Joseph Scaletta, MPH, RN, CIC Director, KDHE Healthcare-Associated Infections Program Kay Brown, BS, CSSGB Quality Improvement Director, Heartland Kidney Network Joseph M. Scaletta, MPH, RN, CIC Disclosures Nothing to disclose National Action Plan to Prevent HAI Phase I: Acute Care Hospitals HHS Action Plan to Prevent HAIs issued: 2009 Progress report on targets and metrics presented: November 27, 2012 Phase II: ASC, ESRD, HCP Flu Vaccination Update to Action Plan included these settings: 2010 Phase III: Long Term Care Facilities (LCTF) LTCF draft issued for public comment: April 2012 Revised National Action Plan with LTCF chapter: late 2012/early 2013 Phase IV: To be determined All outpatient settings? Physicians offices? Injection safety? HHS Steering Committee must approve the expansion Current and Proposed HAI Reporting Requirements HAI Events Facility Type Reporting Start Date CLABSIs Acute Care Hospital ICUs Jan 2011 CAUTIs Acute Care Hospital ICUs (except Jan 2012 NICUs) SSIs Colon Surgeries and Abdominal Jan 2012 Hysterectomies Dialysis Events Dialysis Facilities Jan 2012 CLABSIs Long Term Care Hospitals Oct 2012 CAUTIs Long Term Care Hospitals Oct 2012 CAUTIs Inpatient Rehab Facilities Oct 2012 MRSA Bacteremia LabID Events Acute Care Hospitals Jan 2013 C Difficile LabID Events Acute Care Hospitals Jan 2013 HCP Influenza Vaccination Acute Care Hospitals Jan 2013 HCP Influenza Vaccination Long Term Care Hospitals Oct 2013 HCP Influenza Vaccination Ambulatory Surgical Centers Oct 2014 SSIs and other events ASCs and Hospital Outpatient Depts TBD Source: HHS, Progress Toward Eliminating Healthcare-Associated Infections meeting, November 27, 2012 1
PHASE III: Draft LTC Metrics Priority areas: National Healthcare Safety Network (NHSN) enrollment Goal: 5% of certified nursing homes enroll in NHSN over the 5 years following launch of the component Resident Influenza and Pneumococcal Vaccination Goal: 85% vaccination coverage of eligible residents for both seasonal influenza and pneumococcus HCP Influenza Vaccination Goal: 75% of HCP in LTC receiving the seasonal influenza vaccination by 2015 based on National Health Interview Survey data Urinary Tract Infections (UTI) Goal: Pilot reporting to NHSN, evaluate variability, and obtain consensus on measurable 5-year targets Clostridium difficile infections (CDI) Goal: Pilot implementation of reporting to NHSN, evaluate variability in measure and obtain consensus on a measurable 5-year target Infection Control Surveyor s Worksheet Electronic Health Record Incentive Program Stage 2 Hospital Inpatient and Long- Term Care Prospective Payment System Hospital Outpatient and Ambulatory Prospective Payment System Revised Physician Fee Schedule Proposed Rule End-Stage Renal Disease Prospective Payment System Rule 2012 Regulatory Action Healthcare Personnel Influenza Vaccination Goals for Healthy People 2020 Certification Criteria for Electronic Health Record Technology National Action Plan to Prevent HAIs Revisions to Tiers 1 and 2 National HAI Action Plan Long-Term Care Module Ban on the Extralabel Use of Cephalosporins In Food-Producing Animals Proposed Regulation on a Veterinary Feed Directive (VFD) Guidance on Judicious Use of Antimicrobial Drugs in Food-Producing Animals Guidance on Drugs Administered in Food or Drink of Food-Producing Animals Unique Device Identifiers Common Themes Efforts to align quality reporting measures across programs and healthcare settings Efforts to reduce reporting burden for healthcare providers Efforts to reduce hospital readmissions Use of subregulatory process for non-substantive updates to adopted measures Automatic continuation of adopted measures unless CMS proposes to remove, suspend or replace measure 2013 Federal Funding Remains Uncertain Most federal programs operating under a continuing resolution through March Differences between House and Senate funding levels still need to be worked out Congress needs to act or spending for domestic discretionary programs will be cut by an estimated 8% Automatic cut for CDC would be an estimated $490 million Kay Brown, BS, CSSGB 2
Disclosure This resource was (created, developed, compiled, etc.) while under contract with Center for Medicare and Medicaid Services, Baltimore, Maryland. Contract #HHSM-500-2013-NW012C. The contents presented do not necessarily reflect CMS policy. Definitions QIP=Quality Incentive Program PPS=Prospective Payment System NHSN=National Health Safety Network PY=Payment Year CY=Calendar Year How CY relates to PY PY2013 Data collected in CY2011 PY2014 Data collected in CY2012 PY2015 Data collected in CY2013 We can only proactively impact PY2015 at this time. QIP for PY2015 Consists of Clinical Measures and Reporting Measures Clinical Measures will be weighted equally to comprise 80% of the Total Performance Score Reporting Measures will be weighted equally to comprise 20% of the Total Performance Score PY2015 Clinical Measures Clinical Measures (data from 2013): Anemia Management Kt/V Dialysis Adequacy measure topic Adult Hemodialysis Adult Peritoneal Dialysis Adult Pediatric Dialysis Vascular Access Type (VAT) measure topic Access via arteriovenous fistula (AVF) Access via catheter for 90+ days Clinical Measurement: Anemia Management Percentage of patients with a mean hemoglobin value greater than 12g/dL Lower Percentage indicates better care Measure is unchanged from PY2014 Pts on dialysis <90 days Pts not treated with ESAs during the claim month Hgb<5 Hgb>20 Pts with missing data Pts with fewer than 4 eligible claims at the facility 3
Clinical Measure: Kt/V Dialysis Adequacy Measure Topic Replacing Urea Reduction Ratio (URR) to measure dialysis adequacy Expanding topic to include peritoneal dialysis and pediatrics Kt/V has 3 separate measures: Adult hemodialysis patients (in-center and at home) Adult peritoneal dialysis patients Pediatric hemodialysis patients Higher percentages on each of these measures indicate better care Kt/V Measure: Adult Hemodialysis Percent of hemodialysispatient months with Kt/V greater than or equal to 1.2 Pts on dialysis <90 days Pts dialyzing 4x or more per week Pts dialyzing 2x or fewer per week Pts with Kt/V value <0.5 Pts with Kt/V value >2.5 Pts treated at the facility less than 2x during claim month Kt/V Measure: Adult Peritoneal Percent of peritoneal patient monhswith Kt/V greater than or equal to 1.7 (dialytic+ residual) during 4 month study period years Pts on hemodialysis Pts on dialysis for <90 days Pts with a Kt/V value <0.5 Pts with a Kt/V value >5.0 Kt/V Measure: Pediatric Hemodialysis Percent of pediatric in-center hemodialysis patient-months with Kt/V greater than or equal to 1.2 Pts 18 years or older Pts on home hemodialysis Pts on dialysis <90 days Pts with Kt/V value <0.5 Pts with Kt/V value >2.5 Pts dialyzing 5x or more per week Pts dialyzing 2x or fewer per week Pts treated at the facility less than 2x during claim month Vascular Access Type: AVF Percentage of patient months on hemodialysisduring last hemodialysis treatment of the month using a autogenous AVF with two needles Higher percentage indicates better care Measure unchanged from PY2014 Claims reporting both a fistula and graft Pts with fewer than 4 eligible claims at the facility Vascular Access Type: Catheter Percentage of patient months for patients on hemodialysis during the last hemodialysistreatment of the month with a catheter continuously for 90 days or longer prior to the last hemodialysis session Lower percentage indicates better care Measure is unchanged from PY2014 Exclusions years and 3 months Claims rep9orting both a fistula and graft Pts with fewer than 4 consecutive eligible claims at the facility 4
Hypercalcemia Proportion of patient months with 3 month rolling average of total uncorrected serum calcium > 10.2 mg/dl For PY2015: The first month with a 3-month rolling average will be March Uncorrected means not corrected for albumin Applies to ALL pts treated by the facility (Not just Medicare pts) Higher percentage on this measure indicates better care Exclusions At facility <30 days On dialysis <90 days Pts with missing data Pts with fewer than 3 eligible claims at the facility Reporting Measures In-Center Hemodialysis(ICH) Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey Dialysis event data submission to the National Healthcare Safety Network (NHSN) system Monthly mineral metabolism monitoring (serum calcium and phosphorus) Anemia Management ICH CAHPS Reporting Measure Facilities must attest that they have administered the ICH CAHPS survey via a third party to adult in-center hemodialysis patients Attestation is done via CROWNWeb NHSN Reporting Measure Facilities must report information about dialysis events on a monthly basis to the NHSN A one-month grace period applies January data must be reported by February 28 Data for PY2014 must be entered by March 31, 2013 (3 consecutive months from 2012) Facilities that have not yet enrolled and trained in the NHSN system for dialysis events must do so Mineral Metabolism Reporting Facilities must report the serum calcium and serum phosphorus levels of all patients on a monthly basis to CROWNWeb Applies for hemodialysis patients, peritoneal dialysis patients and pediatric dialysis patients If the pt is treated elsewhere during the month (e.g. hospital), facilities can report lab work performed by the other entity Claims for patients treated only once during the claim month will be excluded from this reporting measure A one-month grace period applies (e.g., February data must be reported by March 31) Anemia Management Reporting Facilities must report hemoglobin or hematocritvalues and any ESA dosage on Medicare claims Applies to hemodialysis, peritoneal and pediatric patients Claims for peritoneal dialysis pts must include ESA dosage and hemoglobin or hematocritvalues If pt is treated elsewhere during the month (e.g., hospital), facilities can report lab work performed by the other entity Claims for hemodialysispatients treated only once during the claim month will be excluded from this reporting measure 5
Questions 1 Joining the Kansas Dialysis HAI Reporting Group Joining the Kansas Dialysis HAI Reporting Group Kansas Dialysis HAI Reporting HAI Reporting Group 27970 Group ID#: 27970 Group Joining Password: ESRD 2 3 Joining the Kansas Dialysis HAI Reporting Group Kansas HAI Dialysis Reporting HAI Reporting Group 27970 IN DE Dialysis Event 2E - Dialysis 2E - Dialysis IN 2E - Dialysis 4 5 6
To contact the Kansas Healthcare Associated Infections Program call or email: X LABID Laboratory-identified MDRO or CDI Event Joseph M. Scaletta, MPH, RN, CIC Director, KDHE Healthcare-Associated Infections Program jscaletta@kdheks.gov (785) 296-4090 (office) or IN Robert L. Geist, MPH Epidemiologist, KDHE Healthcare-Associated Infections Program Kansas Department of Health and Environment rgeist@kdheks.gov (785) 296-4202 (office) Kansas Department of Health and Environment Bureau of Epidemiology and Public Health Informatics 1000 SW Jackson, Suite 210 Topeka KS 66612-1274 6 7 7