1. Table of Contents
Title Overview of presentation CCME background National Quality Strategy Strategy Goals Multi-task approach Primary data source Physician data SNF/HHA data Hospital data Flu map Hospital reports Contact info Community map

2. Heather Jones, PTA, MHA, CPHQ Interim Director, AQIN-SC October 2016
Data Knowledge Academy Using QIO Data to Improve the Health and Healthcare of the Medicare Beneficiary Population
Heather Jones, PTA, MHA, CPHQ
Interim Director, AQIN-SC
October 2016 *

3. Overview Quality Improvement Organization background
National Quality Strategy Goals 11SOW
Data for quality improvement activities *

4. The Carolinas Center for Medical Excellence (CCME)
Centers for Medicare and Medicaid Services (CMS) Quality Improvement Organization (QIO) for South Carolina
Member of Atlantic Quality Innovation Network (AQIN)
New York, District of Columbia and South Carolina
11th Statement of Work (SOW)
August 2014 – July 31, 2019
Medicare Fee for Service population
QIOs bring together thousands of hospitals, nursing homes, physician practices and patient advocates to quicken the pace and broaden
the spread of positive change in health quality. QIO Program initiatives include focusing on reducing health care-associated infections,
improving transitions of care, reducing the potential for adverse drug events, preventing pressure ulcers and reducing restraint use in
nursing homes, and using technology to coordinate preventive care. The work that QIOs perform supports the aims of the Department of
Health and Human Services’ National Quality Strategy.
Quality Improvement Organizations
What are QIOs?
A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the care delivered to people with Medicare. QIOs work under the direction of the Centers for Medicare & Medicaid Services to assist Medicare providers with quality improvement and to review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.
What do QIOs do?
The QIO Program, one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries, is an integral part of the U.S. Department of Health and Human (HHS) Services' National Quality Strategy for providing better care and better health at lower cost. By law, the mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. Based on this statutory charge, and CMS's program experience, CMS identifies the core functions of the QIO Program as:
•Improving quality of care for beneficiaries;
•Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting; and
•Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law.
What are Beneficiary and Family Centered Care (BFCC)-QIOs?
BFCC-QIOs improve healthcare services and protect beneficiaries through expeditious statutory review functions, including complaints and quality of care reviews for people with Medicare. The BFCC-QIO ensures consistency in the case review process while taking into consideration local factors and local needs for general quality of care, medical necessity, and readmissions.
What are Quality Innovation Network (QIN)-QIOs?
QIN-QIOs improve healthcare services through education, outreach, sharing practices that have worked in other areas, using data to measure improvement, working with patients and families and convening community partners for communication and collaboration. QIN-QIOs also work to improve the quality of healthcare for targeted health conditions and priority populations and to reduce the incidence of healthcare-acquired conditions to meet national and local priorities.
Why does CMS have QIOs?
CMS relies on QIOs to improve the quality of health care for all Medicare beneficiaries. Furthermore, QIOs are required under Sections of the Social Security Act. The QIO Program is an important resource in CMS’s effort to improve quality and efficiency of care for Medicare beneficiaries. Throughout its history, the Program has been instrumental in advancing national efforts to motivate providers in improving quality, and in measuring and improving outcomes of quality.
QIO Program Transformation
CMS redesigned its QIO Program to further enhance the quality of services for Medicare beneficiaries. The new program structure maximizes learning and collaboration in improving care, enhances flexibility, supports the spread of effective new practices and models of care, helps achieve the priorities of the National Quality Strategy and the goals of the CMS Quality Strategy, and delivers program value to beneficiaries, patients, and taxpayers.
The QIO Program changes include separating case review from quality improvement, extending the contract period of performance from three (3) to five (5) years, removing requirements to restrict QIO activity to a single entity in each state/ territory, and opening contractor consideration to a broad range of entities to perform the work.
Now, one group of QIOs will handle complaints while another group will provide technical assistance to support providers and suppliers. QIOs will have new skills for transforming practices, employing lean methodologies, assisting with value based purchasing programs and developing innovative approaches to quality improvement.
QIO Reports to Congress
CMS is required to publish a Report to Congress every fiscal year that outlines the administration, cost, and impact of the QIO Program. See the links in the "Downloads" section to read our most recent fiscal year Report to Congress.
Also in the "Downloads" section, read our special Report to Congress in response to the Institute of Medicine's 2006 study on the QIO Program, Medicare's Quality Improvement Organization Program: Maximizing Potential. CMS' response to that report outlines improvements, based on an extensive CMS review and recommendations from the Institute of Medicine, to strengthen Medicare's oversight and evaluation of the QIO Program to better meet the future needs of beneficiaries and health care providers. *

5. National Quality Strategy
Better Care
Goal for Payment Reform:
85% of all Medicare Fee For Service payments tied to quality of care by the end of 2016 increasing to 90% by the end of 2018
Healthier People, Healthier Communities
Smarter Spending *

6. 2016 Quality Strategy
Goal 1: Make care safer by reducing harm caused in the delivery of care
Goal 2: Ensuring that each person and family is engaged as partners in their care
Goal 3: Promoting effective communication and coordination of care
Goal 4: Promoting the most effective prevention and treatment practices, focusing on leading causes of mortality - cardiovascular disease
Goal 5: Working with communities to promote wide use of best practices to enable healthy living *

7. Multi-task Approach to Population Health*

8. Primary Data Source CMS Claims * Medicare Fee For Service (FFS) claims
Medicare Part A
Medicare Part D data is used in Medication Safety initiative
6 month lag in availability due to CMS validation
Data is not risk adjusted *

9. Physician Data Physicians/eligible providers *
CMS Physician Quality Reporting System (PQRS)
Submissions
Payment adjustments
CMS FFS claims data
Ex: Immunization rates – influenza/pneumonia *

10. Skilled Nursing Facility/Home Health Data
Skilled Nursing Facilities
CMS quality measures (Minimum Data Set Casper reports)
Ex: Anti-psychotic medication usage, falls/mobility, infections
National Healthcare Safety Network (NHSN)
C. Difficile (36 participating facilities)
CMS FFS claims data
30-Day All Cause Readmissions to hospitals
Home Health Agencies
CMS quality measures - Home Health Quality Initiative – Outcome and Assessment Information Set (OASIS) reports
30-Day All Cause Readmissions back to hospitals *

11. Hospital Data
CMS – Inpatient Payment System - Value Based Purchasing reports
CMS FFS Claims Data
Readmissions
Potential adverse drug events (pADE) and adverse drug events (ADE)
High risk medications – Opioids, Anticoagulatants, Hypoglycemic medications - Medicare Part A and Part D *

12. Improving Health for the Medicare Population
Physician Data: CMS FFS claims for immunization rates *

13. Improving Health for the Medicare Population
Hospital
Annual Value Based Purchasing reports
Medicare Spending Per Beneficiary
Quarterly readmission reports
Physician visits 7 and 30 days post discharge
Readmission Reduction Program (AMI, COPD, PNEU, CHF, THA/TKA, CABG, 30-Day All Cause)
Additional readmission discharge diagnoses
Readmissions by race/ zip code
Readmission rates for discharges to SNF, HHA, and Home
Community of practice reports *

14. For more information * Heather Jones PTA, MHA, CPHQ
Interim Director, AQIN-SC
(803)
The Carolinas Center for Medical Excellence
12040 Regency Parkway
Suite 100
Cary, NC 27518 *

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