9th Scope of Work Themes

Beneficiary Protection

Overview

Under the Medicare-funded "Ninth Scope of Work," a three-year work plan that begins August 1, 2008, QIOs will continue to carry out statutorily mandated review activities, such as:

Opportunity for Quality Improvement

Individual patient complaints and provider medical record reviews are important starting points for analysis of quality improvement needs among providers. In the 9th SOW, QIOs will be increasing their efforts to link case review activities to improvements in the quality of care, specifically by developing quality improvement activities focused on system-wide changes. QIOs will utilize all data related to case review activities to identify problems related to the quality of care and design quality improvement activities aimed at helping providers correct these problems. The QIOs will be responsible for collaborating with all pertinent CMS contractors to ensure that all available data are considered and to maximize opportunities for quality improvement.

QIO Activities

The activities involved in the Beneficiary Protection Theme will focus on nine Tasks:

  1. Case reviews
  2. Quality improvement activities (QIAs)
  3. Alternative dispute resolution (ADR)
  4. Sanction activities
  5. Physician acknowledgement monitoring
  6. Collaboration with other CMS contractors
  7. Promoting transparency through reporting
  8. Quality data reporting
  9. Communication (education and information)

In carrying out these activities, QIOs are required to ensure consistency and value and must adhere to CMS policies and procedures. This includes the QIOs' responsibility to refer cases to the Department of Health and Human Services' Office for Civil Rights for further investigation if the QIO finds that care is being compromised or denied due to discrimination on the basis of race, color, national origin, disability, or age.

In the 9th SOW, QIOs will now be required to use ADR techniques in appropriate beneficiary complaint cases for which there are no significant concerns about the quality of care provided. ADR options include mediation, facilitated resolution, and external resolution. Mediation involves a mediator in a face-to-face or telephone meeting. Facilitated resolution consists of a QIO facilitator interacting with all parties to generate a resolution or agreement, and does not typically involve a face-to-face meeting. External resolution occurs through direct communication between the provider and the complainant facilitated by the QIO, which follows up to ensure that direct communication occurred and no further review is needed.

With regard to confirmed quality of care concerns, QIOs must follow all CMS instructions. This includes allowing the provider an opportunity for discussion, imposing a corrective action plan where appropriate, and referring cases to the Office of Inspector General (OIG) when a QIO identifies a case in which the provider violates or fails to comply with any obligation in Section 1156(a) of the Social Security Act.

Each QIO must maintain a beneficiary hotline to provide callers with information concerning Medicare beneficiary rights and responsibilities, beneficiary protections, and the various QIO programs and initiatives. The helpline must be staffed during normal business hours with the capability to record calls received outside business hours.

In addition, QIOs must actively promote, and support hospitals in, submission of quality data for reporting and Annual Payment Update (APU) purposes. QIOs must have a basic understanding of all measures, deadlines for submission, and the impact on the APU. QIOs will offer educational and technical assistance to providers on the use of CMS systems and reporting tools such as CART, QualityNet, and the QIO Clinical Warehouse.

Finally, QIOs will continue to fulfill other responsibilities on a regular basis. These responsibilities include physician acknowledgement monitoring, whereby the QIOs ensure that hospitals have a physician acknowledgement statement on file for physicians billing for services provided in the hospital. The QIOs must also work with the Beneficiary Satisfaction Survey Contractor that is surveying beneficiaries regarding their satisfaction with the QIO complaint process. The QIO is responsible for providing complete and timely information to the Survey Contractor. Finally, QIOs must provide an annual public report of all medical service reviews, using a template provided by CMS.

Evaluation

QIOs must complete reviews in a timely manner, with at least 90% of all reviews meeting timeliness standards. QIOs will also be assessed on beneficiary satisfaction. They will be evaluated on the percentage of beneficiaries filing complaints who complete a satisfaction survey and also on the percentage of survey respondents who are satisfied or very satisfied with the complaint process. In addition, QIOs will be assessed on the percentage of QIAs implemented in those cases with confirmed quality of care concerns. For QIAs and both beneficiary performance measures, QIOs will be evaluated by the extent of their improvement each quarter over the baseline value of each measure. Lastly, QIOs will be evaluated on system-wide QIAs, specifically regarding improvements realized as a result of the systems-wide change during the 12-month period immediately following the implementation of the activity.

Resources

CMS: http://www.cms.hhs.gov/BeneComplaintRespProg/

MedQIC: http://www.medqic.org (click on "Beneficiary Protection")

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Care Transitions

Overview

The Care Transitions Theme focuses on improving coordination across the continuum of care. In particular, QIOs will promote seamless transitions from the hospital to home, skilled nursing care, or home health care.

QIOs will work to reduce unnecessary readmissions to hospitals that may increase risk or harm to patients and cost to Medicare. CMS will look to QIOs to implement projects that effect process improvements to address issues in medication management, post-discharge follow-up, and plans of care for patients who move across health care settings.

Opportunity for Quality Improvement

The process by which patients move from hospitals to other care settings is increasingly problematic as hospitals shorten lengths of stay and as care becomes more fragmented. Medicare patients report greater dissatisfaction related to discharges than to any other aspect of care that CMS measures. This situation can be changed. In general, rehospitalization rates and health care utilization vary substantially across geographic locations, suggesting opportunities for improvement in areas with higher observed rates. Improved health care processes at and after discharge correlate with substantial reductions in early rehospitalization for particular conditions, such as heart failure. In addition, prior and ongoing QIO work has assisted providers in analyzing data and in identifying and addressing gaps in care in areas such as transitions and end-of-life planning and care.

QIO Activities

The activities under the Care Transitions Theme will focus on three Tasks:

  1. Community and provider selection and recruitment;
  2. Interventions and;
  3. Monitoring.

Within one month of the contract being awarded, QIOs must provide an initial report to CMS that characterizes the selected target population for which the QIO will aim to reduce readmission rates. The report will give examples of inappropriate or wasteful services affecting rehospitalization rates, describe how health services are delivered to the target population, and specify any opportunities to address disparities.

QIOs will implement quality improvement initiatives throughout their local communities concerning quality care for Medicare beneficiaries at or after hospital discharge. Each QIO is required to work with partners to implement each of the following: hospital and community system-wide interventions (designed to address system-level weaknesses), interventions that target specific diseases or conditions (focused on evidence-based practices and processes designed to have an impact on rehospitalization rates for particular conditions such as acute myocardial infarction, congestive heart failure, or pneumonia), and interventions that target specific reasons for admission (tailored to address the causes that drive local readmission rates).

Based on the findings from the initial report, and in addressing each of the three focus areas, QIOs will partner with appropriate community health care providers to develop and implement an evolving intervention plan, which will aim to reduce rehospitalization among the targeted population defined in the QIO's initial report.

Throughout the intervention period, each QIO will be accountable for ongoing project management and facilitation. The QIO will assist providers and the community in creating resources for more effective transitions and in implementing improvement activities beyond the period of hospital discharge.

QIOs will be responsible for periodic reports updating CMS on progress in the activities of this Theme.

Evaluation

Each local project must show evidence of improvement in the quality of care and in the implementation of strategies to reduce rehospitalization rates. The overall evaluation for this Theme requires that multiple local projects succeed at reducing rehospitalization rates through improved quality of care. QIOs will be evaluated on evidence that appropriate strategies were implemented early in the project and, in turn, were carried out through the entire project.

Resources

MedQIC: http://www.medqic.org (click on "Care Coordination")

The Dartmouth Atlas of Health Care: http://www.dartmouthatlas.org

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Patient Safety

Overview

QIO activities under the Patient Safety Theme will focus on six primary topics:

  1. Reducing rates of health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections;
  2. Reducing rates of pressure ulcers in nursing homes and hospitals;
  3. Reducing rates of use of physical restraints in nursing homes;
  4. Improving inpatient surgical safety and heart failure treatment in hospitals;
  5. Improving drug safety; and
  6. Providing quality improvement technical assistance to nursing homes in need.

Opportunity for Quality Improvement

The requirements of the Patient Safety Theme, also known as the CMS National Patient Safety Initiative (NPSI), are designed to address areas of patient harm for which there is evidence of how to improve safety by improving health care processes and systems. The Theme brings forward several components from the previous SOW (surgical care, heart failure, pressure ulcers and restraints in nursing homes, and drug safety), allowing QIOs to build on the progress they have made with providers over the past three years.

With the new SOW, however, the safety focus also pushes into new areas (MRSA, pressure ulcer prevention in hospitals, and QIO technical assistance for nursing homes in need), giving providers and QIOs the chance to broaden the scope of their patient safety-related improvement activities.

QIO Activities

QIO activities under the NPSI will support the development of an "all-teach, all-learn" community in action to meet the goals within each component of the Initiative. To that end, CMS is requesting that QIOs identify 2-3 individuals from each QIO to serve as National Quality Improvement Leaders. These individuals will serve as liaisons between QIO senior leadership and the work that is occurring at the patient care level in each state/jurisdiction. They will also liaise with health care executives in their respective states/jurisdictions to highlight the work occurring at the national level in their provider groups. The National Quality Improvement Leaders will come together up to three times per year to share practices that are proving to be successful at the local level.

QIOs will have a wealth of tools available to them to assist in reaching the final 28-month goals for specific quality measures. These include survey instruments geared toward leadership and/or patient safety processes in hospitals and nursing homes. Additionally, QIOs can draw upon successful tools that were utilized in the 8th SOW. It is expected that as successful tools and practices develop, the QIOs will share these with one another for implementation in other QIO communities.

QIOs may expand their local quality improvement communities by reaching out to potential patient safety partners and encouraging their participation to expand upon the momentum that will be created by the CMS NPSI.

Evaluation

Evaluation of QIO performance will be performed at 18 and 28 months. The first evaluation period (through the end of the 18th contract month) is intended to serve as the foundation for the QIOs' future success in positively moving the Patient Safety measures by the 28th month. The 18-month evaluation criteria focus on recruitment, protocol implementation, and some improvement successes.

The final contract evaluation at 28 months will be based on provider improvement on the established clinical measures over the course of the contract. For MRSA, at least 50% of the reporting hospitals are expected to effectuate a 40% reduction in the MRSA metrics. Pressure ulcers for both hospitals and nursing homes are expected to show an 8% relative improvement rate, and physical restraints are expected to have a 20% relative improvement rate. Surgical site infection and heart failure improvement will be based upon obtaining at least 70% of the Achievable Benchmark of Care.

CMS is expecting that each QIO will suggest the quantitative evaluation structure for the drug safety component. Nursing homes in need of QIO technical assistance-as defined by CMS (see the Nursing Home Compare Web site)-are expected to have a 20% mean relative improvement from baseline for their pressure ulcer and physical restraint measures and to have obtained at least 90% on a satisfaction survey. A "pass" will be given to those QIOs that meet at least 70% of the target for each measure within a component.

Resources

Most recent version of 9th SOW: http;//www.cms.hhs.gov/QualityImprovementOrgs

MedQIC: http://www.medqic.org (Click on "hospital" or "nursing home" tabs for resources)

AHRQ: http://www.ahrq.gov (Resources available on clinical topics and drug therapy)

Hospital Compare: http://www.medicare.gov

Nursing Home Compare: http://www.medicare.gov

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Prevention

Overview

The overall goal of the Prevention Theme is to improve the quality and frequency of preventive health care services in order to optimize beneficiary quality of life and health care efficiencies. The Prevention theme consists of three focus areas: Core Prevention, Diabetes Disparities, and Chronic Kidney Disease (CKD). The Core Prevention work builds on the QIO 8th SOW by focusing on QIOs' ability to impact the rates of two cancer screenings (mammography and colorectal cancer CRC screening) and two immunizations (influenza and pneumococcal) among Medicare beneficiaries in each state/jurisdiction. A sub-national component of the Prevention Theme will task QIOs in as many as 33 states/jurisdictions that are experiencing disparities in diabetes care across racial/ethnic populations, with providing support for Diabetes Self-Management Education (DSME). A sub-national quality improvement effort for up to 13 QIOs will be to slow the progression of CKD and to improve CKD clinical care.

QIOs will work with a selected group of practices in their states/jurisdictions to accomplish the national tasks and the diabetes management sub-national task. Practices enrolled with a QIO to improve rates of mammography and CRC screenings and immunizations must have already implemented electronic health records (EHRs) certified by a certifying body recognized by the Secretary of Health and Human Services. Collaborating practices will work with their QIOs to implement care management processes, using their certified EHRs, that focus on breast cancer and CRC screening and influenza and pneumococcal vaccination. Providers working on the diabetes sub-national task must have a minimum percentage of diabetic patients from underserved racial/ethnic populations willing to participate in DSME programs.

A central approach for the CKD quality improvement effort is coalition building and collaboration with providers in the state/jurisdiction as well as other partners that can support the QIO CKD efforts at the local, state, and national levels. The characteristics of the providers targeted to participate in CKD quality improvement efforts are not specified by CMS. Rather, the QIO must determine recruitment strategies that would allow statewide CKD improvement targets to be met.

Opportunity for Quality Improvement

QIO interventions that support health information technology (HIT) have the potential to improve screening rates through timely notification of providers and patients when a mammogram or CRC screening should be scheduled. Influenza and pneumococcal vaccination levels among adults 65 years of age and older remain well below the Healthy People 2010 objective of 90%. There is a need for more effective strategies for delivering vaccines to high-risk persons, their providers, and household contacts.

Published research reveals that racial/ethnic minority patients are generally less likely to receive routine medical services than white patients, with African Americans having fewer routine physician visits and more visits to the emergency room. DSME is a proven intervention for allowing patients to control their disease by working with their health care provider.

CKD is the ninth leading cause of death in the U.S. CKD affects 11% of the U.S. population over the age of 65, and those affected are at increased risk of cardiovascular disease and kidney failure. The leading causes of CKD are diabetes and hypertension; furthermore, minority populations are more likely to develop CKD than non-minority populations. Early detection of CKD along with appropriate interventions, such as medication therapy, can achieve a substantial reduction in the progression rate of kidney failure.

QIO Activities

The primary activities involved in the national Prevention Theme will focus on nine Tasks:

  1. Recruiting participating practices;
  2. Identifying the pool of non-participating practices;
  3. Promoting care management processes for preventive services using EHRs;
  4. Completing assessments of care processes;
  5. Assisting with data submission;
  6. Monitoring statewide rates (mammograms, CRC screens, influenza and pneumococcal immunizations);
  7. Administering an assessment of care practices;
  8. Producing an Annual Report of statewide trends, showing baselines and rates; and
  9. Submitting plans to optimize performance at 18 months.

QIOs will recruit a pre-agreed-upon number of practices to participate, securing at least 80% of the targeted number by the end of Quarter 2. QIOs will also identify non-participating practices with EHR capability.

The QIO will educate each participating practice on using its EHR capabilities to improve rates of screenings and immunizations, using Doctor's Office Quality-Information Technology University (DOQ-IT University). At the end of the 18th month, at least 80% of the participating practices should report tracking of each preventive service for at least 75% of patients or patient encounters. This will be determined by an assessment of care practices.

Each participating practice will use its certified EHR to report breast cancer and CRC screening and influenza and pneumococcal immunization data directly to the CMS Clinical Data Warehouse. Reporting will begin during Quarter 3 and continue quarterly thereafter. Every two weeks, beginning in Quarter 3, the QIO will report to CMS the number of and rates for practices that are reporting data.

QIOs will assist both collaborating and comparison practices to complete an assessment of care processes by the end of Month 16. This will assess practices' EHR capabilities and current care processes related to breast and CRC screening and immunizations. Ninety percent of participating practices and 65% of comparison practices must complete this assessment.

For the sub-national task on reducing disparities in diabetes care, QIOs will be responsible for monitoring statewide diabetes rates and monitoring all statewide diabetes education efforts. QIOs will also submit the number of patients who have completed a CMS-approved DSME program on a monthly basis.

QIOs awarded the CKD sub-national task will utilize existing collaborative efforts and develop new mechanisms to support a community effort to effect quality improvement at the system level. The QIOs selected for work on CMS' CKD quality initiative will be required to:

  1. Focus on three clinical areas, each with a corresponding clinical measure. These areas include detection of CKD in diabetic beneficiaries; appropriate medication treatment (ACE inhibitors/ARBs) to slow the progression of kidney failure; and adequate counseling prior to initiation of dialysis as evidenced by placement of an arteriovenous fistula for hemodialysis patients.
  2. Use collaboration as a means of achieving sustainable CKD system-level changes. Partners in the collaborative will include community health centers, community representatives, ESRD Network Organizations, health department diabetes grantees, local chapters of kidney organizations, patient representatives, provider groups, state and county government representatives, and others.

QIOs must address any CKD care disparities identified in their state/jurisdiction and implement interventions to reduce these disparities. QIO activities will include:

  1. Focusing on provider implementation of clinical practices that have been tested and proven to be successful in the prevention and management of CKD;
  2. Targeting beneficiaries who are most likely to benefit from education on risk factors, early identification, and treatment choices for CKD;
  3. Disseminating tools and resources to providers and beneficiaries that are available through federal partners; and
  4. Working through a collaborative model to effectuate system-level change that will have a lasting impact on the prevention and management of CKD.

Evaluation

QIOs will be evaluated at months 18 and 28 of the 9th SOW. QIOs will be accountable for achieving the minimum performance thresholds in the rates of screenings and vaccinations. QIOs will also be responsible for meeting goals related to recruiting and educating practices and the rates of practices reporting quality data.

QIOs engaged in the CKD tasks will be required to successfully pass the established targets in all clinical outcome measures as well as provider recruitment and partner collaboration goals.

For the diabetes sub-national component, QIOs will be evaluated based on improvements within their states/jurisdictions in rates of hemoglobin (HbA1C) control, LDL cholesterol levels, blood pressure control, and eye exams.

Resources

CMS: http://www.cms.hhs.gov/ColorectalCancerScreening/

MedQIC: http://www.medqic.org

CDC: http://www.cdc.gov/flu/keyfacts.htm

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