QIP/CCIP. QIP Background. Quality Improvement Program Requirements CMS regulations 42 CFR

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1 Medicare Advantage Quality Improvement Project (QIP) & Chronic Care Improvement Program (CCIP) Medicare Drug and Health Plan Contract Administration Group Donna Williamson Susan Radke & Heather Kilbourne November 13, 2015 QIP/CCIP Presentation Overview QIP/CCIP Background CMS Quality Strategy Goals 2015 Annual Updates Best Practices/Lessons Learned Impact on readmission rate (QIPs) New QIP Topic for 2016 Effective Management of Chronic Disease 2015 Plan Section Submissions Overview MA Quality Initiatives Current and future direction 2 QIP Background Quality Improvement Program Requirements CMS regulations 42 CFR Quality Improvement Project (QIP) Chronic Care Improvement Program (CCIP) Requires progress be reported to CMS Focus on Interventions and Outcomes Utilize the Plan, Do, Study, Act (PDSA) quality improvement model 3 1

2 CCIP Background CCIP Mandatory topic (5 years) Reducing the incidence and severity of cardiovascular disease CCIPs must be clinically focused Supports the national HHS initiative Million Hearts ABCS of heart disease Aspirin Blood pressure control Cholesterol management Smoking cessation 4 CMS Quality Strategy Goals Safer care by reducing harm; Strengthen person and family engagement as partners in their care; Promote effective communication and coordination of care; Promote effective prevention and treatment of chronic disease; Work with communities to promote best practices of healthy living; and Make care affordable. 5 QIP Annual Updates CMS review currently underway Independent evaluation Years 1, 2, & 3 Quantitative analysis Impact on Readmission Rate Qualitative analysis Intervention types, best practices and lessons learned 6 2

3 QIP Annual Updates Best Practices* Care coordination/transitional care management Focus on high risk enrollees Direct enrollee contact Assessing care coordination, medical, social and behavioral health needs Medication reconciliation PCP Notification/Follow up IT solutions use of EHR s and real time data *Small Sampling by CMS 7 CCIP Annual Updates Best Practices* Disease management Provider education Early engagement with enrollees Medication reconciliation Culturally appropriate materials Timely data sources Enrollee identification & appropriate referrals Connecting enrollees to providers & community resources Motivational interviewing tools *Small Sampling by CMS 8 New QIP Mandatory Topic for 2016 Promote Effective Management of Chronic Disease QIP Objectives Support the National and CMS Quality Strategy Goals; Advance CMS efforts to assure that enrollees receive high quality care & care coordination; Effectively manage enrollees with chronic conditions; Ensure appropriate preventive services for specific conditions; Have favorable effects on health outcomes and enrollee satisfaction; and Eliminate disparities in care. 9 3

4 Promote Effective Management of Chronic Disease Effective management of chronic conditions Is expected to slow disease progression; Helps to prevent complications and development of comorbidities; Helps to prevent emergency room (ER) encounters and inpatient stays; Improves quality of life for the enrollee; and Provides cost savings to the plan and the enrollee. 10 Promote Effective Management of Chronic Disease Role of the MAO/SNP is to Promote: Care coordination/care management; Appropriate services (including prevention); Partnerships/collaboration amongst stakeholders (enrollees, caregivers, providers, vendors, community supports etc.); Linkage to appropriate resources. 11 Promote Effective Management of Chronic Disease Role of the MAO/SNP is to Promote (continued) Use of provider tools to better manage chronic conditions, e.g., clinical guidelines; Enrollee/caregiver engagement; Participation in disease management programs Improve self management skills & health literacy; Health information exchange across provider settings; Addressing gaps and disparities in care. 12 4

5 2015 QIP Plan Submissions Overview Chronic Conditions Selection frequency Target Goals Examples Intervention Types Selection frequency Opportunities for Improvement 13 Attachment A CMS Identified Chronic Conditions Chronic Condition Selection Frequency *Atrial Arrhythmias 4 Behavioral Health Condition Anxiety 2 Disorders Behavioral Health Condition Bipolar 0 Disorders Behavioral Health Condition Major 31 Depression Behavioral Health Condition 1 Schizophrenia Cancer 52 Chronic Kidney Disease (CKD) Stages 4 or 17 5 *These conditions may only be selected if they are not part of a current CCIP initiative 14 Attachment A CMS Identified Chronic Conditions (Continued) Chronic Condition Selection Frequency Chronic Obstructive Pulmonary Disease 118 (COPD) and or Asthma *Congestive Heart Failure (CHF) 27 *Coronary Artery Disease (CAD) 0 Dementia 5 *Diabetes 194 End Stage Renal Disease (ESRD) 3 HIV/AIDS 0 *Hypertension 18 Osteoporosis 101 Parkinson Disease 0 *These conditions may only be selected if they are not part of a current CCIP initiative 15 5

6 2015 QIP Plan Submissions Target Goals Examples Improve blood sugar control Improved HbA1C levels Improve HEDIS rate for Osteoporosis Management in Women (OMW) Medication adherence Diagnostic testing (beyond screening) Appropriate follow up, monitoring/treatment and care coordination Reducing hospital admissions/readmissions Engaging enrollees in CM/DM programs Reducing the progression to dialysis for enrollees with ESRD QIP Plan Submissions Intervention Types Intervention Selection Frequency Provider Education 221 Enrollee Education 296 Medication Adherence 181 Reward and Incentive Program 14 Care Coordination 277 Enrollee Outreach 223 Plan Outreach to Providers 135 Disease Management 214 Home Visits 21 Promoting Lifestyle Changes 53 Other QIP Plan Submissions Opportunities for Improvement Failure to demonstrate Management of Chronic Disease Screening efforts only Misalignment of goals to interventions No clear connection of how goals will be achieved Lack of Quantifiable/Measurable Target Goals Ambiguous Vague interventions Lack of detail 18 6

7 2015 CCIP Plan Submissions High Level Overview ABCS Targets Focus areas Target Goals Examples Intervention Types Examples CCIP Plan Submissions Focus Areas Blood pressure control Medication adherence Diabetes Management Target Goals HEDIS measure for controlling blood pressure Medication adherence Statins and antihypertensives Increase A1c testing CCIP Plan Submissions Intervention Types Disease management Enrollee assessment & individual care plan Complex case management (as needed) Medication Therapy Management (MTM) Provider engagement through outreach & various educational strategies Webinars, podcasts, journals and CE classes Evidence based guidelines included in provider manuals 21 7

8 QIPs/CCIPs Current and Future Direction Where do organizations need to be positioned in relation to the QIP/CCIP programs? Support CMS Quality Strategy Goals Emphasis on care coordination Implement programs that aim to improve enrollee health outcomes How does CMS measure or determine value of these quality initiatives? Quantifiable data Identify/disseminate best practices Will QIPs/CCIPs be incorporated into the STAR Ratings System? Many target goals support current HEDIS/STAR Ratings measures 22 QIP/CCIP Resources MA Quality Mailbox MA Quality Improvement Program Website Plans/Medicare Advantage Quality Improvement Program/Overview.html CMS Quality Strategy Goals Initiatives Patient Assessment Instruments/QualityInitiativesGenInfo/CMS Quality Strategy.html QIP/CCIP HPMS User Guides