
7. Take remedial action to correct problems identified using
ongoing quality improvement
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Defining Quality
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BACKGROUND
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Background
• Identified need to improve reporting tools for both the CCIPs
and the QIPs
• Follow the QI cycle of Plan, Do, Study, Act
• More focused on interventions and outcomes
• Participate in national health initiatives
• CCIPs must be clinical
• QIPs may be clinical or non-clinical
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Background -2• CMS is involved in several important Department of Health
& Human Services (HHS) Initiatives
• Want to ensure that our beneficiaries enrolled in the
Medicare Advantage (MA) program have the opportunity to
benefit from these initiatives
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QI Program Alignment with HHS Initiatives
• Aligning the MA QI program with the HHS quality initiatives:
• Partnership for Patients QIP
,
• Million Hearts Initiative CCIP
• The Quality Improvement Project is an important tool
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Required Quality Improvement Project
• In 2011, HEDIS® introduced a new measure on plan allcause readmission rates
• In 2012, CMS is requiring a QIP focused on decreasing
hospital readmissions
• Supports the national HHS initiative—Partnership for
Patients
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PARTNERSHIP FOR PATIENTS
INITIATIVE
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Goals of Partnership for Patients
• Prevent patients from getting injured or sicker during their
care
• By the end of 2013, preventable hospital-acquired conditions
would decrease by 40% compared to 2010
• Achieving this goal would mean approximately 1.8 million
fewer injuries to patients with more than 60,000 lives saved
over three years
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Goals of Partnership for Patients -2• Help patients heal without complication
• By the end of 2013, preventable complications during a
transition from one care setting to another would be
decreased so that all hospital readmissions would be reduced
by 20% compared to 2010
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Goals of Partnership for Patients -3• Help patients heal without complication
• Achieving this goal would mean more than 1.6 million patients
would recover from illness without suffering a preventable
complication requiring re-hospitalization within 30 days of
discharge
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Key Components of Partnership for Patients
• Hospital Engagement Networks
• Comprised of 26 State, Regional, National and Hospital
System Organizations
• Required to support hospitals in making patient care safer
• Improving Care Transitions
• Care transitions are an opportunity for improvement
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Hospital Readmission Rates
• At any given time, about one in every 20 patients acquires
an infection that results from his or her hospital care
• On average, one in seven Medicare beneficiaries is harmed
in the course of his or her care, costing the government an
estimated $4.4 billion every year
Source: Partnership for Patients
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Hospital Readmission Rates -2• Nearly one in five Medicare patients discharged from the
hospital is readmitted within 30 days
• That’s approximately 2.6 million seniors at a cost of over
$26 billion every year
Source: Partnership for Patients
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Joining the Partnership
Join the Partnership for Patients at:
http://www.healthcare.gov/compare/partnershipfor-patients/join/index.html
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OVERVIEW OF QIP DEVELOPMENT &
EVALUATION
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Steps To Developing a QIP
Identify the potential target of opportunity
Synthesize information about optimal practice
Synthesize information about current practice
Identify reasons for discrepancy between current and optimal
practice
Source: Prabitha Varkey. Medical Quality Management: Theory & Practice. Jones
& Bartlett publishers, 2010.
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Steps To Developing a QIP -2-
Develop a strategy for practice improvement
Assess effectiveness & cost-effectiveness of the practice
improvement strategy
Determine whether the practice improvement strategy should
be implemented and how it can be improved
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Areas of Focus for the QIP
• The focus of the QIP can be to yield improvements in any or
all of the following areas:
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Functional
Clinical
Satisfaction
Costs
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Areas of Focus for the QIP
Functional
•Physical Function
•Mental Health
•Social Role
•Other (e.g., pain, health risk)
Satisfaction
•Health Care
Delivery
•Perceived Benefit
Clinical
•Mortality
•Morbidity
•Complications
Costs
•Direct Medical
•Indirect Social
Source: Prabitha Varkey. Medical Quality Management: Theory & Practice. Jones & Bartlett
publishers, 2010.
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QUALITY IMPROVEMENT PROJECT
CASE STUDY
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Identify the Potential Target of Opportunity
• Developing the focus of the QIP (may be clinical or nonclinical):
• Pressure ulcers are among the most frequent of hospitalacquired conditions and the MAO has identified this as a
recurring reason cited for hospital readmissions
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Synthesize Information About Optimal Practice
• Rationale for Selection:
• Evidence based guidelines inform us that pressure ulcers in
Stages III and IV put patients at significant risk for infection
that can potentially result in death
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Synthesize Information About Current Practice
• Developing the Target Goal:
• The MAO has identified the target population and believes that
enhanced post-discharge follow-up and patient education
regarding wound care can prevent 50% of pressure ulcers
from exacerbating and leading to complications that cause
hospital readmission
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Synthesize Information About Current Practice -2• The goal is to ensure that members of the target population
and their caregivers understand instructions for wound selfcare, recognize symptoms that signify potential
complications requiring immediate attention, and make and
keep follow-up appointments with their primary care
physicians (PCP)
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Identify Reasons for Discrepancy Between Current & Optimal
Practice
• Planning the Intervention:
• The MAO identified that, after hospital discharge, members of
their target population were not currently scheduling follow-up
appointments with their PCPs to monitor pressure ulcers
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Develop A Strategy For Practice Improvement
• Doing the Intervention:
• The MAO chose to send discharged patients and their
caregivers educational materials on the importance of
scheduling follow-up appointments with PCPs to monitor
pressure ulcer wounds
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Assess Effectiveness of the Practice Improvement Strategy
• Studying the Intervention:
• The MAO found that the interventions were able to reduce
25% of the most dangerous pressure ulcer complications that
lead to hospital readmission
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Determining How Practice Improvement Strategy Can Be
Improved
• Developing Next Steps:
• The MAO found that the interventions were able to reduce
25% of hospital readmissions caused by dangerous pressure
ulcer complications, but fell short of the target goal of a 50%
reduction in pressure ulcer-related readmissions
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Determining How Practice Improvement Strategy Can Be
Improved -2• After further review, the MAO decided to adjust its original
intervention to include additional actions focused on increasing
members’ PCP visits for follow-up monitoring of pressure
ulcers
• In addition to mailing information on the importance of followup with their PCP, the MAO started making phone calls to
patients and caregivers to remind/assist them with scheduling
follow-up appointments
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DISCUSSION
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Brief Break/Stretch
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WORKING WITH CMS
REGIONAL OFFICE (RO) ACCOUNT
MANAGERS (AMs)
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Regional Office (RO) Account Managers (AMs)
• Will provide day-to day monitoring of the QI Program
• Provide technical assistance (TA) to health plans to improve
their overall QI program
• Review and approve the Plan Sections of the CCIPs and the
QIPs
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QIP SUBMISSION PROCESS
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CY 2011 QIP Submissions
• The QIPs are based on their quality improvement projects
from CY 2011
• Reported through HPMS using the new template
• Submitted from May 1-15, 2012
• Scored by a contractor
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CY 2012 QIP Submissions
• The QIPs submitted later this Spring are based the planned
quality improvement project for CY2012
• Reported through HPMS using the new template
• Submitted in two sections
• Plan section due June 11-July 31
• Do-Study-Act sections will be required to be
submitted in early 2013
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CY 2012 QIP Submissions -2• MAOs must work with the AMs to have the Plan section
approved
• Plans cannot begin QIP without the AMs approval
• AMs will review and approve/deny the CY2012 QIP “Plan”
Section by July 31
• Completed within HPMS using new template
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QIP REPORTING PROCESS
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Plan-Do-Study-Act (PDSA) Quality Model
• “Plan”
Identify the potential target of opportunity, plan the project
• “Do”
Implementation of the project
• “Study”
Data collection and analysis
• “Act”
Next Steps
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Quality Improvement PDSA
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REVIEW OF THE QIP
REPORTING TOOL
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QIP Reporting Tool in PDSA Model
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
Data Sources used for Problem Identification
Basis for Selection
[QIP Description] [Anticipated Outcome] [Rationale for Selection]
“PLAN”
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Project Goal and Benchmark
[Anticipated Barriers]

“DO”
[Risk Assessment]
Project Implementation, Review, and Revisions
[Barriers Encountered]
[Mitigation Plan for Risk Assessment]
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QIP Reporting Tool in PDSA Model -2-
“STUDY”
“ACT”

Results
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Summary of Findings & Conclusions
Root Cause Analysis Description (Goal/Progress Not
Achieved)
Action Plan Description
Next Steps
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
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THE “PLAN” SECTION
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Key Elements of “PLAN” Section
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Data Sources Used for Problem Identification
Basis for Selection
Prior Focus
Project Goal & Benchmark
CMS Regional Office Approval
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Data Sources
• Section is not scored but critical to the development of the
QIP
• MAOs may chose to use data sources other than the ones
listed in the QIP reporting tool
• Incorporate information into the QIP from as many of the
data sources as appropriate
• Understand the link between the data and the QIP
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Basis for Selection
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A1. Description of the QIP
A2. Impact on Member
A3. Anticipated Outcomes
A4. Rationale for Selection
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A1. Description of the QIP
• Identify the problem or opportunity for improvement
• Describe the methodology the plan will use to determine
problems/opportunities
• Describe the data sources used to determine the QIP
• Include specific timeframes & percentages, where
applicable
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A2. Impact on the Member
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Describe whether the QIP impacts the MA population by:
• Improving health outcomes;
• Improving member satisfaction; or
• Both
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A3. Anticipated Outcomes
• The expected outcome of the program
• How the members will be impacted by the outcome
• A brief description of the evidence based guidelines
considered and how these will be effective in producing
improved health outcomes
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A4. Rationale for Selection
• The rationale for selecting the specific problem or
opportunity for improvement
• How the data sources showed the gap in the current care
that confirms the need for a specialized program
• Incidence and/or prevalence of the disease within the MA
Plan population supported by the data sources
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Prior Focus
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Optional
Describes the outcome achieved and priority assessed
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Project cycle year
Intervention(s) implemented
Outcomes achieved
Priority Assessed
Specific to each intervention
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Project Goal & Benchmark
• A1. Target Goal
• A2. Risk Assessment
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A1. Target Goal & Benchmark
• How the project is relevant to the MA Plan population
through incidence and/or prevalence of the disease
• The impact the problem currently has on the members
• How addressing the problem will demonstrate improvement
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A1. Target Goal & Benchmark -2•
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A1(a). Target Goal
A1(b). Benchmark
A1(c). Rationale
A1(d). Planned Intervention
A1(e). Inclusion Criteria
A1(f). Methodology
A1(g). Timeframe
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A1(a). Target Goal
• A goal that is specific and relevant to the program
• The evidence or factors considered that show how
achieving the goal will impact health outcomes
• How the goal is measureable and attainable in the set
timeframe
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A1(b). Benchmark
• A valid, reliable benchmark that is relevant to the goal of the
program
• How it relates to the demographics of the target population
• How use of it reflects the complexity of the disease state the
program is targeting
• The current date of the benchmark
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A1(c). Rationale
• The reason the specific intervention was chosen
• How it relates to the goal and benchmark
• The factors or evidence considered when developing the
intervention that demonstrates its validity
• How health outcomes are anticipated to be impacted
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A1(d). Planned Intervention
• The planned intervention
• How it is measureable and capable of effecting improved
health outcomes
• How the intervention relates to the goal
• How it is sustainable over time
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A1(e). Inclusion Criteria
• Describe how members of the enrollee population were
included and/or excluded for the purposes of identifying the
target population
• Example: Incidence rate among the members related to the
inclusion criteria
• Example: Demographic and clinical variables used to identify
members appropriate for inclusion in the program
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A1(f). Measurement Methodology
• The specific valid and reliable data that will be collected to
track improvement
• How the identified measurement relates to the intervention,
the goal, and the benchmark
• The systematic method in which that data will be collected
• Frequency of data collection and analysis
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A1(g). Timeframe
• Exact beginning and ending dates for the measurement
cycle
• An explanation of how the timeline reflects an appropriate
amount of time to complete the planned intervention
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A2. Risk Assessment
• A2(a). Target Audience
• A2(b). Anticipated Barrier
• A2(c). Mitigation Plan
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A2(a). Target Audience
• Describe the target population
• Inclusion criteria
• Exclusion criteria
• Incidence rate among the members related to the inclusion
criteria
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A2(a). Target Audience -2• The illness severity level of the members included
• The demographics and clinical variables used to identify
members appropriate for inclusion in the program
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A2(b). Anticipated Barrier
• The plan must provide a description of any barriers they
think they might encounter during the QIP, and how those
barriers will prevent the goal from being reached
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A2(b). Anticipated Barrier -2-
• To identify barriers, plans can consider how the
intervention is carried out, who is involved, and at
what point the intervention may encounter
obstacles to the goal
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A2(c). Mitigation Plan
• Describes the methodology/series of steps that plans will
take to address the barriers they anticipate encountering
during the project
• Describes the target audience upon which the mitigation
plan will focus, and the expected timeframe that the
mitigation plan will adhere to in order to address the
expected barriers
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THE “DO” SECTION
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Program Implementation, Review, Revision
• A1. Education
• A1(a). Patient Self-Management
• A1(b). Provider Education
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A2. Intervention
A3. Results or Findings
A4. Barriers Encountered
A5. Mitigation Plan for Risk Assessment
A6. Anticipated Impact on the Goal and/or Benchmark
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THE “STUDY” SECTION
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Results
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A1. Goal
A2. Benchmark
A3. Timeline
A4. Dates of Implementation
A5. Sample Size or Percent of Total Population
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Results -2•
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A6. Numerator
A7. Denominator
A8. Total Percent or Results
A9. Other Data or Results
A10. Analysis of Results or Findings
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THE “ACT” SECTION
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Root Cause Analysis
• Areas to consider
• Care and Service Delivery Problems
• Contributing Factors
• Analysis should include:
• Description of the problem/incidence and its consequences
• Background & context of the incidence
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Root Cause Analysis -2• Scope of the investigation
• Information and evidence gathered
• A description of root causes that have demonstrated a
causal/strong correlative relationship with the incident
• Lessons Learned
• Recommendations
Source: National Health Service National Patient Safety Agency. “Root Cause
Analysis Investigation Tools”.
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The Next Steps
• A1. Continue the program with no changes
• A2. Continue the program with changes
• A3. Develop a QIP to study one or more aspects of the
program
• A4. Discontinue the program
• A5. Re-evaluate and change the goal or benchmark
selected
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The Next Steps -2•
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•
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A6. Expand the program
A7. Identify additional interventions
A8. Re-evaluate data and criteria
A9. Other
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Next Steps
•
Examples:
• Immediate Response and Recovery Actions
• Preventative or risk-reducing actions or solutions
• Actions for implementing, monitoring, and evaluating
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SUMMARY
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Summary
• Identify requirements of the Quality Improvement (QI)
Program
• Identify requirements of a Quality Improvement Project
(QIP)
• Describe how QIPs improve health outcomes and quality of
care
91
Summary -2• Describe the role of the Regional Office Account Managers
• Describe the QIP submission process
• Describe the QIP reporting tool
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QUESTIONS?
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Contact Information
QI Team, Medicare Drug and Health Plan Contract
Administration Group (MCAG)
Can be reached via:
[email protected]
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