Objectives

THE NATIONAL QUALITY STRATEGY & CMS QUALITY STRATEGY MEDPAC RECOMMENDATIONS AND IMPACT ON NURSING

PRACTICE

LOUISIANA ASSOCIATION FOR HEALTHCARE QUALITYANNUAL EDUCATION CONFERENCE

APRIL 10, 2014

REBECCA HIGHTOWER MS, RN, CPHQ, CPE QUALITY IMPROVEMENT SPECIALIST

EQHEALTH SOLUTIONS

This material is presented by eQHealth Solutions, the Medicare Quality Improvement Organization for Louisiana, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. LA10SoW2B14-3042

Objectives• The learner will be able to describe the National Quality Strategy and the CMS Quality

Strategy and their impact on nursing practice.

• The learner will be able to describe CMS program changes for the hospital readmissions

reduction program (HRRP) and their impact on nursing practice.

• The learner will be able to describe the MedPAC recommendations for refining the HRRP

and the potential impact on nursing practice.

• The learner will be able to describe the MedPAC recommendations for approaches to

CMS provider payment bundling and the potential impact on nursing practice.

• The learner will be able to describe the MedPAC recommendations for approaches to

Medicare hospice policy issues and the potential impact on nursing practice.

The National Quality Strategy

• Patient Protection & Affordable Care Act of

2010 (ACA)– Required a National Quality Strategy to “improve the

delivery of healthcare services, patient health

outcomes, and population health

– Build a consensus on how to measure quality so that

stakeholders can align their efforts for maximum results


• A national blueprint for achieving a high-value

healthcare system

• Sets clear goals to support efforts to improve the

quality of health and healthcare.

www.qualityforum.org/npp/

http://www.qualityforum.org/npp/


3 Aims– Better care

– Affordable care

– Health people & communities




Vision– Safe, affordable, value-driven healthcare is attainable

– Current trends can be reversed with Americans becoming

healthier & stronger

– Public & private sector leaders rowing together in the same

direction toward the same finish line.



The National Priorities Partnership

• Strategic opportunities to accelerate

improvement across all NQS aims &

priorities




• Four National Goals for the NQS

– Eliminating harm

– Eradicating disparities

– Reducing disease burden

– Removing waste in healthcare




Six Priorities for the NQS

Making care safer by reducing harm caused in the delivery of care.

The National Priorities & Goals

The National Priorities & GoalsKey Measures for NQS Priority 1 – Making Care Safer*

Measure Focus Key Measure Name/Description

Baseline Rate Most Recent Rate

Aspirational Target

Hospital-Acquired Conditions (HACs)

Incidence of

measurable

HACs

145 HACs/1000

admissions

142 HACs per

1,000

admissions in

20112

Reduce

preventable

HACs by 40%

by the end of

2013

Hospital Readmissions All-payer 30-day

readmission rate

14.4% based on

32.9 million

admissions

14.4% based

upon 32.7

million

admissions in

20115

Reduce all

readmissions by

20% by the end

of 2013


Engage patients and families as

partners in their care.


Key Measures for NQS Priority 2 – Engage Patients & Families as Partners in their Care*

Measure Focus

Key Measure Name/Description

Current Rate Most Recent Rate

Aspirational Target

Timely Care Adults who needed care right

away for an illness, injury, or

condition in the last 12 months

who sometimes or never got

care as soon as wanted

14.1% Available Fall 2013

Reduce to <10% by 2017

Decision-Making People with a usual source of

care whose healthcare

providers sometimes or never

discuss decisions with them

15.9% Available Fall 2013

Reduce to <10% by 2017

Believe in the Power of the

Patient

Promote effective communication and coordination of care.



Key Measures for NQS Priority 3 – Promote Effective Communication & Coordination of Care*

Measure Focus Key Measure Name/Description

Current Rate

Most Recent Rate

Aspirational Target

Patient-Centered Medical Home

Percentage of children needing care

coordination who receive effective

care coordination

69%8 66.1%9 66.1%9 I

3-Item Care Transition Measure**

1. During this hospital stay, staff

took my preferences & those of

my family/caregiver into account

in deciding what my healthcare

needs would be when I left.

2. When I left the hospital, I had a

good understanding of the things

I was responsible for in managing

my health.

3. When I left the hospital, I clearly

understood the purpose for taking

each of my medications.

**October 2013 data from CMS10

Update available in Fall 2013

Increase to 50% by 2017

Promote the most effective prevention and treatment

practices for the leading causes of mortality



Key Measures for NQS Priority 4 – Promote the Most Effective Prevention & Treatment practices for the Leading Causes of Mortality, Starting with Cardiovascular DiseaseMeasure Focus


Current Rate

Most Recent Rate

Aspirational Target (2017)

Aspirin Use People at increased risk of cardiovascular disease who are taking aspiring

47%* 53% 14 Increase to 65% by 2017

Blood Pressure Control

People with hypertension who

have adequately

controlled blood pressure

46%** 53% 16 Increase to65% by 2017

Cholesterol Management People with high cholesterol

who have adequately-

managed hyperlipidemia

33%** 32% 18 Increase to65% by 2017

Smoking Cessation People trying to quit smoking

who get help

23%*** 22% 20 Increase to 65% by 2017


Work with communities to promote

wide use of best practices to

enable healthy living.


Key Measures for NQS Priority 5 – Working with Communities to Promote Best Practices for Healthy Living*

Measure Focus


Current Rate

Most Recent Rate

Aspirational Target

Depression Percentage of Adults

reporting symptoms of a

major depressive episode

(MDE) in the last 12 months

who received treatment for

depression in the last 12

months

68.2%21 68.1% for 2011

Increase to 78.2% by 2020

Obesity Proportion of Adults who are

obese

35.7%22 Update available in 2014

Reduce to 30.5% by 2020

Make quality care more affordable for individuals, families,

employers, and governments by developing and spreading new

healthcare delivery models.



Key Measures for NQS Priority 6 – Making Quality Care More Affordable by Developing and Spreading New Healthcare Delivery ModelsMeasure Focus

Key Measure Name/Description Current Rate

Most Recent Rate

Aspirational Target

Out-of-Pocket Expenses

Percentage of people under 65 with out-of-pocket medical and premium expenses greater than 10% of income

18.5%24 Update available in Fall 2013

See footnote25

HHS Budget in Brief discussion of investments & healthcare spending reduction proposals

Health spending per capita

Annual all-payer healthcare

spending per person$8,40226 $8,680 per

person in 201127

See footnote28

HHS Budget in Brief discussion of investments & healthcare spending reduction proposals


• Progress– Nationwide initiatives launched to improve healthcare quality in

each of the six priorities

• Partnership for Patients

• Million Hearts Campaign

• Multi-Payer Advance Primary Care Practice Demonstration

– Interagency Working Group on Health Care Quality

– Agency for Healthcare Research and Quality (AHRQ)

www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf

http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf

The National Quality Strategy• Progress

– Alignment of measurement approaches

• Measures Application Partnership

• National Strategy for Data Collection, Measurement, & Reporting

– Reducing the burden of healthcare providers working to improve

quality

• EHR Incentive Program Meaningful Use

• Organizational Infrastructure at the Community Level

– Promote comparability of measurement data


– Established key measures to be used to track national progress

in each of the six priorities

– States adopting the NQS & using it to

• Demand higher quality from private health insurers

• Improve the quality of care for Medicaid recipients

www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf



– Payment & Delivery Systems Reforms• HHS offers more than three dozen opportunities

for providers across the care spectrum to participate in pilot programs to improve quality and reduce the cost of care.


Next Steps

• HHS will continue to pare down and consolidate the measures that providers are

required to collect and report.

– Enthusiastic engagement with private payers, through the Measures Application Partnership and

the Buying Value initiative, will continue to drive this work.

• There is a growing body of evidence on how to keep patients safer, how to best

coordinate care to improve outcomes, and how to lower costs through improvement.

– Future iterations of this report will highlight specific best practices and point stakeholders

from across the health care sector—payers, clinicians, communities, and consumers—to

resources that guide quality improvement work for all populations.

The CMS Quality Strategy

The CMS Quality Strategy - Vision

• To optimize health outcomes by improving clinical quality

and transforming the health system.

The CMS Quality Strategy - Mission

• Lead quality measurement alignment, prioritization, and

implementation and the development of new innovative

measures

• Guide quality improvement across the nation and foster learning

networks that generate results

• Reward value over volume of care

• Develop and implement innovative delivery system and payment

models to improve care and lower costs

• Collaborate across CMS, HHS, and with external stakeholders

The CMS Quality Strategy - Mission

• Listen to the voices of beneficiaries and patients as well as those who

provide healthcare

• Foster an environment that will create the capacity for providers to

improve quality through use of locally generated data and local

innovations in care delivery

• Be a model of effective business operations, customer support, and

innovative information systems that excel in making meaningful

information available

• Develop individuals, create high-functioning teams, foster pride and

joy in work at all levels, continuously learn, and strive to improve

The CMS Quality Strategy - Values

• Beneficiaries and Patients Come First – We put first the best interest

of the people we serve.

• Public Service – We take pride in our unique and privileged role in the

healthcare of the nation.

• Integrity – We hold ourselves to the highest standards of honesty and

ethical behavior.

• Accountability – We earn trust by being responsible for the outcomes

of our actions.

• Teamwork – We foster unconditional teamwork and regard every

employee in CMS as available and willing to help others.

The CMS Quality Strategy - Values

• External Collaboration – We strive to work in full cooperation with the

private sector.

• Innovation – We encourage finding and testing new ideas in all that

CMS does.

• Excellence – We are committed to strengthening our organizational

culture of striving for excellence in our products and services as well

as in how we do business.

• Respect – We treat all our stakeholders and one another with the

utmost respect and professionalism.

The CMS Quality Strategy – Foundational Principles

• Eliminate Racial and Ethnic Disparities

• Strengthen Infrastructure and Data Systems

The CMS Quality Strategy – Foundational Principles

• Enable Local Innovations

• Foster Learning Organizations

The CMS Quality Strategy – Drivers & Policy Levers

• Measuring & publicly reporting providers’ quality

performance

• Providing technical assistance & fostering learning

networks for quality improvement (QI)

• Adopting evidence-based national coverage

determinations

The CMS Quality Strategy – Drivers & Policy Levers

• Setting clinical standards for providers that support QI

• Creating survey and certification processes that evaluate

capacity for quality assurance & QI

The CMS Quality Strategy – Goal #1

• Make care safer by reducing harm caused in the

delivery of care

• Improve support for a culture of safety

• Reduce inappropriate & unnecessary care

• Prevent or minimize harm in all settings


• Strengthen person & family engagement as partners in

their care

• Ensure all care delivery incorporates patient & caregiver

preferences

• Improve experience of care for patients, caregivers, and

families

• Promote patient self-management


• Promote effective communication & coordination of care:

• Reduce admissions and readmissions

• Embed best practices to manage transitions to all practice

settings

• Enable effective healthcare system navigation


• Promote effective prevention & treatment of chronic

disease

• Increase appropriate use of screening & prevention

services

• Strengthen interventions to prevent heart attacks &

strokes

• Improve quality of care for patients with multiple chronic

conditions (MCCs)


• Promote effective prevention & treatment of chronic

disease

• Improve behavioral health access & quality of care

• Improve perinatal outcomes


• Work with communities to promote best practices of

healthy living

• Partner with & support federal, state, and local public

health improvement efforts

• Improve access within communities to best practices of

healthy living


• Work with communities to promote best practices of

healthy living

• Promote evidence-based community interventions to

prevent & treat chronic disease

• Increase use of community-based social services

support


• Make care affordable

• Develop & implement payment systems that reward

value over volume

• Use cost analysis data to inform payment policies

About eQHealth Solutions

• The Department of Health & Human Services’ (DHHS) National Quality

Strategy is the framework for the healthcare initiatives implemented in recent

years by the Centers for Medicare & Medicaid Services (CMS).

– The CMS Medicare Quality Improvement Organizations (QIOs) are an

independent network dedicated to promoting the goals of the National

Quality Strategy in each state & territory.

About eQHealth Solutions

• eQHealth has served as the CMS Medicare QIO in Louisiana for over 27

years.

– As the QIO, our work is based on the goals & priorities of the national

and CMS quality strategies.

• We are a free resource for meeting the requirements of CMS Quality

Reporting programs and improving quality & safety of patient care and care

transitions.

A bold new charter from CMS

Healthcare professionals are experienced,

committed, and understand the challenges

involved in widespread adoption of best

practices for achieving significant

improvements in the quality and safety of

healthcare for their patients.

• Payment reform for hospitals– CMS payment reform increasing the stakes– Potential negative impact to base DRG payments*

Finances

FY VBP HRRP HAC Total2013 1.00% 1.00% -0- 2.00%

2014 1.25% 2.00% -0- 3.25%

2015 1.50% 3.00% 1.00% 5.50%

2016 1.75% 3.00% 1.00% 5.75%

2017 2.00% 3.00% 1.00% 6.00%

*Alexander, K., LHA Legislative & Regulatory Update. LA Assn for Healthcare Quality Annual Education Conference. April 2012

Medicare Payment Reform – MedPAC Recommendations

Hospital Readmissions Reduction Program (HRRP)


Hospital-Acquired Conditions (HAC) Program


Post-Acute-Care Providers

Medicare Payment Reform – PACKey predictors of readmissions, changes in functional status, and resource useSource Domain Examples

Claims Demographics Age

Clinical Diagnoses

Co-morbidities

Patient Assessment Functional Status Mobility & self-care; sitting endurance

Cognitive Function Able to express ideas; Able to understand; Comatose; Depression

Special Services Ventilator; Dialysis; Chemotherapy; Central Line Placement; Total Parenteral Nutrition; IV medications

Medical Condition Severe pressure ulcers; Major wound present

Impairments Inability to hear, see, swallow; Incontinence

Prior Service Use Hospital or PAC use within past 2 months; ICU days

Prior Functioning Mobility & self-care; History of falls

Note: IV (intravenous), PAC (post-acute care), ICU (intensive care unit).Source: Carter et al. 2012, Gage 2011, Kramer et al. 2014, and Nuccio et al. 2011.MedPAC Report March 2014.

Medicare Payment Reform –

Hospice Care –

Medicare Care Choices Model

Medicare Payment Reform

Bundled Payments for Care Improvement Initiative



Model 1 Model 2 Model 3 Model 4

Episode All acute patients, all

DRGs

Selected DRGs, hospital

plus post-acute period

Selected DRGs, post-

acute period only

Selected DRGs, hospital

plus readmissions

Services included in the bundle

All Part A services paid as

part of the MS-DRG

payment

All non-hospice Part A and

B services during the

initial inpatient stay, post-

acute period and

readmissions

All non-hospice Part A and

B services during the

post-acute period and

readmissions

All non-hospice Part A

and B services (including

the hospital and

physician) during initial

inpatient stay and

readmissions

Payment Retrospective Retrospective Retrospective Prospective

Plans for all models include care redesign and enhancements, such as reengineered care pathways using evidence-based medicine, standardized operating protocols, improved care transitions, and care coordination. All may also include proposals for gains-haring among provider partners.



Implementation

Impact of Aging Baby Boomers on Medicare Population

• The Medicare population is projected to grow by over 70

percent over the next 20 years, as the bulk of the baby

boom generation ages into Medicare eligibility.

• With this expansion, the Medicare population will differ in

key ways from the current one.


• First, the average age initially will skew younger than in the

recent past, but then grow rapidly older as the number and

share of beneficiaries ages 85 and older increases.

• Second, it will become more racially and ethnically diverse

than the current population.

• Third, a greater number and share of beneficiaries will

have multiple chronic conditions.


• Finally, beneficiaries entering the program over the next

several years will have had very different experiences with

employer-sponsored and other forms of health care

coverage, due to significant changes that have taken place

and continue in the private and non-Medicare public health

insurance markets.

Remember

”…the secret of the care of the patient is in caring for the patient.”

Francis W. Peabody, MD (1881-1927)

HHS & CMS Programs Supporting National Priorities & Goals

National Priorities Partnership

•National Priorities and Goals: Aligning Our Efforts to

Transform America’s Healthcare. Washington, DC: National

Quality Forum (NQF) 2008 [Supported by the Robert Wood

Johnson Foundation (RWJF)]

•2013 Annual Progress Report to Congress. National

Strategy for Quality Improvement in Health Care. April 2013.

U.S. Department of Health and Human Services.


1CMS-1518-F/1430-F: Final Rule for Changes to the IPPS/LTCH PPS for FY 2012



Department of Health & Human Services (DHHS). FY 2014

Budget in Brief: Strengthening Health and Opportunity for All

Americans•http://dhhs.gov/ budget/fy2014/fy-2014-budget-in-brief.pdf

Million Hearts Campaign•http://millionhearts.hhs.gov/index.html

Community Transformation Grants Program•http://www.cdc.gov/communitytransformation/


http://millionhearts.hhs.gov/index.html

http://www.cdc.gov/communitytransformation/


Partnership for Patients• Public-private partnership to assist in improving the

quality, safety, and affordability of healthcare

Medicare Quality Improvement Organization (QIO)

• Facilitate the accomplishment of CMS Program Priorities• eQHealth Solutions - http://www.eqhealthsolutions.com

http://louisianaqio.eqhs.org


http://www.eqhealthsolutions.com/

http://louisianaqio.eqhs.org/


Center for Medicare & Medicaid Innovation• http://innovation.cms.gov/

•Medicare Care Choices Model – Hospice Demonstration• http://innovation.cms.gov/initiatives/Medicare-Care-Choices/

•Bundled Payments for Care Improvement Initiative•http://innovation.cms.gov/initiatives/Bundled-Payments


http://innovation.cms.gov/

http://innovation.cms.gov/initiatives/Medicare-Care-Choices/

http://innovation.cms.gov/initiatives/Bundled-Payments

Rebecca Hightower MS, RN, CPHQ, CPE

Quality Improvement Specialist

eQHealth Solutions

[email protected]

Contact

mailto:[email protected]

Documents

Objectives