Download Decreasing Re-hospitalization Rates by Improving

THE NATIONAL QUALITY STRATEGY & CMS QUALITY
STRATEGY
MEDPAC RECOMMENDATIONS AND IMPACT ON NURSING
PRACTICE
LOUISIANA ASSOCIATION FOR HEALTHCARE QUALITY
ANNUAL EDUCATION CONFERENCE
APRIL 10, 2014
REBECCA HIGHTOWER MS, RN, CPHQ, CPE
QUALITY IMPROVEMENT SPECIALIST
EQHEALTH SOLUTIONS
This material is presented by eQHealth Solutions, the Medicare Quality Improvement Organization
for Louisiana, 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. LA10SoW2B14-3042
Objectives
• The learner will be able to describe the National Quality Strategy and the CMS Quality
Strategy and their impact on nursing practice.
• The learner will be able to describe CMS program changes for the hospital readmissions
reduction program (HRRP) and their impact on nursing practice.
• The learner will be able to describe the MedPAC recommendations for refining the HRRP
and the potential impact on nursing practice.
• The learner will be able to describe the MedPAC recommendations for approaches to
CMS provider payment bundling and the potential impact on nursing practice.
• The learner will be able to describe the MedPAC recommendations for approaches to
Medicare hospice policy issues and the potential impact on nursing practice.
The National Quality Strategy
• Patient Protection & Affordable Care Act of
2010 (ACA)
– Required a National Quality Strategy to “improve the
delivery of healthcare services, patient health outcomes,
and population health
– Build a consensus on how to measure quality so that
stakeholders can align their efforts for maximum results
The National Quality Strategy
• A national blueprint for achieving a high-value
healthcare system
• Sets clear goals to support efforts to improve the
quality of health and healthcare.
www.qualityforum.org/npp/
The National Quality Strategy
3 Aims
– Better care
– Affordable care
– Health people & communities
www.qualityforum.org/npp/
The National Quality Strategy
Vision
– Safe, affordable, value-driven healthcare is attainable
– Current trends can be reversed with Americans becoming
healthier & stronger
– Public & private sector leaders rowing together in the same
direction toward the same finish line.
www.qualityforum.org/npp/
The National Priorities Partnership
• Strategic opportunities to accelerate
improvement across all NQS aims &
priorities
www.qualityforum.org/npp/
The National Priorities Partnership
• Four National Goals for the NQS
– Eliminating harm
– Eradicating disparities
– Reducing disease burden
– Removing waste in healthcare
www.qualityforum.org/npp/
The National Priorities Partnership
Six Priorities for the NQS
The National Priorities & Goals
Making care safer by reducing harm
caused in the delivery of care.
The National Priorities & Goals
Key Measures for NQS Priority 1 – Making Care Safer*
Measure Focus
Key Measure
Name/Descripti
on
Baseline Rate
Most Recent
Rate
Aspirational
Target
HospitalAcquired
Conditions
(HACs)
Incidence of
145 HACs/1000
142 HACs per
Reduce
measurable
admissions
1,000
preventable
admissions in
HACs by 40%
20112
by the end of
HACs
2013
Hospital
Readmissions
All-payer 30-day
14.4% based on
readmission rate 32.9 million
admissions
14.4% based
Reduce all
upon 32.7
readmissions by
million
20% by the end
admissions in
of 2013
20115
The National Priorities & Goals
Engage patients and families as
partners in their care.
The National Priorities & Goals
Key Measures for NQS Priority 2 – Engage Patients & Families as Partners in
their Care*
Measure
Focus
Key Measure
Name/Description
Current Rate
Most Recent
Rate
Aspirational
Target
Timely
Care
Adults who needed care right
14.1%
Available Fall
2013
Reduce to
<10% by 2017
15.9%
Available Fall
2013
Reduce to
<10% by 2017
away for an illness, injury, or
condition in the last 12 months
who sometimes or never got
care as soon as wanted
DecisionMaking
People with a usual source of
care whose healthcare
providers sometimes or never
discuss decisions with them
Believe in the
Power of the
Patient
The National Priorities & Goals
Promote effective communication
and coordination of care.
The National Priorities & Goals
Key Measures for NQS Priority 3 – Promote Effective Communication & Coordination of Care*
Measure Focus
Key Measure
Name/Description
Current
Rate
Most
Recent Rate
Aspirational
Target
PatientCentered
Medical Home
Percentage of children needing care
69%8
66.1%9
66.1%9
**October
2013 data
from CMS10
Update
available in
Fall 2013
Increase to 50%
by 2017
I
coordination who receive effective care
coordination
3-Item Care
Transition
Measure**
1.
During this hospital stay, staff
took my preferences & those of
my family/caregiver into account
in deciding what my healthcare
needs would be when I left.
2.
When I left the hospital, I had a
good understanding of the things
I was responsible for in managing
my health.
3.
When I left the hospital, I clearly
understood the purpose for taking
each of my medications.
The National Priorities & Goals
Promote the most effective
prevention and treatment
practices for the leading causes
of mortality
The National Priorities & Goals
Key Measures for NQS Priority 4 – Promote the Most Effective Prevention & Treatment practices for
the Leading Causes of Mortality, Starting with Cardiovascular Disease
Measure
Focus
Key Measure
Name/Description
Current
Rate
Most
Recent Rate
Aspirational Target
(2017)
Aspirin Use
People at increased risk of
cardiovascular disease who
are taking aspiring
47%*
53% 14
Increase to 65% by
2017
Blood
Pressure
Control
People with hypertension who
46%**
53% 16
Increase to
65% by 2017
33%**
32% 18
Increase to
65% by 2017
23%***
22% 20
Increase to
65% by 2017
have adequately
controlled blood pressure
Cholesterol
Management
People with high cholesterol
who have adequatelymanaged hyperlipidemia
Smoking
Cessation
People trying to quit smoking
who get help
The National Priorities & Goals
Work with communities to promote
wide use of best practices to
enable healthy living.
The National Priorities & Goals
Key Measures for NQS Priority 5 – Working with Communities to Promote Best
Practices for Healthy Living*
Measure
Focus
Key Measure
Name/Description
Current
Rate
Most
Aspirational
Recent Rate Target
Depression
Percentage of Adults
68.2%21
68.1% for
2011
Increase to
78.2% by 2020
35.7%22
Update
available in
2014
Reduce to 30.5%
by 2020
reporting symptoms of a
major depressive episode
(MDE) in the last 12 months
who received treatment for
depression in the last 12
months
Obesity
Proportion of Adults who are
obese
The National Priorities & Goals
Make quality care more affordable
for individuals, families,
employers, and governments by
developing and spreading new
healthcare delivery models.
The National Priorities & Goals
Key Measures for NQS Priority 6 – Making Quality Care More Affordable by Developing and
Spreading New Healthcare Delivery Models
Measure
Focus
Key Measure Name/Description
Out-of-Pocket
Expenses
Percentage of people under 65 with
out-of-pocket medical and premium
expenses greater than 10% of
income
Health
spending per
capita
Annual all-payer healthcare
spending per person
Current
Rate
Most Recent
Rate
Aspirational
Target
18.5%24
Update
available in Fall
2013
See footnote25
HHS Budget in
Brief discussion
of investments &
healthcare
spending
reduction
proposals
$8,40226
$8,680 per
person in
201127
See footnote28
HHS Budget in
Brief discussion
of investments &
healthcare
spending
reduction
proposals
The National Quality Strategy
• Progress
– Nationwide initiatives launched to improve healthcare quality in
each of the six priorities
•
Partnership for Patients
•
Million Hearts Campaign
•
Multi-Payer Advance Primary Care Practice Demonstration
– Interagency Working Group on Health Care Quality
– Agency for Healthcare Research and Quality (AHRQ)
www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf
The National Quality Strategy
• Progress
– Alignment of measurement approaches
•
Measures Application Partnership
•
National Strategy for Data Collection, Measurement, &
Reporting
– Reducing the burden of healthcare providers working to improve
quality
•
EHR Incentive Program Meaningful Use
•
Organizational Infrastructure at the Community Level
– Promote comparability of measurement data
The National Quality Strategy
• Progress
– Established key measures to be used to track national progress
in each of the six priorities
– States adopting the NQS & using it to
•
Demand higher quality from private health insurers
•
Improve the quality of care for Medicaid recipients
www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf
The National Quality Strategy
• Progress
– Payment & Delivery Systems Reforms
•
HHS offers more than three dozen opportunities
for providers across the care spectrum to
participate in pilot programs to improve quality and
reduce the cost of care.
The National Quality Strategy
Next Steps
•
HHS will continue to pare down and consolidate the measures that
providers are required to collect and report.
– Enthusiastic engagement with private payers, through the Measures Application
Partnership and the Buying Value initiative, will continue to drive this work.
•
There is a growing body of evidence on how to keep patients safer, how to
best coordinate care to improve outcomes, and how to lower costs through
improvement.
– Future iterations of this report will highlight specific best practices and point
stakeholders from across the health care sector—payers, clinicians, communities, and
consumers—to resources that guide quality improvement work for all populations.
The CMS Quality Strategy
The CMS Quality Strategy - Vision
• To optimize health outcomes by improving clinical quality
and transforming the health system.
The CMS Quality Strategy - Mission
• Lead quality measurement alignment, prioritization, and
implementation and the development of new innovative
measures
• Guide quality improvement across the nation and foster learning
networks that generate results
• Reward value over volume of care
• Develop and implement innovative delivery system and
payment models to improve care and lower costs
• Collaborate across CMS, HHS, and with external stakeholders
The CMS Quality Strategy - Mission
• Listen to the voices of beneficiaries and patients as well as those who
provide healthcare
• Foster an environment that will create the capacity for providers to
improve quality through use of locally generated data and local
innovations in care delivery
• Be a model of effective business operations, customer support, and
innovative information systems that excel in making meaningful
information available
• Develop individuals, create high-functioning teams, foster pride and
joy in work at all levels, continuously learn, and strive to improve
The CMS Quality Strategy - Values
• Beneficiaries and Patients Come First – We put first the best interest
of the people we serve.
• Public Service – We take pride in our unique and privileged role in the
healthcare of the nation.
• Integrity – We hold ourselves to the highest standards of honesty and
ethical behavior.
• Accountability – We earn trust by being responsible for the outcomes
of our actions.
• Teamwork – We foster unconditional teamwork and regard every
employee in CMS as available and willing to help others.
The CMS Quality Strategy - Values
• External Collaboration – We strive to work in full cooperation with the
private sector.
• Innovation – We encourage finding and testing new ideas in all that
CMS does.
• Excellence – We are committed to strengthening our organizational
culture of striving for excellence in our products and services as well
as in how we do business.
• Respect – We treat all our stakeholders and one another with the
utmost respect and professionalism.
The CMS Quality Strategy –
Foundational Principles
•Eliminate Racial and Ethnic Disparities
•Strengthen Infrastructure and Data Systems
The CMS Quality Strategy –
Foundational Principles
•Enable Local Innovations
•Foster Learning Organizations
The CMS Quality Strategy –
Drivers & Policy Levers
•Measuring & publicly reporting providers’ quality
performance
•Providing technical assistance & fostering learning
networks for quality improvement (QI)
•Adopting evidence-based national coverage
determinations
The CMS Quality Strategy –
Drivers & Policy Levers
•Setting clinical standards for providers that support QI
•Creating survey and certification processes that evaluate
capacity for quality assurance & QI
The CMS Quality Strategy –
Goal #1
•Make care safer by reducing harm caused in the
delivery of care
•Improve support for a culture of safety
•Reduce inappropriate & unnecessary care
•Prevent or minimize harm in all settings
The CMS Quality Strategy –
Goal #2
•Strengthen person & family engagement as partners in
their care
•Ensure all care delivery incorporates patient &
caregiver preferences
•Improve experience of care for patients, caregivers,
and families
•Promote patient self-management
The CMS Quality Strategy –
Goal #3
•Promote effective communication & coordination of care:
•Reduce admissions and readmissions
•Embed best practices to manage transitions to all
practice settings
•Enable effective healthcare system navigation
The CMS Quality Strategy –
Goal #4
•Promote effective prevention & treatment of chronic disease
•Increase appropriate use of screening & prevention
services
•Strengthen interventions to prevent heart attacks &
strokes
•Improve quality of care for patients with multiple chronic
conditions (MCCs)
The CMS Quality Strategy –
Goal #4
•Promote effective prevention & treatment of chronic disease
•Improve behavioral health access & quality of care
•Improve perinatal outcomes
The CMS Quality Strategy –
Goal #5
•Work with communities to promote best practices of
healthy living
•Partner with & support federal, state, and local public
health improvement efforts
•Improve access within communities to best practices
of healthy living
The CMS Quality Strategy –
Goal #5
•Work with communities to promote best practices of
healthy living
•Promote evidence-based community interventions to
prevent & treat chronic disease
•Increase use of community-based social services
support
The CMS Quality Strategy –
Goal #6
•Make care affordable
•Develop & implement payment systems that reward
value over volume
•Use cost analysis data to inform payment policies
About eQHealth Solutions
•
The Department of Health & Human Services’ (DHHS) National Quality
Strategy is the framework for the healthcare initiatives implemented in recent
years by the Centers for Medicare & Medicaid Services (CMS).
– The CMS Medicare Quality Improvement Organizations (QIOs) are an
independent network dedicated to promoting the goals of the National
Quality Strategy in each state & territory.
About eQHealth Solutions
•
eQHealth has served as the CMS Medicare QIO in Louisiana for over 27
years.
– As the QIO, our work is based on the goals & priorities of the national
and CMS quality strategies.
•
We are a free resource for meeting the requirements of CMS Quality
Reporting programs and improving quality & safety of patient care and care
transitions.
A bold new charter from CMS
Healthcare professionals are experienced,
committed, and understand the challenges
involved in widespread adoption of best
practices for achieving significant
improvements in the quality and safety of
healthcare for their patients.
Finances
• Payment reform for hospitals
– CMS payment reform increasing the stakes
– Potential negative impact to base DRG payments*
FY
VBP
HRRP
HAC
Total
2013
1.00%
1.00%
-0-
2.00%
2014
1.25%
2.00%
-0-
3.25%
2015
1.50%
3.00%
1.00%
5.50%
2016
1.75%
3.00%
1.00%
5.75%
2017
2.00%
3.00%
1.00%
6.00%
*Alexander, K., LHA Legislative & Regulatory Update. LA Assn for Healthcare Quality
Annual Education Conference. April 2012
Medicare Payment Reform –
MedPAC Recommendations
Hospital Readmissions Reduction Program
(HRRP)
Medicare Payment Reform –
MedPAC Recommendations
Hospital-Acquired Conditions (HAC) Program
Medicare Payment Reform –
MedPAC Recommendations
Post-Acute-Care Providers
Medicare Payment Reform – PAC
Key predictors of readmissions, changes in functional status, and resource
use
Source
Domain
Examples
Claims
Demographics
Age
Clinical
Diagnoses
Co-morbidities
Patient Assessment
Functional Status
Mobility & self-care; sitting endurance
Cognitive Function
Able to express ideas; Able to understand; Comatose;
Depression
Special Services
Ventilator; Dialysis; Chemotherapy; Central Line
Placement; Total Parenteral Nutrition; IV medications
Medical Condition
Severe pressure ulcers; Major wound present
Impairments
Inability to hear, see, swallow; Incontinence
Prior Service Use
Hospital or PAC use within past 2 months; ICU days
Prior Functioning
Mobility & self-care; History of falls
Note: IV (intravenous), PAC (post-acute care), ICU (intensive care unit).
Source: Carter et al. 2012, Gage 2011, Kramer et al. 2014, and Nuccio et al. 2011.
MedPAC Report March 2014.
Medicare Payment Reform –
Hospice Care –
Medicare Care Choices Model
Medicare Payment Reform
Bundled Payments for Care Improvement
Initiative
Medicare Payment Reform
Bundled Payments for Care Improvement Initiative
Model 1
Episode
Model 2
Model 4
All acute patients, all
Selected DRGs, hospital Selected DRGs, post-
Selected DRGs, hospital
DRGs
plus post-acute period
acute period only
plus readmissions
All non-hospice Part A
All non-hospice Part A
Services included in the All Part A services paid as All non-hospice Part A
bundle
Model 3
part of the MS-DRG
and B services during the and B services during the and B services (including
payment
initial inpatient stay, post- post-acute period and
the hospital and
acute period and
physician) during initial
readmissions
readmissions
inpatient stay and
readmissions
Payment
Retrospective
Retrospective
Retrospective
Prospective
Plans for all models include care redesign and enhancements, such as reengineered care
pathways using evidence-based medicine, standardized operating protocols, improved care
transitions, and care coordination. All may also include proposals for gains-haring among
provider partners.
Medicare Payment Reform
Bundled Payments for Care Improvement Initiative
Implementation
Impact of Aging Baby Boomers on
Medicare Population
• The Medicare population is projected to grow by over 70
percent over the next 20 years, as the bulk of the baby
boom generation ages into Medicare eligibility.
• With this expansion, the Medicare population will differ in
key ways from the current one.
Impact of Aging Baby Boomers on
Medicare Population
• First, the average age initially will skew younger than in
the recent past, but then grow rapidly older as the number
and share of beneficiaries ages 85 and older increases.
• Second, it will become more racially and ethnically diverse
than the current population.
• Third, a greater number and share of beneficiaries will
have multiple chronic conditions.
Impact of Aging Baby Boomers on
Medicare Population
• Finally, beneficiaries entering the program over the next
several years will have had very different experiences with
employer-sponsored and other forms of health care
coverage, due to significant changes that have taken
place and continue in the private and non-Medicare public
health insurance markets.
Remember
”…the secret of the care of the patient is
in caring for the patient.”
Francis W. Peabody, MD (1881-1927)
HHS & CMS Programs Supporting
National Priorities & Goals
National Priorities Partnership
•National Priorities and Goals: Aligning Our Efforts to Transform
America’s Healthcare. Washington, DC: National Quality Forum
(NQF) 2008 [Supported by the Robert Wood Johnson
Foundation (RWJF)]
•2013 Annual Progress Report to Congress. National Strategy
for Quality Improvement in Health Care. April 2013. U.S.
Department of Health and Human Services.
http://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.pdf
1CMS-1518-F/1430-F:
Final Rule for Changes to the IPPS/LTCH PPS for FY 2012
HHS & CMS Programs Supporting
National Priorities & Goals
Department of Health & Human Services (DHHS). FY 2014
Budget in Brief: Strengthening Health and Opportunity for All
Americans
•http://dhhs.gov/ budget/fy2014/fy-2014-budget-in-brief.pdf
Million Hearts Campaign
•http://millionhearts.hhs.gov/index.html
Community Transformation Grants Program
•http://www.cdc.gov/communitytransformation/
1CMS-1518-F/1430-F:
Final Rule for Changes to the IPPS/LTCH PPS for FY 2012
HHS & CMS Programs Supporting
National Priorities & Goals
Partnership for Patients
• Public-private partnership to assist in improving the
quality, safety, and affordability of healthcare
Medicare Quality Improvement Organization (QIO)
• Facilitate the accomplishment of CMS Program Priorities
• eQHealth Solutions - http://www.eqhealthsolutions.com
http://louisianaqio.eqhs.org
1CMS-1518-F/1430-F:
Final Rule for Changes to the IPPS/LTCH PPS for FY 2012
HHS & CMS Programs Supporting
National Priorities & Goals
Center for Medicare & Medicaid Innovation
• http://innovation.cms.gov/
•Medicare Care Choices Model – Hospice Demonstration
• http://innovation.cms.gov/initiatives/Medicare-Care-Choices/
•Bundled Payments for Care Improvement Initiative
•http://innovation.cms.gov/initiatives/Bundled-Payments
1CMS-1518-F/1430-F:
Final Rule for Changes to the IPPS/LTCH PPS for FY 2012
Contact
Rebecca Hightower MS, RN, CPHQ, CPE
Quality Improvement Specialist
eQHealth Solutions
[email protected]