An Introduction to the TMF Quality Innovation Network Quality Improvement Organization Vanessa Andow, CPHQ Program Manager, Readmissions Oklahoma Home Health Association September 16, 2014

About the QIN-QIO Program Leading rapid, large-scale change in health quality: Goals are bolder. The patient is at the center. All improvers are welcome. Everyone teaches and learns. Greater value is fostered. The Quality Innovation Network-Quality Improvement Organization (QIN-QIO) Program is the largest federal program dedicated to improving health quality at the community level. QIN-QIOs in defined regions across the country, united in a network administered by CMS, have the flexibility to respond to local needs. Leading rapid, large-scale change in health quality In August 2011, the Centers for Medicare & Medicaid Services gave the program an updated charter for leading change. Here are some of the biggest differences between today’s program and that of the past: • Goals are bolder. The QIN-QIO Program supports the aims of the Department of Health and Human Services’ National Quality Strategy. Providers that work with their QIN-QIO, for example, will contribute to improved cardiac health, fewer avoidable hospital readmissions, and a 40% national reduction in health care-acquired conditions. • The patient is at the center. By including the voice of the beneficiary in all their activities, QIN-QIOs are leading the way to patient-centered care. They will equip both providers and patients for shared health care decision making through a national Patient and Family Engagement Campaign. • All improvers are welcome. Embracing “boundarilessness” as a prerequisite for system-wide change, QIN-QIOs are breaking down organizational, cultural and geographic barriers. Initiatives are open to providers at all levels of clinical performance that make a commitment to improvement. • Everyone teaches and learns. Through large-scale learning and action networks, QIN-QIOs are accelerating the pace of change and rapidly spreading best practices. Improvement initiatives include collaborative projects, online interaction and peer-to-peer education. • Greater value is fostered. QIN-QIOs will support CMS’ new value-based purchasing programs with technical assistance to providers that includes sharing best practices, assisting with data analysis and conducting improvement activities.

Major Changes to the CMS Quality Improvement Organization Program The Centers for Medicare & Medicaid Services (CMS) separated medical case review from quality improvement work creating two separate structures: Medical case review to be performed by Beneficiary Family Centered Care Quality Improvement Organizations (BFCC-QIOs) Quality improvement and technical assistance QIOs to be performed by Quality Innovation Network Quality Improvement Organizations (QIN- QIOs) Note: Both types of contracts cannot be held by the same organization BFCC-QIOs are organized among five geographic areas across the Nation. QIN-QIOs are regional and cover up to six states and/or territories. The QIO contract cycle will be extended from 3 to 5 years.

11thSOW QIN-QIO Map

11th Scope of Work (SOW) – Major Changes The Centers for Medicare & Medicaid Services (CMS) separated medical case review from quality improvement work creating two separate structures: Medical case review to be performed by Beneficiary Family Centered Care Quality Improvement Organizations (BFCC-QIOs) Quality improvement and technical assistance to be performed by Quality Innovation Network Quality Improvement Organizations (QIN- QIOs) Note: Both types of contracts cannot be held by the same organization BFCC-QIOs are organized among five geographic areas across the nation. QIN-QIOs will be regional and could cover anywhere from three to six states. The QIO contract cycle will be extended from three to five years.

BFCC-QIO SOW – What’s New? Enhancements to the BFCC-QIO SOW Five CMS defined areas Each required to maintain local presence Business hours seven days a week Staffing to cover the following times in each time zone within the QIO area Mon-Fri 9 a.m.-5 p.m. Weekends/holidays 11 a.m.-3 p.m. On May 9, CMS awarded the Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization (QIO) Program contracts to: Ohio-based KEPRO for 33 states and the District of Columbia; and Maryland-based LIVANTA for 17 states, the USVI and Puerto Rico

BFCC QIO Important Contacts  Area  Address Toll-Free Number  Fax Number Livanta   1 Livanta BFCC-QIO Program 9090 Junction Drive, Suite 10 Annapolis Junction, MD 20701  866-815-5440 Appeals: 855-236-2423 All other reviews 844-420-6671 5  877-588-1123 Appeals: 855-694-2929 844-420-6672 KEPRO 2 5201 W. Kennedy Blvd., Suite 900 Tampa, FL 33609 844-455-8708 844-834-7129 3 5700 Lombardo Center Dr., Suite 100 Seven Hills, OH 44131 844-430-9504 844-878-7921 4 855-408-8557 844-834-7130

CMS Quality Strategy: Aligns with NQS and IOM Strategies Make care safer by reducing harm caused in its delivery Strengthen person and family engagement Promote effective communication and care coordination Promote effective prevention and treatment of chronic disease Work with communities to promote best practices Make care affordable

TMF QIN-QIO Regional Partners TMF has subcontracted with strong, experienced quality improvement partners to provide expert technical assistance and quality improvement support for participating providers across the region. Arkansas Foundation for Medical Care Primaris (Missouri) QIPRO (Puerto Rico) TMF Health Quality Institute (Texas and Oklahoma) TMF Health Quality Institute has partnered with the Arkansas Foundation for Medical Care, Primaris in Missouri and the Quality Improvement Professional Organization, Inc. in Puerto Rico to form the TMF Quality Innovation Network Quality Improvement Organization (TMF QIN-QIO), under contract with the Centers for Medicare & Medicaid Services (CMS). The TMF QIN-QIO works with providers across all care settings to provide quality improvement services in the states of Arkansas, Missouri, Oklahoma and Texas, and the territory of Puerto Rico.

TMF QIN-QIO’s Strategies for Change Community Organizing and Coalition Building Develop shared community leadership Develop a purpose for the community team Work with a cross-continuum of providers Identify the right participants and continuously recruit new members Learning and Action Networks A virtual gathering place to communicate with providers, stakeholders and beneficiaries Provide educational events, resources, tools and data portal Provider/ Practitioner Technical Assistance Hands-on assistance with community organizing, root cause analysis, intervention implementation and monitoring Provider-specific education and consultation

CMS Goal 1: Promote Effective Prevention and Treatment of Chronic Disease Improving Cardiac Health & Reducing Cardiac Disparities Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts Improving Prevention Coordination Through Meaningful Use of Health Information Technology (HIT)

Improving Cardiac Health & Reducing Cardiac Healthcare Disparities: The Data Heart disease and stroke are the first- and fourth-leading causes of death, respectively, according to the Centers for Disease Control and Prevention (CDC) Congestive heart failure is the second most frequent diagnosis related group (DRG) related to 30-day hospital readmissions Morbidity and mortality data suggests the risks are far greater for racial and ethnic populations than whites

The Cardiac Project Work with providers and beneficiaries in collaboration with key partners and stakeholders Work together in a Cardiac Learning and Action Network Target racial and ethnic minority Medicare beneficiaries, dual eligible and providers practitioners who serve them Support Million Hearts® Campaign: prevent one million heart attacks and strokes by 2017 Focus on evidenced-base: ABCS (ASA, BP, Cholesterol, Smoking Cessation)

The Cardiac Project: Targeted Providers Home health agencies Participate in Cardiovascular Data Registry, Home Health Quality Improvement (HHQI) Campaign Practitioner owned and operated offices and clinics Other facilities where physician, nurse practitioner, physicians assistant oversight is provided Providers, practitioners required to be Physician Quality Reporting System (PQRS) aligned Providers, practitioners who serve racial and ethnic minorities

Cardiovascular Health Network Home Health Agencies (HHAs) We help HHAs sign up for the Cardiovascular Data Registry, developed through the Home Health Quality Improvement National Campaign, in order to track progress related to the ABCS (Aspirin therapy, Blood pressure management, Cholesterol control and Smoking/Tobacco cessation). Utilization of health literacy tools to provide education Utilize the Best Practice Intervention Packages (BPIPs) to provide Technical Assistance Participate in cardiac Learning and Action Network activities and share success stories

Improving Cardiac Health: Goals Prevent one million heart attacks and strokes – Support Million Hearts® Campaign Spread the implementation of evidence-based practices: ABCS Practice goals by January 2019: 70 percent patients blood pressure (BP) controlled, per guidelines 70 percent patients screened for tobacco use 70 percent identified as smokers receive smoking cessation counseling

Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts: The Data Our first project focused on the Hispanic and Native American populations and revealed that from the time of diagnosis to the time our participants were receiving Diabetes Self-Management Education (DSME) was... 7 – 13 years Our current project with African-Americans reveals that only 2.9 percent of those with Medicare and diabetes are utilizing their DSME benefits. The need is great for our state of Texas. As we continue each day on these initiatives we learned more and more about the needs of our citizens. During our first project the strong need for free DSME education and improved access to DSME programs was revealed. We identified that from the time of diagnosis to the time a person with diabetes received any diabetes education is ranging from between 7-13 years.

Everyone with Diabetes Counts: The Goals Increase number beneficiaries who complete DSME classes Obtain repeated measurements on the same beneficiaries longitudinally over time HbA1c, lipids, eye exam, BP control, weight Decrease lower extremity amputations Improve health literacy diabetics Increase adherence to clinical guidelines

Improving Prevention Coordination with Meaningful Use of HIT (slide 1 of 3) Closes the gap between patient care (diagnostics, etc.) and outcomes Complete, organized patient’s chart in hand at all times Facilitates implementation of evidence-based best practices Allows management of patient panels Promotes transparency

Improving Prevention Coordination with Meaningful Use of HIT (slide 2 of 3) Influences improved outcomes with data at the practice’s fingertips Alerts and reminders for safer patient care eRxing provides more efficient and accurate drug dispensing Support IT-enabled care management for primary care prevention and early diagnosis Improve specific health care services, processes and health outcomes related to prevention, population health and care coordination

Improving Prevention Coordination with Meaningful Use of HIT (slide 3 of 3) Effective use of clinical decision support and quality measurement Eligible professionals, hospitals and critical access hospitals Recruit providers and hospitals with electronic health records (EHRs) Reduce HIT disparities Target most challenged to meet EHR incentives and quality improvement goals Provide technical assistance and coaching 1-on-1 and virtually Monthly reporting and data analysis Improve care team and patient communication Engage beneficiaries

CMS Goal 2: Make Care Safer by Reducing Harm Caused in the Delivery of Care Reducing Healthcare-Associated Infections (HAIs) in Hospitals Reducing Healthcare-Associated Conditions in Nursing Homes

Reducing HAI Infections in Hospitals: The Data An analysis describes the average total cost of a typical Clostridium difficile (C. diff) case at $12,834.91, or $4,486.09 more (54 percent higher) than the adjusted hospital cost for an inpatient who does not have C. diff. Patients who were admitted for recurrent C. diff had an average length of stay of approximately 8.8 days, and their average direct cost per recurrence was $4,096.93.

Reducing Healthcare-Associated Infections in Hospitals: The Project Recruit hospitals with Central-Line Associated Blood Stream Infection (CLABSI) rates above national averages Work in CLABSI, CAUTI and C. diff reduction in both Intensive Care Unit (ICU) and non-ICU settings Ventilator Associated Events reduction education Use root cause analysis to determine causes of infections and target interventions Educational webinars tailored to identified causes Education on reporting National Healthcare Safety Network (NHSN) data

Reducing Healthcare-Acquired Conditions in Nursing Homes: The Data An estimated 1.4 million Americans live in nursing homes on any given day and approximately one in five, or 22 percent, suffer harm during their stay. Nearly 60 percent of these incidents are deemed preventable, leading to a national call for improved safety and quality of care for nursing home residents. More than ½ of residents who experienced harm returned to the hospital for treatment. $2.8 billion in hospital costs attributed to harm caused in nursing homes in one year.  Oklahoma is 39th (worst in nation) in using antipsychotics inappropriately in nursing homes

Reducing Healthcare-Acquired Conditions in Nursing Homes Recruit 75 percent of all nursing homes including 75 percent of one star facilities – 58 nursing facilities in Oklahoma National Collaborative, two rounds of recruitment Individualized technical assistance to all recruited nursing homes Coaching on initiating a Quality Assurance and Performance Improvement (QAPI) culture Local Area Network for Excellence (LANE) convener Engage beneficiaries

Nursing Home Project Goals Reduction in percentage of residents who receive antipsychotic medications Percentage of long-stay residents with improved mobility Percentage of facilities recruited, including low performers Attain composite score of six or better on the Nursing Home Quality Composite Measure (13 National Quality Forum-endorsed long-stay quality measures)

CMS Goal 3: Promote Effective Communication and Coordination of Care Care Coordination: Reducing Readmissions

Statement of Problem: Readmissions Hospitalizations consume 31 percent of the $2 trillion in total health care expenditures in the United States One in four (25 percent) of hospitalizations are avoidable One in five (20 percent) of all hospitalizations result in 30-day readmissions The chronically ill and frail elderly are the single largest population segment in terms of cost in the US. However, they interact with a health care delivery system that is oriented to acute, episodic interactions. It is the acute, episodic nature of care that is driving the hyper-fragmentation in care delivery, which affects no one more those who rely on continuous interaction with providers- those living with chronic illnesses. You’ll note throughout my comments, I will take a purposefully non-disease specific approach. Much of the work that has been done to understand high rates of rehosptialization and the effectiveness of various approaches to reduce the cycle of rehospitaliziations has been conducted in patients with congestive heart failure. Many of the principles apply broadly. To that end, Massachusetts’ focus on improving the care for patients with DM will undoubtedly go a long way to improving care for patients more generally. Hospitalizations account for almost a third of the $2 trillion in total health care expenditures in the United States Of course, in the majority of situations, hospitalizations for acute and serious illnesses are necessary and appropriate; However, research suggests that approximately a quarter of hospitalizations are avoidable and roughly 20% of all hospitalizations are re-hospitalizations, many of which are potentially avoidable. Source: Lynn J, Straube BM, Bell KM, Jencks SF, Kambic RT. Using population segmentation to provide better health care for all: The “Bridges to Health” model. Milbank Q. 2007;85:185-208.

Care Coordination: Reducing Readmissions Recruit communities where 60 percent of Medicare Fee-for-Service (FFS) beneficiaries reside Provide one-on-one and virtual technical assistance to hospitals, downstream providers and communities Educate on best practices, root cause analysis, implementing interventions, monitoring progress and understanding the data Recruit and form community coalitions Coordinate and conduct community workgroup meetings

Statement of Problem: Medication Safety National estimates suggest that adverse drug events (ADEs) contribute an additional $3.5 billion dollars to U.S. health care costs.1 Given the U.S. population’s large and ever-increasing magnitude of medication exposure, the potential for harm from ADEs is a critical patient safety and public health challenge. ADEs are a direct result of drugs used during medical care that produce harmful events. These harmful events can include, but are not limited to, medication errors, adverse drug reactions, allergic reactions and overdoses.2,3 1Institute of Medicine Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2006. 2Agency for Healthcare Research and Quality. Adverse Drug Event (ADE), in Patient Safety Network: Glossary. Available at: http://psnet.ahrq.gov/glossary.aspx. 3National Action Plan for Adverse Drug Event Prevention. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 2013.

Care Coordination: Reducing Adverse Drug Events (ADEs) Recruit 10 percent of FFS beneficiaries in region, with 10 percent in “rural” areas. Use organization and physician level reports to perform root cause analyses on ADEs for anticoagulants, oral hypoglycemic medications and opioids Use data to map out barriers and solutions Focus on medication reconciliation and medication therapy management Share evidence-based practices and tools with practitioners and patients

Care Coordination: Reducing Adverse Drug Events (ADEs) Provide one-on-one and virtual technical assistance to recruited organizations and stakeholders 10 percent relative improvement rate (RIR) in percentage of 30-day readmissions per 1,000 FFS beneficiaries in a region- wide coalition 7 percent RIR in percentage of admissions per 1,000 beneficiaries in region wide coalition Reduce ADEs in these populations by 50 percent RIR per 1,000 patients by the end of the contract

CMS Goal 4: Make Care More Affordable Quality Improvement through Value-Based Payment, Quality Reporting and Physician Feedback Reporting

Quality Improvement Value-Based Payment Modifier Target hospitals, inpatient psychiatric facilities, ambulatory surgical care centers, outpatient departments, physicians, physician groups, critical access hospitals, cancer hospitals Analyze quality and resource use reports Assist in improving measures Network with similar facilities for support and best practice

TMF QIN-QIO Learning and Action Networks (LANs) Provide targeted technical assistance to participating providers, stakeholders and communities in CMS quality improvement initiatives Engage providers and stakeholders in improvement initiatives through web-based Learning and Action Networks The networks serve as hubs for the regional quality improvement work for each project, including: Project information › Data portal Upcoming events › Project maps and data Discussion forums › Videos Resource library › Recorded events LANs convene stakeholders, providers and improvement experts in an “all teach, all learn” model. Through the LAN, the TMF QIN-QIO’s networks provide educational webinars and conferences, encourage peer sharing, rapid testing of change ideas and support for adapting and spreading successful improvements.

Learning and Action Networks Cardiovascular Health and Million Hearts Health for Life – Everyone with Diabetes Counts Healthcare-Associated Infections Meaningful Use (Health Information Technology) Medication Safety Nursing Home Quality Improvement Quality Reporting and Incentive Programs Quality Improvement Initiative Readmissions Cardiovascular Health and Million Hearts – preventing one million heart attacks and strokes by 2017 • Health for Life-Everyone with Diabetes Counts –improving health outcomes for people with diabetes and helping eliminate health disparities • Healthcare-Associated Infections – reducing healthcare-associated infections in hospitals • Meaningful Use – improving prevention coordination through meaningful use of health information technology and collaborating with Regional Extension Centers • Nursing Home Quality Improvement – reducing healthcare-acquired conditions and improving the quality of care in nursing homes • Medication Safety – improving drug safety practices, reducing medication-related harm and developing innovative care standards • Quality Improvement Initiative – providing technical assistance to providers and practitioners to help them improve the quality of their care. • Quality Reporting and Incentive Programs – assisting physicians, hospitals and other health care settings with value-based payment and quality reporting programs • Readmissions - reducing avoidable hospital readmissions by improving the quality of patients’ transitions between health care settings

TMF QIN-QIO Learning and Action Network: http://www.TMFQIN.org

For more information Vanessa Andow, CPHQ Program Manager, Readmissions TMF Quality Innovation Network Phone: 512-334-1642 Email: Vanessa.Andow@hcqis.org

Questions? It is not the answer that enlightens, but the question… - Eugene Ionesco This material was prepared by TMF Health Quality Institute, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 11SOW-QINQIO-C3-14-07