2018 CMS Priorities, Goals, and Quality Improvement Activities. IPRO ESRD Network of New England Network Council Meeting January 17, 2018

Transcription

1 2018 CMS Priorities, Goals, and Quality Improvement Activities IPRO ESRD Network of New England Network Council Meeting January 17, 2018

2 Meeting Reminders All phone lines have been muted to avoid background noise Be present and engaged in the presentations Remain open-minded when hearing new initiatives Be prepared for active participation and open discussion in the WebEx chat board Questions or comments can be submitted at any time There will be breaks after each section to address items in chat p. 2

3 Agenda Topics Overview of IPRO ESRD Program: Network 1 Emergency Preparedness and Management Patient Engagement and Patient Experience of Care ESRD Statement of Work (SOW) Option Year 2 Purpose and Background CMS Goals / HHS Secretary s Priorities Disparities in Healthcare Collaborations / Learning and Action Networks (LANs) Quality Improvement Activities (QIA) Information Management Closing Comments p. 3

4 Overview of IPRO ESRD Program: Network 1 Danielle Daley, MBA Executive Director

5 Mission Statement The Mission of the IPRO End Stage Renal Disease (ESRD) Network Program is to promote health care for all ESRD patients that is safe, effective, efficient, patient-centered, timely, and equitable. p. 5

6 Island Peer Review Organization IPRO Founded in 1984 Not-for-profit organization Holds contracts with federal, state, and local government agencies Provides services to enhance healthcare quality to achieve better patient outcomes Proven track record of excellent, culture of innovation and breadth of expertise Implementation of innovative programs that bring policy ideas to life Creative use of clinical expertise, emerging technology and data solutions to make the healthcare system work better Headquartered in Lake Success, NY p. 6

7 ESRD Networks 7

8 IPRO ESRD Network Program Network Service Areas Network 2 NY Patients: 29,607 Facilities: 286 Transplant: 13 NW2 NW1 Network 1 CT, MA, ME, NH, RI, VT Patients: 14,417 Facilities: 194 Transplant: 15 Network 9 OH, KY, IN Patients: 33,417 Facilities: 599 Transplant: 14 Network 6 NC, SC, GA Patients: 47,856 Facilities: 707 Transplant: 10 Network 9 IN, KY, OH Network 6 GA, NC, SC IPRO ESRD Program 125,297 ESRD Patients 1,786 Dialysis Facilities 52 Transplant Centers 8

9 Network Demographics By State State ESRD Patient Census # of Dialysis Facilities # of Transplant Facilities Connecticut 4, Maine 1, Massachusetts 6, New Hampshire 1, Rhode Island 1, Vermont TOTAL 14, Data Source: CROWNWeb 9 9

10 Facility Affiliation By State Ownership ESRD Patient Census # of Dialysis Facilities American Renal Associates 1, DaVita 4, Fresenius Kidney Care 5, Diversified Specialty Institutes (DSI) Dialysis Clinic Inc Independent 1, Veteran Affairs TOTAL 14, Data Source: CROWNWeb 10 10

11 Network Staff Administration Department Danielle Daley, MBA Executive Director Cheryl Pettway Sr. Program Support Coordinator Whitney Avenue, 2 nd Floor, Hamden, CT Phone: (203) Fax: (203) p. 11

12 Network Staff Patient Services Department Brittney Jackson, LMSW, MBA Patient Services Director Merari Rosario, MHA Community Outreach Coordinator Whitney Avenue, 2 nd Floor, Hamden, CT Phone: (203) Fax: (203) p. 12

13 Network Staff Quality Improvement Department Sarah Keehner, RN, BSN, CNN Quality Improvement Director Heather Camilleri, CCHT Quality Improvement Coordinator Whitney Avenue, 2 nd Floor, Hamden, CT Phone: (203) Fax: (203) p. 13

14 Network Staff Data Department Jaya Bhargava, PhD, CPHQ Operations Director Krystle Gonzalez Sr. Data Coordinator Whitney Avenue, 2 nd Floor, Hamden, CT Phone: (203) Fax: (203) p. 14

15 CMS Expectations Role of the Network Improve quality of care for ESRD patients Provide assistance to ESRD patients and providers Encourage patient engagement Evaluate and resolve patient grievances Collect data to measure quality of care Support emergency preparedness and disaster response p. 15

16 Technical Assistance We re Here to Help The Network has tools to help with quality improvement activities Catheter reduction Home dialysis Infection control (NHSN) Vocational rehabilitation Transplant referrals The Network provides technical assistance Data reporting Quality Incentive Program (QIP) Patient safety Patient/provider conflict Access to care barriers p. 16

17 Technical Assistance We re Here to Help The Network sponsors educational opportunities Face-to-Face Meetings Webinars Conference Calls The Network shares data Comparative Network, state, and facility level Incidence, prevalent, and demographic statistics Annual Report p. 17

18 enewsletter Provider Insider Professional audience Sent monthly Contact list from facility personnel in CROWNWeb Informational / actionable Important updates Meeting registration Quality improvement resources Education p. 18

19 enewsletter Kidney Chronicles Patient audience Sent quarterly Contact list from self registrants Educational Treatment options Quality of life Patient engagement Peer mentoring p. 19

20 Questions? Comments? p. 20

21 Emergency Preparedness and Management Brittney Jackson, LMSW, MBA Patient Services Director Emergency Coordinator

22 Emergency Management Things to Know Facility Reporting/Tracking Report Facility Status (Open/Closed/Altered) Report patient access to care Contact the Network to assist with local OEM coordination efforts Prepare Patients for an Emergency Be prepared patient worksheet 3-Day Emergency Diet Prepare Your Facility for an Emergency Technical assistance to facilities to develop feasible, comprehensive emergency/disaster plans p. 22

23 Emergency Preparedness Final Rule Survey and Certification memo dated June 2, 2017 Appendix Z: Emergency Preparedness Final Rule Interpretative Guidelines and Survey Procedures Affects 17 providers and suppliers, which includes dialysis facilities and transplant centers Compliance required for participation in Medicare New requirements began November 15, Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html p. 23

24 Technical Assistance Final Rule How can the Network support facilities in meeting these requirements? Please submit questions or comments in chat p. 24

25 Questions? Comments? p. 25

26 Patient Engagement and Patient Experience of Care Brittney Jackson, LMSW, MBA Patient Services Director

27 Patient Subject Matter Experts (PSMEs) How PMSEs Support QIAs Involved in the development of QIA interventions and resources Encouraged to participate in intervention implementation at the facility PSMEs are asked to: Consider becoming a Peer Mentor Joining the Network Patient Advisory Committee Share their ESRD journey story with others Attend meetings led by the Network Participate in national meetings and technical expert panels p. 27

28 Patient Advisory Committee (PAC) Structure and Function PAC members are ESRD patients, family members, or care partners in dialysis and transplant facilities who provide a link between patients and healthcare providers to: Promote communication between patients and staff Inform patients about the ESRD Network Mission is to identify and act upon issues of concern to ESRD patients thereby improving their quality of life 18 Regions throughout New England with Chairs 8-10 facilities per region Current Membership 125 members, representing 77 facilities Chairperson: John Visone p. 28

29 Patient Advisory Committee 2018 Goals Recruit New PAC Representatives Recruitment More PAC Chairs Increase awareness about PAC and the Network Encourage PAC Representatives to participate in regional conference calls Encourage regularly scheduled meetings with staff and patients Increase PAC membership on the closed Facebook group Solicit articles for PAC Speaks patient newsletter p. 29

30 Patient Experience of Care Grievances Definition and the Network s Role What is a grievance? Network s Role Facilitator Expert Investigator Educator Quality Improvement Specialist Advocate Referral Source p. 30

31 Patient Experience of Care Grievance Management and Best Practices Development/support robust grievance process Foster environment that encourages patients, family members, caregivers to voice their opinions Encourage positive resolution focused outcomes Establish an anonymous grievance process Grievance Educational Materials 2018 New Grievance Poster Grievance Toolkit p. 31

32 CMS Expectations: Network Responsibilities The Network assists with patient grievances Evaluate and resolve grievances using a patient centered approach Follow CMS guidelines, document all Network steps of grievance resolution, and adhere to timeframes Perform quality of care reviews using an interdisciplinary approach (LMSW / RN) When necessary, refer cases to the Grievance Committee or Medical Review Board for review p. 32

33 Questions? Comments? p. 33

34 ESRD Statement of Work (SOW) Option Year 2 Danielle Daley, MBA Executive Director

35 ESRD Statement of Work December November 2018 Background & Purpose To delineate tasks to be conducted by each End Stage Renal Disease (ESRD) Network Organization contractor in support of achieving national quality improvement goals and statutory requirements as set forth in Section 1881 of the Social Security Act and the Omnibus Budget Reconciliation Act of 1986 Tasks in this SOW are intended to align Network activities with: Department of Health and Human Services (HHS) National Quality Strategy (NQS) HHS Secretary Priorities Centers for Medicare & Medicaid Services (CMS) goals p. 35

36 ESRD Statement of Work December November 2018 HHS Secretary s Priorities 1. Reform, Strengthen, and Modernize the Nation s Health Care System 2. Protect the Health of Americans Where They Live, Learn, Work, and Play 3. Strengthen the Economic and Social Well-Being of Americans Across the Lifespan 4. Foster Sound, Sustained Advances in the Sciences 5. Promote Effective and Efficient Management and Stewardship p. 36

37 ESRD Statement of Work December November 2018 CMS Goals 1. Empower patients and doctors to make decisions about their health care 2. Usher in a new era of state flexibility and local leadership 3. Support innovative approaches to improve quality, accessibility, and affordability 4. Improve the CMS customer experience p. 37

38 ESRD Statement of Work December November 2018 Addressing Disparities in Healthcare Conduct assessment to identify disparity with the greatest point difference between disparate and non-disparate groups Age (65 and older vs ) Ethnicity (Hispanic vs. Non-Hispanic) Facility Location (Rural vs. Urban) Gender (Female vs. Male) Race (Population other than White, including African American, Asian, Native American, Pacific Islander, etc. vs. White) p. 38

39 ESRD Statement of Work December November 2018 Collaborations National Coordinating Center (NCC) Kidney Community Emergency Response Program (KCER) State Survey Agencies CMS Components Quality Innovation Networks (QIN-QIOs) p. 39

40 ESRD Statement of Work December November 2018 CMS has established Learning & Action Networks (LANs) for each QIA, coordinated by ESRD NCC Create a diverse forum to address barriers Measurable goals to drive decision making Open sharing of best practices Change methodology and rapid cycle improvement Participate in NCC LAN events p. 40

41 ESRD Statement of Work December November 2018 Learning & Action Networks (LANs) Patient Experience of Care Healthcare Associated Infections (HAI) Home Dialysis Patient and Family Engagement (PFE) Transplant Population Health Focused Pilot QIA (PHFPQ) p. 41

42 ESRD Statement of Work December November 2018 Learning & Action Networks (LANs) Criteria All LANs Ensure participation of all facilities participating QIAs Two (2) patients, family members and/or caregivers from each state in the Network service area HAI, Transplant, and Home Dialysis LANs Invite QIN-QIO(s), HIINs, state/local health departments, State Survey Agencies, long-term care facilities, and regional dialysis leadership Minimum of two (2) hospitals from each state in the Network service area p. 42

43 Quality Improvement Activities (QIAs)

44 Bloodstream Infection Reduction Heather Camilleri, CCHT Quality Improvement Coordinator

45 ESRD Statement of Work QIA 1: Patient Safety HAIs Background Contains 3 sub-projects: BSI Reduction LTC Reduction Healthcare Information Exchange (HIE) National goal by 2023: Reduce the national rate of BSIs in dialysis patients by 50% of the blood stream infections (BSI) that occurred in 2016 Support NHSN Assist Enrollment Support Completion of NHSN Annual Training Identify 50% cohort of lowest performing BSI facilities in Network for QIA Population Target 20% of lowest performing BSI facilities Enroll 20% in QIA Population in HIE Target facilities with LTC rate >15% Quarterly Data Checks p. 45

46 Patient Safety: Reduce Rates of BSIs Criteria Select 50% of facilities in Network service area reporting the highest BSI rates (~100 facilities) Project Period Baseline: January June 2017 Re-measurement: January June 2018 Requirements Utilization of CDC Core Interventions Conduct Root Cause Analysis (RCA) NCC HAI LAN participation p. 46

47 Patient Safety: Reduce Rates of BSIs Goals > 20% reduction in semi-annual pooled mean among highest 20% BSI rates Data Source National Healthcare Safety Network (NHSN) p. 47

48 Patient Safety: Reduce Rates of BSIs Interventions Root cause analysis (RCA) using 5 Why Approach CDC Making Dialysis Safer Coalition CDC Core Interventions for Dialysis BSI Prevention Discuss infection control at QAPI meetings Share best practices/evidence based research p. 48

49 Questions? Comments? p. 49

50 Long-Term Catheter Reduction Sarah Keehner, RN, BSN, CNN Quality Improvement Director

51 Patient Safety: Long Term Catheters Criteria Select facilities with a long term catheter (LTC) rate of >15% from the BSI QIA target facilities (~25 facilities) Project Period Baseline: June 2017 Re-measurement: CROWNWeb data as of October 2018 (August 2018 data) Requirements Explore correlation between LTC and BSI through CDC Core Interventions p. 51

52 Patient Safety: Long Term Catheters Goals Decrease aggregate LTC rate of target facilities by at least 2% Data Source CROWNWeb p. 52

53 Patient Safety: Long Term Catheters Interventions Vascular Access Coordinator Monthly meeting with vascular surgeons RCA of barriers Cannulation education for staff Staff/ patient fistula education Data entry in CROWNWeb Sharing best practice Particapation in LAN events p. 53

54 Questions? Comments? p. 54

55 Health Information Exchange (HIE) Jaya Bhargava, PhD, CPHQ Operations Director

56 Patient Safety: What is and HIE? Health information exchange (HIE) is the mobilization of health care information electronically across organizations within a region, community or hospital system. p. 56

57 Patient Safety: Health Information Exchange (HIE) Criteria 20% of the BSI QIA cohort (~20 facilities) Requirements Joining of an HIE or another evidence-based highly effective information transfer system as approved by the COR and CMS SME Goals 20% using HIE Data Source Self-reported p. 57

58 Patient Safety: Health Information Exchange (HIE) Interventions Identifying a state HIE Collaborate with Large Dialysis Organizations (LDOs) Reduce barriers in accessing information during transitions of care p. 58

59 Questions? Comments? p. 59

60 Transplant Coordination Heather Camilleri, CCHT Quality Improvement Coordinator

61 Improve Transplant Coordination Increase Rates of Patients on Waitlist Criteria Include at least 30% of facilities in Network service area (~60 facilities) Project Period Baseline is October 2016 June 2017 Re-measurement: data available in October 2018 Requirements Monitor/track patient progress through seven steps leading to placement on transplant waitlist NCC Transplant LAN participation p. 61

62 Improve Transplant Coordination Increase Rates of Patients on Waitlist Track and report to CMS the number of patients in each of 7 steps each month: 1. Patient suitability for transplant 2. Patient interest in transplant 3. Referral call to transplant center 4. First visit to transplant center 5. Transplant center work-up 6. Successful transplant candidate 7. On waiting list or evaluate potential living donor p. 62

63 Improve Transplant Coordination Increase Rates of Patients on Waitlist Goals 10% point increase of eligible patients placed on transplant waitlist Data Source Facility self-reported (numerator) CROWNWeb (denominator) p. 63

64 Improve Transplant Coordination Increase Rates of Patients on Waitlist Interventions Transplant referral process and center criteria Kidney allocation system Patient self-referral per transplant facility Tracking and reporting the 7 steps leading to a transplant Patient SME s and/or family/caregivers included at facility level monthly QAPI meetings p. 64

65 Questions? Comments? p. 65

66 Home Dialysis Sarah Keehner, RN, BSN, CNN Quality Improvement Director

67 Promote Appropriate Home Dialysis Increase Rates of Patients in Home Criteria Include at least 30% of facilities in Network service area (~60 facilities) Project Period Baseline: October June 2017 Re-measurement: based on data available CROWNWeb in October 2018 Requirements Encourage facilities to incorporate the seven steps leading to home dialysis training into patient education, facility practice, and facility QAPI process NCC Home Dialysis LAN participation p. 67

68 Promote Appropriate Home Dialysis Increase Rates of Patients in Home Track and report to CMS the number of patients in each of 7 steps each month: 1. Patient interest in home dialysis 2. Educational session to determine the patient s preference of home modality 3. Patient suitability for home modality determined by a nephrologist with expertise in home dialysis therapy 4. Assessment for appropriate access placement 5. Placement of appropriate access 6. Patient accepted for home modality training 7. Patient begins home modality training p. 68

69 Promote Appropriate Home Dialysis Increase Rates of Patients in Home Goals 10% increase in rate of patients that start home dialysis training Data Source Facility self-report in CROWNWeb training date (numerator) CROWNWeb (denominator) p. 69

70 Promote Appropriate Home Dialysis Increase Rates of Patients in Home Interventions Incorporating the seven steps into patient education and facility practice Development and implementation of Home Dialysis Peer Mentorship Program Tracking patients at each stage of the 7 steps and monitoring that patients are being moved to the next step Utilization of the Home Therapies Toolkit p. 70

71 Questions? Comments? p. 71

72 Population Health Focused Pilot QIA (PHFPQ) Brittney Jackson, LMSW, MBA Patient Services Director

73 Population Health Focused Pilot QIA (PHFPQ) Vocational Rehabilitation Criteria Select at least 10% of facilities in the Network service area (~20 facilities) Project Period Baseline: October 2016 June 2017 Re-measurement: September 30, 2018 Requirements Patient SME NCC PHFPQ LAN participation p. 73

74 Population Health Focused Pilot QIA (PHFPQ) Vocational Rehabilitation Goals Demonstrate at least a five (5) percentage point increase in referrals to the identified EN and/or VR Demonstrate at least a two (2) percentage point improvement in the number of patients receiving EN and/or VR services Data Source CROWNWeb p. 74

75 Root Cause Analysis and Plan-Do-Study-Act Vocational Rehabilitation RCA Conduct a RCA to identify the barriers to prevalent patients not being referred for VR/EN services PDSA Utilize the PDSA cycle to test the processes initiated to overcome barriers p. 75

76 Population Health Focused Pilot QIA (PHFPQ) Vocational Rehabilitation: Interventions Provider Assessment of current referral process in the dialysis facility Evaluate changes in life events that could change receptiveness to vocational rehabilitation Patient Increase awareness of vocational rehab and change dialysis facility culture Support patients with resources and goal setting tools Employment Network and Vocational Rehab Collaborate with vocational rehabilitation resources to advocate for the needs of ESRD patients p. 76

77 CROWNWeb Definitions Vocational Rehabilitation Common Scenarios Vocational Rehabilitation CROWNWeb Category Scenario: Referred to VR Referred to VR Currently in VR Currently in VR Declines VR Declines VR Not Eligible for VR Not Eligible for VR Completed VR Social worker gave patient phone number for VR Patient is being recommended for VR, but has not agreed to participate Patient went to VR orientation and was assigned a counselor Patient filled out an application Patient went to VR orientation and did not follow up after the orientation Patient has indicated they do not want to participate in VR program Patient has co morbid conditions that prevent them from being able to work Patient is undocumented and does not have a legal right to work in the US Patient went through VR program and achieved their VR goals (got job, completed college, etc.) p. 77

78 CROWNWeb Reporting Vocational Rehabilitation p. 78

79 Questions? Comments? p. 79

80 Data Management Jaya Bhargava, PhD, CPHQ Operations Director

81 CMS Expectations: Facility Responsibilities ESRD Data Collection Systems CMS Designated Data Collection Systems CROWNWeb - Follow Data Management Guidelines National Healthcare Safety Network (NHSN) ESRD Outcome Reports Quality Incentive Program - o Performance Score Reports and Certificates Dialysis Data - o Dialysis Facility Reports and Dialysis Facility Compare In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAPHS) - o Third Party Vendor p. 81

82 CMS Expectations: Network Responsibilities Data Reporting Assistance Educate facilities to follow CMS Data Management Guidelines Inform providers of upcoming deadlines CROWNWeb Streamlined process to inform facilities of missing data NHSN Working towards 100% patient level data submission compliance CROWNWeb NHSN ESRD QIP p. 82

83 CMS Expectations: Facility Responsibilities Data Submission Guidelines Data System Task Frequency CROWNWeb PART Verification CMS 2728 CMS 2746 Forms By 5th business day of each month Within 10 business days of Date Regular Chronic Dialysis Began Within 14 days of the date of death NHSN Resolve Notifications and Accretions Add Key Personnel Event Data Healthcare Personnel (HCP) Within 15 days of issuance Within 5 business days of staff changes Quarterly By May 15 th p. 83

84 CMS Expectations: CROWNWeb Data Quality Goals CMS issued preliminary CROWNWeb Data Quality Goals for Established key indicators and goals are in line with the aforementioned Data Management Guidelines and will be used to assess facility data submission/performance p. 84

85 Technical Assistance Knowledge Base and Customer Portal Level 1 (Self Help): New customer support portal Level 2 ( Technical Assistance): questions submitted NW1Help@iproesrdnetwork.freshdesk.com Level 3 (One on One Technical Assistance): Use of WebEx Meet Now method for real time assistance p. 85

86 Closing Comments

87 CMS Expectations: Facility Responsibilities Participate in Network Quality Improvement Activities (QIAs) Inform patients of available Network resources Grievance resolution Educational materials Peer-to-peer mentoring Notify the Network of major events Facility emergencies Leadership changes Respond to inquiries and requests for information p. 87

88 CMS Expectations: Facility Responsibilities Timely submission of data Keep facility personnel information updated in CROWNWeb Discuss challenges/barriers **Communicate with the Network** p. 88

89 ESRD Network of New England Website p. 89

90 IPRO ESRD Program Facebook Page p. 90

91 ESRD Network of New England 2018 Educational Opportunity 6th Annual ESRD New England Fall Meeting Tuesday, October 30, 2018 Mohegan Sun, Uncasville, Connecticut p. 91

92 Questions? Comments? p. 92

93 For more information: Presentation Template Draft for Review Danielle Daley, MBA Jaya Bhargava, PhD, CPHQ Executive Director Operations Director (203) (203) Corporate Headquarters 1979 Marcus Avenue Lake Success, NY Sarah Keehner, RN, BSN, CNN Brittney Jackson, LMSW, MBA Quality Improvement Director Patient Services Director (203) (203) April 6, 2017 p. 1