Performance Improvement Projects Technical Assistance Who? What? When? and How to Ask? CalEQRO PIP Clinic June 28, 2019 Amy McCurry Schwartz, Esq., MHSA EQRO Consultant Behavioral Health Concepts, Inc. amy.mccurry@bhceqro.com

The purpose of PIPs To assess and improve processes, and thereby outcomes, of care. 42 CFR 438.240(d) defines PIPs as having a “focus on clinical and non-clinical areas.”

Clinical PIPs Might Target Prevention and care of acute and chronic conditions High-volume services High-risk procedures Special health care needs

Non-Clinical PIPs Might Target Coordination of Care Appeals, Grievances Process Access or Authorization Member Services

VALIDATING PERFORMANCE IMPROVEMENT PROJECTS (PIPs) OMB Approval No. 0938-0786 EQR PROTOCOL 3: VALIDATING PERFORMANCE IMPROVEMENT PROJECTS (PIPs) A Mandatory Protocol for External Quality Reviews (EQR)

CMS Protocol: Validating Performance Improvement Projects 10 Protocol Steps: Select the study topic(s) Define the study question(s) Use a Representative and Generalizable study population Select the study variable(s) Use sound sampling techniques

CMS Protocol: Validating Performance Improvement Projects 10 Protocol Steps Continued: Reliably collect data Analyze data and interpret study results Implement intervention/improvement strategies Plan for “real” improvement Achieve sustained improvement

When should I request Technical Assistance (TA)? Early and often When you have a new idea When your data shows an issue When you are crafting a study question and aren’t sure if it will “work” When you are designing interventions When you are determining indicators Outside of the onsite review process, CalEQRO provided individual TA to 39 MHPs for a total of 410 hours through May 2019. One of the most common areas of assistance involved PIP study question formulation and assisting MHPs in the development of a new PIP concept. The MHPs struggle to understand the concept of designing and implementing PIPs as part of the MHPs’ overall QI practices, instead attempting to construct PIPs as standalone projects. This is a substantial increase over the 20 MHPs who received TA and the 70-80 hours of TA that were reported to be given during last year’s contract cycle.

When should I request Technical Assistance (TA)? When you have a new idea A PIP may be winding down and it is time to start a new one PIPs should be active and ongoing during the twelve months prior to your onsite review Continuous Quality Improvement

When you have a new idea Notes from Quality Reviewer following TA call: The MHP submitted a draft write-up for a non-clinical PIP, but both Amy and I determined that it does not meet the criteria for a PIP. During the call with the MHP, we discussed at length the PIP process, how to identify potential PIP topics (using data), and then how to design them. They will be looking deeper into their data, and discussing internally with QI and leadership, possible PIP topics for a non-clinical PIP. We will reconvene on another conference call on October 19 when they will present their ideas for discussion/feedback. Their goal is to have two active PIPs by the time of the review in January 2019.

When should I request Technical Assistance (TA)? When your data shows an issue Identify a problem area or opportunity for improvement in treatment or process, but do not take it “to the bank” without first reviewing your facts and data Include information from beneficiaries, families, staff and community partners Beneficiary, families, community partner and staff input should be obtained on problem What do they see as the barriers to better care? Why do they think the problem is happening? What ideas do they have to fix it?

When your data shows an issue Notes from Quality Reviewer following TA call: Overall, the MHP has made significant progress in both PIPs. Clinical PIP The MHP took the suggestions from the last TA session seriously and applied it. Most notably: Reviewing the literature Gathering local data Including beneficiary input

When your data shows an issue Non-Clinical PIP Since the last session, the MHP gathered information and learned a lot about the reasons behind the assessment time lags. The MHP embraced the use of data to inform the process. The MHP changed the way they gather data and manage it. The MHP is looking at the data monthly.

When should I request Technical Assistance (TA)? When you are crafting a study question and aren’t sure if it will “work”? This step is critical because it sets the framework for data collection and analysis of results

When you are crafting a study question and aren’t sure if it will “work”? Notes from Quality Reviewer following TA call: “This is a proposed new PIP. During the call, the study question was narrowed down to one, and the main emphasis changed from reducing hospitalization to reducing repeat emergency department visits with a secondary aim of reducing hospitalization. The MHP was advised to better define the selection criteria based on the risk factors for recidivism, and thus accomplishing clearer definition of the study population. The other tasks for the MHP are identifying the appropriate interventions and indicators that will capture the success of this PIP. A follow-up call is scheduled for February 2019. (Also, briefly touched base on the new interventions planned for the MHP's existing non-clinical PIP)

When should I request Technical Assistance (TA)? When you are designing interventions Interventions should not focus on procedures, but on beneficiaries.

When you are designing interventions Notes from Quality Reviewer following TA call: This PIP is focused on access for beneficiaries to receive a SUD Comprehensive Assessment once it has been identified at the initial MH Comprehensive Assessment that a SUD referral is needed. The interventions need to include not only the steps for setting things up (training, etc.) but also for actual implementation (which are missing).

When you are designing interventions Notes from Quality Reviewer following TA call: Discussed non-clinical PIP (no-show rates psychiatry). Next steps for non-clinical: Examine impact of no show on individual, and system; Choose intervention based on completed barrier analysis.

When should I request Technical Assistance? When determining indicators Each PIP should have one or more measured indicators to track performance and improvement over a specific period of time. All measured indicators should be: Objective; and Clearly defined; and Based on current clinical knowledge or health services research; and Beneficiary outcomes (e.g. health or functional status, enrollee satisfaction); or a valid indicator of these outcomes.

Study Indicator “tips” The study indicator should be objective and clearly defined The indicator must be “measurable” – do you have the necessary data (or can you get it)? Use an existing, relevant health care guideline to develop the study indicator Use an existing indicator generally accepted in the health care community (ex. HEDIS; Clinical Practice Guidelines…)

From whom should I request Technical Assistance? Check out the PIP Library https://caleqro.com/pip-library

From whom should I request Technical Assistance? Email your assigned Quality Reviewer (QR) Provide them with an idea of where you are in the process of designing a PIP Provide any documentation you may have to support your planned PIP Give your QR amble time to review the information. Contact QR as soon as the idea begins Always give them a week or two to respond to respond to a request

How do I ask for Technical Assistance? Via email Via phone https://caleqro.com/data/MH/Review%20Materials/BHC-Staff- Directory_EXTERNAL_KC_v8.9.pdf

What is PIP Technical Assistance from CalEQRO? Technical Assistance is: Sharing Information and expertise Providing Instruction Transmitting Working Knowledge Consulting on an Idea

What is PIP Technical Assistance from CalEQRO? Technical Assistance is not: A “blessing” or “permission” to pursue a PIP An “approval” of an idea

What should I have before asking for Technical Assistance? As much information as possible Know what data you have or can obtain on the topic Have data to support that a problem exists

What should I expect from Technical Assistance? Development of a plan to get to an Active PIP Follow up TA as needed Homework assignments Back and forth communication

QUESTIONS