CMS ESRD Data Collection. Systems Overview. Jaya Bhargava, PhD, CPHQ Operations Director

Transcription

1 CMS ESRD Data Collection Systems Overview Jaya Bhargava, PhD, CPHQ Operations Director

2 Relationship Between Dialysis Facility & The Network Under conditions for coverage, ESRD providers are required to participate in Network s Goals V Tag Regulation Interpretive Guidance V755 The relationship with the ESRD networks; The ESRD Networks are CMS contractors assigned responsibilities via a Statement of Work to: Collect and analyze data on ESRD patients and their outcomes of care, including the information that allows patients to be enrolled into the ESRD Medicare benefit program Provide education and oversight to improve the quality of care delivered to dialysis and kidney transplant patients Support facilities in developing and maintaining an effective QAPI program Respond to complaints and grievances At the time of publishing these regulations, there were 18 ESRD Networks, each covering a specified geographic area. A signed agreement between the facility and the applicable Network is required prior to the initial certification survey. The CEO or administrator is responsible to receive and act on correspondence from the ESRD Network and to promptly respond to any request from the applicable Networks. Additional requirements related to Networks are found at V772. 2

3 Conditions For Coverage (h) Standard: Furnishing data and information for ESRD program administration. Effective February 1, 2009, the dialysis facility must furnish data and information to CMS and at intervals as specified by the Secretary. This information is used in a national ESRD information system and in compilations relevant to program administration, including claims processing and reimbursement, quality improvement, and performance assessment. Be submitted at the intervals specified by the Secretary; Be submitted electronically in the format specified by the Secretary; Include, but not be limited to (i) Cost reports; (ii) ESRD administrative forms; (iii) Patient survival information; and (iv) Existing ESRD clinical performance measures, and any future clinical performance standards developed in accordance with a voluntary consensus standards process identified by the Secretary. The Conditions for Coverage for End Stage Renal Disease Facilities ( published in April 2008 outline the need for CROWNWeb on page

4 CY 2016 and PY 2018 ICH CAHPS NHSN Claims Claims/CW Claims CW CW Claims Claims NHSN Claims CW 4

5 PY

6 Scoring based on Domains 6

7 AIMS, SOW & Performance Measures Facility Performance Measures Network Statement of Work 7

8 Why Support Facility Data Submission to CMS-Designated Data System(s)? Data for QIP is reported to these data systems CROWNWeb NHSN CLAIMS Moving away Data is used for reports in these systems Quality Incentive Program Performance Score Reports and Certificates DialysisData.org Dialysis Facility Reports Dialysis Facility Compare ICH CAHPS Third Party Vendor 8

9 CMS CROWNWeb Data Management Guidelines Standardized data management Processes Separated by tasks and tiers Three tasks Data Monitoring (Data quality - accuracy, timeliness etc) Data Measuring (Data comparison to a criteria) Data Managing (Data collection) Three tiers Tier 1 enter data directly into CROWNWeb, Facilities Tier 2 provide technical data reporting assistance, Networks Tier 3 support CMS data reporting needs, Help desk 9

10 Activities in CROWNWeb Facility Patients Personnel Clinical Form 2744 Action List Reports Search for a patient Admit patient New to ESRD From another facility Add 2728 (Medical Evidence) form Add death event Add 2746 (death) form Verify Patient Census (PART verification) Complete Action Items data discrepancies 10

11 CROWNWeb Clinical Data Vascular Access data Hemodialysis data Peritoneal dialysis data 11

12 Activities in NHSN Create facility Obtain SAM s access Dialysis event data is reported on a quarterly basis Conduct data quality checks on a quarterly basis Healthcare personnel (HCP) influenza vaccination data is reported 12

13 ESRD Quality Reporting Systems QIP Performance Score Reports Performance Score Certificate DDR Dialysis Facility Reports Dialysis Facility Compare Reports Payment Reduction Star Ratings Pay for Performance Consumers 13

14 5 Star Ratings on DFC and QIP DFC QIP 5 Star Rating System Performance Score Certificate For Beneficiaries 9 Patient Outcome Measures Consumer Choice Patient Education For Providers 7 Clinical Measures and 5 Reporting Measures Payment Reduction Facility Performance / Quality Dialysis Facility Compare: 14

15 Activities For Quality Incentive Program Performance score Reports Performance Score Certificates Network Activities Help set up facility Point of Contact (POC) Communicate release, and comment period (July 15 to Aug 31) Provider education Output Payment reduction Posting of PSC in facility 15

16 Activities for DialysisData.Org Dialysis Facility Reports (DFRs) Quarterly Dialysis Facility Compare Reports (QDFCs) Network Activities Provide MAH password to facilities annually Communicate release, and comment period Provider education Output Dialysis Facility Compare Star Rating System 16

17 Access to (CMS) Designated Data Collection Systems CROWNWeb: Security Officials (SO) and End Users (EU) in CROWNWeb and Facility Point of Contact for QIP NHSN: Facility Administrators and users in NHSN DialysisData.org: Master Account Holders (MAH) Dialysis Facility Reports 17

18 How to Access CROWNWeb Security Awareness Training (SAT) EIDM and QARM Process Create an account in Identity management system Create score and role in Qualitynet Access and Role Management System 18

19 Access To NHSN Create facility Create Users Obtain SAMs access 19

20 Performance Score Reports (PSRs) What are Performance Score Reports (PSRs)? The Performance Score Report (PSR) is an informative report detailing the quality-measure performance of a dialysis facility during a Performance Period. A Total Performance Score (TPS) is also included and represents how CMS will calculate payment to the facility. What are Performance Score Reports (PSRs) used for? On an annual basis, CMS reviews the number of points that each dialysis facility receives based on performance measures, in order to find their Total Performance Score. If a dialysis facility meets the TPS that CMS requires, the facility receives 100% of their expected payment. If a dialysis facility does not meet their TPS requirements, CMS can reduce the facility's reimbursement for services that they provided to patients up to 2%. 20

21 Performance Score Certificate (PSC) What is the Performance Score Certificate? The Performance Score Certificate (PSC) informs patients and family members about how a dialysis facility performed in the ESRD QIP. Facilities are required to post their PSCs within five business days of the certificates becoming available. Facilities are also required to post both an English and Spanish version in an area easily visible to all patients and their families. What is the Performance Score Certificate used for? The PSC provides a picture of how well a facility performed on specific measures. It also enables patients and their family members to make a more informed decision regarding where they would like to receive treatment. CMS encourages patients to discuss PSC with their physicians and other medical staff at their facility. 21

22 How To Access DialysisData.org Obtain MAH Password MAH create users Users access reports 22

23 Dialysis Facility Reports (DFRs) What are Dialysis Facility Reports (DFRs) and Quarterly Dialysis Facility Compare (QDFC) reports? The Dialysis Facility Reports (DFRs) Quarterly Dialysis Facility Compare (QDFC) reports, and State and Region Profiles are created under contract to the Centers for Medicare & Medicaid Services (CMS) to provide dialysis facilities, patients, state surveyors, and regions with valuable information on patient characteristics, treatment patterns, hospitalization, mortality, and transplantation patterns in their facilities. The Quarterly Dialysis Facility Compare (QDFC) Reports provide Networks and Facilities with advance notice of new and updated quality measures for their facility prior to being displayed on Dialysis Facility Compare. These measures are updated quarterly in January, April, July, and October of each year. Please click here for the QDFC report timeline. 23

24 Dialysis Facility Compare What are the DFRs used for? The reports are intended to be used by facilities in their quality improvement efforts. State surveyors use data reported in the DFRs to make decisions on which facilities to survey during the upcoming year. What are QDFC Reports used for? The QDFC report provides facilities with advance notice of new and updated quality measures that will be reported on the Dialysis Facility Compare website, QDFC reports allow dialysis patients to review and compare characteristics and quality information on dialysis facilities in the United States. 24

25 Common CMS Systems Roles Role System System Description Related Systems Login ID Looks Like NHSN Administrator NHSN Report Dialysis Events; Staff Vaccinations EIDM / QARM - Security Official; - User EIDM / QARM Approve, Disable and Edit CROWNWeb User Accounts CROWNWeb; QIP (+SAMS card for code) User created CROWNWeb - Facility Administrator - Facility Editor and/or - Facility Viewer CROWNWeb CMS Data System for Facility, Patient and Clinical Data QIMS; QIP User created QIP Point of Contact - Facility Viewer QIP View, Download and Comment on PSRs and PSCs QIMS; CROWNWeb User created Dialysis Data.org - Master Account Holder DialysisData.org Enable/Disable Accounts; Add/Remove Permissions CCN DialysisData.org - Regular User DialysisData.org View/Edit/Comment on DFR and QDFC 25

26 Data Submission Under QIP CROWNWeb Data Follow data management guidelines Infection data in NHSN - End of quarter after each quarter Data may come from anywhere each facility is responsible for the accuracy and timely submission of their own data 26

27 IPRO ESRD Program Website 27

28 For more information IPRO ESRD Program CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake Success, NY