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Medicare Advantage Quality Improvement ProjectMedicare 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

• 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

• 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 -2-

3. 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 -3-

6. 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 all-cause 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/partnership-for-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:• Functional• Clinical• Satisfaction• Costs

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Areas of Focus for the QIP

Satisfaction• Health Care

Delivery• Perceived

Benefit

Functional• Physical Function• Mental Health• Social Role• Other (e.g., pain, health

risk)

Costs• Direct Medical• Indirect Social

Clinical• Mortality• Morbidity• Complication

s

Source: Prabitha Varkey. Medical Quality Management: Theory & Practice. Jones & Bartlett publishers, 2010.

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QUALITY IMPROVEMENT PROJECTCASE STUDY

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Identify the Potential Target of Opportunity

• Developing the focus of the QIP (may be clinical or non-clinical): • Pressure ulcers are among the most frequent of hospital-

acquired 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 self-care, 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 follow-up 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 CMSREGIONAL 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

“PLAN”

• Data Sources used for Problem Identification

Basis for Selection

[QIP Description] [Anticipated Outcome] [Rationale for Selection]

Project Goal and Benchmark [Anticipated Barriers] [Risk Assessment]

“DO” Project Implementation, Review, and Revisions

[Barriers Encountered] [Mitigation Plan for Risk Assessment]

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QIP Reporting Tool in PDSA Model -2-

“STUDY” Results

“ACT” Summary of Findings & Conclusions Root Cause Analysis Description (Goal/Progress Not

Achieved) Action Plan Description Next Steps

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THE “PLAN” SECTION

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Key Elements of “PLAN” Section

• 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

• 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

• 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

• Optional• Describes the outcome achieved and priority assessed

• 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-

• 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

• 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

• A1. Goal• A2. Benchmark• A3. Timeline• A4. Dates of Implementation• A5. Sample Size or Percent of Total Population

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Results -2-

• 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-

• 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

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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:

MAQuality@cms.hhs.gov