Beneficiary Protection

Overview
Under the 9th SOW, AQAF will continue to carry out statutorily mandated review activities, such as:

• Reviewing the quality of care provided to beneficiaries;
• Reviewing beneficiary appeals of certain provider notices;
• Reviewing potential anti-dumping cases; and
• Implementing quality improvement activities as a result of case review activities.

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, AQAF will be increasing its efforts to link case review activities to improvements in the quality of care, specifically by developing quality improvement activities focused on system-wide changes. AQAF 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. AQAF 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.

AQAF 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, AQAF is required to ensure consistency and value and must adhere to CMS policies and procedures. This includes AQAF’s responsibility to refer cases to the Department of Health and Human Services’ Office for Civil Rights for further investigation if AQAF 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, AQAF 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 an AQAF 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 AQAF, which follows up to ensure that direct communication occurred and no further review is needed.

With regard to confirmed quality of care concerns, AQAF 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 AQAF identifies a case in which the provider violates or fails to comply with any obligation in Section 1156(a) of the Social Security Act.

AQAF 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, AQAF must actively promote, and support hospitals in, submission of quality data for reporting and Annual Payment Update (APU) purposes. AQAF must have a basic understanding of all measures,

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

Evaluation
AQAF must complete reviews in a timely manner, with at least 90% of all reviews meeting timeliness standards. AQAF will also be assessed on beneficiary satisfaction. It 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, AQAF 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, AQAF will be evaluated by the extent of its improvement each quarter over the baseline value of each measure. Lastly, AQAF 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.gov/BeneComplaintRespProg/
MedQIC: www.qualitynet.org/medqic (click on “Beneficiary Protection”)

Care Transitions

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

AQAF will work to reduce unnecessary readmissions to hospitals that may increase risk or harm to patients and cost to Medicare. CMS will look to AQAF 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.

AQAF 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, AQAF must provide an initial report to CMS that characterizes the selected target population for which it 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.

AQAF will implement quality improvement initiatives throughout Alabama concerning quality care for Medicare beneficiaries at or after hospital discharge. AQAF 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, AQAF 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 AQAF’s initial report.

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

AQAF 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. AQAF 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: www.qualitynet.org/medqic (click on “Care Coordination”)
The Dartmouth Atlas of Health Care: www.dartmouthatlas.org

Patient Safety

Overview
AQAF 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 SOWs (surgical care, heart failure, pressure ulcers and restraints in nursing homes, and drug safety), allowing AQAF to build on the progress it has 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 AQAF technical assistance for nursing homes in need), giving providers and AQAF the chance to broaden the scope of their patient safety–related improvement activities.

AQAF Activities
AQAF 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 AQAF identify two to three of its staff members serve as National Quality Improvement Leaders. These individuals will serve as liaisons between AQAF senior leadership and the work that is occurring at the patient care level in each Alabama. They will also liaise with Alabama health care executives 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.

AQAF will have a wealth of tools available to it 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, AQAF can draw upon successful tools that were utilized in the 8th SOW. It is expected that as successful tools and practices develop, AQAF will share these with other QIOs for implementation in other QIO communities.

AQAF may expand itsr 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 AQAF’s 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 AQAF’s 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 AQAF will suggest the quantitative evaluation structure for the drug safety component. Nursing homes in need of AQAF 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. CMS will give AQAF a “pass” if it meets at least 70% of the target for each measure within a component.

Resources
Most recent version of 9th SOW: www.cms.gov/QualityImprovementOrgs
MedQIC: www.qualitynet.org/medqic (Click on “hospital” or “nursing home” tabs for resources)
AHRQ: www.ahrq.gov (Resources available on clinical topics and drug therapy)
Hospital Compare: www.medicare.gov
Nursing Home Compare: www.medicare.gov

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 Core Prevention work builds on the QIO 8th SOW by focusing on AQAF’s 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 Alabama.

AQAF will work with a selected group of practices in Alabama to accomplish the national tasks. Practices enrolled with AQAF 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 AQAF to implement care management processes, using their certified EHRs, that focus on breast cancer and CRC screening and influenza and pneumococcal vaccination.

Opportunity for Quality Improvement
AQAF 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.

AQAF 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.

AQAF 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. AQAF will also identify non-participating practices with EHR capability.

AQAF 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, AQAF will report to CMS the number of and rates for practices that are reporting data.
AQAF 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.

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

Resources
CMS: http://www.cms.gov/ColorectalCancerScreening/
MedQIC: http://www.qualitynet.org/medqic
CDC: http://www.cdc.gov/flu/keyfacts.htm