This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement Organization for New England, 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. 11SOWQIN-B1_201512_0327. A Data Driven Approach to Improve Your Immunization Rates Making Your CASPER Data Work For You

Obtain and use your CASPER Passwords Identify the primary reports in CASPER and how each can benefit your agency Understand how the data is developed, reported, interpreted Understand the Immunization queries Create a PDSA plan to improve Immunization rates for

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Your Agency QIES User ID and Password 4

Welcome to CMS OASIS System 5

Welcome Provider 6

Get Focused - CASPER Data Five Essential Reports 1.Agency Patient-Related Characteristics Report 2.Risk Adjusted Outcome Report 3.All Patients’ Process Quality Measures Report 4.Risk Adjusted Potentially Avoidable Events 5.Error Summary Report by HHA Desired Agency Patient-Related Characteristics (Case Mix) Analysis Summary Report 7

Report Categories 8

Where does the data come from? All data is based on “completed episodes” –Start of Care to Transfer/Discharge –Resumption to Transfer/Discharge “Outcome Measures”: What was the end result of the episode of care? “Process Measures”: How did you arrive at that end result? 9

What is “Risk Adjustment”? Risk Adjustment compares you to your peers If your “Case Mix” is younger/healthier, the ACH rate should be lower than an agency whose “Case Mix” was older/frailer If the “actual” ACH rates are the same, Risk Adjustment will raise yours to reflect the younger/healthier “Case Mix” Risk Adjustment levels the playing field 10

Pre-Survey Agency Assessment 11

Pre-Survey Auto Default 12

All Data Periods Default to 1 Year 13

Improving Immunization Rates with a PDSA Process OBQI PBQI OBQM Collect OASIS Data Measure Patient Outcome Interpret Reports Specifiy Target Outcome Investigate Care Processes Identify Problems, Strengths, Best Practices Develop Action Plan Implement Action Plan Monitor Action Plan 14

Establish a Plan (PLAN) What CASPER data do you need? Select “Tally Report” Select parameters (Immunization rates) Analyze the characteristics of the non- immunized to identify the “why” Create a plan to intervene and alter the outcome 15

Tally Reports 16

Implement the Plan (DO) Staff Education –Why does this matter to your agency? Patient Education materials In-Home Immunization Program Enlist Physician cooperation and assistance Identify what data to collect as you implement the plan 17

Track Your Progress (STUDY) Track immunization rates by clinician/team –Scrubber tool: reports by clinician/team for M01041/1046 Track agency progress monthly/quarterly –Process/Outcome Three Bar Risk Adjusted –Tally Report Immunization Rates 18

Revise Your Plan (ACT) What does the data tell you? Are your clinicians interested/motivated? What are the obstacles they are meeting? How do you reduce those to improve the outcome? 19

QUESTIONS? How can we help you? 20