1. 1 Medicare Advantage Quality Improvement Project Medicare Advantage Industry Training Jaya Ghildiyal and Vanessa Sammy Medicare Drug and Health Plan Contract Administration Group April 11, 2012

2. 2 Objectives Identify requirements of the Quality Improvement (QI) Program Identify requirements of a Quality Improvement Project (QIP) Describe how QIPs improve health outcomes and quality of care

3. 3 Objectives -2- Describe the role of the Regional Office Account Managers Describe the QIP submission process Describe the QIP reporting tool

4. 4 Presentation Overview: Part I QI Program Overview Background on QIP Required Topic Partnership for Patients Initiative Overview of QIP Development & Evaluation Case Studies Discussion Brief break/Stretch

5. 5 Presentation Overview: Part II Role of the Regional Office (RO) Account Managers QIP Reporting & Submission Process Plan, Do, Study, Act (PDSA) Framework Review QIP Reporting Tool Wrap up & Questions

6. 6 Quality Improvement (QI) Program Overview

7. 7 Quality Improvement (QI) Program 42 Code of Federal Regulations (CFR) § 422.152 Applies to all MAOs, including SNPs Serves to integrate and coordinate all of the assessment tools and reporting requirements Seven components of the QI Program

8. 8 Components of the QI Program 1. Chronic Care Improvement Program (CCIP) Meets requirements at 42CFR §422.152(c) Addresses populations that CMS identifies by reviewing current quality performance 2. Quality Improvement Projects (QIPs) Meets requirements at 42CFR §422.152(d) Expected to favorably affect health outcomes and enrollee satisfaction Address areas identified by CMS

9. 9 Components of the QI Program -2- 3. Develop and maintain a health information system 4. Encourage providers to participate in CMS and Health &Human Services (HHS) QI initiatives 5. Contract with an approved Medicare CAHPS vendor to conduct the Medicare CAHPS satisfaction survey

10. 10 Components of the QI Program -3- 6. Include a program review process for the formal evaluation of the QI Program that addresses at least the following areas on an annual basis: Impact Effectiveness 7. Take remedial action to correct problems identified using ongoing quality improvement

11. 11 Defining Quality

12. 12 BACKGROUND

13. 13 Background Identified need to improve reporting tools for both the CCIPs and the QIPs Follow the QI cycle of Plan, Do, Study, Act More focused on interventions and outcomes Participate in national health initiatives CCIPs must be clinical QIPs may be clinical or non-clinical

14. 14 Background -2- CMS is involved in several important Department of Health & Human Services (HHS) Initiatives Want to ensure that our beneficiaries enrolled in the Medicare Advantage (MA) program have the opportunity to benefit from these initiatives

15. 15 QI Program Alignment with HHS Initiatives Aligning the MA QI program with the HHS quality initiatives: Partnership for Patients  QIP Million Hearts Initiative  CCIP The Quality Improvement Project is an important tool,

16. 16 Required Quality Improvement Project In 2011, HEDIS® introduced a new measure on plan all- cause readmission rates In 2012, CMS is requiring a QIP focused on decreasing hospital readmissions Supports the national HHS initiative—Partnership for Patients

17. 17 PARTNERSHIP FOR PATIENTS INITIATIVE

18. 18 Goals of Partnership for Patients Prevent patients from getting injured or sicker during their care By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010 Achieving this goal would mean approximately 1.8 million fewer injuries to patients with more than 60,000 lives saved over three years

19. 19 Goals of Partnership for Patients -2- Help patients heal without complication By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010

20. 20 Goals of Partnership for Patients -3- Help patients heal without complication Achieving this goal would mean more than 1.6 million patients would recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge

21. 21 Key Components of Partnership for Patients Hospital Engagement Networks Comprised of 26 State, Regional, National and Hospital System Organizations Required to support hospitals in making patient care safer Improving Care Transitions Care transitions are an opportunity for improvement

22. 22 Hospital Readmission Rates At any given time, about one in every 20 patients acquires an infection that results from his or her hospital care On average, one in seven Medicare beneficiaries is harmed in the course of his or her care, costing the government an estimated $4.4 billion every year Source: Partnership for Patients

23. 23 Hospital Readmission Rates -2- Nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days That’s approximately 2.6 million seniors at a cost of over $26 billion every year Source: Partnership for Patients

24. 24 Joining the Partnership Join the Partnership for Patients at: http://www.healthcare.gov/compare/partnership- for-patients/join/index.html

25. 25 OVERVIEW OF QIP DEVELOPMENT & EVALUATION

26. 26 Steps To Developing a QIP Identify the potential target of opportunity Synthesize information about optimal practice Synthesize information about current practice Identify reasons for discrepancy between current and optimal practice Source: Prabitha Varkey. Medical Quality Management: Theory & Practice. Jones & Bartlett publishers, 2010.

27. 27 Steps To Developing a QIP -2- Develop a strategy for practice improvement Assess effectiveness & cost-effectiveness of the practice improvement strategy Determine whether the practice improvement strategy should be implemented and how it can be improved

28. 28 Areas of Focus for the QIP The focus of the QIP can be to yield improvements in any or all of the following areas: Functional Clinical Satisfaction Costs

29. 29 Areas of Focus for the QIP Satisfaction Health Care Delivery Perceived Benefit Functional Physical Function Mental Health Social Role Other (e.g., pain, health risk) Costs Direct Medical Indirect Social Clinical Mortality Morbidity Complications Source: Prabitha Varkey. Medical Quality Management: Theory & Practice. Jones & Bartlett publishers, 2010.

30. 30 QUALITY IMPROVEMENT PROJECT CASE STUDY

31. 31 Identify the Potential Target of Opportunity Developing the focus of the QIP (may be clinical or non- clinical): Pressure ulcers are among the most frequent of hospital- acquired conditions and the MAO has identified this as a recurring reason cited for hospital readmissions

32. 32 Synthesize Information About Optimal Practice Rationale for Selection: Evidence based guidelines inform us that pressure ulcers in Stages III and IV put patients at significant risk for infection that can potentially result in death

33. 33 Synthesize Information About Current Practice Developing the Target Goal: The MAO has identified the target population and believes that enhanced post-discharge follow-up and patient education regarding wound care can prevent 50% of pressure ulcers from exacerbating and leading to complications that cause hospital readmission

34. 34 Synthesize Information About Current Practice -2- The goal is to ensure that members of the target population and their caregivers understand instructions for wound self- care, recognize symptoms that signify potential complications requiring immediate attention, and make and keep follow-up appointments with their primary care physicians (PCP)

35. 35 Identify Reasons for Discrepancy Between Current & Optimal Practice Planning the Intervention: The MAO identified that, after hospital discharge, members of their target population were not currently scheduling follow-up appointments with their PCPs to monitor pressure ulcers

36. 36 Develop A Strategy For Practice Improvement Doing the Intervention: The MAO chose to send discharged patients and their caregivers educational materials on the importance of scheduling follow-up appointments with PCPs to monitor pressure ulcer wounds

37. 37 Assess Effectiveness of the Practice Improvement Strategy Studying the Intervention: The MAO found that the interventions were able to reduce 25% of the most dangerous pressure ulcer complications that lead to hospital readmission

38. 38 Determining How Practice Improvement Strategy Can Be Improved Developing Next Steps: The MAO found that the interventions were able to reduce 25% of hospital readmissions caused by dangerous pressure ulcer complications, but fell short of the target goal of a 50% reduction in pressure ulcer-related readmissions

39. 39 Determining How Practice Improvement Strategy Can Be Improved -2- After further review, the MAO decided to adjust its original intervention to include additional actions focused on increasing members’ PCP visits for follow-up monitoring of pressure ulcers In addition to mailing information on the importance of follow- up with their PCP, the MAO started making phone calls to patients and caregivers to remind/assist them with scheduling follow-up appointments

40. 40 DISCUSSION

41. 41 Brief Break/Stretch

42. 42 WORKING WITH CMS REGIONAL OFFICE (RO) ACCOUNT MANAGERS (AMs)

43. 43 Regional Office (RO) Account Managers (AMs) Will provide day-to day monitoring of the QI Program Provide technical assistance (TA) to health plans to improve their overall QI program Review and approve the Plan Sections of the CCIPs and the QIPs

44. 44 QIP SUBMISSION PROCESS

45. 45 CY 2011 QIP Submissions The QIPs are based on their quality improvement projects from CY 2011 Reported through HPMS using the new template Submitted from May 1-15, 2012 Scored by a contractor

46. 46 CY 2012 QIP Submissions The QIPs submitted later this Spring are based the planned quality improvement project for CY2012 Reported through HPMS using the new template Submitted in two sections Plan section due June 11-July 31 Do-Study-Act sections will be required to be submitted in early 2013

47. 47 CY 2012 QIP Submissions -2- MAOs must work with the AMs to have the Plan section approved Plans cannot begin QIP without the AMs approval AMs will review and approve/deny the CY2012 QIP “Plan” Section by July 31 Completed within HPMS using new template

48. 48 QIP REPORTING PROCESS

49. 49 Plan-Do-Study-Act (PDSA) Quality Model “Plan” Identify the potential target of opportunity, plan the project “Do” Implementation of the project “Study” Data collection and analysis “Act” Next Steps

50. 50 Quality Improvement PDSA

51. 51 REVIEW OF THE QIP REPORTING TOOL

52. 52 QIP Reporting Tool in PDSA Model “PLAN” Data Sources used for Problem Identification  Basis for Selection [QIP Description] [Anticipated Outcome] [Rationale for Selection]  Project Goal and Benchmark [Anticipated Barriers] [Risk Assessment] “DO”  Project Implementation, Review, and Revisions [Barriers Encountered] [Mitigation Plan for Risk Assessment]

53. 53 QIP Reporting Tool in PDSA Model -2- “STUDY”  Results “ACT”  Summary of Findings & Conclusions  Root Cause Analysis Description (Goal/Progress Not Achieved)  Action Plan Description  Next Steps

54. 54 THE “PLAN” SECTION

55. 55 Key Elements of “PLAN” Section Data Sources Used for Problem Identification Basis for Selection Prior Focus Project Goal & Benchmark CMS Regional Office Approval

56. 56 Data Sources Section is not scored but critical to the development of the QIP MAOs may chose to use data sources other than the ones listed in the QIP reporting tool Incorporate information into the QIP from as many of the data sources as appropriate Understand the link between the data and the QIP

57. 57 Basis for Selection A1. Description of the QIP A2. Impact on Member A3. Anticipated Outcomes A4. Rationale for Selection

58. 58 A1. Description of the QIP Identify the problem or opportunity for improvement Describe the methodology the plan will use to determine problems/opportunities Describe the data sources used to determine the QIP Include specific timeframes & percentages, where applicable

59. 59 A2. Impact on the Member Describe whether the QIP impacts the MA population by: Improving health outcomes; Improving member satisfaction; or Both

60. 60 A3. Anticipated Outcomes The expected outcome of the program How the members will be impacted by the outcome A brief description of the evidence based guidelines considered and how these will be effective in producing improved health outcomes

61. 61 A4. Rationale for Selection The rationale for selecting the specific problem or opportunity for improvement How the data sources showed the gap in the current care that confirms the need for a specialized program Incidence and/or prevalence of the disease within the MA Plan population supported by the data sources

62. 62 Prior Focus Optional Describes the outcome achieved and priority assessed Project cycle year Intervention(s) implemented Outcomes achieved Priority Assessed Specific to each intervention

63. 63 Project Goal & Benchmark A1. Target Goal A2. Risk Assessment

64. 64 A1. Target Goal & Benchmark How the project is relevant to the MA Plan population through incidence and/or prevalence of the disease The impact the problem currently has on the members How addressing the problem will demonstrate improvement

65. 65 A1. Target Goal & Benchmark -2- A1(a). Target Goal A1(b). Benchmark A1(c). Rationale A1(d). Planned Intervention A1(e). Inclusion Criteria A1(f). Methodology A1(g). Timeframe

66. 66 A1(a). Target Goal A goal that is specific and relevant to the program The evidence or factors considered that show how achieving the goal will impact health outcomes How the goal is measureable and attainable in the set timeframe

67. 67 A1(b). Benchmark A valid, reliable benchmark that is relevant to the goal of the program How it relates to the demographics of the target population How use of it reflects the complexity of the disease state the program is targeting The current date of the benchmark

68. 68 A1(c). Rationale The reason the specific intervention was chosen How it relates to the goal and benchmark The factors or evidence considered when developing the intervention that demonstrates its validity How health outcomes are anticipated to be impacted

69. 69 A1(d). Planned Intervention The planned intervention How it is measureable and capable of effecting improved health outcomes How the intervention relates to the goal How it is sustainable over time

70. 70 A1(e). Inclusion Criteria Describe how members of the enrollee population were included and/or excluded for the purposes of identifying the target population Example: Incidence rate among the members related to the inclusion criteria Example: Demographic and clinical variables used to identify members appropriate for inclusion in the program

71. 71 A1(f). Measurement Methodology The specific valid and reliable data that will be collected to track improvement How the identified measurement relates to the intervention, the goal, and the benchmark The systematic method in which that data will be collected Frequency of data collection and analysis

72. 72 A1(g). Timeframe Exact beginning and ending dates for the measurement cycle An explanation of how the timeline reflects an appropriate amount of time to complete the planned intervention

73. 73 A2. Risk Assessment A2(a). Target Audience A2(b). Anticipated Barrier A2(c). Mitigation Plan

74. 74 A2(a). Target Audience Describe the target population Inclusion criteria Exclusion criteria Incidence rate among the members related to the inclusion criteria

75. 75 A2(a). Target Audience -2- The illness severity level of the members included The demographics and clinical variables used to identify members appropriate for inclusion in the program

76. 76 A2(b). Anticipated Barrier The plan must provide a description of any barriers they think they might encounter during the QIP, and how those barriers will prevent the goal from being reached

77. 77 A2(b). Anticipated Barrier -2- To identify barriers, plans can consider how the intervention is carried out, who is involved, and at what point the intervention may encounter obstacles to the goal

78. 78 A2(c). Mitigation Plan Describes the methodology/series of steps that plans will take to address the barriers they anticipate encountering during the project Describes the target audience upon which the mitigation plan will focus, and the expected timeframe that the mitigation plan will adhere to in order to address the expected barriers

79. 79 THE “DO” SECTION

80. 80 Program Implementation, Review, Revision A1. Education A1(a). Patient Self-Management A1(b). Provider Education A2. Intervention A3. Results or Findings A4. Barriers Encountered A5. Mitigation Plan for Risk Assessment A6. Anticipated Impact on the Goal and/or Benchmark

81. 81 THE “STUDY” SECTION

82. 82 Results A1. Goal A2. Benchmark A3. Timeline A4. Dates of Implementation A5. Sample Size or Percent of Total Population

83. 83 Results -2- A6. Numerator A7. Denominator A8. Total Percent or Results A9. Other Data or Results A10. Analysis of Results or Findings

84. 84 THE “ACT” SECTION

85. 85 Root Cause Analysis Areas to consider Care and Service Delivery Problems Contributing Factors Analysis should include: Description of the problem/incidence and its consequences Background & context of the incidence

86. 86 Root Cause Analysis -2- Scope of the investigation Information and evidence gathered A description of root causes that have demonstrated a causal/strong correlative relationship with the incident Lessons Learned Recommendations Source: National Health Service National Patient Safety Agency. “Root Cause Analysis Investigation Tools”.

87. 87 The Next Steps A1. Continue the program with no changes A2. Continue the program with changes A3. Develop a QIP to study one or more aspects of the program A4. Discontinue the program A5. Re-evaluate and change the goal or benchmark selected

88. 88 The Next Steps -2- A6. Expand the program A7. Identify additional interventions A8. Re-evaluate data and criteria A9. Other

89. 89 Next Steps Examples: Immediate Response and Recovery Actions Preventative or risk-reducing actions or solutions Actions for implementing, monitoring, and evaluating

90. 90 SUMMARY

91. 91 Summary Identify requirements of the Quality Improvement (QI) Program Identify requirements of a Quality Improvement Project (QIP) Describe how QIPs improve health outcomes and quality of care

92. 92 Summary -2- Describe the role of the Regional Office Account Managers Describe the QIP submission process Describe the QIP reporting tool

93. 93 QUESTIONS?

94. 94 Contact Information QI Team, Medicare Drug and Health Plan Contract Administration Group (MCAG) Can be reached via: MAQuality@cms.hhs.gov