Transforming Provider Care in ACOs through Quality Improvement Programs

FLAACO Fall Conference 2014

Diane Chronis, BS, RN, CMUP Beth Kramer, RN, BSN, CPHQ

HSAG

Presentation Outline

• Health Services Advisory Group (HSAG) overview • The Quality Improvement Organization

(QIO) Program – Recent QIO Program Success – QIO Program Changes

• Quality Innovation Network (QIN-QIO) Focus Areas – Coordination of Care through Community

Coalitions

• ACO Measures Reporting Requirements

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HSAG Overview

HSAG Overview

• Committed to improving quality of healthcare for more than 35 years

• Provides quality expertise to those who deliver care and those who receive care

• Engages healthcare providers, stakeholders, Medicare patients, families, and caregivers

• Provides technical assistance, convenes learning and action networks, and analyzes data for improvement

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The QIO Program

QIO Program

Funded by the Centers for Medicare & Medicaid Services (CMS)

– Dedicated to improving health quality at the community level

– Ensures people with Medicare get the care they deserve, and improves care for everyone

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QIO Program (cont’d)

• Brings together hospitals, nursing homes, physician practices, and patient advocates – Quickens pace and broadens spread of positive

change in health quality

• Supports national priorities – U.S. Department of Health and Human Services’

National Quality Strategy – Partnership for Patients

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QIO Program (cont’d)

Aligns with the CMS Quality Strategy

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www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/CMS-Quality-Strategy.pdf

Recent QIO Program Success

QIO Program Successes

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QIO Program Changes

QIO Program Changes

• Previously, medical case review and quality improvement functions were performed by the QIO

• Effective August 1, 2014, functions now performed by different contractors – Medical case review – Quality Improvement

• Changed from three-year, state-based contracts to five-year, regional contracts

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How Does CMS Propose to Operate the QIO Program in the Future?

Program Collaboration Center

Independent Evaluation Center

Quality Innovation Network (QIN) NCC

BFCC National Coordinating Center

(NCC)

1. Outreach & Education – Hospital Inpatient, Psych, and

Cancer Facilities

Beneficiary and Family Centered Care (BFCC)

Oversight & Review Center

BFCC 1

BFCC—QIO 5 Areas

BFCC 2

BFCC 5

BFCC 3 BFCC 4

QIN—QIO

Strategic Innovation Center

Value Incentives and Quality Reporting Centers

2. Outreach & Education – ASCs

and Hospital Outpatient

3. Coordination & Policy Advisory

Contractor

4. Monitoring & Evaluation /Analytics

5. Validation Support 6. Appeals

14 Service Areas covering the

entire country

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BFCC-QIO

BFCC-QIO

• BFCC-QIOs

– New contract August 1, 2014–July 31, 2019

– Manage all beneficiary case-review activities

– Ensure consistency in review process

– Consider local factors important to beneficiaries and their families

• Livanta, LLC

• KEPRO

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QIN-QIO

QIN-QIO

• QIN-QIO – New contract August 1, 2014–July 31, 2019 – Work regionally with providers and the

community – Data-driven quality initiatives

• Key roles – Champion local-level, results-oriented change – Facilitate learning and action networks (LANs) – Teach and advise as technical experts – Communicate effectively

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QIN-QIO Framework

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HSAG: QIN-QIO

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QIN-QIO Focus Areas

QIN-QIO Focus Areas

• Improve Cardiac Health and Reducing Cardiac Healthcare Disparities – Provider Groups: Hospitals, Physician Practices &

Home Health Agencies

• Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts (EDC) – Provider Groups: Physician/Practitioner

Clinics/Offices/Practices; Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHCs)

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QIN-QIO Focus Areas (cont’d)

• Improving Prevention Coordination through Meaningful Use of Health Information Technology (HIT) – Provider Groups: Accountable Care Organizations

(ACOs) and Pioneer ACOs to recruit Eligible Professional (EPs), Eligible Hospitals (EHs) and Critical Access Hospitals (CAHs)

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QIN-QIO Focus Areas (cont’d)

• Reducing Healthcare-Associated infections in Hospitals

• Reducing Healthcare Acquired Conditions in Nursing Homes (NHs) – QIN-QIOs will work with 75% or more of the NHs

in state or 510 NHs • Coordination of Care (Prevent Readmissions)

– Community Partners: Hospitals, Home Health Agencies, Nursing Homes, Practitioners, Hospices, Long-term Services and Support (LTSS), and Pharmacies

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QIN-QIO Focus Areas (cont’d)

• Quality Improvement through Value-Based Payment, Hospital Quality Reporting, and Physician Feedback Reporting Program – Participating Providers: Inpatient Psychiatric

Facilities (IPFs); PPS-exempt Cancer Hospitals (PCHs), Inpatient and Outpatient Departments of Hospitals, Physicians, and Ambulatory Surgical Centers (ASCs)

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BFCC-QIO and QIN-QIO Coordination

Recommendations for Quality Improvement Initiatives (QIIs) and Technical Assistance

– BFCC to make recommendations to QIN-QIOs for QIIs associated with quality of care concerns

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Coordination of Care through Community Coalitions

Care Coordination: Scope of the Problem

• Avoidable readmissions and patient satisfaction with discharge-related care are recognized challenges nationwide. In Florida, more than 19 percent of Medicare fee-for-service (FFS) patients return to the hospital within 30 days of their hospital stay, costing Medicare approximately $1.2 billion.1

• This costly and quick return to the hospital indicates that there may have been a failure in the coordination of care as the patient transferred from the hospital to other care settings. Furthermore, people with Medicare coverage report greater dissatisfaction regarding discharge-related care than with any other aspect of care that Medicare measures.2

1 CMS, 2013. Part-A claims for Fee-for-Service beneficiaries. Part A Standard Analytical Table (ASAT) data file for HSAG. 2 http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html.

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30-Day All-Cause Readmission Rates

Source: ICPC Quarterly Scorecard for Florida, 1/1/2009-12/31/2013 issued 6/6/2014 from Colorado Foundation for Medical Care (CFMC) for the year 2013.

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19.14%

Source: Medicare fee-for-service claims for Florida inpatient discharges July 1, 2013 – December 31, 2013.

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30-Day All-Cause Readmissions by Regions

CMS Coordination of Care Goals

• Reduce readmission rates by 20% by 2019 • Increase medication safety through improved

quality of care coordination • Expand the length of time a beneficiary

remains in their home between hospitalizations and short-term institutional stays (community tenure)

• Increase the number of cross-setting communities to positively impact the majority of Medicare beneficiaries in the state

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“Reforms Leading to Lower Hospital Readmission

rates”

“The all-cause 30-day hospital readmission rate among Medicare fee-for-service beneficiaries held constant from 2007 to 2011. In 2012, when the Affordable

Care Act’s reforms focused on reducing avoidable readmissions kicked in, this rate began to fall. After holding steady at 19 percent from 2007 to 2011, the all-

cause 30-day hospital readmission rate among Medicare fee-for-service beneficiaries fell to 18.5 percent in 2012 … We are pleased to report that the decline in

readmission rates is continuing into 2013.”

ICPC Care Transitions

Programs Initiated

Source: the CMS Blog; http://blog.cms.gov/2013/12/06/new-data-shows-affordable-care-act-reforms-are-leading-to-lower-hospital-readmission-

rates-for-medicare-beneficiaries/ Accessed 3/31/2014

Coordination of Care: Aligning Readmission Goals

Aligning readmission goals across providers: • Patient Centered Medical Homes and Accountable

Care Organizations now report 30-day readmission rates to Agency for Healthcare Research and Quality (AHRQ) for certification.

• Physician Quality Reporting System (PQRS) will collect and report 30-day readmissions by physician.

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Coordination of Care: Aligning Readmission Goals (cont’d)

• Home health agencies now report 30-day hospital readmissions.

• Nursing facilities will report 30-day hospital readmission rates.

• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys include Care Transitions measures.

• Readmission rates will become part of value-based measures for provider groups over the next 1 - 4 years.

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Coordination of Care: Community Coalitions

Community Coalitions • Provide the community with great health care and

services through the collaboration of providers, community service organizations, payers, and others while fulfilling each organization’s mission;

• Build and strengthen communication and partnership with others in the community in an open, non-competitive forum;

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Coordination of Care: Community Coalitions (cont’d)

• Work together to develop strategies and processes to support patient’s as they move across the continuum;

• Measure the progress of efforts using data for the entire community; and

• Receive QIO support for technical assistance, resources, and data.

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Coordination of Care: HSAG Support

QIOs will support development of community coalitions that: • Define a shared, measureable, population goal for

improving care coordination in a defined geographic community;

• Support the implementation of community-level interventions that improve the coordination of care across provider settings;

• Increase medication safety in the community to prevent ADEs and reduce readmissions;

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Coordination of Care: HSAG Support (cont’d)

• Support community-specific root cause analyses identifying drivers of ineffective care transitions such as poor communication, poor patient activation, and other process deficiencies that can lead to poor outcomes, including ADEs that can lead to increased utilization of acute care services; and

• Assist the community coalition to collect data to monitor community-level interventions that demonstrate improved outcomes across various populations.

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Coordination of Care: Contact information

Contact for more information about joining a Community Coalitions:

Beth Kramer

ekramer@HSAG.com

813-865-3178

A contact list is also available at our HSAG booth.

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ACO Reporting Measures

ACO Reporting Measures

Measure quality of care in four key domains: 1. Patient/caregiver experience (7 measures) 2. Care coordination/patient safety (6 measures) 3. Preventive health (8 measures) 4. At-risk population:

• Diabetes (1 measure and 1 composite consisting of five measures)

• Hypertension (1 measure)

• Ischemic vascular disease (2 measures)

• Heart failure (1 measure)

• Coronary artery disease (1 composite consisting of 2 measures)

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Quality Measure

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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf

Data Submission and Source

• Centers for Medicare & Medicaid Services (CMS) claims and administrative data – 4 measures

• ACO Group Practice Reporting Option (GPRO) Web Interface – 22 measures

• Patient experience of care surveys – 7 measures

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Claims Based Measures

• The CMS ACO Program Analysis Contractor (ACO PAC) coordinates with CMS

• ACO PAC calculates the rates • ACOs not involved in data collection

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ACO GPRO Web Interface

• Demonstration for solo to medium-sized practices

• Aligned with PQRS GPRO • Database pre-populated with an ACO-assigned

beneficiary sample under each condition module (e.g., diabetes, heart failure, etc.)

• Serves as a data collection mechanism for groups

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Survey

• CMS administers and pays for the survey for the calendar year (CY) 2013 reporting period.

• Shared Savings Program ACOs responsible for selecting and paying for a CMS-certified vendor to administer the patient survey after this period.

• Pioneer ACOs are responsible for selecting and paying for a CMS-approved vendor to administer the patient survey beginning with the CY 2013 reporting period.

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Quality Performance Scoring

• First performance year – Defined at the level of complete and accurate

reporting for all quality measures – Maximum sharing rate (60 percent for the two-

sided model and 50 percent for the one-sided model) if the ACO generates sufficient savings and successfully reports the required quality measures

• After year 1: – Be assessed on performance – Perform well on selected quality measures

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Pay for Peformance

• Year 1: Pay for reporting applies to all 33 measures.

• Year 2: Pay for performance applies to 25 measures. Pay for reporting applies to eight measures.

• Year 3: Pay for performance applies to 32 measures. Pay for reporting applies to one measure that is a survey measure of functional status.

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QIN-QIO Partnership

Quality Improvement Programs: • Use data to drive improvement and

transformation • Increase quality scores • Support recognition by National Committee

for Quality Assurance and other organizations • Support working as a community to improve

coordination of care and prevent readmissions

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Thank you!

Diane Chronis Beth Kramer

Dchronis@HSAG.com Ekramer@HSAG.com

813-865-3170 813-865-3178

This material was prepared by Health Services Advisory Group, Inc., the Medicare Quality Innovation Network-Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands under contract with the

Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. FL-11SOW-B.1-09262014-01