Quality Improvement Organizations And . - The Consumer

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Quality ImprovementOrganizations andConsumersEngaged to Improve CareAcross the ContinuumAgenda Discuss the roles of the BFCC-QIOand the QIN-QIO Discuss how the two collaborate Q&A session21

QIO ChangesAs of August 1, 2014, there are two QualityImprovement Organizations (QIOs) per state Beneficiary and Family Centered Care QIO (BFCC-QIO)– Perform medical case review– Organized among five geographic areas across the United States Quality Innovation Network QIO (QIN-QIO)– Offer quality improvement and technical assistance– Composed of two to six states Contract: August 1, 2014 – July 31, 2019 One organization can’t hold both contracts3KEPRO: BFCC-QIOTara Cooke, MSGOutreach Specialist42

KEPRO: BFCC-QIOKEPRO is the BFCC-QIO for the Centers for Medicare& Medicaid Services (CMS) Areas 2, 3, and 4Area 2 Delaware, District of Columbia, Florida, Georgia, Maryland,North Carolina, South Carolina, Virginia, and West VirginiaArea 3 Alabama, Arkansas, Colorado, Kentucky, Louisiana,Mississippi, Montana, New Mexico, North Dakota, Oklahoma,South Dakota, Tennessee, Texas, Utah, and WyomingArea 4 Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota,Missouri, Nebraska, Ohio, and Wisconsin5KEPRO’s Phone Numbersand Additional Resourceswww.keproqio.com63

KEPRO’s Services Discharge Appeals and Service Terminations Beneficiary Complaints Immediate Advocacy (IA)– KEPRO’s services are also available for Medicare Advantagebeneficiaries and beneficiaries with Medicare as a secondary7AppealsAcute Care Important Message from Medicare Preadmission/Admission Hospital Issued Notice ofNon-coverage (HINN)Post-Acute Care Notice of Medicare Non-coverage84

Appeals Process Overview9Appeals Financial liabilityTime framesObservation statuswww.cms.gov/bniAppeal status updates105

Beneficiary Complaints Must be about quality of care (medical record review)– Examples include wrong diagnosis and wrong treatment Care must have occurred within the last three years and becovered under Medicare Important aspects about the process:– Encouraged to complete a CMS complaint form– Must be filed by a Medicare beneficiary or his or her representative– Findings not admissible in a lawsuit11Quality of Care Reviews*Time Frame Changes* Providers will now have 14 days (instead of 30) to send in themedical record when a quality of care complaint is filed Providers that wish to respond to an inquiry from KEPRO willalso have a shortened time frame, which will be noted on theinquiry letter After the medical records are received, KEPRO has 30 days tocomplete the review Due to these shortened time frames, we encourage providers tofax medical records to KEPRO rather than sending them via mail KEPRO will post an update on our website in regard to theeffective date of these changes when provided by CMS126

Quality of Care Review*Reconsiderations*Complaint form issubmitted to KEPRONurse contacts thebeneficiary orrepresentative todiscuss the concernsNurse prepares thecase for thePhysician ReviewerPhysician Reviewerdetermines whetherthe care metprofessionallyrecognized standardsof careCare that does not meetstandards is referred tothe Quality InnovationNetwork QIO (QIN-QIO)for a QualityImprovement Plan (QIP)A final letter is sent tothe beneficiary orrepresentative with anopportunity for areconsideration13Immediate AdvocacyImmediate Advocacy is an informal process usedby the BFCC-QIO to resolve a complaint quickly.This process begins when the Medicare beneficiaryor representative gives verbal consent to proceedwith the complaint. Once the beneficiary orrepresentative agrees to the process and givesconsent, the BFCC-QIO contacts the provider orpractitioner on behalf of the beneficiary.147

IA Success StoriesA Medicare beneficiary contacted the BFCC-QIO with concerns about her health. She hadjust been discharged from the hospital after a light stroke. She was at home in bed and feltthat she needed assistance. She continued to feel some numbness on the left side of herface and was confused about whether home care was ordered and when it would start.The Intake Specialist then called the hospital and was able to speak with the CaseManager. She stated that the physician’s orders were for home health. The beneficiary wasindependent with her activities of daily living and could walk 300 feet, so she did not needinpatient skilled nursing care. The Intake Specialist explained the beneficiary’s concerns.The Case Manager agreed to contact the Physical Therapist regarding the assessment visitthat was scheduled for that day. The Intake Specialist also recommended a Social Workvisit, to determine what resources and referrals may be available for the beneficiary. TheIntake Specialist then contacted the beneficiary to let her know that the home health agencywould be coming to her home that day for an assessment of her needs. The beneficiary wasvery appreciative of the assistance and the assurance KEPRO provided.15KEPRO AvailabilityKEPRO appeals staff work(local time): Weekdays: 9 am – 5 pm Weekends: 11 am – 3 pm Holidays: 11 am – 3 pmVoicemails may be leftduring all other hoursTranslation servicesare available168

Collaboration with KEPRONewslettersJoint presentationsAdvisory boardsWebsite17Summary KEPRO provides three services for beneficiaries:– Discharge appeals– Beneficiary complaints– Immediate Advocacy KEPRO’s services are free for Medicare beneficiaries and theirrepresentatives More information can be found at www.keproqio.com To subscribe to KEPRO’s newsletter, 9

BFCC-QIOContact Information19Quality InsightsQuality Innovation NetworkPamela Meador, RN, BSN-BCServing the states of DE, LA, NJ, PA, and WV2010

Previous Structure The QIO Program was administered through 53 state-basedQIO contracts with 41 independent organizations Focused on three drivers– Supporting and convening Learningand Action Networks– Providing technical assistance– Care improvement throughinnovation, spread, andsustainability21Current Structure New name: Quality Innovation Network Quality ImprovementOrganizations or QIN-QIOs Narrow focus: systematic quality improvement Increased flexibility: addressing local needs2211

QIN-QIO GoalsBetterHealthGoalsMake care saferStrengthen person and family engagementBetterCareLowerCostPromote effective communication andcoordination of carePromote effective prevention and treatmentPromote best practices for healthy livingFoundational Principles:Make care affordable Enable innovation Foster learning organizations Eliminate disparities Strengthen infrastructure and data systems23Four Key Roles of QIN-QIOs1. Champion local-level, results-oriented change Data-driven Active engagement of patients and other partners Proactive, intentional innovation and spread of best practicesthat “stick”2. Facilitate Learning and Action Networks (LANs) Creating an “all-teach, all-learn” environment Placing impetus for improvement at the bedside level– e.g., hand washing2412

Four Key Roles of QIN-QIOs3. Teach and advise as technical experts Consultation and education The management of knowledge so learning is never lost4. Communicate effectively Optimal learning, patient activation, and sustainedbehavior change25Resources and Tools My Quality Insights Education and materialsQuality improvement projectsTracks engagementFosters collaboration2613

Quality ImprovementQIN-QIO Learning andAction NetworksThe networks serve as the hub for regional qualityimprovement work for each project, including: Project informationUpcoming eventsDiscussion forumResource libraryProvider-focused coachingTechnical assistanceKnowledge transferProvider-focused data portalSharing best practices Project maps and dataVideos and podcastsRecorded eventsProvider-focused coachingSharing of tools and resourcesfor technical Quality Improvement(QI) assistance with data Rapid improvement with testingof change ideas27Nursing Home Task –Alignment Efforts Engage consumers and families in healthcare decisions thatenhance good quality care Use Quality Assurance and Performance Improvement (QAPI) asthe framework for all QI methodology Focus on system-wide improvement to decrease healthcareacquired conditions and improve resident satisfaction Create strategic approaches through partnerships in the LAN Transform health care through innovation and involvement inCollaboratives I and II– Partner with key stakeholders – past and new– Participate in Quality Insights and the National Nursing Home QualityCare Collaborative (NNHQCC)2814

National Goals Recruit nursing homes to attain a score of 6 or lower on theNational Nursing Home Composite Quality Measure Improve the rate of long-stay mobility Reduce the use of antipsychotic medications in dementia patients Recruit all nursing homes for NNHQCC participation Coordinate high performing nursing homes as peer coaches tomentor lower performing facilities29Team Strategies toAccomplish Our GoalsLeverage partnerships to increase nursing homeparticipation in the LANs State survey agenciesNursing home trade associations: profit and non-profitEngage and actively utilize stakeholdersInclude residents/families in quality improvement activitiesCollaborate with aligned communities of focus Reduction of readmissions Healthcare-associated infections: MRSA, C. diff, etc.3015

Get InvolvedIn each of our states, experienced staff, many fromthe previous Medicare QIOs, will be available to: Facilitate your participation in regional QIN activities Provide individual consultation on quality projects Directly support your ongoing quality initiatives or collaborations31QIN-QIO Region Map3216

QIN-QIO Contact InformationQIN-QIOStatesQIO SubcontractorsGreat Plans Quality Innovation Network1230 O StreetLincoln, NE 68508217-352-1060KS, ND,NE, SDKansas Foundation for Medical Care (KS)North Dakota Health Care Review (ND)CIMRO of Nebraska (NE)SD Foundation for Medical Care (SD)TMF5918 West Courtyard Dr.Austin, TX 78730512-334-1614AR, MO,OK, TX,PRArkansas Foundation for Medical Care (AR)Primaris (MO)Lake Superior2901 Metro DriveMinneapolis, MN 55425952-854-3306MN, WI, MIStratis (MN)MetaStar (WI)Michigan Peer Review Organization (MI)Telligen1776 West Lakes ParkwayWest Des Moines, IA515-440-8519CO, IA, ILNoneHealthInsights6830 W. Oquendo Rd.Las Vegas, NV 89118702-385-9933NM, NV,OR, UTAcumentra (OR)33QIN-QIO Contact InformationQIN-QIOStatesQIO SubcontractorsGMCF1455 Lincoln ParkwayAtlanta, GA 30346678-527-3404GANCNoneAtom3340 Players Club ParkwayMemphis, TN 381251-800-528-2655AL, IN, KY,MS, TNAlabama Quality Assurance Foundation (AL)Mississippi Foundation for Medical Care dba IQH(MS)Mountain Pacific Quality Health Foundation3404 Cooney DriveHelena, MT 59602406-457-5820AK, HI, MT,WYNoneAQIN1979 Marcus AvenueLake Success, NY 11042516-209-5540DC, NY, SCDelmarva (DC)The Carolinas Centers for Medical Excellence (SC)WVMI dba Quality Insights3001 Chesterfield PlaceCharleston, WV 25304304-346-9864DE, LA,NJ, PA, WVQuality Insights of Delaware (DE)eQHealth (LA)Healthcare Quality Strategies (NJ)Quality Insights of Pennsylvania (PA)3417

QIN-QIO Contact InformationQIN-QIOStatesQIO SubcontractorsVHQC9830 Mayland DriveRichmond, VA 23233804-289-5320VA, MDNoneQualis Health10700 Meridian Ave N.Seattle, WA 98133206-364-9700ID, WANoneHealth Services Advisory Group (HSAG)313 East Camelback roadPhoenix, AZ 85016602-801-6701AZ, CA,FL, OH, VINoneHealthcentric Advisors235 Promenade St.Providence, RI 02908401-528-3238CT, MA,ME, NH,RI, VTQualidigm (CT, NH, and VT)35How do the two QIOswork together?3618

Contact InformationPamela Meador, RN, BSN-BC1.800.642.8686, ext. 4216pmeador@wvmi.orgTara Cooke, MSG216.396.7538Tara.Cooke@bfcc2.hcqis.orgFor more information, please visit:www.qualityinsights-qin.orgFor more information, please visit:www.keproqio.comYour feedback on today’spresentation is appreciated:www.tiny.cc/BFCCoutreach37Questions and AnswersThis material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization for West Virginia,Pennsylvania, Delaware, New Jersey, and Louisiana and KEPRO, a Beneficiary and Family Centered Care Quality Improvement Organization, bothunder contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Thecontents presented do not necessarily reflect CMS policy. KEPRO Publication No. A234-218-10/2015.3819

3 5 KEPRO: BFCC-QIO KEPRO is the BFCC-QIO for the Centers for Medicare & Medicaid Services (CMS) Areas 2, 3, and 4 Area 2 Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, and West Virginia

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