For Dialysis Facilities

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1 The QIP Newsletter For Dialysis Facilities Inside this issue: What does the QIP 2 Measure? What has Changed? 3 QIP Measures 3 Clinical measure 3-5 focus Measures that 6-7 Matter Reporting measure 8 focus What is the QIP? The End-Stage Renal Disease Quality Incentive Program (QIP) is a type of program known as pay-for-performance or value-based purchasing. The intent of the QIP is to promote patient health by providing a financial incentive for renal dialysis facilities to deliver high-quality patient care. The QIP does this by setting minimum goals across a selected group of measures, and then allowing for up to a 2% payment reduction for dialysis facilities that do not meet or exceed the minimum Total Performance Score (TPS). In the most basic terms, your facility works to achieve the QIP clinical and reporting measures to maximize income and promote optimal dialysis-related outcomes. Spring 2015 Volume 2 How does the QIP affect me? Poor QIP performance can lead to payment reductions to the facility, and this can affect everyone in a facility. Reduction in payments can affect profit and influence staffing. One may ask, How much difference can a 2% reduction in payment really make? That is an excellent question. Based on the average unit size of 70 patients, one can expect a 2% reduction to cost a facility over $50,000 in a single year. In addition, since each facility will have their (TPS) posted publicly, patients may decide to transfer to another facility that they perceive will provide better care. Next Steps/ Evolution of the QIP 9 Poor QIP Scores Can: Patient Word Search 10 Negatively Affect Profit 2015 QIP Calendar 11 Reduce Staffing Lower Morale Important Resources 12 Cause Patients to go Elsewhere SPECIAL POINTS OF INTEREST: Affect Yearly Monetary Rewards Network contacts MRB Clinical Recommendations *Credit for the figures: Nephrology Clinical Solutions

2 Page 2 The QIP Newsletter What Does the QIP Measure The measurements taken each calendar year (CY) will affect Medicare reimbursements for the payment year (PY) that will follow two years later. For example, the first year the QIP was implemented was CY 2010, and the performance that year produced the results for PY Therefore, the performance of your facility now (in 2015) will affect reimbursement for PY Ever evolving, the ESRD QIP that will measure performance for CY 2015 is comprised of eight clinical measures that constitute 75% of your facility s TPS. The remaining 25% of your facility s TPS is comprised of three additional measures based on reporting. Facility measures are scored by achievement (a comparison to set goals) or by improvement (a comparison to previous facility performance). The minimum score required for zero payment reduction is 60 points. (Example below is from the National Provider Call, held January 21, 2015, regarding CMS final rule for PY 2017 and 2018: Education/Outreach/NPC/Downloads/ ESRD-QIP-PY2017-and-2018-Final -Rule.pdf) For more information on the QIP from CMS, visit the CMS ESRD Quality Incentive Program website: Medicare/Quality-Initiatives- Patient-Assessment- Instruments/ESRDQIP/ index.html New Measure for PY2017

3 Volume 2 Page 3 What has Changed? Measures for the ESRD QIP have changed yearly since its inception, and PY 2017 is no exception. While the PY 2017 Scoring and Payment Reduction Methodology chart on the previous page looks eerily similar to the one for PY 2016, several things have changed. The reporting measures stayed the same, as well as their weight associated with the TPS. However, the Standardized Readmission Ratio (SRR) raises the total number of clinical measures on the QIP to eight. Also, while the weights the clinical and reporting measures carry will remain the same, the minimum TPS to receive no reduction have increased from 54 to 60. Lastly, the TPS ceilings for the payment reduction percentages have been raised across the board. What are the QIP Measures? Clinical Measures (8) (2) Vascular Access Type Access via Arteriovenous Fistula (AVF) Access via Catheter (3) Kt/V Dialysis Adequacy Measures Adult Hemodialysis Adult Peritoneal Dialysis Pediatric Dialysis (1) Hypercalcemia (1) National Healthcare Safety Network (NHSN) Bloodstream Infection (1) Standardized Readmission Ratio (SRR) Reporting Measures (3) In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Patient Experience of Care Survey Mineral Metabolism Anemia Management A Focus on Each Clinical Measure Vascular Access Type Arteriovenous (AV) Fistula: percentage of qualifying patient-months for patients on hemodialysis during the last hemodialysis treatment of the month using autogenous AV fistula with two needles Catheter 90 Days: percentage of qualifying patient-months for patients on hemodialysis during the last hemodialysis treatment of the month with a catheter continuously for 90 days or longer prior to the last hemodialysis session It requires a team effort, collaboration, and trust. The nephrologist must play a central role. Make a vascular access plan for each patient.

4 Page 4 The QIP Newsletter A Focus on Each Clinical Measure (Continued) When possible, place fistula approximately three months before dialysis is needed. Establish a relationship of trust with primary care physicians and surgeons. Educate patients and their families. Start early and have a continuous education plan in place with specific educator roles by position (social worker, dialysis tech, nurse, dietician, etc.). Use simple terms and visuals/pictures. Stress the importance of protecting veins. Encourage patients referred late to consider home PD. Coach staff to properly cannulate fistula. Assign a Vascular Access Coordinator. Measure your rates and monitor to encourage changes in practice. Kt/V Dialysis Adequacy Adult Hemodialysis: percent of qualifying hemodialysis patient-months with spkt/v 1.2 Adult Peritoneal Dialysis: percent of qualifying peritoneal dialysis patient-months with Kt/V 1.7 (dialytic + residual) during the four-month study period Pediatric Hemodialysis: percent of qualifying pediatric in-center hemodialysis patient-months with spkt/v 1.2 Measure your performance monthly. More dialysis time generally improves outcomes. Evaluate potential reasons for low scores. Dialysis prescription: time, blood, and dialysate flow rates, dialyzer, needle size Patient vascular access issues Error in blood sampling Re-educate staff when indicated. Monitor staff practices for compliance. Hypercalcemia This measure focuses on the proportion of qualifying patient-months with three-month rolling average of total uncorrected serum calcium greater than 10.2 mg/dl. Report the serum calcium value monthly in CROWNWeb. NHSN Bloodstream Infection in Hemodialysis Outpatients This is measured using a standardized number of qualifying hemodialysis outpatients with positive blood cultures per 100 hemodialysis patient-months. Facilities submit accurately reported dialysis event data to the Centers for Disease Control and

5 Volume 2 Page 5 A Focus on Each Clinical Measure (Continued) Prevention (CDC). If a facility fails to report 12 months of data, the facility will receive zero points for this measure. Review the dialysis event protocol at least annually. Use the guides available on the NSHN website to assist in gathering data that must be reported. Complete NHSN trainings available on the CDC website ( Promote infection prevention practices such as hand hygiene and immunizations. Standardized Readmission Ratio (SRR) New Measure for PY2017 This measure reflects the number of readmission events for the patients at a facility relative to the number of readmission events that would be expected based on overall national rates and the characteristics of the patients at that facility, as well as the number of discharges. According to the Medicare Payment Advisory Commission (MedPAC), for Medicare beneficiaries hospitalized in 2005, more than three-quarters of 30-day and 15-day readmissions were potentially preventable. How you can maximize this score: Start by tracking hospital admissions internally. Communicate with patients, especially those that recently had a hospital visit. Review medical records for patients recently hospitalized during QAPI meetings.

6 Page 6 The QIP Newsletter Measures That Matter The ESRD QIP uses a Performance Score Certificate (PSC) to publicly report both clinical and reporting measures. The purpose of the ESRD QIP is to promote the delivery of high-quality services to all dialysis patients. The QIP is comprised of measures that dialysis facilities must report to receive a score. What is your facility's score? It will show on the facility Performance Score Certificate given to facilities by CMS every year. The PSCs comparison can be found at Measures That Matter is an educational tool developed by the Southeastern Kidney Council, Inc. (ESRD Network 6).

7 Page 7 The QIP Newsletter A Focus on Each Reporting Measure ICH CAHPS Survey This is an expanded measure that consists of three requirements: 1. Facilities must arrange to have a CMS-approved vendor administer the survey once during the spring (March, April, May) and once during the fall (September, October, November) of Facilities register on ichcahps.org to allow their vendors to submit data on their behalf. 3. Facilities ensure that their vendors submit results by the spring and fall deadlines. The vendors page is live NOW. If facilities have not done so already, please visit ichcahps.org Identify a third-party vendor to conduct the survey. to select a vendor to Ensure that this survey is administered during the spring and fall of conduct the survey. Mineral Metabolism Each facility submits serum phosphorus data for each qualifying Medicare patient in CROWNWeb. The facility s score is based on the number of months it submits this data. (This is revised from PY 2015 to include home peritoneal dialysis patients, AND serum calcium is no longer included, as it is now captured in the Hypercalcemia clinical measure.) Have a system to ensure review of each patient s serum phosphorus each month. Routinely request lab results from hospitals and transient dialysis providers. Review lab results and document the review in the patient record. Anemia Management Facilities must submit erythropoietin-stimulating agent (ESA) dosage (as applicable) and hemoglobin/hematocrit for each qualifying Medicare patient via billing claims data. The facility s score is based on the number of months it submits this data. (This is revised from PY 2015 to include home peritoneal dialysis patients.) Give special attention to hemoglobin trends. Investigate other causes contributing to anemia. Have you been to our website? For professionals: Go to esrdnetwork.org. Under the Professionals tab you can click on Quality Incentive Program. For patients: Go to esrdnetwork.org. Under the Patients & Families tab, you can click on Quality Incentive Program.

8 Volume 2 Page 8 What are the Next Steps? The next steps are to ensure that you are part of the facility s plan to make your facility successful when it comes to the QIP. It s vital to understand what your position can do to influence each clinical and reporting measure. You may be able to directly influence all 11 measures, or maybe only two. The number of measures you can directly influence does not mean your job is any more important or less important than any other. In the team setting that is the dialysis facility, EVERYONE has, at the very least, an indirect influence over a number of things that can occur in your facility. ESRD Network 14 is interested in how your facility promotes the QIP to patients and facility associates alike. Do you have an idea that promotes transparency to your patients? How about outside-the-box education that has worked well in your facility? Feel free to share those ideas with us. Who knows? Maybe we ll include your idea in our next newsletter. The Evolution of the ESRD QIP The scope of the QIP has increased since its implementation in The first ESRD QIP contained only three total metrics and has gradually grown into what it is today. With this trend in mind, it is important to understand the chances that the number of metrics in the QIP increasing each year is high. Additionally, there is a possibility that reporting measures could evolve into clinical measures. For example, while ICH CAHPS is currently assessed as completed or not completed, future rule proposals could tie facility performance on specific ICH CAHPS questions or question sets to measure calculations. QIP Contacts for ESRD Network 14 Jason Simmington, MHS Quality Improvement Specialist jsimmington@nw14.esrd.net or Ext. 317 Kelly Shipley, RHIA Quality Improvement Director kshipley@nw14.esrd.net or Ext. 314 Resources for the QIP Centers for Medicare & Medicaid Services Centers for Disease Control and Prevention ESRD Network of Texas, Inc.

9 Page 9 The QIP Newsletter This QIP word search was developed by the Southeastern Kidney Council, Inc. (ESRD Network 6).

10 Volume 2 Page 10 Calendar Year 2015 ESRD QIP Calendar

11 We re on the Web: Join us on ESRD-Network-of- Texas/ Or send us a Phone: Fax: Patient Toll Free Line: info@nw14.esrd.net 4040 McEwen Road Suite #350 Dallas, TX Important Resources Kidney School One of the BEST resources available for almost everything you need to know about kidney failure, dialysis and transplant. This site is organized into interactive, self-paced chapters. Texas Department of State Health Services (TDSHS) Bureau of Kidney Health default.shtm Medicare Customer Service Line United Network of Organ Sharing (UNOS) Medicare Part D Updates and Information American Kidney Fund American Association of Kidney Patients (AAKP) AAKP The Renal Support Network (RSN) National Kidney Foundation Modality/Treatment Options This material was prepared by the ESRD Network of Texas, Inc. (ESRD Network 14), under contract #HHS NW014C with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The ideas presented do not necessarily reflect CMS policies or positions.