11th SOW QIO-QIE Task Order SOW · Web viewSee Attachment B, Task Order 001, Evaluation Measures...

Attachment J.1- Task Order 001HHSM-500-2014-RFP-QIN-QIO

Centers for Medicare & Medicaid ServicesCenter for Clinical Standards & Quality

Quality Improvement Group

Quality Innovation Network (QIN)

Quality Improvement Organization (QIO)Scope of Work (SOW)

Task Order No. 001:Excellence in Operations and

Quality Improvement

Contract No. _______________


QIN-QIO SOWTask Order 001:Excellence in Operations and Quality Improvement

Contract Number: (Completed by the Contracting Officer (CO) at time of Task Order (TO) award)

Task Order Number: 001Date: (Completed by the CO at time of award)

Follow-on to Task Order Number: N/A

Period of Performance August 1, 2014 through July 31, 2019

Place of Performance (Insert the place of performance; e.g., QIN Area, state or states )

Scope (IDIQ Base Contract) Section C– Description/Specifications/Work Statement

Type of Task Order Cost Plus Fixed Fee

Cost/Price (Completed by the CO at time of TO award)

Contractor’s Task Order Technical Proposal is Incorporated by Reference

(Insert title and date of contractor’s Task Order Technical Proposal)

Government Task Lead (GTL)

Task A.1 – Excellence in Operations A. Primary GTL

Name:Agency: Centers for Medicare & Medicaid ServicesOrganization:Address:Phone Number:Fax Number:Email Address:

B. Alternate GTL


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Attachment J.1- Task Order 001

HHSM-500-2014-RFP-QIN-QIO

Task B.1 – Improving Cardiac Health and Reducing Cardiac Healthcare Disparities C. Primary GTL


D. Alternate GTL


Task B.2 – Reducing Disparities in Diabetes Care: Everyone with Diabetes CountsA. Primary GTL


B. Alternate GTL


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Task B.3 – Using Immunization Information Systems to Improve Prevention CoordinationA. Primary GTL


B. Alternate GTL


Task B.4 – Improving Prevention Coordination through Meaningful Use of HIT and Collaborating with Regional Extension CentersA. Primary GTL


B. Alternate GTL


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Task C.1 – Reducing Healthcare Associated Infections in HospitalsA. Primary GTL


B. Alternate GTL


Task C.2 – Reducing Healthcare Acquired Conditions in Nursing HomesA. Primary GTL


B. Alternate GTL


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Task C.3. Coordination of CareA. Primary GTL


B. Alternate GTL


Task D.1. Quality Improvement through Physician Value-Based Modifier and the Physician Feedback Reporting ProgramA. Primary GTL


B. Alternate GTL


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Task D.2. QIN-QIO Proposed Projects That Advance Efforts for Better Care at Lower CostA. Primary GTL


B. Alternate GTL


Task E.1. Other Technical Assistance Projects – Quality Improvement InitiativesA. Primary GTL


B. Alternate GTL


Table of Contents

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1. Introduction..................................................................................................................1

2. Personnel Requirements..............................................................................................12.1. Designation of Key Personnel............................................................................................1

3. Definitions.....................................................................................................................1

4. Core Requirements Applicable to All Task Orders..................................................2

5. Task Order Requirements...........................................................................................25.1 Excellence in Operations....................................................................................................25.2 Quality ImprovementAims.................................................................................................25.3 Tasks...................................................................................................................................4

A. Task A.1: Excellence in Operations............................................................................4A.1.1. QIN-QIO Comprehensive Strategic Plan........................................................................4A.1.2. Management Plan............................................................................................................6A.1.3. QIN-QIO Integrated Communications Plan...................................................................7A.1.4. Information Systems and Emergency Preparedness Plans.............................................7A.1.5. Task Order Work Plan Compendium..............................................................................7A.1.6. Continuous Internal Quality Improvement Program Plan..............................................8A.1.7. Reporting Requirements...............................................................................................10A.1.8. General Contract Management.....................................................................................10

B. AIM: Healthy People, Healthy Communities: Improving the Health Status of Communities.....................................................................................................................14

Goal 1: Promote Effective Prevention and Treatment of Chronic Disease...............14

Task B.1: Improving Cardiac Health and Reducing Cardiac Healthcare Disparities14Task B.1.1. Work Plan.............................................................................................................15Task B.1.2. Provider Recruitment............................................................................................15Task B.1.3. Beneficiary and Family Engagement...................................................................17Task B.1.4. Partner and Stakeholder Recruitment and Collaboration.....................................17Task B.1.5. Technical Assistance............................................................................................18Task B.1.6. Learning and Action Networks (LANs)...............................................................22Task B.1.7. Monitoring and Reporting Requirements.............................................................24Task B.1.8. Sustainability Plan................................................................................................24

Task B.2: Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts (EDC)................................................................................................................................25

Task B.2.1. Work Plan.............................................................................................................28Task B.2.2. Provider Recruitment............................................................................................28Task B.2.3. Beneficiary and Family Engagement...................................................................28Task B.2.4. Partner and Stakeholder Recruitment and Collaboration.....................................29

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Task B.2.5. Provider Technical Assistance.............................................................................29Task B.2.6. Monitoring and Reporting Requirements.............................................................31Task B.2.7. Sustainability Plan................................................................................................31Task B.2.8. QIN-QIO Technical Requirements.......................................................................31

Task B.3: Using Immunization Information Systems to Improve Prevention Coordination.....................................................................................................................35

Task B.3.1. Work Plan.............................................................................................................37Task B.3.2. Provider Recruitment............................................................................................37Task B.3.3. Beneficiary and Family Engagement...................................................................37Task B.3.4. Partner and Stakeholder Recruitment and Collaboration.....................................37Task B.3.5. Provider and Practitioner Technical Assistance...................................................37Task B.3.6. Sustainability Plan................................................................................................39

Task B.4: Improving Prevention Coordination through Meaningful Use of HIT and Collaborating with Regional Extension Centers...........................................................40

Task B.4.1. Work Plan.............................................................................................................42Task B.4.2. Provider and Practitioner Recruitment................................................................42Task B.4.3. Beneficiary and Family Engagement...................................................................43Task B.4.4. Partner and Stakeholder Recruitment and Collaboration.....................................43Task B.4.5. Provider Technical Assistance.............................................................................44Task B.4.6. Learning Action Networks (LANs)......................................................................45Task B.4.7. Monitoring and Reporting Requirements.............................................................47Task B.4.8. Sustainability Plan................................................................................................47

C. AIM: Better Healthcare for Communities: Beneficiary-Centered, Reliable, Accessible, and Safe Care................................................................................................48

GOAL 2: Make Care Safer by Reducing Harm Caused in the Delivery of Care.....48

Task C.1: Reducing Healthcare-Associated Infections in Hospitals..........................48Task C.1.1. Task Work Plan....................................................................................................49Task C.1.2. Provider Hospital Recruitment.............................................................................49Task C.1.3. Beneficiary and Family Engagement...................................................................50Task C.1.4. Partner and Stakeholder Recruitment and Collaboration.....................................50Task C.1.5. Provider Technical Assistance.............................................................................51Task C.1.6. HAI-Specific Tasks..............................................................................................52Task C.1.7. Learning and Action Networks (LANs)...............................................................55Task C.1.8. Monitoring and Reporting Requirements.............................................................56Task C.1.9. Sustainability Plan................................................................................................59

Task C.2: Reducing Healthcare-Acquired Conditions in Nursing Homes................60Task C.2.1. Task Work Plan....................................................................................................63Task C.2.2. Provider Recruitment............................................................................................63Task C.2.3. Peer-Coach Recruitment.......................................................................................65Task C.2.4. Beneficiary Recruitment.......................................................................................66

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Task C.2.5. Partner and Stakeholder Recruitment and Collaboration.....................................66Task C.2.6. Learning and Action Networks (LANs)...............................................................67Task C.2.7. Monitoring and Data Collection...........................................................................68Task C.2.8. Sustainability Plan................................................................................................69Task C.2. Appendix 1: Required Timeline for C.2 Activity....................................................69Task C.2. Appendix 2: Calculation of Nursing Home Recruitment Target Number (RTN) and

Star Category Target Number (SCTN)............................................................................70Task C.2. Appendix 3: Nursing Home Compare Provider Rating Table as of 04/23/2013. . .72

GOAL 3: Promote Effective Communication and Coordination of Care.................75

Task C.3: Coordination of Care.....................................................................................75Task C.3.1. Task Work Plan....................................................................................................78Task C.3.2. Framework for Improvement (e.g. Logic Models)...............................................78Task C.3.3. Community Recruitment .....................................................................................78Task C.3.4. Intervention and Measurement Selection.............................................................80Task C.3.5. LAN and Integrated Communication Support.....................................................82Task C.3.6. Medication Safety and Adverse Drug Event Prevention......................................83Task C.3.8. Reporting Requirements.......................................................................................85Task C.3.9. Additional Requirements......................................................................................87

D. AIM: Better Care at Lower Cost...............................................................................90

GOAL 4: Make Care More Affordable.........................................................................90

Task D.1: Quality Improvement through Value-Based Payment, Quality Reporting, and the Physician Feedback Reporting Program.........................................................90

Task D.1.1. Task Work Plan....................................................................................................93Task D.1.2. Provider and Practitioner Recruitment.................................................................93Task D.1.3. Beneficiary and Family Engagement...................................................................94Task D.1.4. Partner and Stakeholder Recruitment and Collaboration.....................................94Task D.1.5. Develop Expertise in Physician Feedback/Value-Based Modifier Program.......94Task D.1.6. Outreach and Education.......................................................................................94Task D.1.7. Technical Assistance to Physicians & Analysis of Data......................................96Task D.1.8. Address Gaps in Quality of Care..........................................................................96Task D.1.9. Physician Feedback Reporting Program..............................................................96Task D.1.10. Learning and Action Networks (LANs).............................................................97Task D.1.11. Alignment and Coordination with related CMS Programs (including VBP

Programs).........................................................................................................................97Task D.1.12. Physician Data Collection..................................................................................98Task D.1.13. Monitoring and Reporting Requirements...........................................................98Task D.1.14. Sustainability Plan..............................................................................................98

Task D.2: QIN-QIO-Proposed Projects that Advance Efforts for Better Care at Lower Cost......................................................................................................................100

Task D.2.1. Proposing Special Innovation Projects...............................................................100

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Task D.2.2. Other Provisions of SIP Proposals.....................................................................102Task D.2.3. Interim and Quarterly Reports............................................................................102Task D.2.4. SIP Final Reports...............................................................................................103

E. Other Technical Assistance Projects.......................................................................105

Task E.1: Quality Improvement Initiatives................................................................105Task E.1.1. QII Referrals.......................................................................................................106Task E.1.2. QII Development................................................................................................107Task E.1.3. QII Report...........................................................................................................107

List of Tables

Table 1. Minimum Recruitment for Participating Physician Practices/Offices/Clinics and Beneficiary DSME Targets.........................................................................................................33

Table 2. Nursing Home Provider Ratings.................................................................................71

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1. IntroductionThe Centers for Medicare & Medicaid Services (CMS), Center for Clinical Standards and Quality (CCSQ) requires expert healthcare quality improvement services. The contractor performing these services will be referred to as a Quality Innovation Network (QIN) Quality Improvement Organization (QIO) (referenced as QIN-QIO). This Task Order (TO) is issued under the terms and conditions of the QIN Indefinite Delivery/Indefinite Quantity (IDIQ) contract. Independently, and not as an agent of the Government (except if noted herein), the QIN-QIO shall furnish all the necessary services, qualified personnel, material, equipment, and workspace facilities, not otherwise provided by the Government, as needed to perform the requirements of this task order. The Contractor's technical proposal will be made a part of this task order. In the event of any inconsistency between the provisions of this contract/task order and the Contractor's technical proposal, the contract/task order provisions take precedence.

2. Personnel RequirementsThe QIN-QIO shall provide personnel for this task order in accordance with Section C.6.3, Personnel Core Requirements of the Base Contract. Qualifications for Key Personnel and Other Recommended Personnel positions are provided in Section C.6.3. of the Base Contract and will not be restated in Task Orders. Recommended positions unique to individual tasks and their corresponding qualifications along with other designated Key Personnel, which are not provided in Section C.6.3. of the Base Contract, will be provided in Task Orders and specified at the Task level.

2.1. Designation of Key Personnel Certain positions may be designated as “Key Personnel”, within the meaning of Health and Human Services Acquisition Regulation 352.270-5. For this TO, the following position is determined as Key Personnel:

Program Director – Required for the overall contract (1 FTE with 100% commitment)

3. DefinitionsSee Attachment J-8 , Glossary of Terms and Acronyms for definitions of terms and the list of acronyms associated with this contract and all task orders.

4. Core Requirements Applicable to All Task OrdersThe following list of task requirements is applicable to all Task Orders. Specific requirements for these tasks can be found in the Base Contract at Section C.7.4, “Execution Requirements for All Task Orders.”

C.7.4.1 Work Plan C.7.4.2 Recruitment Plan

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C.7.4.3 Provider and Practitioner Recruitment C.7.4.4 Beneficiary (“Patient”) and Family Engagement (PFE) C.7.4.5 Partner and Stakeholder Recruitment and Collaboration C.7.4.6 Sustainability Plan C.7.4.7 Monitoring and Reporting Requirements C.7.4.8 Measurement and Interventions

5. Task Order Requirements

5.1 Excellence in OperationsThe QIN-QIO shall perform quality improvement work in the designated area(s) for the specified period of performance. Such quality improvement work shall include requirements as specified in the Base Contract and Tasks pursuant to Task Orders issued during the contract term. In performing its work, the QIN-QIO shall take into account servicing multiple areas and the unique needs and characteristics of the Medicare population and healthcare providers of the QIO’s designated area(s). The Tasks for Excellence in Operations spans ALL contract requirements (Base Contract and Task Orders) over the life of the contract to ensure an overall comprehensive operational framework is established to support CMS objectives, concurrent execution of multiple Quality Improvement Tasks for multiple QIN areas, and overall project management. Task A.1, Excellence in Operations provides the specific tasks..

5.2 Quality ImprovementQuality improvement initiatives are authorized by the Social Security Act (the Act), in particular §§1862(g) and 1154(a)) (18)). Under § 1862(g) of the Act, the Secretary must enter into contracts with QIOs for a number of reasons, including assisting the Secretary in making determinations about whether services are reasonable and medically necessary, and for the purposes of promoting effective, efficient, and economical delivery of healthcare services and of promoting the quality of services of the type for which payment may be made under Medicare. The Centers for Medicare & Medicaid Services (CMS) has interpreted the term “promoting the quality of services” to involve not only beneficiary case reviews, but also as covering a broad range of innovations designed to promote higher quality. Under § 1154(a)(18) of the Act, a QIO must perform, subject to the terms of its contract with CMS, activities that are not explicitly listed in § 1154(a) but are determined by the Secretary to be necessary for the purposes of improving the quality of care furnished to individuals under Medicare.

Quality Improvement Aims comprises of three high-level Aims, each of which has separate Tasks, and technical assistance projects as follows:

AIM: Healthy People, Healthy Communities: Improving the Health Status of CommunitiesGoal 1: Promote Effective Prevention and Treatment of Chronic Disease

Task B.1: Improving Cardiac Health and Reducing Cardiac Healthcare Disparities Task B.2: Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts (EDC) Task B.3: Using Immunization Information Systems to Improve Prevention Coordination

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Task B.4: Improving Prevention Coordination through Meaningful Use of HIT and Collaborating with Regional Extension Centers

AIM: Better Healthcare for Communities: Beneficiary-Centered, Reliable, Accessible, and Safe CareGoal 2: Make Care Safer by Reducing Harm Caused in the Delivery of Care

Task C.1: Reducing Healthcare-Associated Infections Task C.2: Reducing Healthcare-Acquired Conditions in Nursing Homes

Goal 3: Promote Effective Communication and Coordination of Care Task C.3: Coordination of Care

AIM: Better Care at Lower CostGoal 4: Make Care More Affordable

Task D.1: Quality Improvement through Physician Value-Based Modifier and the Physician Feedback Reporting Program

Task D.2: QIN-QIOproposed Projects that Advance Efforts for Better Care at Lower Cost

Other Technical Assistance Projects Task E.1: Quality Improvement Initiatives

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5.3 TasksThe QIN-QIO shall perform the following tasks as described below.

A. Task A.1: Excellence in OperationsThe purpose of this task is to provide CMS objectives and requirements for management of the contract inclusive of all administrative activities/functions and overall management of all TOs issued under the QIN-QIO contract. The QIN-QIO shall achieve excellence in operations through managing for results. Overall project management is the key to the success of the QIN-QIO contract, the overall QIO Program, and the improvement in the quality of care and health for Medicare beneficiaries. The SOW requirements are results-oriented including measures and performance goals for contract requirements aligned to many Agency/Department goals and industry standards. Projects of such complexity require a systematic, deliberate, and calculated approach to achieve overall QIO Program goals. The QIN-QIO shall follow a basic project management framework, which includes, but may not be limited to a contract management plan, comprehensive strategic plan, integrated communications plan, and a continuous internal quality improvement program.

A.1.1. QIN-QIO Comprehensive Strategic Plan The QIN-QIO Comprehensive Strategic Plan, hereafter referred to as “Strategic Plan”, shall at a minimum, include the requirements specified in Section C.6.1.1, QIN-QIO Comprehensive Strategic Plan in the Base Contract. The minimum components are:

a. Vision Statement

b. Mission Statement

c. Organization Core Values

d. Implementation Strategy

e. Management Plan

f. Integrated Communications Plan

g. Information Security Plan

h. QIO System Security Plan

i. Emergency Preparedness Plans

i. Continuity of Operations Plan (COOP

ii. Contingency Plan

1. Disaster Recovery Plan

To optimize QIN-QIO internal operations, the QIN-QIO shall provide a comprehensive strategic plan that allows CMS to understand the method(s), modes and actions the QIN-QIO will use over the life of the contract to ensure all requirements are successfully executed and goals met. As with CMS’s goals for the QIO Program, the strategic plan should align the QIN-QIO’s work,

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methods, modes and actions with the CMS Quality Strategy. The QIN-QIO shall provide the strategies and activities it will use to address the strategic requirements as set forth in Section C.6 of the Base Contract. All individual components of the Strategic Plan shall be identified and discussed in separate sections. Of particular note, it is imperative that the QIN-QIO shall clearly articulate how it will carry out the following activities:

a. Collaborate with other healthcare quality improvement and delivery system reform initiatives within and outside of CMS and avoid duplication of work with other CMS contractors involved in those initiatives. Furthermore, the QIN-QIO shall share the names of recruited participants with other healthcare quality improvement and delivery system reform leaders if the sharing of this information will aid the QIN-QIO in the avoidance of the duplication of work.

b. Integrate and/or coordinate Tasks within and across all Task Orders throughout the life of the contract. CMS requires the QIN-QIO to foster the most efficient use of resources, interventions (including recruitment and quality improvement strategies), personnel and achievement of desired outcomes for quality improvement tasks under this contract. For example, a Task Order with multiple separate tasks presents an opportunity for collaboration and cross-integration between the Care Coordination Task and the following Tasks: Improving Cardiac Health and Reducing Cardiac Disparities, Reducing Disparities in Diabetes Care: Everyone With Diabetes Counts, Healthcare acquired infections in Hospitals, Nursing Home Healthcare Acquired Conditions and/or QIN-QIO Proposed Projects that Advance Efforts for Better Care at Lower Costs.

Another example, although not limited to integration and coordination between Tasks is Improving Prevention Coordination Through Meaningful Use of HIT and Collaborating with Regional Extension Centers and Quality Improvement Through Physician Value-Based Modifier and/or the Physician Feedback Reporting Program and QIN-QIO Proposed Projects that Advance Efforts for Better Care at Lower Costs. The QIN-QIO may identify other opportunities for integration and coordination between Tasks.

c. The QIN-QIO shall use an innovative and iterative cyclic approach to incorporate a data-driven monitoring and communication system for network-based interventions across and within Tasks. “Network interventions” is a relatively new term that describes the process of using network mapping and the resultant network data to guide, accelerate, and measure behavior change, including improvements in organizational performance and capabilities, internally and with cross-sector partnerships. A network intervention approach is ideal for the visualization of community and stakeholder interventions, illuminating both strengths and weaknesses. The visualization of interventions is used as a means to engage and inform communities, partners, stakeholders, teams, and organizations, thus creating shared knowledge for all that can be applied to accelerate cycles of improvement (More information is available at www.sciencemag.org Valente, T.W. 6 July 2012, Network Interventions or Adams, J. 17 December 2010,

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Exploring Links to Improve Health). A network intervention approach may be used in conjunction with Community Organizing techniques (Organizing for Health, http://www.cfmc.org/integratingcare/files/Organizing%20for%20Health%20-%20Introduction%20to%20Organizing%20-%20Kate%20B%20%20Hilton.pdf ). Enabling utilization of network interventions, another innovative approach is known as Relational Network Optimization (RNO) which is the combination of organizational network analysis and relational coordination to optimize delivery of wellness programs and disease treatment (Houston et al 2013 in preparation, Relational Network Optimization). To illustrate, RNO is intended to support identifying structural gaps and quantify operational weakness in collaborations and coalitions for care coordination, thereby supporting specific network interventions, such as creating new bridges between groups, when needed. Including both a social process and specialized enterprise-scale web technology, RNO dynamically operationalizes measurement between roles of key relational coordination constructs of shared knowledge, shared goals, mutual respect, and effective communication, rapid feedback to all stakeholders, and the ongoing creation of new data, information, and scientific knowledge. With the creation of new scientific knowledge, RNO integrates ongoing cycles of inclusive (of all stakeholders) research with improvements in organizational efficiency and effectiveness. RNO scientifically makes evident opportunities for rapid cycle improvement.

d. Contribute to the creation of a culture of sharing (with CORs, GTLs, and other QIOs) the following information: successful interventions, promising practices, lessons learned and/or other relevant information that has led to significant improvement in health, healthcare and/ or lower costs of healthcare for Medicare beneficiaries.

The Strategic Plan shall be submitted as part of the Task Order proposal and updated within 45 calendar days of Task Order award. The approved plan shall be updated within 5 days of any other change event.

A.1.2. Management Plan The QIN-QIO shall establish and execute a management structure that strongly and seamlessly supports contract operations. A Management Plan shall be provided that is results oriented and, at a minimum, includes effective lines of communication, budget and cost controls, quality assurance reviews, project schedule management, resource management to include staffing matrices by task/subtask, progress reviews and performance monitoring, risk management, change management, timely delivery, and clearly defined roles, responsibilities, lines of authority, and resources appropriately aligned to services and deliverables. Task Orders will involve multiple concurrent tasks and may involve multiple levels of subcontracting. QIN-QIOs shall ensure that all work efforts are integrated and also give attention to cross-cutting tasks. As the prime contractor, the QIN-QIO shall coordinate all subcontracted work to ensure that the efforts of all parties under the contract (management, administrative, and TO staff) are combined into a cohesive whole.

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http://www.cfmc.org/integratingcare/files/Organizing%20for%20Health%20-%20Introduction%20to%20Organizing%20-%20Kate%20B%20%20Hilton.pdf





A.1.3. QIN-QIO Integrated Communications Plan To optimize effective communication, the QIN-QIO shall provide for CMS approval a comprehensive and integrated communications plan to ensure access to the right information and services, in the right form, at the right time, to the right people, in the right place. This communication plan will focus the QIN-QIO’s energy such that each policy, action, and decision is made with an educated and strategic consideration of the impacts they have on stakeholders.

The QIN-QIO Integrated Communications Plan shall be developed in accordance with Section C.6.1.2. QIN-QIO Integrated Communications Plan of the Base Contract SOW.

QIN-QIOs shall work with providers and practitioners in underserved communities within its area. The communications plan provided to CMS as required by the contract, must provide details at both state-specific and overall area levels. Additionally, the QIN-QIO must describe the proportionate amount of each plan’s subject (e.g. providers recruited in the recruitment plan, activities in the Task Order Work Plan, etc.) by state compared to the QIN-QIO’s overall area along with the rationale/justification for that proportion. The rationale/justification must demonstrate that no state has been excluded and, if numbers are disproportionate for one state versus another that the reason for disproportionate amounts is to work with providers/practitioners most in need of assistance and/or to maximize the amount of improvement achieved. For example, if a QIN-QIO area covers 5 states, each with an equal number of providers, yet 50% of the worst performers were found in just one of those 5 states, the QIN-QIO could disproportionately recruit and plan activities in that single state in order to work with those providers most in need of assistance and maximize the improvement achieved. Some providers must still be recruited from each of the 5 states with activities also planned for each of the 5 states.

A.1.4. Information Systems and Emergency Preparedness Plans The QIN-QIO shall develop the Information Security Plan, QIN-QIO System Security Plan, and the Emergency Preparedness Plans in accordance with the requirements in Sections C.4, Technical Considerations and C.5, General Requirements. These plans shall be provided as subsections of the Strategic Plan.

A.1.5. Task Order Work Plan CompendiumQuality Improvement Task Orders issued under this contract may contain one or multiple separate quality improvement tasks. Section C.6.4.1, Task Order Work Plan in the Base Contract requires that QIN-QIOs provide a Task Order Work Plan for each Quality Improvement Task Order which encompasses separate work plans for each quality improvement task in the Task Order. The Task Order Work Plan provides essential documentation of objectives, goals, timeframes, and staffing to complete each Task. The QIN-QIO shall create a Task Order Work Plan Compendium (hereafter referred to as “Compendium”) within 5 calendar days of the first Task Order award for quality improvement services. The Compendium shall contain all CMS approved Quality Improvement Task Order Work Plans and shall be maintained throughout the life of the contract.

The Task Order Work Plans shall be identified by Task Order number, title, date, and follow the format specified in Section C.6.4.1 in the Base Contract. Task Order Work Plans are to be added to the Compendium on a real-time basis. This means that Task Order Work Plans shall be added

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to the Compendium upon Task Order award, updated when Task Order contract modifications are executed, and when any changes are made to approved Task Order Work Plan(s).

A.1.6. Continuous Internal Quality Improvement Program PlanThe purpose of the Continuous Internal Quality Improvement Program (CIQIP) Plan is to support and foster an environment of continuous quality improvement within the QIN-QIO. Such an environment helps to assure success of the QIN-QIO in their performance of the contract through ongoing assessment of and improvement when necessary in areas that are critical to organizational success. These include but, are not limited to:

Leadership Human Resources Customer Satisfaction Performance Measures Process Management Task Order Results

A.1.6.1. Objectives of the CIQIPThe objectives of the CIQIP are to:

Support and foster continuous quality improvement within the QIN-QIO in support of the Health Care Quality Improvement Program (HCQIP), the Medicare Beneficiary Protection Program (MBPP), and other Statement of Work (SOW) activities.

Develop and implement measures and targets that relate to the Contract Management Plan and Strategic Plan that ensure all aspects of QIN-QIO activities run efficiently, comply with the contract, and are consistent with and on track to achieve CMS’s goals and objectives for the HCQIP, MBPP, and the SOW.

Maintain QIN-QIO activities within a permissible range of deviation with minimum effort

Ensure the financial integrity of the contract by actively monitoring and staying within the total estimated cost and indirect cost ceilings of the contract;

Create a positive work environment in which opportunities for improvement are sought out and addressed at all levels of the organization

Improve the reliability, accuracy, consistency, and timeliness of data processing, data reports

Ensure the support, understanding, and participation of all beneficiaries, practitioners, providers, and other constituencies that are affected by QIN-QIO activities

Provide contract services that consider and meet the needs of both internal and external customers, and result in high levels of customer satisfaction

CMS encourages each QIN-QIO to collaborate with other QIN-QIOs in developing and implementing CIQI programs. The QIN-QIO shall share lessons learned regarding these CIQIP activities with other QIN-QIOs using the available mechanisms, including QIN-QIO conferences, newsletters, and databases.

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A.1.6.2. CIQIP Requirements The QIN-QIO shall have a CIQIP that encompasses all quality improvement (QI) requirements, and other major activities including administrative functions such as financial management. As new Task Orders are added to the contract, the CIQIP must be modified to address the new areas of work. The CIQIP shall include the following elements:

Identify QI components and/or activities that are included; Based on the Contract Management Plan and Strategic Plan, identify measures/monitors

of performance that relate to the elements of those plans, including but not limited to each of the QI components and/or activities.

Include measures that assess critical outcomes or SOW targets, as well as measures that assess processes related to those outcomes (e.g. measures that assess the implementation and effectiveness of activities designed to achieve the outcome);

Develop goals or thresholds for all measures, including goals or targets at various points within the contract period that allow for correction when performance does not appear to be on track to achieve contract goals or targets;

Develop timeframes at which measures are to be assessed against the goals/targets; At least quarterly, or more often as performance indicates, or as otherwise directed, use

measures, results, and other information to assess whether you are likely to meet goals/targets.

Analyze those areas where performance fails to achieve expected targets or thresholds and identify any causes of failure;

Identify changes in the process that address the identified causes of failure and that you believe will improve performance;

Implement selected changes designed to improve your process and performance; and Determine whether improvements were successful, and make further adjustments to the

process as needed. Document all aspects of the CIQIP including but not limited to

o QI Components and major activities included,o Measures,o Targets/goals and timeframes at which the targets/goals are to be achieved,o Results of performance at the specified timeframes,o Description of the analysis conducted when measures fail to achieve targets/goals and

results of the analysis,o Improvement actions identified and those selected that address the findings of the

analysis,o Critical dates and planning for the implementation of improvement actions, and o Re-measurement results.

Communication of the CIQIP and its results across the organization as well as to leadership and QIN-QIO Board of Directors.

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The QIN-QIO shall make available in accordance with the schedule of deliverables and on request by CMS, documentation of measurements/monitoring, plan, results, and improvement actions for all quality improvement components and major activities.The QIN-QIO shall submit its draft CIQIP plan for CMS approval within 45 days of Task Order award. The approved plan shall be updated within 5 days of any other change event.

A.1.7. Reporting RequirementsThe QIN-QIO shall provide the following reports as described below and in accordance with the Schedule of Deliverables:

a. Monthly Documentation of QIN-QIO Activities – at a minimum, the monthly report shall include a summary of QIN-QIO activities by Task including a separate section on Task A. This report is due to the COR at least 3 days prior to the monthly COR monitoring call. The COR will provided guidance on the format and any additional content.

b. Draft Final QIN-QIO Report for All Tasks – at a minimum,, the draft final report shall include the following:

A summary of the Excellence in Operations Task and the impact of the various plans required to execute tasks under the overall contract.

A summary of the QIN-QIO Activities spanning the life of the contract by task.

A summary of the impact of each task that includes a discussion on measures, targets/goals, and results.

An overall summary of how Medicare beneficiaries in the QIN-QIO’s area benefitted from QIN-QIO activities which is supported by data analysis. Also, include a discussion on activities that will be sustained by providers, practitioners, communities, and beneficiaries at the conclusion of the QIN-QIO contract.

A summary of lessons-learned on successful practices and non-productive interventions.

The draft final report is due to the COR/GTL by December 15, 2018 for review and comment. CMS will provide comments no later than January 10, 2019

c. The Final QIN-QIO Report for All Tasks shall be updated to include CMS comments/changes and submitted to the COR/GTL by February 1, 2019.

A.1.8. General Contract Managementa. The QIN-QIO shall participate in an orientation meeting (s) with the CMS Government

Task Leads (GTL) and/COR within 5 calendar days of task order award.

b. Within 21 calendar days of the effective date of the Task Order, the QIN-QIO shall confer with the GTL and COR by conference call to discuss the award. This will include a discussion of the QIN-QIO’s proposal and CMS’ expectations for project objectives and goals, the project design, expected timeframes, project staff, and the project tasks. The discussion shall also include the transition process from previous SOWs to current SOW, if applicable for the QIN-QIO. For this meeting, the QIN-QIO shall prepare

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discussion materials for its plan on completing the draft QIN-QIO Integrated Communications Plan and the CIQIP Plan.

c. Within 20 calendar days after Task Order award, the QIN-QIO shall submit to COR and GTL with approval by COR in consultation with GTL, the draft QIN-QIO Integrated Communications Plan and the CIQIP Plan along with any changes to the Project Management Plan or Comprehensive Strategic Plan, integrating the decisions reached at the orientation conference call. Within 14 calendar days after COR approval of the draft QIN-QIO Integrated Communications Plan and the CIQIP Plan, the QIN-QIO shall submit the final versions of the plans.

d. The QIN-QIO shall establish standing conference calls every month (unless otherwise indicated) with the COR on a mutually agreed upon timeframe which may include the CMS Contracting Officer, Contracting Specialists, GTL and/or others with a vested interest in how the contract is progressing.

e. The QIN-QIO shall assist in previous SOW to current SOW transition process after Task Order award in accordance with Section C of the Base Contract.

f. The QIN-QIO shall cooperate and collaborate with CMS partners, stakeholders and other Federal Agencies involved in similar efforts as applicable to tasks specified in this SOW.

g. Conference Attendance Requests (CARs): When the QIN-QIO plans to have a meeting and/or conference directly related to the performance of the contract, the QIN-QIO shall follow the current HHS and CMS travel and meeting policy.

h. In accordance with Section C.4.3.1 Certification by Security Point of Contact (SPOC) for Compliance with CMS Systems Security Requirements of the Base Contract, the QIN-QIO shall:

1) Appoint a SPOC within 14 days of Task Order award.

2) Provide a list of assigned QIN IT staff with the required information.

3) Conduct Security Awareness Training (SAT) for all employees utilizing or accessing CMS data within the HCQIS environment on an annual basis. The training shall be tracked and a log maintained of employees trained. A QNET SAT Certification Letter shall be provided to CMS 90 days after Task Order award in accordance with Task Order 001, Schedule of Deliverables.

4) Visit the CMS security website (www.cms.hhs.gov/informationsecurity) and the QualityNet security website (http://qionet.sdps.org) at least every 30 calendar days for updates. [Note: The QualityNet security website is an Intranet website; thus, access is restricted to only active users within the QualityNet Enterprise.]

5) Submit a Business Continuity and Contingency Plan (BCCP) within 90 days after Task Order award and updates provided 30 days after completion of any serious structural changes. Serious structural changes consist of building relocations or major structural changes to the current infrastructure.

6) Provide upon request, all related artifacts, in the format and method prescribed by CMS, resulting from compliance with CMS, FISMA, OIG, and other relevant audits,

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http://qionet.sdps.org/

http://www.cms.hhs.gov/informationsecurity



reviews, evaluations, tests, and assessments of QIN systems, processes, and facilities as it relates to program security and compliance.

7) Provide a QIN System Security Plan (SSP) and Information Security (IS) Risk Assessment (RA) within 90 days of after task order award, annually thereafter, and updates 30 days after any major changes.

8) Develop, in conjunction with CMS, Corrective Action Plans (CAP) for all identified weaknesses, findings, gaps, or other deficiencies in the IS Program (e.g., those items identified during a FISMA audit or similar activity) in accordance with IOM Pub. 100-17 (BPSSM) or as otherwise directed by CMS. Submit CAPs within 30 days after the audit or finding in accordance with Task Order 001, Schedule of Deliverables.

9) Submit the Plan of Action & Milestones (POA&M) within 15 days of approval of a CAP and monthly thereafter until the CAP is closed.

10) Maintain a list of all purchased and leased equipment in a HHS 565 submission Final Report.

11) Comply with all CMS system and software maintenance procedures. All digital media must be encrypted before physically leaving the QIN. The QIN-QIO shall perform maintenance of systems and software in compliance with applicable configuration requirements. QIN IT staffs are responsible for completion of IT tasks as assigned in Remedy tickets for QIN local systems.

12) Comply with CMS Incident Handling Standards and Procedures (RMH Vol III Standard 7-1 Incident Handling, RMH Vol II Procedure 7-2 Incident Handling Procedure) located at http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/InformationSecurity/Information-Security-Library.html and report suspected security breaches within the designated time periods. The QIN shall assist the CMS ISSO on active investigations and provide requested documentation as needed for all security incidents.

i. In accordance with Section C.4 General Requirements in the Base Contract, the QIN-QIO shall:

1) Adhere to the privacy, confidentiality, and disclosure requirements set forth in Section 1160 of the Act, and in Title 42 of the Code of Federal Regulations (CFR) Part 480, which are incorporated by reference in Attachment J-2 in the Base Contract and be prepared to document adherence to these privacy, confidential and disclosure requirements. http://www.access.gpo.gov/nara/cfr/waisidx_02/42cfr480_02.html .

2) Be prepared, if required to provide a copy of training materials developed or used to meet the confidentiality training requirement specified in 42 CFR 480.115. CMS may request documentation that users of the QIO review system have been trained in the proper handling of confidential information prior to being given access to that information and review system.

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http://www.access.gpo.gov/nara/cfr/waisidx_02/42cfr480_02.html

http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/InformationSecurity/Information-Security-Library.html

http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/InformationSecurity/Information-Security-Library.html



3) Obtain all Data Use Agreements (DUAs) necessary to comply with contract requirements and to execute required services.

4) Execute a data abstraction subcontract with the Clinical Data Abstraction Centers (CDACs).

5) Copy the COR on all communication between the QIN-QIO and the CDAC related to these subcontracting arrangements.

6) At a minimum, participate annually in collaborative activities that are sponsored by the applicable CMS Regional Office and focus on CMS-identified priority initiatives.

7) Follow the CMS Contractor Website Guidelines as specified in www.cms.hhs.gov/AboutWebsite/13_contractorwebguidlines.asp, which is incorporated into this contract by reference in Attachment J-2 in the Base Contract. The QIN-QIO shall refer to this website at least every 90 days for the current standards and guidelines.

8) Assist CMS’ public health efforts by disseminating information and messages as directed by the CO.

9) Develop and provide to CMS two different plans to address emergency preparedness: (1) a Continuity of Operations Plan (COOP) and (2) Contingency Plan (CP), which includes a Disaster Recovery (DR) Plan.

10) Prepare a “Table Top” test to evaluate the effectiveness of the COOP/CP/DR Plans, annually. At a minimum, this test shall include a structured walk-thru of each Plan with all key staff needed for CMS to evaluate each Plan.

11) Fully cooperate with and provide, subject to the QIO confidentiality provisions in Section 1160 of the Social Security Act and 42 CFR Part 480, requested data for any evaluation of the QIO program that the Secretary, or CMS on behalf of the Secretary, chooses to conduct. Such evaluations may be conducted by a CMS contractor.

12) Fully comply with all conflict of interest requirements as outlined in Section H of the QIN Solicitation.

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http://www.cms.hhs.gov/AboutWebsite/13_contractorwebguidlines.asp



B. AIM: Healthy People, Healthy Communities: Improving the Health Status of Communities

Goal 1: Promote Effective Prevention and Treatment of Chronic Disease

Task B.1: Improving Cardiac Health and Reducing Cardiac Healthcare Disparities

Section A. Overview/BackgroundAccording to the Centers for Disease Control and Prevention (CDC), heart disease and stroke are the first and fourth leading causes of death, respectively, in the United States for all groups. The CDC also presents morbidity and mortality data that suggest the risk for heart attacks and strokes are far greater for racial and ethnic populations (non-whites) than whites. The CDC’s State Maps on Heart Disease and Strokes at http://apps.nccd.cdc.gov/NCVDSS_DTM/ present data on heart attacks and strokes. It includes a breakdown by race and ethnicity and demonstrates the necessity for supporting the Million Hearts® initiative with an intense focus on the ABCS (Aspirin therapy when appropriate, Blood pressure control, Cholesterol management, and Smoking screening and cessation) for racial and ethnic minorities.

In September 2011, the HHS Secretary launched the Million Hearts® initiative to prevent one million heart attacks and strokes by the year 2017. The initiative focuses on improving the ABCS (Aspirin therapy when appropriate, Blood pressure control, Cholesterol management, and Smoking screening and cessation). This work also supports the National Prevention Strategy and three of its core strategic directions to a) promote clinical and community preventive services that ensure prevention-focused healthcare and community prevention efforts are available, integrated, and mutually reinforcing; b) empower people by supporting healthy choices; and c) elimination of health disparities to improve the quality of life for all Americans.

The Million Hearts® initiative created a priority focus on blood pressure measurement and control. High blood pressure has long been considered a “silent killer” in that many will not demonstrate signs and/or symptoms of the disease. Consequently, blood pressure measurement and control are essential to preventing heart attacks and strokes and decreasing the associated high mortality rates in the nation.

Section B. General Desired OutcomesUnder the provisions of this Task, the QIN-QIOs shall work with providers and beneficiaries in collaboration with key partners and stakeholders to implement evidence-based practices to support the Million Hearts® initiative goal in connection with care provided to Medicare beneficiaries to prevent one million heart attacks and strokes by the year 2017.

The specific targets and time periods for these outcomes are listed in the Evaluation Measures Table for this Task. These goals shall be accomplished by working with participating providers and beneficiaries in collaboration with key partners and stakeholders. The interventions to support the achievement of the Million Hearts® initiative goals shall include, but should not be limited to, the following:

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http://apps.nccd.cdc.gov/NCVDSS_DTM/



1. Spread the implementation of evidence-based practices to: Promote the use of Aspirin therapy when appropriate; Blood pressure (BP) control; Cholesterol management; and Smoking assessment and cessation.

2. Target racial and ethnic minority Medicare beneficiaries, dual-eligible Medicaid and Medicare beneficiaries, and the community providers and/or practitioners who serve them to improve on the ABCS using evidence-based practices.

Section C. Personnel Requirements1. Designation of Key Personnel-- See Part 2., Personnel Requirements in this TO.

2. Other Recommended Personnel--

a. Cardiac Healthcare Practitioner (RN, NP,) Physician (MD) or allied health professional

Section D. Task B.1 Requirements

Task B.1.1. Work PlanSee Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Task B.1.2. Provider RecruitmentIn addition to the requirements in Section C.6.4.3, Provider and Practitioner Recruitment in the Base Contract, the QIN-QIO shall, propose the number of participating providers it will recruit in its area including identification of those in rural communities. A recruitment proposal is required for this task rather than a Recruitment Plan as specified in the Base Contract. The recruitment proposal shall be submitted to and reviewed by CMS for approval. The recruitment shall include but not be limited to home health agencies (HHAs); practitioner-owned and/or -operated offices/clinics; and other healthcare facilities where physician, nurse practitioner and/or physician assistant oversight is provided. While this work targets all races and ethnicities, the QIN-QIO shall also propose the number of providers it will recruit that provide healthcare services to African American, Hispanic, and other racial and ethnic minority beneficiaries. The focus for recruitment shall be on those providers who manage patients with the greatest cardiovascular health needs and those most challenged to succeed in implementing evidence-based practices to improve cardiovascular health and support the Million Hearts® initiative. The QIN-QIO shall target recruitment of those who have not yet achieved the target rates indicated in the Evaluation Measures table. With its proposed recruitment, the QIN-QIO shall document the methodology and sources used to determine how and why the proposed providers were selected. Only the providers recruited under Task B.1.2.2 are required to be certified electronic health record (CEHRT) users.

For all participating providers, including HHAs, the QIN-QIO shall also propose a mechanism to keep the recruitment numbers at the level proposed and maintain those recruitment levels throughout the project. The QIN-QIO shall submit an initial recruitment report and quarterly reports as specified in the Evaluation Measures Table and/or Schedule of Deliverables.

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When targeting racial and ethnic minority patients through all participating providers including HHAs, the QIN-QIO shall also design its recruitment to target populations with the greatest need based on all available data and/or research sources. This shall include, but may not be limited to utilizing sources from the Centers for Disease Control and Prevention (CDC), Agency for Healthcare Research and Quality (AHRQ), Health Resources and Services Administration (HRSA) and other sources as applicable and appropriate.

While the QIN-QIO shall maintain the approved number of recruited participants, the QIN-QIO shall work with other participants beyond what is proposed and approved to spread the work to providers, patients, partners, and stakeholders wherever the need exists.

Task B.1.2.1. Home Health Agencies (HHAs)The QIN-QIO shall recruit HHAs based on being open, non-pediatric agencies in the Program Resource System (PRS) database as of June 1, 2014. Recruitment shall consist of non-profit and for-profit HHAs. The QIN-QIO shall propose to CMS the number of HHAs that the QIN-QIO shall commit to work with. The QIN-QIO shall document the number of these agencies in its Recruitment Plan.

Task B.1.2.2. Certified Electronic Health Record Technology (CEHRT) by Offices/ClinicsThe QIN-QIO’s work in this area shall include at least the following:

a. Recruitment of a subset of practitioner-owned/operated clinics or offices (practitioners serving both minority and non-minority beneficiaries) who agree to report on the following Physician Quality Reporting System (PQRS) measures via the CEHRT. :

1) Hypertension: Controlling High Blood Pressure (PQRS #236, NQF #0018)2) Tobacco Use: Screening and Cessation Intervention (PQRS #226, NQF #00283) Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic (PQRS

#204, NQF #0068)4) Cholesterol: Fasting Low Density Lipoprotein (LDL-C) Test Performed and

Risk-Stratified Fasting LDL (PQRS #316)

b. The QIN-QIO’s work and progress in connection with PQRS #236 and PQRS #226 will be evaluated as noted in the Evaluation Measures Table. In addition, the QIN-QIO shall submit a report on progress associated with PQRS#s 204 and 316 as part of the QIN-QIO’s quarterly monitoring requirements as specified in the Schedule of Deliverables.

The QIN-QIO shall maintain the proposed and approved recruitment numbers for CEHRT users throughout the contract term. The QIN-QIO shall recruit new or use the same recruited stakeholders, partners, and others as described in Task B.1.4 for the CEHRT work, if appropriate. The QIN-QIO shall target recruitment of CEHRT users who have not yet achieved the target rates indicated in the Evaluation Measures Table. At a minimum, CEHRT user

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recruitment shall include the following:

a. Intentionally target CEHRT users who serve racial and ethnic minority beneficiaries with a need for blood pressure measurement and control. This includes African American beneficiaries and other racial and ethnic minority beneficiaries.

b. Follow the technical assistance requirements for blood pressure described in the Provider Technical Assistance for Blood Pressure Control section of this Task.

c. Work with the participating providers to promote smoking screening and cessation counseling for beneficiaries who are managed by the participating providers.

d. Collaborate with the Regional Extension Centers (RECs), State Medicaid Agencies (SMAs), State Health Information Exchanges (HIEs), other QIN-QIOs, other CMS contractors, state and local departments of health, stakeholders, partners, beneficiaries, and others in the QIN-QIOs designated area to scale and spread the work.

e. Work to improve the use of CEHRT for effective and timely data capture, standardization of blood pressure and smoking related data elements and electronic reporting. Leverage EHR functionality including clinical decision support, registry functions and beneficiary reminders/alerts.

f. Support providers to increase participation in incentive programs such as the Physician Quality Reporting Program (PQRS), CEHRT-based reporting, and demonstration of Meaningful Use of CEHRT to track on functional objectives related to improving overall beneficiary care. This includes, but not limited to, capturing demographic data, including race, ethnicity and/or gender, preventive reminders, vital signs, beneficiary secure messaging, and other items.

g. The QIN-QIO shall submit baseline data for all CEHRT as specified in the Evaluation Measures Table.

h. Report on data progress and all activities quarterly as specified in the Schedule of Deliverables and Evaluation Measures Table..

Task B.1.3. Beneficiary and Family Engagement See Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Task B.1.4. Partner and Stakeholder Recruitment and CollaborationThe QIN-QIO shall propose the number and type of partners and stakeholders in its designated area that it will recruit. The QIN-QIO shall recruit partners and stakeholders to work together in a Cardiac Learning and Action Network described in this TO, to share information and resources, and complete joint collaboration/strategic action plans for improving the ABCS. The QIN-QIO shall remain actively engaged with these stakeholders and partners to help achieve the goals of this TO.

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Partners and stakeholders shall include any of the following, along with any other entities the QIN-QIO believes are appropriate: National Coordinating Centers (NCCs); Agency for Healthcare Research and Quality (AHRQ); Administration for Community Living (ACL); Centers for Disease Control and Prevention (CDC); CDC’s Heart Disease and Stroke Prevention (HDSP) Program participants; National Institutes of Health (NIH) (including the NIH Community Health Workers); Regional Extension Centers (RECs); State Medicaid Agencies; State Health Information Exchanges (HIEs); Office of Minority Health (OMH); National Hispanic Medical Association; Association of Black Cardiologists; American Heart Association (and its local offices); American Medical Association (AMA); Veterans Health Administration (VHA); Tribal Delivery Systems; QIN-QIOs and/or other contractors working on this SOW; and others who support any cardiovascular health related tasks and/or Million Hearts®. Consistent with the National Prevention Strategy’s recommendations on cross sector partnerships, QIN-QIOs shall also consider state/local health departments, state/local healthcare professional organizations, faith-based religious organizations (e.g. churches, synagogues); community-based safety net providers (e.g. Health Centers, Rural Health Networks), community health workers; advocacy groups for the target population; and other organizations and agencies working on similar cardiovascular and cardiovascular disparities issues.

While the recruitment of the approved stakeholders and partners shall be maintained, the QIN-QIO shall work with other partners and stakeholders to spread the work wherever the need exists at the local level.

Task B.1.5. Technical Assistance The QIN-QIO shall provide technical assistance to all participants as required in this TO and report on all activities in accordance with the Schedule of Deliverables.

Task B.1.5.1. Technical Assistance for Home Health Agencies (HHAs) a. The QIN-QIO shall provide technical assistance to HHAs.

b. For the HHAs technical assistance, the QIN-QIO shall utilize the Best Practice Intervention Packages (BPIPs) developed through the Home Health Quality Improvement (HHQI) National Campaign to prevent heart attacks and strokes for beneficiaries receiving services from home health agencies.

c. The QIN-QIOs shall work with the HHA to sign up for the Cardiovascular Data Registry developed through the HHQI National Campaign in order to track progress related to the ABCS.

d. The QIN-QIO’s technical assistance with the HHAs shall include at least, but is not limited to, the following tasks:

1) Utilization of health literacy and educational tools for HHAs to provide beneficiary education including successful interventions and literature appropriate for all racial and ethnic beneficiaries served by the agency. The QIN-QIO shall confirm that such materials account for health literacy levels, and are

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linguistically and culturally appropriate for beneficiaries receiving services from home health agencies.

2) Ensuring that home health agencies are invited to and participate in the cardiac LAN activities, any forum and/or LISTSERV or other mechanism by which the home health agencies may collaborate with and share success stories, strategies, successful interventions, and activities with others to improve the ABCS for home health patients.

3) Providing more intensive one-on-one technical assistance for HHAs on processes and procedures that shall be beneficial, including training HHAs on the use of Home Health Quality Improvement (HHQI) National Campaign successful interventions, tools, health information technology and interoperable key clinical information and other resources focused on the ABCS and as described in B.1.5.2.;

4) Providing technical assistance to HHAs experiencing staffing shortages and those with limited technological infrastructure unable to download educational resources and literature. This technical assistance shall consider the costs associated with downloading and printing resources for HHAs where this may be a financial burden.

e. The QIN-QIO shall complete a quarterly report on technical assistance provided to the home health agencies. The report shall include, but may not be limited to a) the number of agencies the QIN-QIO worked with, b) the number of beneficiaries impacted with a breakdown based on race and ethnicity, where possible, c) a summary of the type of activities, d) an indication of how and/or why the activities are (or are not) successful, and e) quantitative data from the Cardiovascular Data Registry.

Task B.1.5.2. Technical Assistance for the ABCS (Non-HHA Participants)The QIN-QIO shall provide technical assistance to participating providers and practitioners. The assistance shall include strategies for reaching and educating beneficiaries, including racial and ethnic minority beneficiaries, to prevent heart attacks and strokes. This task shall include, at a minimum, but may not be limited to performance of the following:

a. Focused assistance and strategies on the ABCS – Aspirin therapy when appropriate, Blood pressure control, Cholesterol management, and Smoking screening and cessation counseling. As the Secretary’s priority focus (i.e., Blood Pressure) changes to one of the other ABCS goals, the QIN-QIO shall focus on that priority goal as well.

b. Assist providers and/or practitioners with the utilization of existing best practices, such as those from the Cardiac Population Health Toolkit, the Home Health Quality Improvement (HHQI) National Campaign, best practices from the Million Hearts® website at www.millionhearts.hhs.gov, the American Heart Association and/or other resources identified by CMS, the Cardiac LAN, the Quality Innovation Network (QIN)

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NCC, and others.

c. Encourage the selection and spread of successful interventions and interventions focused on the ABCS that include at least the following:

1) Promoting beneficiary engagement and beneficiary self-management including ensuring beneficiary and/or caregiver preferences are assessed and incorporated.

2) Developing and implementing a plan for sustained improvement and work by the participating providers in the absence of the QIN-QIO.

3) Utilizing successful interventions and literature appropriate for racial and ethnic minorities. The QIN-QIO shall confirm that materials account for health literacy levels and are linguistically and culturally appropriate for the beneficiaries. The QIN-QIO shall review the HHS Action Plan to Reduce Racial and Ethnic Health Disparities in order to align disparities-related plans, successful interventions, and interventions to support the HHS goals where appropriate.

4) Utilizing appropriate interventions to maximize improvement in cardiac health disparities exist, including in gender, racial and ethnic disparities.

5) Utilizing plans, strategies, and practices that consider the social determinants that may contribute to poor health outcomes. Factors such as low income, lack of access to a primary care provider, poor nutrition due either to poor choices and/or lack of availability of healthy and affordable food items e.g. “food deserts”, and other environmental, social, and/or emotional issues affect compliance and/or adherence. Improving other health conditions (obesity, poor diet, poor dental care, etc.) that contribute to the cardiac morbidity and mortality for racial and ethnic groups.

d. The QIN-QIO shall provide technical assistance that shall include, at a minimum, but may not be limited to the following activities:

1) Targeting and implementing work with providers and beneficiaries in the QIN-QIO area. The technical assistance plan shall include specifics on beneficiary engagement and learning and action related to beneficiary self-management.

2) Dissemination of successful interventions that support the technical assistance provided under this Task. Existing resources may be utilized for this dissemination process where appropriate.

3) Include promotion, facilitation, learning, and action related to team-based care to achieve the goals of this Task. The QIN-QIO shall develop new and/or utilize existing team based care resources as available and where appropriate.

e. Work with participating providers and/or practitioners to identify and advance policy and

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system level changes that facilitate and promote equitable and better quality cardiac care for beneficiaries served by the provider. For example, the identification of racial, ethnic and gender disparities within the practitioner’s practice or provider setting as an initial step to implementing change.

f. Through the LAN meetings, site visits, and/or other communications with the participating providers, the QIN-QIO will work through the Plan Do Study Act (PDSA) cycle with the providers to maximize successful implementation of successful interventions based on the technical assistance provided by the QIN-QIO.

g. The QIN-QIO shall report on all ABCS technical assistance activities quarterly. The report shall include, but may not be limited to: a) the number and type of participating providers and practitioners the QIN-QIO worked with, b) the number of beneficiaries impacted with a breakdown based on race and ethnicity where possible, c) a summary of the type of activities, and d) an indication of how and/or why the activities are (or are not) successful. This report shall be submitted in accordance with the Schedule of Deliverables.

Task B.1.5.3. Provider Technical Assistance for Blood Pressure (BP) ControlThe QIN-QIO shall provide technical assistance on BP measurement and control to benefit all Medicare beneficiaries. Additionally, the QIN-QIO shall intentionally target African Americans, Hispanics, other racial and ethnic minority beneficiaries, and dual-eligible beneficiaries and the providers and practitioners who serve them to improve on BP measurement and control. The activities shall include, but shall not be limited to, technical assistance to beneficiaries and/or providers on the following:

a. High blood pressure evaluation, including (a) lifestyle, risk factor, and concomitant disorder assessment that may affect prognosis and/or treatment; (b) identifying the cause of high blood pressure; and (c) assessing the presence or absence of other organ damage and cardiovascular disease.

b. Using medication to reduce the complications of hypertension.

c. Maximizing treatment goals of therapy including treating BP to treatment recommendations outlined by the guidelines established by Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, which provides treatment goals based on race, age, and chronic disease status.

d. Ensuring appropriate beneficiary care management occurs including, but may not be limited to, follow-up medical appointments and medication adjustments as needed until BP reaches treatment goals as outlined by the guidelines established by Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

e. Utilizing the technical assistance strategies as described in the Technical Assistance for the ABCS section of this Task.

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f. Implementing strategies to maximize patient self-management, learning and action, and beneficiary and family engagement in the QIN-QIO area.

g. Provision of technical assistance to enable the participating providers to self-manage and monitor performance on the various cardiac measures for the beneficiaries they serve.

h. Reporting on all BP technical assistance activities and include a breakdown by race and ethnicity related to the number and types of beneficiaries, participating providers, and others served by the QIN-QIO. This report will be submitted quarterly in accordance with the Schedule of Deliverables.

i. Dissemination of best practices that support the technical assistance provided under this Task. Existing resources may be utilized for this dissemination process where appropriate.

j. Include promotion, facilitation, learning, and action related to team-based care to achieve the goals of this work.

k. The QIN-QIO shall develop new and/or utilize existing resources as available and where appropriate.

Task B.1.6. Learning and Action Networks (LANs)The QIN-QIO shall facilitate collaboration meetings and discussions among stakeholders (e.g., participating providers, practitioners, beneficiaries and/or their family member(s) and/or patient advocate(s)/representative(s)) and partners through a Cardiac Learning and Action Network (LAN) in the QIN-QIO’s area. These LANs shall include activities focused on working together to share information, resources, and strategies to achieve the goals for the target populations, including racial and ethnic minorities and dual eligible beneficiaries.

At a minimum, the QIN-QIO shall:a. Ensure that at least two beneficiaries (or family member and/or patient

advocate/representative) participate in patient-relevant LAN meetings and have a participatory place “at the table” during these meetings.

b. Include, at a minimum, in the LAN a composition of stakeholders participating practitioners, providers; beneficiaries and their families, advocates and representatives) and partners who commit to active engagement and work for preventing heart attacks and strokes. State Medicaid Agencies, Aging and Disability Resource Centers, Veterans Health Administration, and tribal community providers shall be invited to participate in the cardiac LAN. The QIN-QIO shall open all LAN meetings, activities, and resources to any and all interested parties and not just the participating providers, stakeholders, and partners the QIN-QIO is required to recruit.

c. Use the LAN meetings and teleconferences to discuss and spread successful interventions that have demonstrated success in the QIN-QIO area or beyond and to assist LAN

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participants with implementation of those successful interventions.

d. Convene the LAN and have at least one overall LAN meeting and conduct sub-group meetings with the LAN participants monthly. The QIN-QIO shall meet more often, if needed. These meetings may be face-to-face or via teleconference, web-conference, or other mechanism deemed appropriate for successful implementation.

e. Convene LAN meetings that, at a minimum, shall include:

1) Discussions and education related to successful interventions, data, or other cardiac health related items to support prevention of heart attacks and strokes;

2) Discussions of progress to date including successful intervention implementation and operational strategies related to heart attack and stroke prevention;

3) Work with LAN participants to identify and advance policy and system level changes that facilitate and promote equitable and better quality care for beneficiaries served by the participating providers and practitioners in the QIN-QIO’s area; and

4) Sharing knowledge and resources to promote engagement of beneficiaries and their families to improve beneficiary health and the use of self-management tools (including the use of validated, evidence-based mobile technologies).

5) Assisting participating providers and practitioners to allow beneficiaries secure access to their health information via web-based platforms or email.

f. Report on LAN activities quarterly. This report will be submitted to CMS for approval in accordance with the Schedule of Deliverables. At a minimum, the report shall include:

1) Strategies, activities, and successful interventions LAN participants are implementing successfully; identification of the LAN participants who are successful, how and why they are successful; and identification of the beneficiary population impacted including the number of beneficiaries impacted;

2) Strategies, activities, and successful interventions most effective based on gender, race, and ethnicity, and why and how they are effective despite the social determinants of health that may be identified;

3) Recommendations to spread successful strategies and successful interventions more broadly throughout the QIN-QIO area or beyond; and

4) A summary and dates of the monthly meetings held, type of meeting (e.g., face-to-face, Web-conference, teleconference), agenda items discussed as well as the number and type of attendees.

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g. Convene the first LAN meeting on or before the end of quarter two of the contract.

Task B.1.7. Monitoring and Reporting RequirementsSee Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Task B.1.8. Sustainability PlanSee Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Section E. Schedule of DeliverablesThe contractor shall provide all deliverables for Task B.1 – Improving Cardiac Health and Cardiac Healthcare Disparities in accordance with Attachment A, Task Order 001, Schedule of Deliverables.

Section F. Measurement, Evaluation and PerformanceSee Attachment B, Task Order 001, Evaluation Measures Tables for Task B.1 – Improving Cardiac Health and Cardiac Healthcare Disparities measures. Also, see Section C.6, Contractor Performance Measurement in the base contract.

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Task B.2: Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts (EDC)

Section A. Overview/BackgroundIn the United States nearly 13% of adults age 20 and over have diabetes, according to epidemiologists from the National Institutes of Health (NIH, 2011) and the Centers for Disease Control and Prevention (CDC 2011). Nearly one-third of persons 65 years and older have diabetes. Diabetes is a group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. It is the most common cause of blindness, kidney failure, and amputations in adults and a leading cause of heart disease and stroke. Type 2 diabetes accounts for up to 95 % of all diabetes cases and virtually all cases of undiagnosed diabetes. The CDC reports an annual incidence rate of 1.3 million newly diagnosed people with diabetes over the age of 20 years. Consistent with the 2011 Agency for Healthcare Research and Quality (AHRQ) report, the target beneficiary populations (including diabetes prevalence) for this Task are as follows:

1. African Americans (African Americans are from 1.4 to 2.2 times more likely to have diabetes than white persons).

2. Hispanic/Latino Americans (Hispanic/Latino populations have a higher prevalence of diabetes than non-Hispanic individuals).

3. American Indians/Native Americans (The prevalence of diabetes among American Indians/ Native Americans is 2.8 times the overall rate).

4. Japanese Americans, Chinese Americans, Filipino Americans, and Korean Americans (These major groups within the Asian and Pacific Islander communities had higher prevalence of diabetes than those of whites).

5. Beneficiaries living in rural areas (Twenty percent of Americans live in rural areas, but only nine percent of the nation’s physicians practice there. According to the Rural Health Research & Policy Centers, funded by the Federal Office of Rural Health Policy, 2011 statistics: Diabetes is more common among beneficiaries who live in rural counties (16.7%) than among those who live in urban areas (13.5%). According to the Center for Rural Affairs, residents of rural counties face access to health care and transportation issues, low literacy issues, and socioeconomic issues such as poverty and unemployment. Compared to their urban counterparts, residents of rural areas face longer distances to reach healthcare delivery sites, more often have chronic conditions such as diabetes, and have higher mortality rates from heart disease.

The Affordable Care Act (ACA) mandates the development of programs that address, identify and ameliorate healthcare disparities among principal at-risk subpopulations.

Diabetes self- management education (DSME) is a proven intervention for empowering persons with diabetes to take an active role in controlling their disease. By working with healthcare

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providers, practitioners, certified diabetes educators (CDEs), and community health workers (CHWs) persons with diabetes can acquire the knowledge and skills necessary to improve the quality of their lives, by preventing/lessening the severity of complications resulting from diabetes such as kidney failure, amputations, loss of vision, heart failure and stroke.

In the context of this background, we intend to align the QIN-QIO work under this Task with efforts to address diabetes generally.

Section B. General Desired Outcomes1. The general desired outcomes for this task are:

a. To improve clinical outcomes of HbA1c, Lipids, Blood Pressure and Weight control. for Medicare beneficiaries.

b. To decrease the number of beneficiaries who require lower extremity amputation due to complications resulting from poorly controlled diabetes.

c. To improve health literacy of Medicare and dual-eligible beneficiaries with diabetes in the targeted population(s) described in Section A above by providing and facilitating diabetes self-management education (DSME) training classes.

d. To increase adherence to clinical guidelines by participating practitioners for appropriate use of utilization measures for HbA1c, Lipids, and Eye Exams, as evidenced by Medicare Fee for Service (FFS) claims billed for Medicare beneficiaries with diabetes in the targeted populations.

2. The specific targets and time periods for achieving these outcomes are listed in the Evaluation Measures Table for this Task. These goals shall be accomplished by working with participating providers and/or practitioners and beneficiaries, including dual-eligible beneficiaries, in collaboration with key partners and stakeholders. The QIN-QIO shall use at least the following interventions to support the achievement of these outcomes, but is not limited to these interventions only:

a. Developing, implementing and operationalizing a train-the-trainer program in the QIN-QIO’s designated area to increase the numbers of certified diabetes educators (CDEs).

b. Developing, implementing, and operationalizing a sustainability plan in the QIN-QIO area; the plan must be designed to promote and encourage the continuation of training diabetes educators, the continuation of DSME training classes after the QIN-QIO has completed its work, and increase the numbers of certified diabetes centers and must submitted to CMS for approval prior to implementation of the plan. The QIN-QIO should consider coordinating this plan with partners and stakeholders in its QIN-QIO area.

c. Working with providers to educate them on the Medicare DSMT (diabetes self-

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management training) and MNT (medical nutrition therapy) benefits.

d. Developing, implementing, and operationalizing a train-the-trainer program in the QIN-QIO’s area to increase the numbers of certified diabetes educators (CDEs) and community health workers (CHWs) available, and facilitate the development of statewide DMSE/DSMT training sites.

Section C. Personnel RequirementsFollowing are additional personnel requirements for this task:

1. Other Recommended Personnel and Qualifications -- a. Certified Diabetes Educator Physician (MD), Community Health Worker (CHW),

or other allied health professional.

2. Other Recommended Personnel and Qualifications – Unique to This Taska. Community Program and Training Coordinator

(Minimum Requirements)1) Proven ability and experience with overseeing the research, development, and

delivery of comprehensive training courses.2) Proven skill and experience in excellent oral and written communication;

preferably through conduct of seminars, organizational meetings, presentations, participation on boards, white papers, articles and the like, in the clinical field.

3) Proven ability and experience building outreach and meaningful connections to underrepresented communities and target populations.

b. Senior Community Program Specialist(Minimum Requirements)1) Proven ability and experience in working with the community in a community

organization and/or as a facilitator performing as a key communications link between neighborhood/community organizations within a specified area.

2) Proven ability and experience building outreach and meaningful connections to underrepresented communities and target populations.

3) Proven ability and experience in managing a staff of Community Program Specialist(s), if applicable.

4) Proven skill and experience in excellent oral and written communication.

c. Community Program Specialist(Minimum Requirements)1) Proven ability and experience building outreach and meaningful connections

to underrepresented communities and target populations.2) Proven ability and experience with developing a wide range of educational

materials, including pamphlets, flyers, posters, news releases and audio-visual materials.

3) Proven skill and experience in excellent oral and written communication.

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Task B.2.1. Work Plan

See Part 4 of this TO, Core Requirements Applicable to All Task Orders. See Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Task B.2.2. Provider RecruitmentIn addition to the Base Contract requirements in Section C.6.4.3., Provider and Practitioner Recruitment, the QIN-QIO shall recruit in its area, participating provider and/or practitioner clinics/offices/practices, with a focus on those participants most challenged to succeed, to participate in EDC according to the criteria for participation. See EDC Table 1, “Minimum Recruitment for Participating Providers and DSME Thresholds.”

Task B.2.3. Beneficiary and Family Engagement a. The QIN-QIO shall recruit beneficiaries that meet eligibility criteria for at least one

and/or a combination of the populations described in Section A.

b. The QIN-QIO shall ensure that at least two beneficiaries (or their family and/or patient advocate/representative) participate in the LAN meetings for this Task and have a participatory place “at the table” during these meetings.

c. The QIN-QIO shall work with the CMS-designated contractor to provide this contractor with both pre-DSME and post-DSME Diabetes Knowledge and Patient Activation Surveys (PAS) completed by each beneficiary who completes DSME training. This contractor will score the surveys. These survey instruments will be provided to the QIN-QIOs by CMS. To accomplish this, the QIN-QIO shall provide complete and timely information and shall cooperate and coordinate with this contractor to ensure the accuracy of the survey data.

d. The QIN-QIO shall recruit Medicare beneficiaries to participate in DSME classes from the beneficiary population of the providers and practitioners the QIN-QIO has recruited. The QIN-QIO shall also recruit Medicare beneficiaries using a community-based approach. Examples of organizations which may help the QIN-QIO achieve a community-based approach to recruit for this Task include, but are not limited to: faith-based organizations, senior centers, community health centers, private businesses, state/local departments of public health, public housing authorities, state chapters of professional medical and nursing associations, and academic teaching institutions.

e. The QIN-QIO shall ensure that at least ten percent of the Medicare beneficiaries who complete DSME training have a diagnosis of “pre diabetes.” The American Diabetes Association (ADA) defines pre-diabetes as having an HbA1c between 5.7% and 6.4%, or a fasting blood glucose level between 100 and 125mg/dL, or a random non-fasting blood glucose level of between 140mg/dL and 199mg/dL.

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f. The QIN-QIO shall ensure that 90% of the beneficiaries who complete DSME training are from the target population identified in Section A.

g. The QIN-QIO shall ensure that the remaining 10% (from No. 6 above) who complete DSME training must be Medicare beneficiaries with diabetes or pre-diabetes, but can be from other racial/ethnic or rural geographic populations outside of the target population for this Task.

h. To be considered as completing DSME training, and count toward the quarterly targets in Table 1, a beneficiary must: a) Meet the eligibility criteria in Task B.2.8.3; b) Complete 80% of the DSME modules required for the particular diabetes education curriculum the QIN-QIO is teaching; and c) Complete both a pre DSME and a post DSME patient activation survey (PAS). However, 5% of the CMS approved QIN-QIO target number of Medicare beneficiaries do not have to complete a pre and/or post PAS, and may still be counted toward the quarterly targets in Table 1, provided these beneficiaries: a) Have diabetes or pre-diabetes; b) Are from the target population; and c) Complete 80% of the DSME modules required for the particular diabetes education curriculum the QIN-QIO is teaching.

i. The QIN-QIO shall provide data to CMS in accordance with the Schedule of Deliverables. See below EDC Table 1: “Minimum Recruitment for Participating Providers and DSME Thresholds.”

Task B.2.4. Partner and Stakeholder Recruitment and CollaborationSee Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Task B.2.5. Provider Technical Assistance

The QIN-QIO shall provide technical assistance as required in the following subtasks.

Task B.2.5.1. Promote Appropriate use of Utilization Measures by ProvidersThe QIN-QIO shall work directly with providers to achieve an improvement in the Medicare claims and clinical utilization measures (HbA1c, Lipids, Eye Exam, Foot Exam, Weight and Blood Pressure). The QIN-QIO shall work with providers and practitioners to increase their adherence to clinical guidelines for appropriate use of utilization measures for HbA1c, Lipids, and Eye Exams as evidenced by Medicare FFS claims billed for beneficiaries with diabetes in the targeted populations.

Task B.2.5.2. Improve Clinical Outcomes of HbA1c, Lipids, Eye Exam, BP, Weight and FeetQIN-QIOs shall obtain clinical data results of HbA1c, Lipids, Eye Exams, Blood Pressure, Weight, and Foot Exam for at least 10% of the beneficiaries who complete DSME training, both prior to and post training completion. If eye exam results are not available, the QIN-QIO will provide the date of the beneficiary’s most recent eye exam. If foot exam results are not available, the QIN-QIO will provide the date of the beneficiary’s most recent foot exam. The

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QIN-QIO shall report all test and exam results to CMS in accordance with the Schedule of Deliverables.

Task B.2.5.3. Lower Extremity Amputation RatesThe QIN-QIO shall track and monitor lower extremity amputation (LE Amputation) rates for the Medicare targeted population for this Task in the QIN-QIO area. Claims data will be supplied to the QIN-QIO by the designated CMS contractor and/or gathered by the QIN-QIO under applicable regulatory authority. The QIN-QIO shall report rates to CMS in accordance with the Schedule of Deliverables.

Task B.2.5.4. Environmental Scan of BeneficiariesThe QIN-QIO shall submit an environmental scan to CMS detailing the numbers of Medicare beneficiaries with diabetes in the targeted populations by county and zip code of the area. This scan shall be submitted to CMS in accordance with the Schedule of Deliverables.

Task B.2.5.5. Environmental Scan of CDEs/CHWsThe QIN-QIO shall submit a report to CMS detailing the numbers of certified diabetes educators (CDEs) and community health workers (CHWs) in its QIN-QIO area by county and zip code. To achieve this, the organizations the QIN-QIO may work with shall include, but are not limited to: the local state chapter of the American Association of Diabetes Educators (AADE), and the American Diabetes Association (ADA). This scan shall be submitted to CMS in accordance with the Schedule of Deliverables.

Task B.2.5.6. Train-the-Trainer ProgramThe QIN-QIO shall develop and implement a Train-the-Trainer program in its QIN-QIO area to increase the number of certified diabetes educators (CDEs), community health workers (CHWs), trained direct service workers (DSWs), and trained caregivers. The QIN-QIO, through its Train-the-Trainer program, shall facilitate the development of statewide DSME/DSMT training sites, as well as certified diabetes centers.

To achieve this Task, the QIN-QIO shall submit a plan for this program. Examples of stakeholders and organizations that the QIN-QIO may work with in developing and implementing its plan shall include, but are not limited to: academic institutions, faith-based organizations, local, State Medicaid Agencies (SMAs), state and Federal agencies such as Departments of Public Health, AADE, ADA, CDC, HRSA, VHA, Indian Health Service (IHS) and ACL (formerly Administration on Aging [AoA]).

This program plan shall include, at a minimum,: the locations of existing training sites in the QIN-QIO’s area, plans for the locations of future training sites, time tables/time frames for the development and openings of these sites, and the numbers of diabetes educators expected to complete training at these sites. Based on the needs in the QIN-QIO area, the program plan shall be supplemented with additional information. The plan for this program shall be submitted to CMS for approval in accordance with the Schedule of Deliverables.

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Task B.2.6. Monitoring and Reporting Requirements See Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Task B.2.7. Sustainability PlanIn addition to the requirements in the Base Contract, for the development and content of the Task sustainability plan, the QIN-QIO shall, for this Task, further develop and implement specific EDC elements that will be designed to promote, facilitate, and ensure: (a) the continued training of diabetes educators (both CDEs and CHWs), (b) the continuation of DSME/DSMT training classes after the QIN-QIO has completed this contract, and (c) dissemination of train-the-trainer materials. Examples of stakeholders and organizations that the QIN-QIO may work with to develop and implement the sustainability plan shall include, but are not limited to: academic institutions, professional organizations, SMAs, other state and Federal agencies such as Departments of Public Health, AADE, ADA, CDC, HRSA, HUD, IHS and ACL (formerly Administration on Aging [AoA]).

This sustainability plan shall include, at a minimum,: the projected numbers of Medicare beneficiaries expected to attend training classes; the existing working relationships in the state/jurisdiction, for example, HRSA and FQHCs and/or the Diabetes Prevention Control Program (DPCP) and the CDC; the funding sources available in the state/jurisdiction to sustain teaching centers and classes; and a strategy, which should include utilizing economies of scale to leverage these resources into sustainable resources after the QIN-QIO completes its scope of work. Based on the needs of the QIN-QIO area, the sustainability plan shall include additional information. The sustainability plan shall be developed with the input of at least one person with diabetes.

If the QIN-QIO coordinates this sustainability plan with the Task B.3 Coordination of Care sustainability plan (or other sustainability plans in its area), this information must be included. The sustainability plan shall be submitted to CMS for approval in accordance with the Schedule of Deliverables.

Task B.2.8. QIN-QIO Technical Requirements

Task B.2.8.1. Technical Requirements for Participating Practitioner Clinics/Offices/PracticesThe QIN-QIO shall recruit the Participating Practitioner (e.g., Physician) Practices to perform the following:

a. Agree to participate by signing consent form. b. Agree to submit aggregate rates for clinical diabetes measures (HbA1c, Lipids, Weight,

Eye Exam, and Blood Pressure) to the QIN NCC or another CMS-designated contractor other than the QIN-QIO.

c. Agree to refer beneficiaries within the target population to DMSE training.

To be eligible as a Participating Practitioner Clinic/Office/Practice for this Task, the following standards shall apply:

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a. At least 25% of a Participating Practitioner Clinics/Offices/Practices Medicare diabetes population must meet one or more of the targeted population definitions as stated above.

b. Based on analysis of Medicare claims, each Participating Practitioner Clinic/Office/Practice with claims results ranked in the lower 50th percentile among all practices in the QIN-QIO area for at least two of the three utilization measures: HbA1c, Lipids, and Eye Exam.

c. For a federally qualified health center (FQHC) or rural health center (RHC) to qualify as a Participating Practitioner clinic/office/practice it must meet the following: free-standing RHCs and FQHCs bill laboratory services to the Medicare Administrative Contract (MAC), and provider-based RHCs and FQHCs bill laboratory tests to the MAC under the hospital provider's bill type for the following: HbA1c, Lipids, Eye Exam.

Task B.2.8.2. Technical Requirements for Utilizing CMS-approved DSME Programsa. The QIN-QIO shall use one the following CMS-approved evidence-based DSME

programs in connection with this Task: Stanford, DEEP (diabetes education empowerment program), or Project Dulce. The QIN-QIO shall not alter or otherwise modify the content of the CMS-approved DSME programs used by the QIN-QIO without approval from CMS.

b. The QIN-QIO may use other evidenced-based DSME programs with prior written CMS approval. To ensure standardization of interventions, evaluation of additional approved programs shall be based on: (a) evidence of scientifically-valid data of the DSME program with comparison data for comparable populations (either receiving another related intervention or as a control group); (b) whether the program is recognized by the American Diabetes Association (although this is not essential if other factors are positive); and (c) whether the program has no other significant restrictions based on cost, licensure, royalties, or other federal regulations which would prohibit adoption, as deemed reasonable by CMS.

Task B.2.8.3. Technical Requirements for Beneficiary Eligibility to Participate in DSME TrainingThe QIN-QIO shall engage beneficiary participation using the following eligibility criteria:

a. Meets at least one criterion for the targeted population as described in this Task. b. Has a diabetes mellitus diagnosis (type 1, or type 2), or a diagnosis of “pre diabetes.”c. Is a Medicare beneficiary 18 years of age or older. Medicare eligibility shall be verified

by QIN-QIO via the enrollment database (EDB). QIN-QIOs shall keep a record of all Medicare Health Insurance Claim (HIC) numbers for all beneficiaries who complete DSME training.

d. Agrees to complete a minimum of 80% of the DSME training modules with a CMS-approved DSME program.

e. Agrees to complete a pre- DSME, as well as a post-DSME beneficiary knowledge and activation survey (PAS). The PAS survey instrument is provided to the QIN-QIOs by

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CMS.

Task B.2.8.4. Technical Requirements for Submitting DSME DataTo optimally assess the effectiveness of the DSME/DSMT programs, actual lab results and clinical data measures results would yield the highest evidence of efficacy. These measures are HbA1c, Lipids, Weight, and Blood Pressure. It is the intention of CMS to create one additional reporting mechanism to include these measures. CMS shall conduct this through a separate contractor. Data shall flow from the participating practitioner clinics/offices to the individual QIN-QIO, and then from the QIN-QIO to the designated CMS contractor. The QIN-QIOs shall provide technical support to the participating practitioner to accomplish the data reporting. This support shall include, without limitation: teaching the participating practitioner how to perform data abstraction from the medical records, and/or performing the actual data abstraction.

Additionally, the QIN-QIO shall encourage the use of EHRs and provide support to providers and practitioners using EHRs. This should be in the form of education regarding beneficiary registries, and referring the practices to resources such as, but not limited to, the Regional Health Extension Center(s) (RECs). Each QIN-QIO working in EDC is required to cooperate with RECs under contract with CMS.

Task B.2.8.5. Technical Requirements for Submitting Train-the-Trainer ProgramThe QIN-QIO shall obtain from each of its partners/stakeholders a signed statement of intent outlining the partner/stakeholder’s role in and contribution to the Train-the-Trainer program.

Task B.2.8.6. Technical Requirements for Submitting Sustainability PlanThe QIN-QIO shall obtain from each of its partners/ stakeholders a signed statement of intent outlining the partner/stakeholder’s role in and contribution to the sustainability plan. The focus of this requirement is to illustrate how the partners/stakeholders view their role in continuing this project after the QIN-QIO contract ends.

The QIN-QIO shall obtain input from at least one beneficiary with diabetes and/ or a family member to review and comment on the sustainability plan’s feasibility. Such input should be identified in the submission to CMS of the sustainability plan. If the QIN-QIO is coordinating this plan with the care transitions sustainability plan, or other sustainability plans in its area, this information shall be included in the submission.

Section E. Schedule of Deliverables The contractor shall provide all deliverables for Task B.2 – Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts (EDC) in accordance with Attachment A, Task Order 001, Schedule of Deliverables.

Section F. Measurement and Evaluation of PerformanceSee Attachment B, Task Order 001, Evaluation Measures Table for Task B.2. Everyone with Diabetes Counts measures. Also, see Section C.6, Contractor Performance Measurement in the base contract.

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Section G. Quarterly Minimum Recruitment for Participating Physician Practices and Beneficiary DSME Completion TargetsEach of the following minimum quarterly performance targets contained in Table 1 must be met for each state/territory in the area.

Table 1. Minimum Recruitment for Participating Physician Practices/Offices/Clinics and Beneficiary DSME Targets

Monitoring Period(by Quarter)

% of New PPs Recruited(% of QIN-QIO Target)

% of New Beneficiaries Completing DSME (% of QIN-

QIO Target)Year 1 Year 1 Year 1

1 – Aug 1, 2014 – Oct 31, 2014 0% 0%2 – Nov 1, 2014 – Jan 31, 2015 4% 0%3 – Feb 1, 2015 – Apr 30, 2015 6% 3%4 – May 1, 2015 – Jul 31, 2015 10% 4%

Year 2 Year 2 Year 25 – Aug 1, 2015 – Oct 31, 2015 10% 7%6 – Nov 1, 2015 – Jan 31, 2016 10% 7%7 – Feb 1, 2016 – Apr 30, 2016 10% 7%8 – May 1, 2016 – Jul 31, 2016 10% 7%


Year 4 Year 4 Maintain % of PP Target

Year 4

13 – Aug 1, 2017 – Oct 31, 2017 100% 7%14 – Nov 1, 2017 – Jan 31, 2018 100% 7%15 – Feb 1, 2018 – Apr 30, 2018 100% 7%16 – May 1, 2018 – Jul 31, 2018 100% 7%


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Task B.3: Using Immunization Information Systems to Improve Prevention Coordination(Please see Request for Proposal for special proposal instructions for this task. For Task Order 001, this task will be limited to a specified number of QIN-QIOs or to specific states.)

Section A. Overview/BackgroundAn immunization information system (IIS), also known as an immunization registry, is a confidential, population-based, computerized database that collects and consolidates vaccination data from vaccine providers, and provides tools for designing and sustaining effective immunization strategies at the provider and immunization program levels. Among the capabilities of an IIS are the capacity to inform vaccine providers of upcoming beneficiaries’ vaccination needs; generate vaccination coverage reports, client reminders, or recalls for past due vaccinations; and interoperate with electronic health record (EHR) systems.

At the point of clinical care, an IIS can provide consolidated immunization histories for use by a vaccination provider in determining appropriate client vaccinations. Efficiencies are gained as clients receive only recommended vaccines, avoid extra-immunizations, and reduce office time needed to gather and review immunization records. Providers have the ability to run reports and query the immunization data base.

At the population level, an IIS provides aggregate data on vaccinations for use in surveillance and program operations, and in guiding public health action with the goals of improving vaccination rates, reducing vaccine-preventable disease and can support vaccine safety surveillance if vaccine registry data can be linked to healthcare data through electronic health records.

Minimum functional standards for the operation of immunization information systems were initially developed in 1997 by the Centers for Disease Control and Prevention (CDC), the National Vaccination Advisory Committee, and immunization program grantees. In recognition of the growing importance of IIS to the broader health information technology landscape, the IIS minimum functional standards were revised in 2012. IIS collect immunization-related information such as (but not limited to): client name, birth date, place of birth, names and addresses of parents or guardians for children, date of vaccination, specific type of vaccine(s) administered, and adverse events. Children typically are entered into IIS at birth or at the time of their first contact with the healthcare system or provider. IIS can be used throughout the lifetime of the individual. The CDC has established a goal of including lifespan immunization records in IIS and improving EHR utilization by primary care practices. (Reference: CDC - IIS - Functional Standards - Registry - Vaccines)

Fifty states, five cities, the District of Columbia, and the Pacific Islands receive funding under section 317 of the Public Health Service Act for Immunization Program activities. All but one state awardee (New Hampshire) has an IIS. Of the 56 immunization program awardees, 53 have lifespan IIS (include data for all ages). Approximately 19.2 million (84%) of children aged < 6 years with 2 or more immunizations are recorded in an IIS. Although child participation is high, only 56.7 million (24%) adults >19 years and just 25.1million (24%) of adults aged >50 years

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have 1 or more immunizations recorded in the IIS as of December 31, 2011.

Section B. General Desired Outcomes1. The desired outcomes for this task are:

a. To achieve an absolute improvement in Medicare beneficiary immunization rates (influenza and pneumococcal immunization).

b. To improve routine reporting of Medicare beneficiary immunizations to the state IIS via electronic health records (EHRs) and other electronic methods, particularly among practitioner clinics/offices, home health agencies, and other healthcare providers and/or practitioners that are not currently submitting this data.

2. The specific targets and time periods for these goals are listed in the Evaluation Measures Table for this Task.

Section C. Personnel Requirements 1. Designation of Key Personnel--

a. See Part 2., Personnel Requirements in this TO.

2. Other Recommended Personnel and Qualifications—Unique to This Task a. IIS-specific Task Lead

(Minimum Requirements)1) Proven skills and experience working with practitioner clinics/offices/practices

and EHR vendors to implement and optimize electronic health record systems.

2) Proven skills and knowledge of quality improvement tools that lead to large scale change and improvement including quality improvement processes to reduce waste and increase value in healthcare expenditures.

3) Proven skills and experience to manage the Task at a strategic level including managing and navigating internal and external relationships.

4) Proven skills and experience with having authority and the ability to maintain accountability for meeting all deliverables and Task requirements within budget.

5) Proven skills and abilities to work with staff assigned to this Task to establish project resource assignments, plans, and operations, and to ensure staff levels are appropriate.

6) Proven skills and abilities to design and complete progress reports.

7) Proven skills and experience in excellent oral and written communication skills.

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Task B.3.2. Provider RecruitmentIn addition to the requirements in Section C.6.4.3, Provider and Practitioner Recruitment in the Base Contract, the QIN-QIO shall specify its recruitment goal for participating practitioner practices and other healthcare providers and shall specify how the recruitment goal was determined.

Task B.3.3. Beneficiary and Family Engagement See Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Task B.3.4. Partner and Stakeholder Recruitment and CollaborationSee Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Task B.3.5. Provider and Practitioner Technical Assistance Thirty (30) days after the effective date of this Task, the QIN-QIO shall develop an action plan for providing technical assistance in connection with this Task. The Technical Assistance plan shall include, at a minimum, quality improvement support, which ensures that the QIN-QIO shall work with participating practitioner clinics/offices/practices and other healthcare providers to improve EHR and other electronic reporting to the IIS. The plan shall address how to integrate and align this work with other QIN-QIO tasks and to create synergy and reduce redundancy where possible. To this end, appropriate partners for providing technical assistance shall be identified. The QIN-QIO shall perform the additional activities as listed below in connection with technical assistance for this Task.

Task B.3.5.1. CDC Grantee RelationsThe QIN-QIO shall meet with the CDC grantee within each state in its QIN-QIO area to discuss and come to agreement on logistics, operations and interagency agreements. The QIN-QIO shall meet with the CDC grantee on a regularly scheduled basis, e.g., bi-weekly, monthly.

Task B.3.5.2. Training on IIS UtilizationThe QIN-QIO shall meet with the CDC grantee or designee to begin training on the utilization of the IIS. The QIN-QIO shall be responsible for ensuring that the appropriate QIN-QIO staff is available to attend the training.

Task B.3.5.3. Identifying and Recruiting Provider and Practitioner Clinics/OfficesThe QIN-QIO shall identify the participating provider and practitioner clinics/offices for recruitment. The recruitment of the practitioner clinics/offices and other healthcare providers includes the QIN-QIO securing a signed consent form. At least 40% of the recruited practitioner

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clinics/offices must provide care to a predominately minority/underserved Medicare beneficiary population.

Task B.3.5.4. Technical Assistance to Practitioner Clinics/Offices/PracticesOngoing throughout the contract, the QIN-QIO shall provide to the participating practitioner clinics/offices/practices:

a. Technical assistance in reporting data about adult immunization of Medicare beneficiaries to the IIS via the EHR.

b. Education in using the EHR to report data about adult immunization data of Medicare beneficiaries to the IIS.

c. If EHR is not available or not used, education in using other electronic reporting methods shall be provided. For home health agencies, the QIN-QIO shall also encourage reporting of influenza and pneumonia immunization status via OASIS C. These data are captured via OASIS C items M1040, M1045, M1050, and M1055. For nursing homes, these data are captured in the Minimum Data Set (MDS) in Section O.

d. Education in using the IIS and/or the EHR to track and report needed immunizations and other immunization-related information for Medicare beneficiaries.

e. The practices/healthcare providers are expected to report adult immunization (of at least Medicare beneficiaries) information to the IIS at least quarterly.

f. The QIN-QIO shall provide and facilitate listening and learning opportunities for the QIN-QIO team and participating providers, state grantees, and other stakeholders who share common immunization goals. The outputs of listening and learning shall be spread across providers, other QIN-QIOs, and provided to the QIN NCC.

Task B.3.5.5. EHR Vendor RelationsAs needed, throughout the contract term, the QIN-QIO shall work with the relevant EHR vendors (e.g., KeyHIE www. keyhie .org ) to identify barriers and solutions in connection with increased use of EHR and CEHRT for immunization data.

Task B.3.5.6. Quarterly Reports to CMSThe QIN-QIO shall provide quarterly reports to CMS regarding this Task. The reports shall include, at a minimum: recruitment process, technical assistance and education provided to clinics/offices/practices, new insights gained based on plan do study act (PDSA) actions, practices’ immunization submission progress and data, timeliness and completeness of practices’ reporting to the IIS, tracking and trending of immunization rates, use of beneficiary recall/reminder functionality (EHR-level and IIS-level), run query reports, etc. Additional information and data elements shall be included in the monthly reports as appropriate or requested by CMS.

Task B.3.5.7. Monitoring Practices’ ProgressThe QIN-QIO shall begin to review IIS reports to monitor progress of practices, i.e., registry data submission, immunization rates, training needs, etc. For home health agencies and nursing

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http://www.keyhie.org/



homes, progress shall be monitored via OASIS and MDS reports.

Task B.3.6. Sustainability Plan See Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Section E. Schedule of Deliverables The contractor shall provide all deliverables for Task B.3, Immunization Information Systems in accordance with Attachment A – Task Order 001, Schedule of Deliverables.

Section F. Measurement and Evaluation of PerformanceThe evaluation of the improvement in influenza and pneumococcal immunization rates will be based on the reduction of the quality deficit. The quality deficit is the difference between the baseline percentage for each immunization and the Healthy People 2020 goal of 90% for each immunization. The QIN-QIO shall reduce its quality deficit by 50% for each immunization unless the expected improvement is less than the floor of five percentage (5%) points or greater than the ceiling of ten percentage (10%) point, at which point the floor or ceiling will apply.

See Attachment B, Task Order 001, Evaluation Measures Tables for Task B.3 – Immunization Information Systems measures. Also, see Section C.6, Contractor Performance Measurement in the base contract.

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Task B.4: Improving Prevention Coordination through Meaningful Use of HIT and Collaborating with Regional Extension Centers

Section A. Overview/BackgroundThe QIN-QIO program has developed the foundation for effective collaboration with several key stakeholders to implement innovative tools and successful interventions to assist providers in addressing quality improvement interventions for Medicare beneficiaries and quality measurement reporting in the Medicare program. The QIN-QIOs currently coordinate with the Regional Extension Centers (RECs) to align their respective efforts with the goals of the National Quality Strategy to improve health for populations and communities. The QIN-QIOs and RECs collaborate to support IT-enabled care management for primary care prevention and early diagnosis by participating in existing LANs and other quality improvement initiatives. The focus of this current collaboration has been framed around the adoption and use of certified electronic health records (EHRs) to improve specific healthcare services, processes and health outcomes related to prevention and population health through the LAN. The RECs have been able to provide services to over 100,000 primary care providers1, within a 2-year timeframe while focusing on the acceleration of EHR adoption and Meaningful Use (Reference: http://dashboard.healthit.gov/onc/).

The existing LAN includes a focus on effective use of, clinical quality improvement using clinical decision support and quality measurement, using the EHR to track and improve population health and clinical outcomes, and sharing successful interventions and care coordination using the Health Information Technology Research Center (HITRC).

In this contract, we anticipate that QIN-QIOs will collaborate with RECs to showcase the successful interventions and success that is a result of primary care providers successfully meeting the requirements of the Medicare EHR Incentive Program, and improving quality of and transitions in care through health information exchange using Health Information Technology (HIT) in connection with the Medicare program. The QIN-QIOs should coordinate with multiple stakeholders and partners including the Accountable Care Organizations (ACOs) and Pioneer ACOs to recruit eligible professionals (EPs) and eligible hospitals (EHs), build on the lessons learned, share successful interventions about how the meaningful use of HIT/CEHRT enables EPs and EHs to accomplish their beneficiary care goals and improve care management in the Medicare program. In addition, the QIN-QIOs shall provide targeted technical assistance to EPs and EHs that are most challenged to successfully meet the requirements of the Medicare EHR Incentive Programs and utilizing EHR functionality for quality improvement.

The work of the QIN-QIOs shall target the following foundational principles in connection with the Medicare program in order to align with the goals of the CMS Quality Strategy: a) 1 Primary care providers in the context of Regional Extension Centers “includes physicians (Internal Medicine,Family Practice, OB/GYN, Pediatrics) and other healthcare professionals (PA, NP, Nurse Midwife) with prescribingprivileges in the following settings, which are prioritized by the program: small group practices (10 or lessproviders); ambulatory clinics connected with a public or critical access hospital; community health centers andrural health clinics; other ambulatory settings that predominantly serve uninsured, underinsured, and medicallyunderserved populations” (http://dashboard.healthit.gov/rec/ )

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http://dashboard.healthit.gov/rec/



eliminating disparities, b) strengthening infrastructure and data systems, c) enabling local innovations, and d) fostering learning organizations.

Section B. General Desired OutcomesThe general desired outcomes for this task are:

a. Sustain the relationship established by the REC-QIN-QIO collaboration and continue to showcase successful interventions and lessons learned for dissemination at a larger scale across the healthcare continuum.

b. Collaboration with multiple stakeholders to recruit practitioners and providers in order to further education about the benefits of using HIT to accomplish their beneficiary care goals and improve care.

c. To increase EP and EH screening and delivery of preventive services for Medicare

beneficiaries through care coordination, monitoring and data analytics with the use of certified EHR technology.

d. Align with HHS priorities (as appropriate) based on the CMS Quality Strategy and the National Prevention Strategy.

e. To improve care access and coordination for Medicare beneficiaries by supporting beneficiary and family engagement.

f. To reduce disparities in access and utilization of healthcare services for Medicare beneficiaries by promoting the use of information technology (IT) enabled tools for collection of demographics data and to target underserved populations with the greatest need based on all available data and/or research sources. The QIN-QIOs shall support the priorities of the Federal Strategic Plan to Reduce Health IT Disparities and collaborate with other partners focusing on the reduction of disparities including, but not limited to, CMS Office of Minority Health, Centers for Disease Control and Prevention (CDC), Agency for Healthcare Research and Quality (AHRQ), Health Resources and Services Administration (HRSA), and other sources as applicable and appropriate.

g. The specific targets and time periods for these outcomes are listed in the Evaluation Measures Table for this Task. These goals shall be accomplished by working with participating providers, practitioners, and beneficiaries in collaboration with key partners and stakeholders. The interventions to support the achievement of these goals at a minimum, shall include:

1. Collaboration with the REC to improve EHR adoption and workflow and support practice transformation.

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2. Collaboration with the REC program and other partners to develop ways to motivate and support those practitioners and providers who are not eligible for incentives such as behavioral health, post-acute and long term care providers so that they realize the true benefits of system improvement.

Section C. Personnel Requirements1. Designation of Key Personnel—


2. Other Recommended Personnel and Qualifications—Unique to This Task a. Informatics Task Lead

(Minimum Requirements)1) Proven ability and experience with in the planning, development, training,

implementation, evaluation, and maintenance of clinical information systems across the healthcare continuum.

2) Demonstrated knowledge and expertise across the care continuum regarding: CEHRT/modules, accepted HIT standards, and need for interoperable health information exchange (HIE).

3) Proven ability and experience in facilitating communication from the clinical end users across the patient care settings while working collaboratively and directly with the vendors and technical experts.

4) Proven ability and experience with optimizing clinical design to meet the needs of a large group of interdisciplinary end users, including healthcare practitioners, and administrative staff.

5) Proven ability and experience working in a team environment to coordinate the deployment of information systems, technical assistance, and human resources in collaboration with other stakeholders.

6) Proven ability and skills related to effective problem solving, critical thinking, customer service and oral and written communications.



Task B.4.2. Provider and Practitioner Recruitment In addition to the requirements in Section C.6.4.3, Provider and Practitioner Recruitment in the Base Contract,, the QIN-QIO shall: identify and recruit a minimum number (See Evaluation Measures Table) of providers and practitioners in its area to participate in QIN-QIO direct technical assistance and LAN activities. Practitioners and providers to be recruited for technical assistance shall include, but are not limited to, EPs and EHs (as defined by the EHR Incentive Program), and other health care providers with installed CEHRT.

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The QIN-QIOs shall be responsible for building communities focusing on population health, prevention and treatment of chronic conditions, electronic clinical quality measure reporting and quality improvement for Medicare beneficiaries, including EPs and EHs challenged to successfully meet the requirements of the Medicare EHR Incentive Program and utilizing EHR functionality. Participants (practitioners and providers) must sign an agreement or pledge.

For all participating practitioners and providers, the QIN-QIO shall also propose a mechanism to keep the recruitment numbers at the level proposed and maintain those recruitment levels throughout the contract term.

While the QIN-QIO shall recruit a minimum number of practitioners and providers, the QIN-QIO is encouraged to work with more participants than what is required to scale and spread the work to further improve quality services and outcomes wherever the need exists.

Task B.4.3. Beneficiary and Family Engagement In addition to the requirements set forth in Part 4 of this TO, Core Requirements Applicable to All Quality Improvement Task Orders, the QIN-QIO shall recruit and engage beneficiaries (or family member of patient and/or patient advocates/representatives) to participate in the LAN meetings and have a participatory place “at the table” during these meetings. The QIN-QIO shall encourage the use of innovative health information technology applications (e.g., Blue Button Initiative) to promote engagement by beneficiaries and/or family members and/or patient advocates/representatives. The QIN-QIO shall urge providers to take reasonable steps to ensure health literacy and that Limited English Proficient (LEP) beneficiaries receive language access services (including competent interpreters and the translation of vital documents); and individuals with disabilities receive auxiliary aids and services (including sign language interpreters, materials in Braille and accessible electronic formats for patient portals to EHRs).

Task B.4.4. Partner and Stakeholder Recruitment and Collaboration In addition to the requirements set forth in Part 4 of this TO, Core Requirements Applicable to All Task Orders, the QIN-QIO shall perform the following:

a. Recruit and ensure participation by community representatives in educational sessions with the QIN-QIO as outlined in this Task.

b. Ensure that recruited communities representatives receive direct technical assistance from the QIN-QIO to focus on workflow adjustments needed to improve the use of EHR functionality, data analytics, EHR-based reporting of clinical data focusing on population health and prevention, and treatment of chronic conditions, and HIE to support care coordination.

c. Continue to support the collaboration and partnership with the RECs, to sustain the improvements and successes from existing efforts, and to share successful

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interventions and lessons learned through learning collaboratives (including virtual collaborative spaces).

d. Collaborate with RECs to promote beneficiary and family engagement by assisting practitioners and providers to connect with their beneficiaries, improve communication, and provide patients with scheduling and alerts/reminders.

e. Work in collaboration with other stakeholders, associations and groups working on improving preventive services and population health through meaningful use of HIT, EHRs, and HIE across the care continuum.

f. Advance and support existing initiatives at the Federal, State and local level including the work of the ACOs, Pioneer Accountable Care Organizations, and other new coordinated care models being tested by the CMS Innovation Center. QIN-QIOs shall collaborate with the CMS Innovation Center’s established learning systems for these models to ensure there is no duplication of effort.

g. Identify a target number of communities and providers to recruit per quarter through quarter 10. The recruitment plan must identify the number of communities in need of assistance.

Task B.4.5. Provider Technical AssistanceIn addition to the requirements set forth in Part 4 of this TO, Core Requirements Applicable to All Task Orders, the QIN-QIO shall perform the following:

a. Provide targeted technical assistance to EPs and EHs that are most challenged to succeed in achieving meaningful use of CEHRT for quality improvement.

b. Leverage the capabilities of participating EPs and EHs using CEHRT to collect, track and report data, through the use of automated tools for data extraction, for prevention and quality improvement at the beneficiary, provider and healthcare system level.

c. Promote the use of CEHRT functionality by participating EPs and EHs by supporting the use of clinical decision support, registry functions, preventive reminders, data analytics, and HIE.

d. Promote the use of CEHRT functionality by participating EPs and EHs by maintaining a problem and diagnosis list, identifying specific beneficiaries by age and disease or disease risk; creating population-based quality improvement reports and beneficiary-oriented, interoperable care plans to communicate and alert beneficiaries for needed preventive services.

e. Support participating EPs and EHs to increase EHR-based reporting of clinical quality measures to address preventive services and public health objectives, and treatment of chronic conditions, as established by the Meaningful Use program and

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consistent with the Medicare EHR Incentive Program (http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/), and other required quality reporting requirements. (http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/index.html).

f. Support beneficiary and family engagement in self-management and beneficiary-specific education resources and the involvement of participating EPs and EHs in such efforts.

g. Support participating EPs and EHs use of data (for tracking purposes and otherwise) to monitor and improve population health and prevention of illness and treatment of chronic conditions, and reduction of healthcare disparities.

h. Support to participating EPs and EHs to encourage CEHRT adoption and successfully meeting the requirements of the Medicare EHR Incentive Programs through the sharing of successful interventions and case studies by leveraging LAN activities.

i. Support and encourage EPs and EHs to participate in CMS quality reporting programs to better link payment with quality improvement.

j. Support and encourage participating EPs and EHs to integrate efforts that promote interoperability and the capability to exchange key clinical information in order to support preventive care and treatment for chronic conditions through HIE.

k. To increase EP and EH screening and delivery of preventive services for Medicare beneficiaries through care coordination, monitoring and data analytics with the use of certified EHR technology.

l. Support cross-setting sharing of information and health IT enablement of transitions of care across acute and long-term and post-acute settings, including the exchange of interoperable Summary Care Records to support the exchange of transition of care information and care plans.

Task B.4.6. Learning Action Networks (LANs)In addition to the Base Contract requirements, the QIN-QIO shall:

a. Ensure that at least two beneficiaries (or family members and/or advocate/(s)/representative(s) of beneficiaries) actively participate and contribute in the LAN meetings and have a participatory place “at the table” during these meetings.

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http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/index.html

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/index.html



b. Provide a communication and collaboration strategy with multiple stakeholders including plans for joint presentations, co-branding and educational sessions.

c. Promote community-based initiatives and educational activities to support IT-enabled care management for primary care prevention and early diagnosis.

d. Facilitate collaboration and discussion among participating EPs, EHs, and stakeholders through LANs on a quarterly basis and develop a Learning Community Strategy.

e. Share knowledge and resources to promote engagement of the beneficiary and his/her family in order to improve beneficiary health and use of self-management tools (including the use of mobile technologies). The QIN-QIO shall assist EPs and EHs by providing technical assistance and guidance for methods to allow their beneficiaries’ access to their health information on-line and through secure messaging; such information shall be focused on quality improvement and preventive care.

f. Promote the use of HIT to reduce disparities and improve beneficiary-centered care for Medicare beneficiaries. Reduce disparities in access and utilization of healthcare services for Medicare beneficiaries by promoting the use of information technology (IT) enabled tools for collection of demographics data and to target underserved populations with the greatest need based on all available data and/or research sources.

g. Use learning system intervention packages from the QIN NCC and act as a LAN to promote population health and care coordination within the Medicare program.

h. Develop a strategy for educational sessions and material for EPs and EHs. Such sessions and material shall have the goal to foster healthy living for Medicare beneficiaries and sharing successful interventions among EPs and EHs. The National Prevention Strategy (NPS) framework shall be utilized to establish an effective structure. QIN-QIO shall provide list of educational materials, invitations, webinar information and others.

i. Enroll and convene EPs and EHs in educational sessions, community collaborative and/or social media related to prevention, cardiovascular health, and treatment of chronic conditions.

j. Assist EPs and EHs in selecting and reporting quality measures focused on prevention, cardiovascular health and treatment of chronic conditions.

k. Support EPs’ and EHs’ achievement of outcomes on selected clinical quality measures by setting a baseline and target for each measure.

l. Educate EPs and EHs on the linkage between EHR Incentive Programs and Prevention Health.

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m. Provide recommendations and guidance to CMS in the efforts to align quality reporting programs (such recommendations shall be informed by communication and outreach to LANs).

Task B.4.7. Monitoring and Reporting Requirements See Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Task B.4.8. Sustainability Plan See Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Section E. Schedule of Deliverables The QIN-QIO shall provide all deliverables for Task B.4. - REC Collaboration Schedule of Deliverables in accordance with Attachment A, Task Order 001 Schedule of Deliverables.

Section F. Measurement and Evaluation of PerformanceSee Attachment B, Task Order 001, Evaluation Measures Tables for Task B.4. – REC Collaboration measures. Also, see Section C.6, Contractor Performance Measurement in the base contract.

m.

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C. AIM: Better Healthcare for Communities: Beneficiary-Centered, Reliable, Accessible, and Safe Care

GOAL 2: Make Care Safer by Reducing Harm Caused in the Delivery of Care

Task C.1: Reducing Healthcare-Associated Infections in Hospitals

Section A. Overview/BackgroundThe Health and Human Services (HHS) National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination has taken a tiered approach to healthcare-associated infection prevention and reduction, with one of the major priorities being the reduction of Healthcare Associated Infections (HAIs) in the hospital setting. QIN-QIOs shall fulfill the purposes of the QIO statute by performing activities that align with the HAI goals as outlined in the HHS HAI National Action Plan and with other public and private programmatic initiatives such as the Agency for Healthcare Research and Quality’s (AHRQ) Comprehensive Unit-based Safety Program (CUSP) work, the Centers for Disease Control and Prevention (CDC) sponsored state based HAI initiatives and the work of the CMS Hospital Engagement Networks (HENs) in the Partnership for Patients.

The HAI work in the HHS National Action Plan and this contract focuses on using evidence-based strategies and data to drive HAI prevention and reduction. The use of evidence-based strategies such as guidelines for infection control released by the CDC and operational principles that promote a culture of safety within a healthcare institution have been shown to increase the quality of beneficiary care, save lives and significantly decrease healthcare expenditures.

The QIN-QIO shall also work in conjunction with other components of this contract to address additional facets of a patient-centered, comprehensive HAI prevention and reduction plan. This includes working with participating providers to comply with meaningful use and subsequent electronic standards, focusing on the principles of appropriate medication use through antimicrobial stewardship programs, examining the role of improved care transitions in HAI reduction and emphasizing the importance of vaccination health in infection control and prevention.

The QIN-QIO shall work with participating hospitals with a focus on those most challenged to succeed, to comply with meaningful use and subsequent electronic standards to optimize HAI data interoperability across multiple healthcare delivery settings. In addition, QIN-QIOs shall facilitate collaborative ties with partners in the healthcare community. QIN-QIOs shall also focus on the principles of appropriate medication use in HAI prevention through antimicrobial stewardship programs, care coordination and transitions through a focus on tracking HAIs in multiple settings and the importance of vaccination health and employing methods to ensure updated immunization status’ in our most at-risk Medicare beneficiaries as a way to avoid infections.

The QIN-QIO shall also lead local LANs to address HAI reduction and prevention. These LANs shall focus on the importance of collaboration with the QIN NCC. As leaders of LANs, QIN-QIOs shall identify key partners working in HAI reduction across the region they serve. As such, QIN-QIOs shall lead, convene, join and/or coordinate these efforts in order to create synergy and

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impact outcomes. QIN-QIOs shall also ensure that they are not duplicating federal, state or local efforts and/or be able to mitigate any duplication they may identify.


a. To decrease HAI Standardized Infection Ratio (SIRs) nationally by demonstrating significant, quantitative and measurable reductions in hospital acute care settings for Medicare beneficiaries.

b. To prevent the occurrence of HAIs in hospital provider settings using evidence based HAI prevention strategies.

2. The specific targets and time periods for these goals are listed in the Evaluation Measures Table for this Task. These goals shall be accomplished by working with participating providers, practitioners, and beneficiaries and key partners through methods such as the following:

a. Use of data-driven, beneficiary-centered, evidence-based strategies that target the operational issues/needs of each participating hospital provider to impact the prevention and reduction of HAIs.

b. Use of the results of HAI activities to initiate quality improvement efforts in both intensive care and non-intensive care participating hospital provider units.

c. Use of the results from ongoing Quality Improvement Initiatives (QIIs) (see Task D.1, Technical Assistance, for more information) to continually develop and provide recommendations for improvement strategies as the science and data evolve. The QIN-QIO shall submit their recommendations to CMS for approval and potential implementation.

d. Use of HAI data and outcomes to inform results and policy at the national level.

Section C. Personnel Requirements1. Designation of Key Personnel--


Section D. Task C.1 Requirements

Task C.1.1. Task Work Plan See Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Task C.1.2. Provider Hospital RecruitmentIn addition to the requirements in Section C.6.4.3, Provider and Practitioner Recruitment in the Base Contract, for general recruitment of hospitals, the QIN-QIO shall:

a. Recruit participating hospitals for the HAI initiatives that will be conducted in Intensive Care Units (ICU) and non-ICU hospital settings. The QIN-QIO shall provide directed assistance to hospital provider settings recruited for Central Line-

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Associated Bloodstream Infection (CLABSI) in previous work that have not reached a national CLABSI SIR. Facilities shall also be recruited for Catheter-Associated Urinary Tract Infection (CAUTI) and Clostridium Difficile Infection (CDI) project if they previously worked with a QIO and wish to continue the affiliation. The QIN-QIO is shall recruit hospitals or unit(s) within a hospital that have been identified by a survey or accrediting body as having open infection control deficiencies.

b. Secure the commitment of participating hospitals by obtaining a commitment letter signed by at least two members of each hospital’s leadership (with at least one being a member of the hospital board of directors), if a current commitment is not in place. The commitment letter shall include:

1) An agreement allowing access from each hospital recruited to the applicable hospital-wide HAI National Healthcare Safety Network (NHSN) data (i.e., includes all individual patient care location data that are reported for HAIs and FacWideIN data that are reported for CDI LabID Events) for the duration of the commitment. Access to a recruited hospital’s data is required for the QIN-QIO and the QIN NCC. (A provider that does not provide such access may not be considered a participating provider.)

2) An agreement from the participating hospital provider settings that its HAI data may be shared with (identified) partners with whom the QIN-QIO primarily collaborates specifically and solely for the purposes of quality improvement as it relates to this task. This agreement is not an absolute requirement for facilities to participate in this project but is strongly encouraged to optimize outcomes and spread.

c. Secure access from each participating hospital provider recruited the provider’s HAI NHSN data for the QIN-QIO’s own use and for the QIN NCC. A hospital that does not provide such access may not be considered a participating hospital.

Additional data elements about each hospital shall be included as necessary and as requested by CMS.

Task C.1.3. Beneficiary and Family Engagement In addition to the requirements set forth in Part 4 of this TO, Core Requirements Applicable to All Task Orders, the QIN-QIO shall engage beneficiaries and/or family members and/or patient advocate/representatives to participate in LAN meetings with participating hospitals. The QIN-QIO shall ensure that beneficiaries, their families, and/or patient advocates and representatives have a participatory place during these LAN meetings.

Task C.1.4. Partner and Stakeholder Recruitment and Collaboration In addition to the requirements set forth in Part 4 of this TO, Core Requirements Applicable to All Task Orders, the QIN-QIO shall partner with federal, state and/or local entities such as the CDC, AHRQ, Office of the Assistant Secretary of Health (OASH), HENs, state health departments, state hospital associations, Medicare Advantage Plans, local and community organizations, and others that are actively engaged in implementing HAI-related plans or other such public or private initiatives to reduce HAI among Medicare beneficiaries.

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The QIN-QIO shall partner with other entities for the purpose of performing, enhancing and expanding the required work of this task by enhancing and expanding but not duplicating ongoing efforts to lower HAI. All partnerships with other agencies and entities shall focus on achieving the objectives of this Task and aligning with the goals of the HHS National Action Plan to Prevent HAIs: Roadmap to Elimination on HAI prevention and reduction in a manner that fulfills the purposes of the QIN-QIO program.

The QIN-QIO shall develop a request letter that shall identify the partner, purpose of the partnership, and an attestation that the partnership efforts will not duplicate State and Federally-sponsored efforts. The QIN-QIO can use its own letter as long as components as described above are included or may use a template letter as provided by the QIN NCC.

The QIN-QIO shall provide an annual plan to CMS that describes committed partnerships and collaborations. This plan shall detail how QIN-QIOs work together with identified partners in a way that creates synergy, spreads resources and avoids duplication of effort. An initial plan of identifying potential duplication of efforts and mitigating this situation, if found, should also be included no later than three months after the end of recruitment. The annual plan should update this process and provide any success stories resulting from it.

In addition, the QIN-QIO shall provide a report on committed partnerships and collaborations along with activities undertaken as they contribute to national HAI reduction and prevention goals. The QIN-QIO shall demonstrate and document in the above mentioned report, the activities, partnerships, and collaborations they have with local agencies to develop and implement HAI prevention and reduction interventions as well as the data that was used to document progress of said interventions. Submission of the report to CMS, shall be in accordance with the Schedule of Deliverables.

Task C.1.5. Provider Technical Assistance

Task C.1.5.1. General HAI TasksThe QIN-QIO shall work to develop a comprehensive, patient-focused approach to prevent and reduce HAIs within its area. In each case, the QIN-QIO must evaluate the needs of their participating hospitals and tailor their technical assistance strategies to meet those needs. Tasks required to perform this function shall include but, not be limited to:

a. Provide education and training for participating providers, collaborative partners, beneficiaries, family members and/or patient advocates/representatives on infection transmission control practices such as catheter maintenance, environmental disinfection, hand hygiene, appropriate vaccination practices providers and other strategies to prevent HAI transmission.

b. Work in conjunction with AHRQ and their contractors to optimize the culture of safety in recruited facilities through education and training on CUSP and/or TeamSTEPPS™ principles.

c. Ensure that areas of health disparities, including but not limited to occurrence at the regional, state, community, and/or facility level are identified. Where health disparities are identified as it pertains to this work, QIN-QIOs shall be active partners in a development and institution of a comprehensive plan to address and eliminate

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these disparities.

Task C.1.5.2. Collaboration with QIN NCCIn conjunction with the QIN NCC, the QIN-QIO shall perform the following:

a. Introduce and disseminate evidence-based tools for HAI prevention and reduction into their LANs.

b. Maintain NHSN Expertise: QIN-QIOs are required to have expert knowledge of the NHSN infection surveillance system for the HAIs they will be working on in this contract. That includes but is not limited to the ability to:

1) Understand and educate participating hospital providers on HAI definitions, data reporting elements, calculations and changes in these data elements as they evolve per the CDC.

2) Develop a plan or protocol that addresses continuing NHSN training needs for both existing and new QIN-QIO and hospital staff.

3) Maintain up-to,-date monitoring and knowledge of the HAI data for participating hospitals at the unit and facility data. QIN-QIOs shall understand how this data compares with other unit-specific, facility and regional HAI trends in their area.

4) Monitoring not only the raw data from their units, but looking for performance improvement trends of lack thereof. The QIN-QIO shall monitor closely for trends showing significant lack or deterioration of performance results (of HAI incident rates-awaiting CDC guidance) over a (awaiting CDC guidance) especially where associated with corresponding morbidity and mortality. In such a situation, the QIN-QIO shall follow the alert system as referenced in Section D of this task order requirement D.1.1. QII Referrals. .

c. Serve as national HAI resource: The QIN-QIO shall serve as a major resource to providers and practitioners in the following areas:

1) Hospital and regional-level data to inform the national HAI landscape.

2) NHSN and evolving HAI activities for CMS, CDC, AHRQ, OASH and other partners at the national level.

3) Hospital level inpatient and hospital expert training programs in coordination with AHRQ and the CDC

4) Translation and/or specification of clinical decision support interventions into the Health eDecisions format, and/or assisting providers/organizations in implementing them in their own CEHRT.

Task C.1.6. HAI-Specific Tasks The QIN-QIO shall continue to work in the CLABSI, CAUTI, and CDI reduction in both ICUs and non-ICU settings. The QIN-QIO has the direction to determine its case-mix of non-ICUs

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versus ICU settings but, is strongly encouraged to seek out those units that either have the highest SIRs of these HAIs, have not made much progress in reducing these HAIs or that have open surveys with deficiencies noted in infection control and prevention practices.

Task C.1.6.1. Central Line-Associated Bloodstream Infection (CLABSI) a. The QIN-QIO shall continue existing QIO Program hospital work in CLABSI

working with the same hospitals (known as Cohort #1. However, QIN-QIOs have the option to discontinue active CLABSI for those hospitals that have already reached a SIR that is significantly less than 1.0. In this case, the QIN-QIO shall develop a sustainability plan as described below with quarterly hospital AND unit-level SIR updates to ensure that CLABSI SIR are remaining low or steadily decreasing. Given that regional variations may account for any rises, the QIN-QIO shall formulate a mitigation plan and document actions related to the following:

1. The QIN-QIO shall perform an initial statewide environmental scan of CLABSI SIRs. Quarterly scans shall be done subsequently to follow trends. This information shall be provided to the QIN NCC for review and further evaluation by CMS.

2. If the designated area environmental scan shows that CLABSI SIR is increasing above the defined benchmark 1.0, the QIN-QIO shall work with the QIN NCC and healthcare partners in their area to determine root causes for increase in HAIs. CMS reserves the right to change the benchmark during the contract period.

3. QIN-QIOs in these instances shall engage participating providers in CLABSI quality improvement methodologies tailored to their designated area (e.g., collaborative, directed technical assistance to providers, participation in spread of evidence-based guidelines).

4. QIN-QIOs working in their designated area where CLABSI SIRs have increased shall provide reports to CMS on efforts to reduce these SIRs and provide CMS CLABSI outcome data quarterly until the national benchmark SIR has been reached.

b. The QIN-QIO will have the opportunity to recruit new hospitals with CLABSI SIR (>1.0) in future Task Orders.

Task C.1.6.2. Catheter-Associated Urinary Tract Infections (CAUTI)a. QIN-QIO shall perform an initial statewide environmental scan of CAUTI SIRs.

Quarterly scans shall be performed subsequently to follow trends. This information shall be provided to the QIN NCC for review and further evaluation by CMS.

b. The QIN-QIO shall participate in CAUTI reduction work, to include reduction in the number of urinary catheter days, with participating providers. There is no minimum incident CAUTI SIR for providers to be eligible to participate in CAUTI work.

c. The QIN-QIO shall continue existing work, if applicable and the QIN-QIO may choose to continue to work with providers previously recruited for CAUTI work. The QIN-QIO may choose to change the composition (e.g., initially, the QIN-QIO may

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add facilities with high rates of CAUTI in and then remove units where CAUTI SIR may have substantially decreased to a point where resources should be directed toward other facilities needing improvement).

d. The QIN-QIO shall work with recruited partners and/or stakeholders to: Identify participating providers that require additional assistance to reduce rates using data-driven results, lowering CAUTI SIRs, and identifying high performing providers using developed high performing criteria. The high performers will serve as mentors within the partnership.

e. The QIN-QIO shall engage high performing CAUTI participating providers and such engagement may take the form of asking high-performers to join the LANs as a mentor.

f. Providers that have six months of baseline CAUTI data in the National Healthcare Safety Network (NHSN) prior to the start of the contract and those that have not previously reported data to NHSN are eligible for recruitment (i.e. those facilities exempt from the Hospital Inpatient Quality Reporting Program [HIQR].)

g. The deadline for submission of the CAUTI recruited hospital list is listed in the Schedule of Deliverables.

h. Baseline period for recruited hospitals with six months of CAUTI data in the NHSN before the start of the contract.

i. For participating provider hospitals that are recruited the QIN-QIO shall employ a measurement strategy, which utilizes a standardized infection ratio (SIR) as a way to measure improvement. The CAUTI SIR target for evaluation will be based on the national SIR benchmark. The CAUTI SIR national benchmark of 1.0 will be determined by the most current CAUTI baseline data available from NHSN at the time of evaluation.

Task C.1.6.3 Clostridium Difficile Infection (CDI)a. The QIN-QIO shall continue existing QIO Program work, if applicable, related to

CDI, but have the option to expand participating provider (i.e., hospital) recruitment for CDI with a focus on facilities most challenged to succeed.

b. For QIN-QIOs who decide to expand recruitment, the QIN-QIO shall recruit participating providers with facility-wide Healthcare Onset (HO) CDI Lab ID SIR > 1.0.

c. The QIN-QIO shall engage recruited participating providers to enter their baseline CDI date into the NHSN according to the Schedule of Deliverables.

d. The deadline for recruitment of additional participating providers is noted in the Schedule of Deliverables.

e. The CDI SIR will be used for participating providers recruited at the beginning of this contract for participating providers with CDI baseline information six months of CDI SIR data in the NHSN before the start of the contract.

f. The CDI target for measurement and evaluation shall be based on the national

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benchmark CDI SIR of 1.0 which is determined by the most current CDI baseline data available from the NHSN at the time of evaluation.

g. The QIN-QIO shall perform an initial environmental scan of CDI SIRs in its area. The QIN-QIO shall perform quarterly scans throughout the contract life to follow trends. This information will be provided to the QIN NCC. The QIN-QIO shall hold at least two (2) educational sessions (face-to-face and/or virtual web-based conferences) for appropriate participating provider personnel on what constitutes an effective program of antimicrobial stewardship.

Task C.1.6.4 Ventilator-Associated Events (VAE)a. The QIN-QIO shall conduct at least one (1) educational LAN event regarding VAE by

7/31/15.

b.. The QIN-QIO shall document the number of QIN-QIOs that have attended the LAN and have been trained on the elements of VAE reduction and reporting in hospitals to the NHSN by 7/31/16 .

c. The QIN-QIO shall report the number of QIN-QIO recruited hospitals trained by QIN-QIOs with or without conjunction from their regional partner on VAE including, but not limited to definitions, NHSN reporting, interventional strategies, and cultural competency by 7/31/17.

d. The QIN-QIO shall establish a baseline for VAE by 7/31/17.

e. The QIN-QIO shall report baseline data by 7/31/18 and continue to work and monitor VAE.

Task C.1.7. Learning and Action Networks (LANs)a. The QIN-QIO shall develop and maintain a LAN for task C.1 and shall act as collaboration

leaders in HAI prevention and reduction in their designated area. This includes knowledge of the current HAI reduction activity currently ongoing in their area by federal and non-federal partners (i.e., federal agencies and the current QIN-QIOs, state health departments, state hospital associations, hospital engagement networks, academic institutions, third party payers, etc.) and their points of contacts. The QIN-QIO shall perform the following to ensure that collaborative relations with these and other partners are developed and maintained:

1) Shared learning opportunities and spread of evidence-based HAI guidelines are maximized;

2) There is coordination of HAI activities and messaging to the current QIN-QIOs and the area audience shared by the QIN-QIO and its partners’, when applicable;

3) Strategies for identifying duplication (both current and potential) of HAI work and mitigating such duplication when and if it occurs;

4) Identification of duplicative activities and their resolution should be reported to CMS; and

5) Partnerships should be identified to CMS.

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b. The QIN-QIO shall add members to the LAN(s) at any time to ensure successful outcomes with HAI reduction and prevention.

c. The QIN-QIO shall identify high-performing providers or provider units with HAI SIRs (< or equal to 10th percentile) using the criteria to identify high performing QIN-QIOs and facilities. These criteria will be provided by CMS during the contract term. Those who meet these criteria may serve as mentors to targeted providers working on HAI reduction in order to allow sharing of successful intervention methods.

Task C.1.8. Monitoring and Reporting Requirements In addition to Part 4 of this TO, Core Requirements Applicable to All Task Orders, the QIN-QIO shall develop and maintain a regional-level HAI map for their area. The map shall have the capability to capture specific regional, state and facility level HAI activity to help visualize and analyze resources secured and areas where resource gaps exist. The information from this scan should focus primarily on CLABSI, CAUTI and CDI work which is the emphasis in this Task. However, mapping out work on other HAIs by partners in the QIN-QIO area may be added as space and resources allow. The required data should also be able to inform a national-level map which will be developed and maintained by the QIN NCC. A report describing the elements of the environmental scans shall be updated quarterly and include the following:

a. The area(s) covered by the scans.

b. The hospital unit-level SIR of the HAIs – CLABSI, CAUTI and CDI of the hospital unit which the QIN-QIO has specifically recruited.

c. The hospital facility-level and state-level SIRs within the QIN-QIO area. The QIN-QIO shall understand how its hospital unit, facility and state-level data compares to those of other facilities and states in their area.

d. Where QIN-QIO partners or entities are engaged in similar HAI work within the QIN-QIO area, identification of what that work entails to ensure that HAI prevention and reduction message(s) are delivered as consistently as possible; a mechanism to avoid duplicative work is in place; and a mitigation strategy can be implemented if this situation arises.

e. Any collaborative partnerships developed with End Stage Renal Disease (ESRD) Networks in terms of partnering to optimize HAI data collection from hospitals to outpatient facilities such as ESRD dialysis facilities. Also, the sharing of successful intervention that focuses on ensuring up-to-date vaccination status and communication about early access planning between hospital and ESRD dialysis facilities. The QIN-QIO is only required to provide this information in this Task Order, if it collaborates with ESRD dialysis facilities. Otherwise, QIN-QIOs may use “not applicable” at this time.

Efforts to reduce HAIs, particularly in hospitals, have been ongoing at the federal, state and local level for several years. The importance of collaboration and coordination of QIN-QIO efforts in this Task cannot be overstated. In December of 2012, CMS released technical guidance for two of its contracting entities, the QIN-QIOs and the Partnership for Patients (PFP) Hospital Engagement Network (HENs), on strengthening interactions, CMS’s expectations for documentation of a communication plan, methodologies for identifying potential duplication of effort, and methodologies for developing a mitigation plan which must be reported to CMS if

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duplication of effort is identified.

The technical guidance is provided below and applicable not only between QIN-QIOs and HENs but across QIN-QIOs and all of their regional partners engaged in HAI work so as to prevent duplication of effort.

In addition to Part 4 of this TO, Core Requirements Applicable to All Task Orders, the QIN-QIO shall:

a. Develop and submit documentation of HAI work ongoing in their area according to the Schedule of Deliverables (i.e., to coincide w/completion of environmental scan) for this Task. This documentation shall be updated as part of the quarterly report to the COR and GTL, and contribute to the national HAI map to be maintained by the QIN NCC.

b. Develop, maintain and document a plan to avoid duplication of HAI efforts among its partners in the QIN-QIO area and a method to mitigate duplication of effort if identified. This plan shall be an evolving document to be updated and presented to CMS for monitoring, as applicable.

c. Communicate with the HENs and other regional partners at regular intervals to coordinate and collaborate on actions to avoid wasteful duplication of effort.

d. When requested by the COR and in conjunction with HENs and the QIN NCC, prepare and/ or provide information about current activities, including patient beneficiary stories and/or known successful interventions.

e. In order to expand the reach and avoid the duplication of existing HAI work and to complement other federally-sponsored programs, the QIN-QIOs shall engage in some or all of the following activities:

1) Align activity schedules, across HAI work, into a single schedule for each participating hospital.

2) Update the QIN-QIO integrated communication plan to include a communication process between participating hospitals and other partners to ensure hospitals receive the information they need in a timely manner.

3) Track hospitals in which both HEN and QIN-QIO contractors are working. In the event new recruitment occurs, the HEN/QIN-QIO and other regional partners shall notify the other as well as the COR and immediately to prevent duplication of effort.

4) Communicate to stakeholders outside of the QIN-QIO area regarding HAI educational activities such as webinars, LAN activities, HEN coaching calls, NHSN trainings and CUSP training sessions to encourage shared attendance as space and resources permit.

5) Complete joint QIN-QIO/HEN hospital onsite visits.

6) Assume the role as experts in the area on providing information and insights regarding key HAI partners and stakeholders.

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7) Provide partner and stakeholder contact information, if appropriate, to hospitals.

8) Collaborate with partners and stakeholders when offering numerous on-going education and training events through this contract. Events could include invited participation in webinars, individualized plans, coaching calls, site visits, and face-to-face network and national meetings. Additionally, participating entities will also benefit from the sharing of data reporting support, evidence-based tools, and resources from all host organizations.

f. According to the Schedule of Deliverables, the QIN-QIO shall monitor, assess, and report out the degree (e.g. does, does not or unknown) in which hospital providers engage beneficiaries/patients and/or their family members and/or patient representatives in the following activities:

1) Prior to admission, hospital staff provides and discusses a discharge planning check list with every patient that has a scheduled admission, allowing questions or comments from the patient or family(e.g., the planning checklist may be similar to the CMS Discharge Planning Checklist available at http://www.medicare.gov/Pubs/pdf/11376.pdf),

2) Conducts both shift change huddles for staff and do bedside reporting with patients and family members in all feasible cases,

3) Dedicates a person or functional area that is proactively responsible for Patient and Family Engagement and systematically evaluates Patient and Family Engagement activities.

4) Has an active Patient and Family Engagement Committee (PFEC) OR at least one former patient that serves on a patient safety or quality improvement committee or team.

5) Has one or more patient(s) who serve on a Governing and/or Leadership Board and serves as a patient representative.

The QIN-QIO shall submit reports on recruitment, statewide LANs and other stakeholder collaborations and interactions. Recruitment reports shall include description of HAI project enrollment (new and continuing), activities and plans for HAI work. LAN reports shall include the elements. Stakeholder interaction reports shall include stakeholder identification, HAI activity work plan and strategies for each state/territory in the QIN-QIOs area.

The QIN-QIO shall report on tool development and distribution. Reporting information shall identify tools developed and/or distributed through action networks, purpose of tool, distribution date, and technical assistance provided by the QIN-QIO.

The QIN-QIO shall monitor hospital collection and submission of HAI data into the NHSN system on a monthly basis. During the monitoring process, the QIN-QIO shall identify data issues and discrepancies. When issues and/or data discrepancies arise, the QIN-QIO shall work with the hospitals, NCC, the COR and the CDC regarding the NHSN system to correct issues.

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Task C.1.9. Sustainability Plan See Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Section E. Schedule of Deliverables The contractor shall provide all deliverables for Task C.1 – Reducing HAIs in Hospitals Schedule of Deliverables in accordance with Attachment A, Task Order 001 Schedule of Deliverables.

Section F. Measurement, Evaluation and PerformanceSee Attachment B, Task Order 001, Evaluation Measures Tables for Task C.1. Reducing HAIs in Hospitals measures. Also, see Section C.6, Contractor Performance Measurement in the base contract.

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Task C.2: Reducing Healthcare-Acquired Conditions in Nursing Homes

Section A. Overview and BackgroundMore than 3 million Americans rely on services provided by nursing homes at some point during the year. There are 1.4 million Americans that reside in the Nation’s 15,600 nursing homes on any given day. Those individuals and an even larger number of their family members, friends, and relatives, must be able to count on nursing homes to provide reliable, high quality care. The Affordable Care Act of 2010 called for the Centers for Medicare & Medicaid Services (CMS) to develop a strategy that will guide local, state and national efforts to improve the quality of care in nursing homes. The most effective approach to ensure quality is one that mobilizes and integrates all available tools and resources – aligning them in a comprehensive, actionable strategy.

In December 2008, CMS added a star rating system to the Nursing Home Compare website. This rating system provides three purposes: to provide residents and their families with an assessment of nursing home quality, to make a distinction between high and low performing nursing homes, and to provide incentives for nursing homes to improve their performance. According to a report of the first three years (2008 – 2011) of the star-rating system by Abt Associates, “Nursing Home Compare Five-Star Quality Rating System: Year Three Report [Public Version], Draft Report, October 25, 2012,” during 2011 “…facilities most likely to have no variation in their overall rating during the year [2011] are those that started as either one-star or five-star facilities. Specifically, 60.4% of one-star facilities and 70.2% of five-star facilities had no variation in their overall rating throughout the year [2011].”

In alignment with the National and CMS Quality Strategies (See Section C.6.6., Appendix A – Conceptual Framework for QIN-QIO Work of the Base Contract), CMS developed the “Nursing Home Action Plan 2012 ” which outlines a comprehensive, actionable strategy for improving the quality of care and quality of life received by our nation’s nursing home residents. The Nursing Home Action Plan 2012 identifies five approaches: 1) enhance consumer engagement, 2) strengthen survey processes, standards, and enforcement, 3) promote quality improvement, 4) create strategic approaches through partnerships, and 5) advance quality through innovation and demonstration.

We intend to align QIN-QIO efforts with the Nursing Home Action Plan in connection with QIN-QIO responsibilities and purpose to improve the Medicare program. The QIN-QIO shall use multiple and various approaches in its alignments efforts to:

a. Enhance Consumer Engagement (Approach #1): Consumers are essential participants in ensuring the quality of care in any healthcare system. Involving consumers, families, and others in healthcare decisions as well as resident-centered care on an individual basis will enhance the overall individual experience of care.

The QIN-QIO shall ensure that residents who are Medicare beneficiaries and their family-members are recruited for participation as a part of the QIN-QIO’s High-Performing Nursing Home Peer-Coach Group. Participation, at a minimum, includes actively participating in no less than two QIN-QIO quality improvement efforts in the QIN-QIO area.

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http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/2012-Nursing-Home-Action-Plan.pdf

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/2012-Nursing-Home-Action-Plan.pdf



b. Strengthen Survey Processes, Standards, and Enforcement (Approach #2): The adoption of a quality improvement methodology by nursing homes, especially those challenged to succeed will improve internal system operations and lead to overall improvement as documented by lessening the rate of healthcare acquired conditions and in other measured outcomes.

The QIN-QIO shall support the adoption and utilization of the Division of Nursing Homes’ Quality Assurance Performance Improvement (QAPI) as the framework for nursing homes participating in any National Nursing Home Quality Care Collaborative (NNHQCC) (See Attachment J-8 Glossary of Terms and Acronyms ).

c. Promote Quality Improvement (Approach #3): The National Nursing Home Quality Care Collaborative(s) shall focus on achieving system wide improvement and ensuring that every nursing home resident receives the highest quality of care.

The QIN-QIO via the NNHQCC shall strive to instill practices for the improvement of quality and performance by nursing homes serving beneficiaries, eliminate healthcare acquired conditions (HACs), and dramatically improve resident satisfaction. The QIN-QIO’s efforts related to improving beneficiary satisfaction with nursing homes shall focus on the nursing home systems that impact quality, such as consistent/permanent staff assignment, communications, leadership, regulatory compliance, clinical models, and quality of life indicators. The QIN-QIO shall also have a targeted focus on increasing mobility among long-stay residents/beneficiaries, decreasing unnecessary use of antipsychotics in dementia residents/beneficiaries, decreasing potentially avoidable hospitalizations (PAH), and decreasing HAIs and other HACs.

The QIN-QIO shall recruit nursing homes according to the provider recruitment methodology outlined in Appendix 2 in this Task with a focus on nursing homes with One-Star status.

d. Create Strategic Approaches through Partnerships (Approach #4): As stated in the Nursing Home Action Plan 2012, “…no single approach or individual can fully assure better health care. We must combine, coordinate and mobilize many people and techniques through partnerships.”

The QIN-QIO shall engage and align its work under this Task with the work under Tasks C.1. Reducing Healthcare-Associated Infections in Hospitals and C.3. Coordination of Care in the QIN-QIO area.

The QIN-QIO shall expand its LAN network to include state chapters of the National Association Directors of Nursing Administration in Long Term Care (NADONA), state chapters of the American Medical Directors Association (AMDA), university programs of gerontology, colleges/universities of nursing, community colleges or others training medical assistants, accountable care organizations (ACOs), and others, including HHS or CMS agencies, committed to mutual goals that promote nursing home excellence.

The QIN-QIO shall recruit nursing homes, key stakeholders and organizations for participation in Learning and Action Network(s) and collaborative activities, and provide technical assistance within the collaborative framework or as identified in this Task.

e. Advance Quality through Innovation and Demonstration (Approach #5): The goal is to foster healthcare transformation by finding new ways to pay for and deliver care that

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improve care and health while lowering costs.

The QIN-QIO shall recruit nursing homes to participate in The National Nursing Home Quality Care Collaboratives I and II and seek to reduce healthcare acquired conditions and improve resident care and increase resident satisfaction. The QIN-QIO will attain this goal by working to incorporate successful interventions into nursing homes, promote resident-centered care and clinical care focused on the needs of long-stay residents, and actively include residents in quality improvement activities within QIN-QIO activities.

We anticipate that improvement in these efforts will result in lower healthcare costs in the Medicare program, associated with decreasing resident morbidity, resulting from decreases in HAIs and HAC, while increasing resident satisfaction and longevity.

Section B. General Desired Outcomes1. National Goals: The QIN-QIO, via recruitment of Nursing Homes and other activities,

shall support the creation of a National Nursing Home Quality Care Collaborative (NNHQCC). The purpose of the NNHQCC is for it and its partners to seek to ensure that every nursing home resident receives the highest quality of care. Specifically, the QIN-QIO shall support the Collaborative objective to “instill quality and performance improvement practices, eliminate healthcare acquired conditions, and improve resident satisfaction.” by performing the following:

a. Work with recruited nursing home participants in the Collaborative to attain a score of six or better on the National Nursing Home Composite Quality Measure by 2019 and to attain other national goal(s) and sub goal(s) as identified by CMS.

b. Recruit sufficient nursing homes to meet or to exceed the minimum Nursing Home Total Recruitment Number by 2017 (See Evaluation Measures Table).

c. Increase the percentage of One-Star nursing homes participating in the National Nursing Home Quality Care Collaborative(s) by 2017 (See Evaluation Measures Table).

d. Improve the rate of mobility among long-stay nursing home residents who are Medicare beneficiaries nationally by 2019 (See Evaluation Measures Table).

e. Improve the targeted rate of reduction in the use of unnecessary antipsychotic medication in dementia residents who are beneficiaries by 2019 (See Evaluation Measures Table).

2. The outcomes described above shall be accomplished by the QIN-QIO working with participating nursing homes, beneficiaries, beneficiary family members and/or beneficiary advocates/representatives, and in collaboration with key partners and stakeholders. Examples of QIN-QIO interventions to support the achievement of these outcomes shall include, but are not limited to, the following:

a. The QIN-QIO adopting, practicing, and demonstrating competency in all components identified in the Base Contract.

b. The QIN-QIO participating in Task C.2. Reducing Healthcare Acquired Conditions in Nursing Homes shall align with and support the efforts of Task C.1. Reducing Healthcare-Associated Infections in Hospitals and Task C.3.

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Coordination of Care.

c. The QIN-QIO actively aligning to support development of Community Coalitions and development of community specific measure(s) to reduce avoidable hospital admissions and readmissions.

d. The QIN-QIO creating an operational infrastructure for each participating Collaborative.

e. The QIN-QIO recruiting nursing homes; specifically, One-Star facilities. However, all nursing homes are eligible for recruitment.

f. The QIN-QIO recruiting nursing homes for participation in the National Nursing Home Quality Care Collaborative, giving attention to nursing homes that may have prior collaborative experience.



Section D. Task C.2 Requirements

Task C.2.1. Task Work Plan In addition to Part 4 of this TO, Core Requirements Applicable to All Task Orders, the Work Plan shall include these activities and how the QIN-QIO shall perform these activities:

a. Under this Task, NNHQCC Collaborative(s) I and II shall commence in Year 1 and Year 3 of the contract term, respectively, and each Collaborative shall operate for 18 months.

b. The QIN-QIO shall use an updated version of the Collaborative Change Package.

c. The QIN-QIO shall use and instruct nursing homes in the Quality Assurance Performance Improvement (QAPI) principles, tools and resources.

d. The QAPI model for nursing home quality improvement shall serve as the framework for each NNHQCC developed or maintained by the QIN-QIO.

e. The QIN-QIO shall strive to ensure that every nursing home participating in a NNHQCC Collaborative initiates, updates and maintains a QAPI Assessment Tool.

f. CMS reserves the right to add or remove Collaborative(s) during the contract term.

g. As other HACs, HAIs or other areas of focus are identified by CMS, the QIN-QIO shall develop and roll-out effective practices and aims/goals for their prevention or treatment as part of a Collaborative or LAN process.

h. See Appendix 1 for a required timeline for activities under Task C.2.

CMS reserves the right to add, modify or remove activities and focus areas.

Task C.2.2. Provider Recruitmenta. In addition to the requirements in Section C.6.4.3, Provider and Practitioner Recruitment

in the Base Contract, the QIN-QIO shall perform the individual subtasks of this Task as

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provided below:

To instill systems improvement in nursing homes across the Five-Star system and target nursing homes challenged to succeed (such as those with One-Star status), the QIN-QIO shall recruit One-Star nursing homes in a sufficient number to meet the minimum recruitment goal (see below). The QIN-QIO shall work to incorporate One-Star facilities into the Collaborative structure. To facilitate recruitment of One-Star facilities, the QIN-QIO shall identify reasons that keep One-Star facilities from participating in large group learning activities (such as LANs and Collaboratives), and create mitigation strategies to offset these issues. The QIN-QIO shall include this information into their strategic plans and work plans.

The QIN-QIO shall recruit no less than 75% of the total number of nursing homes (NHs) with an existing star rating status in each participating state and territory. However, all nursing homes or facilities providing long term care services to Medicare beneficiaries are eligible and the QIN-QIO shall encourage them to participate.

Minimum Recruitment Goals. See Appendix 2: Calculation of the Target Recruitment Number (TRN) and Appendix 3: Nursing Home Compare Provider Rating Table to calculate the QIN-QIO-specific TRN and Star Category Target Number (SCTN) for each participating QIN-QIO area. CMS reserves the right to identify an alternate date for the Nursing Home Compare Provider Rating Table provided in this Task. The QIN-QIO shall submit data regarding NHHQCC recruitment according to the Schedule of Deliverables.

b. Establishing and Maintaining the Minimum Recruitment Target

1. Participant Agreement: The QIN-QIO shall acquire a Participation Agreement from each nursing home identified as a part of the QIN-QIO’s Recruitment Target Number (RTN). The participation agreement shall include no less than the following information:

a) The nursing home’s name, address, and CMS Certification Number (CCN), and

b) A statement that the nursing home will actively participate in the Collaborative, including data submission and data sharing.

The QIN-QIO may consider a nursing home “recruited” if the nursing home has the signature of at least one of its executive leadership signifying the nursing home’s intent to be involved. Leadership is defined as the Chief Executive Officer, the Chief Operating Officer, the Administrator or the Owner. The QIN-QIO shall upload all Participation Agreements into the CMS designated data storage system.

2. Notice of Decision Not to Participate: The QIN-QIO shall acquire a written notice of the Decision Not to Participate for any One-Star facility directly solicited to become

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a part of the QIN-QIOs Star Category Target Number (SCTN), where the One-Star declines to participate in NHHQCC Collaborative I or II. The QIN-QIO shall upload all notices of Decisions Not to Participate into the identified data storage system. The notice shall include no less than the following information:

a) The nursing home’s name, address, and CCN; and the name, date, and leadership position of the person declining the invitation. Leadership is defined as the Chief Executive Officer, the Chief Operating Officer, the Administrator or the Owner.

b) Reason(s) for the decision not to participate must be identified and included as a part of the notice.

c) Identification of all mitigation strategies instituted by the QIN-QIO/QIN to prevent One-Star facilities from declining to participate.

Task C.2.3. Peer-Coach RecruitmentIn addition to the requirements in Section C.6.4.3, Provider and Practitioner Recruitment in the Base Contract, the QIN-QIO shall recruit nursing homes to act as “Peer-Coaches” for other nursing homes in the Collaborative if they are identified as high-performing nursing homes. A high-performing nursing home is in the top 10% of the National Nursing Home Composite Quality Measure to be provided by CMS.

Nursing Homes identified as being in the top 10%, working in conjunction with their QIN-QIO, may recommend Peer-Coaches. Peer-Coaches will (1) represent diverse levels of nursing home staff, both administrative and direct care, (2) provide best-practice support for other nursing homes participating in this SOW, (3) assist the QIN-QIO to instill quality improvement methodologies, and (4) along with the QIN-QIO, foster the creation of quality centric nursing homes amount their peer nursing homes.

The QIN-QIO shall engage nursing home staff, residents, and beneficiary family members to serve as Peer-Coaches as follows:

a. A nursing home identified as high-performing nursing home (if it is in the top 10% of the National Nursing Home Composite Quality Measure Rate provided by CMS) may recommend Peer-Coaches to the QIN-QIO.

b. The QIN-QIO will select Peer-Coaches from the individuals recommended by high-performing nursing homes and otherwise identified by the QIN-QIO for participation based on the alignment of the individual’s personal areas of expertise with the areas in which the nursing home attained high-performance, diversity of communities, support of nursing home leadership, geographic areas of the QIN-QIO area, and passion for the work.

c. In addition to the requirements in Section C.6.4.4, Beneficiary (“Patient”) and Family Engagement, the QIN-QIO shall recruit at least one resident/beneficiary or family member per participating area shall also be selected to be a Peer-Coach. CMS reserves the right to define and/or modify the definition of an area and/or the minimum number required for resident/beneficiary or family member recruitment.

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d. The QIN-QIO shall provide training to Peer-Coaches in the following areas: coaching, quality improvement methodology, Certification and Survey Provider Enhanced Reporting (CASPER) data, and adult learning techniques.

e. The QIN-QIO shall begin the process of recruiting Peer-Coaches on day one of the contract. Identification of high-performing nursing homes, selection of Peer-Coaches, and training of Peer-Coaches will end on the last calendar day of the sixth month of the contract.

Task C.2.4. Beneficiary RecruitmentResidents and family members are essential participants in ensuring the quality of care and the quality of nursing home life for long-stay residents who are Medicare beneficiaries. The QIN-QIO shall recruit residents/beneficiaries and their family-members for participation as a part of the QIN-QIO’s Peer-Coach activity. In addition, the QIN-QIO shall include residents/beneficiaries and/or family members in at least two quality improvement activities initiated or performed by the QIN-QIO under Task C.2. The QIN-QIO shall encourage nursing homes to include residents and family members in nursing home quality improvement activities.

Task C.2.5. Partner and Stakeholder Recruitment and Collaboration In addition to the requirements in Section C.6.4.5, Partner and Stakeholder Recruitment and Collaboration in the Base Contract, the QIN-QIO shall work to combine, coordinate and mobilize many people and techniques through partnerships and commitments of action in connection with this Task.

a. State Survey and Certification Agency

1) The QIN-QIO shall work closely with their respective State Survey and Certification Agency (SSA), such that the SSA Director shall be informed of the SOW within the first 60 days of the start of the contract. The QIN-QIO shall document when, where and with whom this information is shared.

2) The QIN-QIO shall work closely with each SSA, such that any nursing home referred by the SSA is targeted for enrollment in the NHHQCC prior to the start of Collaborative I or II.

3) The QIN-QIO shall prepare and submit an executed Letter of Agreement from each SSA.

i. The Letter of Agreement will identify how and when the SSA shall participate in a LAN.

ii. If the SSA Director will not directly participate in QIN-QIO activities, SSA will identify in the Letter of Agreement the staff that will participate or indicate that the SSA will not be participating in any QIN-QIO activities.

iii. The Letter of Agreement for each state shall be uploaded into the identified data storage system.

4) QIN-QIOs shall document and provide evidence of SSA interactions, as requested by the COR.

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b. The QIN-QIO shall engage with other LANs and other organizations, such as, Advancing Excellence in America’s Nursing Homes Local Area Networks for Excellence (LANEs), Long Term Care Ombudsmen, nursing homes, HHS and CMS agencies, and others committed to nursing home excellence.

c. The QIN-QIO shall expand the network of organizations participating in LANs to include, but not be limited to organizations, such as: state chapters of the National Association of Directors of Nursing Administrators (NADONA), state nursing home medical director association chapters (AMDA), university programs of gerontology, colleges/universities of nursing, community colleges or others training medical assistants, ACOs and others (e.g., HHS, CMS, state, local and federal agencies) committed to nursing home excellence.

d. The QIN-QIO shall join the state coalition(s) within its QIN-QIO area that work with the National Partnership to Improve Dementia Care in Nursing Homes.

Task C.2.6. Learning and Action Networks (LANs)See Part 4 of this TO, Core Requirements Applicable to All Task Orders for TO requirements related to LAN and collaborative management in the Base Contract. The QIN-QIO shall perform the following requirements in addition to those specified in the Base Contract:

Task C.2.6.1. National Nursing Home Quality Care Collaborative The QIN-QIO shall support the creation of a National Nursing Home Quality Care Collaborative (NNHQCC) beginning in Year 1 and beginning in Year 3 of the QIN-QIO contract. Each Collaborative will operate for a period of 18 months.

a. The QIN-QIO shall facilitate a Breakthrough Series-type Collaborative as a part of the Learning and Action Network for the NNHQCC.

b. The QIN-QIO shall, in consultation with the QIN NCC, create an organizational infrastructure for each Collaborative.

c. The QIN-QIO shall support participating nursing homes in their self-selected focus areas.

d. The QIN-QIO shall host a minimum of three Learning Sessions per Collaborative and provide support during action periods to drive engagement and improvement.

e. During the Collaborative and throughout the duration of the QIN-QIO contract, activities conducted within the QIN-QIO area may be referred to as [insert name] Nursing Home Quality Care Collaborative (NHQCC).

CMS shall direct the adoption and implementation of best-practices and processes throughout the Collaborative for rapid cycle testing and use in nursing homes, such as those related to QAPI.

Task C.2.6.2. TrainingThe QIN-QIO shall provide training via LANs and Collaboratives that include learning sessions and action periods to participating nursing homes either virtually or face-to-face, with CMS approval. Training shall occur during the LANs and Collaborative(s) and throughout the duration of this Task. The QIN-QIOs shall submit the necessary paperwork and gain approval for learning sessions in advance of their occurrence, as required by CMS policy.

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The QIN-QIO shall not be limited to the information or interventions described in this Task Order in the pursuit of nursing home excellence in connection with the Medicare program.

Task C.2.6.3. Areas for Rapid Cycle Quality Improvement Testing and ImplementationThe QIN-QIO shall operate the Collaborative with a focus on engaging nursing homes in rapid-cycle improvements in areas at the systems level. These areas may include, but are not limited to:

a. Systems level improvement, such as, staff stability, consistent/permanent staff assignment, team building, finance, and/or leadership;

b. QAPI Assessment Tool, increasing mobility among long-stay residents, and decreasing the use of unnecessary Antipsychotics Medication in residents with dementia;

c. HACs such as: urinary tract infections, pressure ulcers, physical restraints, and ensuring an “injury and violence free living” environment as noted in the National Prevention Strategy; and

d. Other areas that nursing homes may choose to work on include: HAIs like Methicillin - resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C.Diff), and vaccinations, such as pneumonia and influenza, are examples.

CMS recognizes that high performing nursing homes routinely assess their data, culture, financial status and other factors, and address many prioritized areas in order to attain and maintain the highest practicable quality of life and care for their residents. Using the quality improvement skills that the QIN-QIOs shall be teaching the nursing homes’ Collaborative teams, the QIN-QIOs shall assist each nursing home to strive to address as many areas as necessary to become a quality focused and learning organization. In addition to focusing on QAPI Assessments, mobility and unnecessary antipsychotic use in residents with dementia, the QIN-QIO shall assist nursing homes with choosing specific nursing home-identified focus areas.

Task C.2.6.4. Eliminating Duplication of LANsThe QIN-QIO shall identify other LANs operating in its area and collaborate to align and coordinate efforts. Where a LAN exists based on Task C.3. (Coordination of Care) and/or Task C.1. (Healthcare Acquired Infection), the QIN-QIO shall coordinate and integrate activities. The QIN-QIO shall submit documentation attesting to the coordination of efforts and absence of wasteful duplication.

Task C.2.7. Monitoring and Data CollectionThe measurement strategy for assessing QIN-QIO progress in this Task shall be evaluated upon a decrease in the National Nursing Home Composite Quality Measure, as evidenced by 50% of recruited nursing homes achieving the national target of six or better, and attaining no less than the minimum indicator of success for other national goals, other sub-goals, as identified. Additions or amendments shall be made throughout the contract term.

The QIN-QIO shall collect and report information in accordance with Attachment J-1a - Task C.2 – Nursing Homes Schedule of Deliverables. Data and information submitted via these deliverables shall be used for purposes of the QIN-QIO’s contract evaluation.

a. The QIN-QIO shall collect and report information on LANs.

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b. The QIN-QIO shall collect and report information for each collaborative.

c. The QIN-QIO shall collect and report information for all other efforts identified by CMS.

Task C.2.8. Sustainability PlanIn addition to the requirements of Part 4 of this TO, Core Requirements Applicable to All Task Orders, the QIN-QIO shall develop and implement a sustainability plan that shall promote, facilitate, and ensure continued existence of and participation of nursing homes in the NNHQCCs and LANs after the QIN-QIO has completed this Task.

Section E. Schedule of Deliverables The contractor shall provide all deliverables for Task C.2 – Nursing Homes Schedule of Deliverables in accordance with Attachment A, Task Order 001 Schedule of Deliverables.

Section F. Measurement, Evaluation and PerformanceThe QIN-QIO will be evaluated on an annual basis, as identified, regarding progress towards achieving the CMS-designated evaluation measures. See Attachment B, Task Order 001, Evaluation Measures Tables for the Task C.2 – Nursing Homes measures. While a recruitment methodology is utilized for recruitment efforts, CMS shall also use a combination of process and outcome related measurement for QIN-QIO Contract Evaluation. Also, see Section C.6, Contractor Performance Measurement in the base contract.

Section G. Task C.2. Appendices

Task C.2. Appendix 1: Required Timeline for C.2 Activity The QIN-QIO shall expect that new practices and focus areas will be introduced for implementation at intervals throughout this Task.

1. Year One:

a. Integration of C.1, C.2, and C.3 Learning & Action Networks

b. Recruitment of nursing homes for participation in National Nursing Home Quality Care Collaborative I

c. NNHQCC I: systems improvement for areas of focus identified by participating nursing homes, beneficiary/resident mobility and antipsychotic medication

2. Year Two:

a. Integration of LANs: C.1, C.2 and C.3 LANs

b. Continuation of NNHQCC I : systems improvement, nursing home areas of focus, beneficiary/resident mobility and antipsychotic medication

3. Year Three

a. Integration of C.1, C.2 and C.3 LANs

b. Sustainment of NNHQCC I efforts

c. Recruitment of nursing homes for NNHQCC II

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d. Start of NNHQCC II: additional areas of focus will be added in addition to beneficiary/resident mobility and antipsychotic medication

4. Year Four

a. Integration of C.1, C.2, and C.3 LANs

b. Sustainment of NNHQCC I efforts

c. Continuation of NNHQCC II

5. Year Five

a. Integration of C.1, C.2 and C.3 LANs

b. Sustainment of NNHQCC I and II efforts

CMS shall amend, add or delete task activities at any time during Task C.2.

Task C.2. Appendix 2: Calculation of Nursing Home Recruitment Target Number (RTN) and Star Category Target Number (SCTN)

Recruitment Target Number

The QIN-QIO shall calculate the minimum participating nursing home Recruitment Target Number (RTN) and Star Category Target Number (SCTN) as follows:

a. Recruitment Target Number (RTN): Locate a state or territory within the QIN-QIO area in Appendix 3 of this TO: Nursing Home Provider Ratings table.

1. To calculate the minimum participating state or territory RTN, multiple the number provided in the column titled, “Total with Star Rating” by 75%, and round down to the next lower integer, e.g.:

i. Alabama has 227 nursing homes in the identified column: 227 x 0.75 = 170.25. Rounding down to the next lower integer = 170. The minimum RTN for Alabama = 170

ii. California has 1227 nursing homes in the identified column: 1227 x 0.75 = 920.25. Rounding down to the next lower integer = 920. The minimum RTN for California = 920.

2. Each participating state and/or territory shall have an individual RTN.

3. The Nursing Home Provider Rating table is located at https://data.medicare.gov/data/nursing-home-compare/Star%20Ratings.

b. Star Category Target Number (SCTN): Locate the columns titled 5-Star through 1-Star in Appendix 3 of this Task: Nursing Home Provider Ratings Table (Also available at https://data.medicare.gov/data/nursing-home-compare/Star%20Ratings ) .

One-Star Recruitment

1. To calculate the minimum One-Star Category Target Number (SCTN), multiply the

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https://data.medicare.gov/data/nursing-home-compare/Star%20Ratings

https://data.medicare.gov/data/nursing-home-compare/Star%20Ratings



number provided in the One-Star column by 75%, e.g., for Alabama and California, the calculations will be:

i. Alabama has 12 One-Star homes: 12 X 0.75 = 9.0 nursing homes. Rounding down, Alabama has a minimum recruitment target of 9 One-Star NHs to recruit.

ii. California has 118 One-Star homes: 118 x 0.75 = 88.5 nursing homes. Rounding down, California has a minimum recruitment target of 88 NHs to recruit.

2. The QIN-QIO with zero (0) One-Star homes in a state within its QIN-QIO area shall validate the “zero” One-Star status with the COR, and may be exempt from Collaborative recruitment efforts for that specific state or territory, depending upon the One-Star count during the recruitment period of each collaborative.

3. The QIN-QIO with one (1) One-Star nursing homes shall recruit that nursing home. In the absence of recruitment, the QIN-QIO shall upload the notice into the identified data storage system.

4. The QIN-QIO with two (2) One-Star homes shall recruit a minimum of 1 One-Star home.

As the SOW includes multiple Collaboratives with individual recruitment periods, a QIN-QIO with only 1 or 2 One-Star Category Target Numbers and unable to recruit at least 1 One-Star home for Collaborative I, the QIN-QIO shall re-recruit nursing home(s) that have not previously engaged (or declined participation) in the Collaborative.

Five-Star Recruitment

To calculate the minimum Five-Star Category Target Number (SCTN), multiply the Recruitment Target Number (RTN) by 10%, e.g., for Alabama and California, the calculations will be:

i. Alabama’s RTN = 170: 170 x 0.10 =17.0 nursing homes. Rounding down equals a minimum recruitment target of 17 Five-Star nursing homes to recruit.

ii. California’s RTN = 920: 920 x 0.10 = 92.0 nursing homes. Rounding down equals a minimum recruitment target of 92 NHs.

Any Star Recruitment

To calculate the minimum “Any Star” recruitment number, subtract the sum of the One-Star and Five-Star Category Target Counts from the RTN and the QIN-QIO shall recruit the minimum number of nursing homes from any star category, e.g., for Alabama and California, the calculations will be:

a. Alabama’s RTN = 170: 170 – [9 +17] = 144 star-nursing homes that

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Alabama shall recruit in addition to One-Star and Five-Star nursing homes to attain its minimum RTN.

b. California’s RTN = 920: 920 – [88 + 92] = 740 star-nursing homes that California shall recruit in addition to the One-Star and Five-Star nursing homes to attain its minimum RTN.

Task C.2. Appendix 3: Nursing Home Compare Provider Rating Table as of 04/23/2013

The data in Table 2 was exported from the Nursing Home Compare Provider Ratings Table via Data.Medicare.Gov on 04/23/2013 (https://data.medicare.gov/data/nursing-home-compare/Star%20Ratings).

Table 2. Nursing Home Provider Ratings

State Total # of Homes

Total with Star Rating 5-star 4-star 3-star 2-star 1-star

AK 17 16 6 2 3 4 1

AL 228 227 62 75 38 40 12

AR 231 228 48 65 50 41 24

AZ 145 141 37 35 24 31 14

CA 1,231 1,227 338 316 228 227 118

CO 214 210 55 61 38 41 15

CT 231 231 68 64 45 36 18

DC 19 19 9 3 3 3 1

DE 46 45 16 9 11 9 0

FL 684 680 149 218 123 134 56

GA 359 356 63 73 76 84 60

GU 1 1 0 0 0 1 0

HI 45 43 17 11 7 7 1

IA 444 443 104 135 76 83 45

ID 76 76 22 22 11 14 7

IL 772 765 157 200 165 150 93

IN 516 505 91 125 107 109 73

KS 343 333 82 99 63 51 38

KY 285 281 40 68 63 66 44

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LA 280 279 36 54 57 58 74

MA 422 420 120 125 63 82 30

MD 229 226 62 64 41 47 12

ME 107 107 33 34 16 21 3

MI 427 420 97 117 92 76 38

MN 381 379 93 125 70 66 25

MO 513 510 94 153 101 104 58

MS 204 200 37 60 38 42 23

MT 83 83 18 24 13 20 8

NC 419 415 85 102 84 80 64

ND 82 82 18 32 14 13 5

NE 218 218 42 67 51 39 19

NH 76 76 25 21 14 11 5

NJ 365 362 95 95 66 71 35

NM 71 69 10 18 16 13 12

NV 51 51 10 13 11 13 4

NY 630 628 120 161 127 144 76

OH 951 944 144 237 190 203 170

OK 310 306 32 71 70 68 65

OR 139 135 29 44 29 29 4

PA 707 707 155 174 134 136 108

PR 7 7 1 3 2 1 0

RI 84 84 21 26 14 17 6

SC 189 188 40 64 29 39 16

SD 112 109 20 34 23 28 4

TN 320 314 55 74 61 62 62

TX 1,200 1,178 145 238 252 282 261

UT 97 94 16 22 19 24 13

VA 285 283 66 64 54 65 34

VT 38 38 6 16 8 7 1

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WA 225 223 58 59 44 43 19

WI 390 389 105 112 67 73 32

WV 126 123 16 34 23 27 23

WY 39 38 7 17 6 5 3

Total 15,664 15,512 3,275 4,135 3,030 3,140 1,932

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GOAL 3: Promote Effective Communication and Coordination of Care

Task C.3: Coordination of Care

Section A. Overview and BackgroundImproving communication and the coordination of clinical decisions is a cornerstone of both the National and CMS Quality Strategies, and the IOM provides concrete recommendations for fostering organizational and leadership cultures that strengthen community-clinical partnerships. QIN-QIOs are uniquely situated to engage cross-cutting communities of practitioners, long-term services and support providers, and other community stakeholders to improve the quality of care for a population of Medicare beneficiaries.

Employing a framework for quality improvement that centers on community organizing tactics, QIN-QIOs shall support the development of community coalitions that:

1. Define a shared, measureable, population goal for improving care coordination in a defined geographic community.

2. Perform community specific root cause analyses to identify the drivers of ineffective care transitions such as a lack of timely and complete communication, poor patient activation, and other system level process deficiencies that can lead to poor health outcomes including ADEs that can lead to increased utilization of acute care services

3. Identify and implement appropriate community-level interventions that improve the coordination of care for beneficiaries and their family members across provider settings.

4. Increase medication safety in the community to prevent adverse drug events, reduce readmissions, and improve care coordination for beneficiaries across provider settings.

5. Collect data and determine measures to monitor community-level interventions that demonstrate improved outcomes across various populations of Medicare beneficiaries.

CMS and its federal partners have employed many strategies focused on improving the care coordination and transition of Medicare beneficiaries across settings. Programs and interventions that improve care transitions from hospital to post-acute care settings such as the Community-based Care Transitions Program and Partnership for Patients Initiatives under Center for Medicare and Medicaid Innovation (CMMI), the Administration for Community Living’s Aging and Disability Resource Center Grant Programs, AHRQ’s Project RED and the Integrated Care for Populations and Communities Aim under the QIO 10th SOW have contributed to national declines in readmission and admission rates in hospitals across the country.

But while there have been significant gains in reducing readmissions and admissions in hospitals, care coordination does not begin or end with an in-patient hospital stay. Beneficiaries and family members typically receive medical care from multiple providers and practitioners in their communities. Poorly coordinated care can lead to duplicative and unnecessary medical and diagnostic tests, risks of adverse drug events through the use of multiple medications and

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complications with medication delivery. Adverse drug events disproportionally affect beneficiaries over the age of 65 across all settings including in hospital, ambulatory care, long-term care facilities and home settings and can result in serious health complications, increases in hospitalizations and length of hospital stays and increased costs to the health system2.

Long-term services and supports (LTSS) are under-utilized services that could maximize beneficiary medical care and quality of life. LTSS is defined as assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) provided to beneficiaries (older people and other adults with disabilities) that cannot perform these activities on their own due to a physical, cognitive, or chronic health condition. LTSS may provide care and service coordination for people who live in their own home, a residential setting, a nursing facility or other institutional setting. LTSS also include supports provided to family members and other unpaid caregivers. The confluence of clinical care and LTSS is necessary for communities to support the goals of individuals to live independently and thrive as active community members while also providing necessary coordination of care. Further improvement is still possible for our most frail and vulnerable beneficiaries who can least afford the risks associated with disruptions in care between settings.

QIN-QIOs shall coordinate with existing community-based efforts and recruit community stakeholders to form community coalitions that focus on improving care coordination. This shall include the recruitment and engagement of providers across all care settings, including acute, post-acute (e.g. dialysis facilities, nursing homes) and LTSS at the community level. QIN-QIOs shall use a population based measurement strategy to show targeted improvement of beneficiaries that reside within specified ZIP codes.

QIN-QIOs and recruited communities shall work together to identify and effectively target special and vulnerable populations affected by poor care coordination. QIN-QIOs shall assist community members and additional regional LAN participants to identify and effectively target interventions for special and vulnerable populations such as individuals with multiple chronic conditions (e.g. dialysis and/or diabetic patients) who take multiple medications, behavioral health issues socioeconomic issues as well as dually-enrolled individuals. QIN-QIOs shall assist communities in identifying the appropriate measurement methodologies, data collection strategies, metrics, and support monitoring and reporting of underlying factors for poor care coordination and for intervention ineffectiveness.

Section B. General Desired OutcomesCMS has identified the goals to measure successful performance of the QIN-QIO in performing this Task as:

a. To reduce hospital readmission rates in the Medicare program by twenty-percent by 2019.

b. To reduce hospital admissions rates in the Medicare program by twenty-percent by 2019c. To increase community tenure, as evidenced by increased number of nights spent at

home, for Medicare beneficiaries by ten percent by 2019.d. To reduce the prevalence of adverse drug events that contribute to significant patient

2 http://www.ahrq.gov/research/findings/factsheets/errors-safety/aderia/index.html

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http://www.ahrq.gov/research/findings/factsheets/errors-safety/aderia/index.html



harm, emergency department visits, observation stays, hospital admissions or readmissions occurring as a result of the care transitions process.

The specific targets and time periods for these goals are listed in the Evaluation Measures Table for this Task. These goals shall be accomplished by the QIN-QIO working with participating communities (see glossary for the definition of “community”) of providers, practitioners and beneficiaries in collaboration with key partners and stakeholders. Examples of QIN-QIO activities to support the achievement of these goals shall include, but are not limited to, the following:

a. Convene community providers and stakeholders to collaborate and share time and resources to meet the needs of the population of beneficiaries that they serve.

b. Provide mentorship to community leaders as they work within the community coalition to develop and achieve community wide goals using community organizing tactics.

c. Provide data and analytic support to communities to identify gaps in quality and develop strategies for improvement

d. Assist communities with implementing and measuring the impact of interventions and connecting those successes to community-wide goals.



2. Other Recommended Personnel—Unique to This Task a. Community Coalition Lead

(Minimum Requirements)1) Demonstrated experience in healthcare quality improvement and the ability to

motivate and lead large-scale community coalition(s) and/or initiative(s). 2) Proven interpersonal skills and experience in community coalition building

and/or organizing including effective leadership, coalition member engagement, establishment and maintenance of stakeholder relationships, ability to adapt to changing political and/or environmental community issues.

3) Proven skill and experience in critical-thinking, innovation, conflict resolution, and problem-solving, recommending successful solutions, including the spread and implementation of such solutions for large scale change.

4) Proven skill and experience in excellent oral and written communication spanning executives to the general public.

b. Medication Safety and Adverse Drug Event Prevention Subtask Lead;1) Registered Pharmacist (RPh. or Pharm.D.): Active pharmacy license with

good standing in at least one state.

Section D. DefinitionsSee Attachment J-8 Glossary of Terms and Acronyms .

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Note that the terms “Community” and “Coalition” are defined to have a specific/technical meaning for purposes of this contract and the work performed under this Task.

Section E. Task C.3 Requirements

Task C.3.1. Task Work Plan See Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Task C.3.2. Framework for Improvement (e.g. Logic Models)The QIN-QIO shall, in accordance with the Base Contract, employ community organizing techniques and a population-based approach to improving care coordination in communities across the QIN-QIO area. The QIN-QIO will accomplish this by utilizing the following results-oriented quality improvement activities: (1) Actively Engage and Partner with Key Stakeholders, Including Patients and Families, and (2) Implement a Spread Plan That Results in System-level Improvement and Sustainability.

Task C.3.3. Community Recruitment In accordance with the requirements in Section C.6.4.3, Provider and Practitioner Recruitment and Section C.6.2.1.3. Successful Interventions: Effective Dissemination of Successful Interventions that Lead to System-level Improvement and Sustainability of Efforts in the Base Contract, the QIN-QIO shall develop a Community Recruitment Plan. This recruitment plan shall include the recruitment of providers, practitioners, beneficiaries and their family members, partners and stakeholders who may be recruited for other Tasks in the TO. This plan must achieve and take into consideration the following:

a. The QIN-QIO shall include at a minimum 40% of the Medicare Fee-for-Service (FFS) beneficiary population residing within each state and a total of 60% of Medicare Fee-for-Service (FFS) beneficiary population residing within each QIN-QIO area within recruited communities.

1) A minimum of 10% of beneficiaries included in QIN-QIO recruited communities must reside in rural areas.

b. The QIN-QIO shall complete an environmental scan of existing community activities across the QIN-QIO area. The scan must include, at a minimum, the following:

1) The identification of existing Community Coalitions which have identified improving care transitions (i.e., care coordination) as a priority for the community coalition. The QIN-QIO shall define (based on criteria to be provided by CMS after contract award) the level of experience of each community as one of the following:

i. Experienced communities: Communities with existing care transitions programs/initiatives; communities that have implemented and tracked interventions and shown improvement.

ii. Intermediate communities: Communities that have implemented some setting-specific care transition improvement interventions but have yet to utilize a community coalition structure to improve care

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coordination across community settings.iii. New communities: Communities engaged in the preliminary work of

identifying partners and stakeholders that are interested in addressing care coordination or have held meetings with stakeholders who are committed to working with the QIN-QIO and other partners and are prepared to create and sign a community coalition charter or similar agreement within 90 days.

2) The QIN-QIO shall reference CMS guidelines for defining new geographic communities. These guidelines will be provided by CMS after the award of the contract.

3) The scan may include other elements at the discretion of the QIN-QIO or the request of CMS.

c. The QIN-QIO shall develop a recruitment plan to recruit communities.1) Initial targeting for recruiting communities (new, intermediate and

experienced) shall include the following:i. Strategy for identifying and targeting improvement for beneficiaries

in/but not limited to the following categories: Individuals dually-enrolled in Medicare and Medicaid, Individuals with multiple chronic conditions including subsets

of individuals taking three or more medications, Individuals with behavioral health issues, Individuals with Alzheimer’s and other dementia disorders, Individuals impacted by socioeconomic status and other social

determinants of health2) The recruitment plan shall include provisions for “rolling recruitment”

throughout the contract term, including a timeline for proposed community recruitment.

d. The Community coalition shall seek to engage the following types of stakeholders in order to gain community wide commitments:

1) State and local government(s), such as mayoral offices, legislators, state or local health departments, and state or local licensing agencies.

2) Major purchasers and payers of healthcare, such as state Medicaid programs, commercial insurers, and large employers.

3) Advocacy and service organizations, such as Medicare beneficiary and patient advocacy organizations, Area Agencies on Aging, Aging and Disability Resource Centers, local disability councils, and local centers for independent living.

4) Provider groups Hospitals Home health agencies Nursing homes and rehabilitation facilities Practitioners Hospices LTSS providers

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Pharmacies 5) Patient Safety Organizations (PSO) http://www.healthit.gov/policy-

researchers-implementers/health-it-and-patient-safety.e. The QIN-QIO shall assist community leadership to develop a decentralized leadership

infrastructure within each Community Coalition. The purpose of the decentralized leadership structure is to embed community organizing, intervention implementation and measurement strategies within the existing workflow of the coalition and their membership organizations.

The Community Coalition Recruitment Plan shall be submitted using a template provided by CMS and shall be updated quarterly.

Task C.3.4. Intervention and Measurement Selection The QIN-QIO shall, in accordance with the Base Contract, use results-oriented quality improvement efforts to provide support for the development of logic models3 by the community (ies); such logic models shall be for improving care coordination. The QIN-QIO shall support the development of logic models and the identification of interventions and measures through activities described in this section.

a. The QIN-QIO shall support each community when the community performs a root cause analysis (RCA) to examine the causes of poor care coordination. Examples of potential causes of poor care coordination include, but are not limited to:

1) Decreased beneficiary (patient), family or caregiver activation (see glossary) or self-management of health such as poor management of medications or difficulty in arranging follow-up services.

2) Poor communication and information transfer between providers and/or practitioners at the transition of care including but not limited to medication reconciliation, discharge and care plans, and enrollment in community-based long-term services and supports.

3) Lack of standard or known processes for providers and practitioners to use in transitioning beneficiaries across settings such as coordinating medication reconciliation, falls prevention assessments and follow-up phone calls.

b. The QIN-QIO shall engage community partners experienced in aspects of care related to social determinants of health including, but not limited to, enrollment in self-management services, LTSS, securing transportation, nutrition services and additional ongoing unmet needs of beneficiaries.

c. The QIN-QIO shall submit community-developed logic models based on the RCA findings, in particular the findings that describe the selection of cross-provider and cross-setting interventions, and intervention measures of the effectiveness of interventions. These logic models shall include the following components at a minimum:

1) Assumptions: Root cause analysis findings, including target populations and community specific factors that may impact intervention implementation.

3 The term “logic model” is defined in Attachment J-8, Glossary of Terms and Acronyms.

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2) Inputs, including resources and contributions made by community members. This shall include, but is not limited to, existing partnerships, tools, technology or evidence-based interventions as well as human resources and funding.

3) Outputs and outcomes, including implementation strategy and who is impacted by community efforts including short, medium and long-term changes and improvements as well as implications of potential negative changes. The outputs and outcomes shall include:

i. Selection of interventions ii. Defined measures including the following:

Reach measures: process measures that show that indicate the numbers of beneficiaries receiving the intervention

Intervention Effectiveness Measures: proximal outcome measures that indicate whether the intervention achieves its intended effectiveness

4) External factors or community specific conditions that may influence the community’s success that are beyond the community coalition’s control, such as natural disasters or shifts in economic or healthcare policy conditions.

5) A template for completing community logic models will be provided by CMS. 6) The QIN-QIO shall report updates to logic models quarterly.

d. Using the community-developed logic models, the QIN-QIO shall support the

community in identifying interventions and measurement collection methods associated with the root causes of poor care coordination. Selection of the intervention(s) may be based on the following:

1) Identified target Medicare beneficiary population(s), such as: i. Individuals dually-enrolled in Medicare and Medicaid

ii. Individuals with multiple chronic conditions including subsets of individuals taking three or more medications including but not limited to any of the following medications: anticoagulants, diabetic agents, and opioids.

iii. Individuals with behavioral health issuesiv. Individuals with Alzheimer’s and other dementia disordersv. Individuals impacted by socioeconomic status and other social

determinants of health2) Known evidence-based interventions and successful intervention strategies

that address both community and national goals for improved care coordination.

e. The QIN-QIO shall support the community development and tracking of reach measures and intervention effectiveness measures related to improving care coordination. In addition to the Base Contract Measurement and Interventions requirements, the QIN-QIO shall consider and provide expertise in the following to provide support to the community(ies):

1) Identification of reach and intervention effectiveness measures related to care coordination. These may include:

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i. Improved beneficiary, family or caregiver activation or self-management of health.

ii. Improved communication and information transfer between providers at the transition of care including but not limited to the following:

Medication reconciliation. Discharge and care plans. Enrollment in community-based LTSS.

2) Improved processes for transitioning patients across settings. These processes may include engaging community partners experienced in aspects of care related to social determinants of health including the following:

i. Enrollment in self-management, prevention and supportive services.

ii. Securing transportation, nutrition services and additional ongoing unmet needs of beneficiaries.

3) Measurement collection methods should be planned in accordance with selected interventions and should be incorporated, where possible, into existing community member standard processes, protocols and policies as appropriate. QIN-QIOs shall provide support to help communities develop a data collection strategy that includes identifying specific beneficiary characteristics such as diagnoses or payer status.

Task C.3.5. LAN and Integrated Communication SupportThe QIN-QIO shall, in accordance with the Base Contract, utilize results-oriented LANs and the QIN-QIO integrated communication plan, to maintain a strategy for responding to and tracking Community Coalition member inquiries and activities. In coordination with other QIN-QIO area tasks, the QIN-QIO shall focus care coordination LAN and integrated communication activities in the following areas:

a. The QIN-QIO shall identify themes and promote successful interventions and successes for targeting and coordinating interventions for the following types of Medicare beneficiaries:

1) Individuals dually-enrolled in Medicare and Medicaid,2) Individuals with multiple chronic conditions including subsets of individuals

taking three or more medications including but not limited to any of the following medications: anticoagulants, diabetic agents, and opioids

3) Individuals with behavioral health issues,4) Individuals with Alzheimer’s and other dementia disorders, and 5) Individuals impacted by socioeconomic status and other social determinants of

health.b. The QIN-QIO shall use LAN and integrated communication tasks to promote successful

interventions and other efforts to improve care coordination; the intended audience of these communication is all relevant providers, practitioners, patients, family members, including stakeholders who are not currently recruited or able to be engaged in a local Community Coalition.

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Task C.3.6. Medication Safety and Adverse Drug Event Prevention Adverse drug events are a leading cause of preventable patient harm. With an increasing number of the Medicare population taking prescription medications and seeing multiple providers, medication safety in all healthcare settings is essential to care coordination and improving the health of beneficiaries. Improving medication safety and coordination of care can prevent adverse drug events, increase patient engagement and thereby reduce harm. The QIN-QIO shall improve medication safety and aim to reduce and prevent adverse drug events by implementing evidence based and or proven best practice strategies, and tools that align with the National Quality Strategy and the Health and Human Services National Action Plan for Drug Event Prevention and other national, state or local initiatives. The QIN-QIO shall also ensure not to duplicate efforts that are in place by other federal, state or local entities. Tasks required to perform this function shall be integrated into the coordination of care work and include but not be limited to:

a. Recruitment and CollaborationThe QIN-QIO shall follow recruitment requirements specified in Task C.3.2. and in addition the QIN-QIO shall:

1) Recruit beneficiaries using three or more medications including one of the following high risk medications: anticoagulants, diabetic agents, and opioids. Recruitment of beneficiaries should be at least 10% of the population identified in C.3.2.a.

2) Recruit pharmacies within the community including but not limited to retail pharmacies, ambulatory pharmacies, hospital pharmacies and long term care pharmacies.

3) Work with existing national pharmacy collaborations and local schools of pharmacy and national pharmacy organizations.

b. Learning and Action Networks (LANs)See Part 4 of this TO, Core Requirements Applicable to All Task Orders for TO requirements related to LAN and Collaborative management in the Base Contract. The QIN-QIO shall follow the requirements in the base contract and coordinate with work in Task C.3.4 and other tasks as applicable and in addition:

1) Provide Medication Safety training to providers including but not limited to evidence based and proven strategies for medication therapy management, medication reconciliation post-discharge, and anticoagulant, diabetic, opioid medication specific safety.

2) Provide specific training on evidence based toolkits and strategies to reduce and prevent adverse drug events.

3) In addition to core requirements applicable provide educational activities and resources to promote engagement of beneficiaries and his/her family.

4) In conjunction with the QIN NCC the QIN-QIO shall share lessons learned and spread best practices for medication safety and adverse drug event prevention.

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c. InterventionsThe QIN-QIO shall apply the following interventions that promote medication safety, adverse drug event prevention and reduction including but not limited to:

1) Establish relationships and collaborations in the community to coordinate provider communication and medication therapy management across care settings with a patient centered focus.

2) Develop or promote evidence-based or proven best practice adverse drug event prevention toolkits for overall medication safety as well as specifically for Anticoagulants, Diabetic agents, and Opioids. The toolkits shall :

a. Easily be applicable in different care settings, retail pharmacies, hospitals, nursing homes, etc.

b. Easily be implemented for rapid adoption and testing (for feasibility and validity).

c. Collate best practices for medication reconciliation and medication therapy management applicable specifically to the community.

d. Include measurable and achievable improvement goals.3) Identify barriers specific to the community to reduce adverse drug events.

a. Develop suggested solutions to identified barriers.b. Promote suggested solutions to identified barriers to applicable care settings in

the community.c. Identify systemic or wide spread problems if present to health officials in a

timely manner to prevent patient harm.4) The QIN-QIO shall work with the community teams to screen all recruited

beneficiaries for potential adverse drug events and adverse drug events and use medication therapy management tools to prevent adverse drug events and patient harm.

5) Implement new tools or utilizing existing tools and/or using Health Information technology to screen beneficiaries for adverse drug events and thereby improve surveillance of high risk medications (anticoagulants, diabetic agents and opioids). The tools should:

a. Track the overall number of beneficiaries screened in the community by care setting, state and region.

b. Track the overall number of beneficiaries with adverse drug events in the community by care setting, state and region.

c. Track the number of beneficiaries on anticoagulants, diabetic agents, and or opioids in the screened population by care setting, state, region.

d. Track the number of readmissions associated with adverse drug events in the screened population by state and region.

e. Identify systemic or wide spread problems if present to health officials in a timely manner to prevent patient harm

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Task C.3.7. Sustainability Plan The QIN-QIO shall support community strategies to sustain improvement and progress; QIN-QIO support of community strategies shall begin with the onset of QIN-QIO involvement with each community. The support shall include, but is not limited to the following:

a. Assistance in identifying Federal, state, local and private funding sources to support community coalition infrastructure

b. Provision of support for other care coordination application processes, including but not limited to:

1) Data analysis and trending reports;2) Intervention selection rationale(s);3) Pricing and cost-saving estimates for interventions; and4) Other application requirements.

c. Coordination with any community-specific Sustainability/Business Plans.

Task C.3.8. Reporting Requirementsa. The QIN-QIO shall submit monthly Community Logs to CMS using a template provided

by CMS. The Community Log shall include, at a minimum, a description of QIN-QIO activities and analysis of the impact of the QIN-QIO’s work in the following areas:

a. Recruitment of newly engaged communities indicated by community-developed coalition charter or similar agreement.

i. The community coalition charter or agreement should formalize the rules, roles, infrastructure and resources available to support the communities’ shared goals.

ii. The community charter or agreement should include plans for re-evaluating and recommitting to community goals annually.

2) Identification of the level of experience of the community (new, intermediate, experienced).

3) List, by type, of community coalition members.4) Intervention implementation and measurement status updates.

b. The QIN-QIO shall submit monthly Community Logs to CMS using a template provided by CMS. The Community Log shall include, at a minimum, a description of QIN-QIO activities and analysis of the impact of the QIN-QIO’s work for Medication Safety and Adverse Drug event Prevention in the following areas:

a. Recruitment of newly engaged communities indicated by community-developed coalition charter or similar agreement.

i. The community coalition charter or agreement should formalize the rules, roles, infrastructure and resources available to support the communities’ shared goals.

ii. The community charter or agreement should include plans for re-evaluating and recommitting to community goals annually.

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b. Identification of the level of experience of the community (new, intermediate, experienced).

c. List, by type, of community coalition members.d. Intervention implementation and measurement status updates.e. Statistics on screened beneficiaries.

c. The QIN-QIO shall submit quarterly narrative reports using a template provided by CMS. The report shall include at least the following:

1) Types of support provided to communities,2) Engagement of current community coalition members by type of stakeholder in

LAN activities,3) Engagement of additional stakeholders by type of stakeholder in the region not

currently involved in a community coalition in LAN activities,4) Status of sustainable community coalition plans (e.g. formal funding)

d. Additional information about strengths and barriers may be requested by CMS or provided at the discretion of the QIN-QIO. QIN-QIOs shall collect intervention level data for a minimum of 5 interventions across the region annually. CMS will provide a template for the QIN-QIO to illustrate the intervention measures and trends which QIN-QIOs shall submit quarterly in an Intervention Effectiveness Measurement Report. Examples of components of the report template include:

1) Framing outcomes in terms that demonstrate value to the target population,2) Intervention and measurement description,3) Minimum number of beneficiaries impacted,4) Community-led data collection methods,5) Intervention dates,6) Rationale for continuing or discontinuing an intervention based on data analyses

including process changes for interventions that lack positive trends and strategy for adjusting processes,

7) Intervention trends in the form of rates, time series trend, or other rational for interpreting improvement,

8) Standardized display of improvement for community beneficiaries that includes intervention effectiveness (such as process and proximal outcome measures) and community-level outcome measures. Data display shall be used to:

i. Demonstrate sustained improvement over time; including minimum of 6 monthly data points that show improvement (through control/run charts, best fit lines), and sustained improvement for an additional 4-6 months;

ii. Motivate local community stakeholders to engage them in consistent data collection;

iii. Connect local community outcomes to national level goals;

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iv. Demonstrate the breadth of impact on the community and intervention target population, including percent of population eligible for interventions, percent of population receiving interventions, percent completing interventions, percent of other communities in the region utilizing similar interventions;

v. QIN-QIOs shall facilitate the collection of intervention level data at the beneficiary level for two of the following populations for two interventions per year and provide this data quarterly to CMS:

Individuals dually-enrolled in Medicare and Medicaid, Individuals with multiple chronic conditions including subsets of

individuals taking three or more medications including but not limited to any of the following medications: anticoagulants, diabetic agents, and opioids

Individuals with behavioral health issues, Individuals with Alzheimer’s and other dementia disorders, Individuals impacted by socioeconomic status and other social

determinants of health.

Task C.3.9. Additional RequirementsCohesive Community Readmission Measurement Strategy: The QIN-QIO shall provide leadership and guidance for selecting appropriate measures at the community and provider-specific level. The QIN-QIO shall, in accordance with the Base Contract, provide results-oriented technical assistance, data analytic support, and mentorship to Community Coalition members, providers, and practitioners on the use of various strategies to measure readmission. This technical assistance shall include at a minimum the following:

a. Provide and educate providers and community stakeholders with up to date national, state and local utilization measures, including, but not limited to:

1) Population-based measures (readmission and admissions per 1,000 beneficiaries)

2) Hospital-wide all-cause readmission measures b. Provide up to date national, state and local perspective on the initiatives that use

various types of readmission measures, including but not limited to: 1) Hospital Compare2) Hospital Readmission Reduction Program3) Accountable Care Organizations4) Community-based Care Transitions Program5) Aging and Disability Resource Centers6) Medicaid Health Homes

c. Provide and make meaningful, quarterly hospital specific reports to all acute care and critical access hospitals in their region so hospitals and community coalitions

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have timely access to hospital specific readmission data (analytic reports will be provided by the NCC).

d. The QIN-QIO shall report data quarterly among providers and community coalition members for ongoing monitoring and support for community interventions and measurement strategies. The community metrics (provided by the NCC) may include but are not limited to:

1) Proportion of Transitions Tables2) Coalition Readmission Rates3) Hospital Readmission Rates4) Post-Acute Care Setting Readmission Rates5) Post-Acute Care Setting Discharge Rates by location6) Disease Specific Readmission Rates7) ED Visit without admission Rates8) Observation Stay Rates9) Mortality Rates10) Percent of community coalition providers providing summary of care

documents electronically across provider settings11) Enrollment rates in community-based long-term services and supports

e. Intervention Performance Progress Reports: The QIN-QIO shall produce four reports that meet the quality and relevance criteria utilized by peer-reviewed journals. In developing these reports, the QIN-QIO shall use SQUIRE guidelines (See Attachment J-1c). The reports must illustrate the trends for effectiveness of interventions and the beneficiary populations reached by the interventions. The reports must also illustrate how the interventions address the causes of poor care coordination and discuss how the differences and similarities across communities and targeted beneficiary populations relate to the effectiveness of an intervention.

f. The targeted Medicare beneficiary populations to be addressed shall include, at a minimum, one of the following:

1) Individuals dually-enrolled in Medicare and Medicaid2) Individuals with multiple chronic conditions including subsets of

individuals taking three or more medications including but not limited to any of the following medications: anticoagulants, diabetic agents, and opioids

3) Individuals with behavioral health issues4) Individuals with Alzheimer’s and other dementia disorders5) Individuals impacted by socioeconomic status and other social

determinants of health

Section F. Schedule of DeliverablesThe QIN-QIO shall provide all deliverables for - Task C.3 – Coordination of Care in accordance with Attachment A, Task Order 001 Schedule of Deliverables.

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Section G. Measurement, Evaluation, and PerformanceThe QIN-QIO will be evaluated on an annual basis regarding progress towards achieving the CMS-designated evaluation measures.

1. The QIN-QIO shall collect and report the impact of its efforts on the QIN-QIO area by reporting the following metrics:

a. Number of communities recruited,

b. Number of community coalition charters signed,

c. Progress of communities across the regional coalition,

d. Community and intervention-level improvement,

e. Additional or other measures as directed by CMS, such as patient-level data for two or more of the beneficiary populations for two interventions annually.

2. The QIN-QIO shall show improvement in care coordination by assessing the outcomes and reach of interventions; the QIN-QIO performance shall be measured against a target of demonstrating region-wide improvement across 60% of all community-level interventions with a minimum of 5 interventions implemented and reported. The QIN-QIO must show improvement data for at least two of the following populations across the QIN-QIO area:

a. Individuals dually-enrolled in Medicare and Medicaid

b. Individuals with multiple chronic conditions

c. Individuals with behavioral health issues

d. Individuals with Alzheimer’s and other dementia disorders

e. Individuals impacted by socioeconomic status and other social determinants of health

3. The QIN-QIO shall be evaluated based on population-level measures that demonstrate improvement in care coordination across multiple provider and care settings in the community. These shall include the following:

a. Percentage reduced in rate of 30 day readmissions per 1,000 FFS beneficiaries region-wide,

b. Percentage reduced in rate of admissions per 1,000 FFS beneficiaries region-wide,

c. Percentage reduced in rate of adverse drug events per 1,000 beneficiaries screened for Adverse Drug Events region-wide,

d. Percentage increases in community tenure.

Also, see Attachment B, Task Order 001, Evaluation Measures Tables and Section C.6, Contractor Performance Measurement in the base contract.

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D. AIM: Better Care at Lower Cost

GOAL 4: Make Care More Affordable

Task D.1: Quality Improvement through Value-Based Payment, Quality Reporting, and the Physician Feedback Reporting Program

Section A. Overview and BackgroundCMS is seeking to promote higher quality of care and more efficient health care for all Medicare beneficiaries. This effort is supported by the implementation of an increasing number of -agreed upon quality measures, value based payment, and quality reporting programs including Inpatient Psychiatric Facilities (IPFs), PPS-exempt Cancer Hospitals (PCHs) inpatient and outpatient departments of hospitals, physicians, and Ambulatory Surgical Centers (ASCs). CMS has worked with stakeholders to define measures of quality in almost every setting and currently measures some aspect of care for Medicare beneficiaries. These measures assess clinical quality of care, care coordination, patient safety, patient experience of care, caregiver experience of care; population/community health, and efficiency.

Section 3001 of the Affordable Care Act H.R. 3590, TITLE III adds Section 1886(o) to the Act, and authorizes the establishment of a quality incentive payment program for IPPS subsection (d) hospitals as defined under the Reporting Hospital Quality Data for Annual Payment Update (Inpatient Quality Reporting ((IQR)) program, effective with the FY 2013 payment determination for discharges occurring on or after October 1, 2012. The provision requires participation in the Inpatient Quality Reporting ((IQR) program and that participating hospitals meet quality metrics endorsed by consensus based standard-setting bodies by demonstrating improvement or high levels of achievement. Under the Hospital VBP program, payments to high-performing hospitals would be larger than those to lower performing hospitals, using the Inpatient Prospective Payment System (IPPS) to provide financial incentives to drive improvements in clinical quality, patient-centeredness and efficiency. Public reporting of quality measures and value based payment performance data on the CMS Hospital Compare website will remain an essential component of HVBP, and our quality programs.

The Physician Value-Based Payment Modifier (Value Modifier; VM) and the Physician Feedback Program, part of the Affordable Care Act, link physician performance in quality and cost with Physician Fee Schedule payments under Medicare Part B (SSA, Sections 1848(p) and (n)). CMS has finalized its approach to the value-based payment modifier (VM) for calendar year 2015.

For the VM for 2015, groups of physicians with 100 or more eligible professionals will be assigned to one of two categories based on a group’s participation in the Physician Quality Reporting System (PQRS) during 2013. The first category includes groups that (a) self-nominate for the PQRS as a group and report at least one measure or (b) elect the PQRS administrative claims option as a group. For groups in the first category, the VM for 2015 will be 0%, unless a group elects to have its VM for 2015 calculated using the quality-tiering methodology, which could result in an upward, neutral, or downward payment adjustment. The second category

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includes groups that do not fall under the first category. Groups in the second category will have a VM of -1% for 2015. In the CY 2014 Physician Fee Schedule Proposed Rule, CMS has proposed that in 2016, CMS will expand application of the VM to cover physician groups with 10 or more eligible professionals.

By 2017, the VM will apply to all eligible physicians and groups of physicians with regard to payments for items and services under the Medicare Physician Fee Schedule. The value-based payment modifier has the potential to transform Medicare from a passive payer to an active purchaser of higher quality, more efficient and effective healthcare by providing upward payment adjustments to high performing physicians (and groups of physicians) and downward adjustments for low performing physicians (and groups of physicians) through tiered methodology (77 FR 44993). This Task refers primarily to the Physician Value-Based Payment Modifier component of the Physician Value-Based Payment Modifier/Physician Feedback Program. Additional information on the Physician Value-Based Payment Modifier is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/CY2015ValueModifierPolicies.pdf

Role of the QIN-QIO

Under this task, QIOs shall be called upon to assist hospitals, PCH’s, IPF’s, ASC’s, and physicians (as defined in Social Security Act Section 1861(r)) in improving their quality of care and efficiency of care through outreach and education about CMS hospital and physician value based payment programs, quality reporting programs, and Physician Feedback Reporting Program and use of the quality and cost measure information contained in the confidential quality and resource use reports (QRURs).

The expectation is that through QIN-QIO activities, gaps will be identified and opportunities for quality improvement and for improvement in efficiency and care coordination will be identified and utilized to improve healthcare.

Section B. General Desired OutcomesThe QIN-QIO work under this Task is an effort to support CMS, providers, ASCs, and physicians in activities essential for the continued efficient, effective and successful implementation of our value based payment, quality reporting, and the Physician Feedback Report Program. The goals are as follows:

1. To increase the number of eligible physicians and physician groups that submit data through PQRS by 100% (an approximately 75% participation rate).

2. To increase the percentage of eligible physician groups that demonstrate improvement in quality of care delivered (as determined by reported quality measures) over a five (5) year period by 50%. [Improvement is signified by movement towards the targets specified by the measures that are reported on.]

3. To increase the national performance levels on Hospital VBP measures by at least 15% annually over baseline period performance.

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http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/CY2015ValueModifierPolicies.pdf

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/CY2015ValueModifierPolicies.pdf



4. To increase the percentage of ASC’s and IPF’s that successfully improve quality on a poorly performing quality measure to at least 15% annually (currently 0%)

5. To increase the percentage of Hospital outpatient departments that demonstrate improvement in quality of care delivered (as determined by reported quality measures) over a five (5) year period by 50%. [Improvement is signified by movement towards the targets specified by the measures that are reported on.]

6. To increase PPS-exempt cancer hospital performance on ACoS and CDC NHSN measures included in the PCH quality reporting program by at least 50% over a five year period.

The specific targets and time periods for these goals are listed in the Evaluation Measures Table for this Task. These goals shall be accomplished by working with participating physicians in collaboration with key partners and stakeholders, both within and outside of CMS. An approach to support the achievement of the goals may include, but not be limited to, the education of and technical assistance to providers, ASC’s, eligible physicians and physician groups to improve their quality and efficiency of care related to value-based purchasing initiatives, such as the VM Program. The target audience for education and technical assistance shall be all subsection (d) and CAH hospitals, PPS-exempt cancer hospitals, ASC’s, IPF’s, physicians/physician groups and especially those most challenged to succeed. For physicians and physician groups, the technical assistance shall address how and when the VM and Physician Feedback Report Programs apply to which medical groups, requirements of said programs, registration modes, in addition to other elements of the program, such as using the QRUR as a resource of information to improve quality, efficiency and patient coordination of care. . For subsection (d) and CAH hospitals, PPS-exempt cancer hospitals, ASC’s, and IPF’s, the technical assistance shall focus on improving performance of quality, patient experience of care, cost and efficiency, and outcomes measures included in the CMS value based payment and quality reporting programs in the applicable care setting.

Section C. Personnel Requirements 1. Designation of Key Personnel--


Section D. Task D.1 RequirementsThe QIN-QIO shall perform the following activities under this Task:

a. Help providers and practitioners understand the linkages and inter-relationships between the Value-Modifier Program, PQRS, and other programs and initiatives that affect Eligible Practitioners (e.g., the EHR Incentive Program, Medicare Shared Savings Program, Pioneer Accountable Care Organization (ACO) model, Physician Group Practice Transition Demonstration, Comprehensive Primary Care Initiative);4

4 Note: The Value Modifier applies only to physician payments under the Medicare PFS. The Value Modifier does not apply to payments that are NOT made under the Medicare PFS, including those for physicians providing services in Rural Health Clinics, Federally Qualified Health Centers, and Critical Access Hospitals (CAHs) (for CAHs electing method II billing).

Additionally, for 2015 and 2016, the Value Modifier does not apply to groups of physicians in which any of the group’s physicians participate in the Medicare Shared Savings Program Accountable Care Organizations (ACOs), the testing of the Pioneer ACO model, or the Comprehensive

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b. Help hospitals understand the linkages and inter-relationships between the Hospital VBP program, Hospital IQR and OQR programs, and other program that affect eligible hospitals (e.g., E H R Incentive Program, Hospital Acquired Condition Reduction program, Hospital Readmission Reduction program, Accountable Care Organization (ACO) model, Medicare Shared Savings Program, Physician Value Modifier program, etc.);

c. Assist physicians/physician groups in submitting data through PQRS and in participating in the Value Modifier / Physician Feedback Program;

d. Support physician and physician group quality reporting to promote health information exchange;

e. Identify a pathway(s) that would allow EPs and/or group practices to participate and receive credit for multiple programs through a single data submission;

f. Provide quality improvement technical assistance to subsection (d) and CAH hospitals, PPS-exempt cancer hospitals, ASC’s, IPF’s, and physicians;;

g. Provide technical assistance to physicians in using the QRURs. QRURs are tools used to summarize quality of care provided by a physician in the Physician Feedback Program to identify causes of excessive resource use and/or overuse and opportunities to improve their efficiency through improvements in care coordination;

h. In addition to (f), convene forums for interested physician providers to discuss QRUR and obtain feedback on QI efforts to address disparities in quality identified in the QRUR and through Value Modifier Program;

i. Share successful interventions and quality of care efficiency improvement efforts, as well as provide feedback on quality improvement efforts (to physicians and other QIN-QIOs) through Learning Action Networks;

j. Utilize data to identify gaps in quality of care (including disparities) and care coordination and develop interventions for addressing these gaps; and

k. Support value-based program initiatives related to collecting, reporting and analysis of beneficiary quality data by providers that may develop during the course of this contract.

Task D.1.1. Task Work PlanSee Part 4 of this TO, Core Requirements Applicable to All Task Orders. The Task Work Plan shall demonstrate how the QIN-QIO will fulfill the performance requirements of this Task.

Task D.1.2. Provider and Practitioner RecruitmentSee Section C.6.4.3, Provider and Practitioner Recruitment in the Base Contract for requirements for provider recruitment and the Recruitment Plan. The physician types eligible for the Value-Based Payment Modifier Program include: Doctor of Medicine, Doctor of Osteopathy, Doctor of Podiatric Medicine, Doctor of Optometry, Doctor of Oral Surgery, Doctor of Dental Medicine, and Doctor of Chiropractic. . The provider types eligible include subsection (d) and CAH hospitals, PPS-exempt cancer hospitals, ASC’s, and IPF’s.

Primary Care Initiative.

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Task D.1.3. Beneficiary and Family EngagementDue to the nature of this Task, the beneficiary and family engagement provisions of the Base Contract do not apply to this Task.

Task D.1.4. Partner and Stakeholder Recruitment and CollaborationIn addition to the Base Contract requirements, the QIN-QIO shall support alignment across other value-based initiatives for the Medicare program and, where needed, work with the Value Incentives Quality Reporting Centers (VIQRCs), which oversee hospital value-based programs as they relate to quality reporting.

Task D.1.5. Develop Expertise in Physician Feedback/Value-Based Modifier Program

The QIN-QIO shall develop an expert understanding of Physician Feedback / Value Modifier (VM) Program including requirements, eligibility criteria and incentive/penalty determinations. The QIN-QIO shall have an expert understanding of how the VM interacts and/or relates with other reporting programs for physicians, group practices, ACOs and the like. Additionally, the QIN-QIO shall possess expertise in interpreting the QRURs and the quality and resource use data contained within. Knowledge would be used to provide assistance to eligible physicians and physician groups. CMS reserves the right to require the QIN-QIO to participate in CMS-led training related to the Physician Feedback/ VM Program. This training is expected to enhance expertise and technical assistance capacity of QIN-QIOs performing the activities outlined in this Task Order. (Of note: QRURs are confidential feedback reports provided to physician offices/groups. Physician offices/groups can and should request assistance with interpretation of reports and with the help of QIN-QIOs develop solutions to address areas where quality of care delivered can be improved.)

Task D.1.6. Outreach and EducationPractitioner Physician Offices/GroupsQIN-QIOs shall support physicians participating in the VM Program by developing and executing targeted outreach and education plans for physicians, physician groups and other stakeholders regarding the Value-Based Modifier and QRURs used to determine payment and to assess quality.

Non-participating Practitioner Physicians’ Offices/ Groups QIN-QIOs shall assist physician and physician groups that are not yet participating, yet are eligible for the Value Modifier / Physician Feedback Programs. Such assistance shall include, but not be limited to, promotion and outreach to physicians not currently reporting data on PQRS, and educating them on the specifics of the VM and how it is calculated and how to use the QRURs.Outreach shall include, but is not limited to, physician practices, physician groups, local medical/subspecialty societies (state, regional or city/county level), healthcare-related affinity groups, and other associations where physicians are likely to be present.

Hospital Inpatient and Outpatient Departments, PPS-Exempt Cancer Hospitals, Inpatient Psychiatric Facilities, and Ambulatory Surgical CentersQIOs shall support Hospital Inpatient and Outpatient Departments, PPS-Exempt Cancer

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Hospitals, Inpatient Psychiatric Facilities, and Ambulatory Surgical Centers by developing and executing targeted outreach and education plans for hospital inpatient and outpatient departments, PCH’s, IPF’s, and ASC’s, and other stakeholders regarding improving quality of care, patient experience of care, health outcomes, efficiency, and reducing cost on measures included in the value based payment and quality reporting programs in these settings.

Task D.1.6.1. Program Education and CommunicationThe QIN-QIO shall promote program education and communication by performing the following activities:

a. Provide communication and education about subsection (d) and CAH hospitals, PPS-exempt cancer hospitals, ASC’s, IPF’s, and physician quality improvement and the PQRS Data Reporting and Physician Value Modifier Program. Such communication and education shall be performed consistent with processes determined by the COR and GTL for communicating information to physicians, vendors, and other stakeholders. Communication and education efforts may occur through any or all of the following

1) LISTSERV administration, communication, and archives;2) Quality Net 508 compliant content;3) CMS official PQRS Reporting, VM/Physician Feedback websites;4) CMS official PQRS Reporting, VM/Physician Feedback web material; 5) Quality Improvement website and web material; and6) As needed and directed by the COR and GTL.

b. Arrange, facilitate, and conduct (at least quarterly) conference calls with appropriate stakeholders; agendas and minutes of prior call to be provided by the QIN-QIO for each scheduled call.

c. Maintain and update information on the subsection (d) and CAH hospital, PPS-exempt cancer hospitals, ASC’s, IPF’s, and physicians quality improvement outreach and education and VM/Physician Feedback Reporting Programs, including:

1) General information;2) Training tools;3) Educational programs;4) Program progress (including data reports, charts, and tables); and5) Other resources as needed and directed by the COR and GTL.

d. Work with appropriate parties to develop and present quality improvement educational materials for subsection (d) and CAH hospitals, PPS-exempt cancer hospitals, ASC’s, IPF’s. Work with appropriate parties to develop and present educational materials for physicians and other stakeholders explaining the VM/Physician Feedback Reporting Programs and their role within these programs.

e. Work with the appropriate QIN-QIOs of the Eligible Practitioner Medicare EHR Incentive Program to develop and present educational materials to physicians to report quality data electronically using Certified EHR technology.

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f. Provide recommendations and guidance to CMS in efforts to the align quality reporting programs (such recommendations shall be informed by communication and outreach to subsection (d) and CAH hospitals, PPS-exempt cancer hospitals, ASC’s, IPF’s, and physicians/physician groups).

g. Respond to questions from CMS, other QIN-QIOs, or physicians/physician groups regarding Physician Feedback/Value-Based Modifier Program and make any necessary referrals to CMS or CMS-designated Contractors.

h. Respond to questions from CMS, other QIO’s, or subsection (d) and CAH hospitals, PPS-exempt cancer hospitals, ASC’s, and IPF’s about quality improvement outreach and educational materials, and make any necessary referrals to CMS or CMS-designated contractors

Task D.1.7. Technical Assistance to Physicians & Analysis of DataQIN-QIOs shall provide technical assistance to physicians that request assistance on quality and efficiency of care improvement efforts as a result of feedback from the Physician Feedback/Value-Based Modifier (VM) Program. This assistance shall include but, is not limited to:

a. Supporting physicians reporting under PQRS (topics for technical assistance include submission of data through GPRO, administrative claims, EHRs, qualified (CMS-certified) registries, or proposed clinical data registries);

b. Identifying needs and opportunities for assistance based on feedback from physicians regarding VM;

c. Convening forums where physicians can receive feedback on QRUR reports and learn QI methods for improving quality from peers and QIN-QIOs; and

d. Using Value Modifier and / or QRUR data and relevant quality data to determine trends in cost growth of healthcare within the QIN-QIO’s area(s).

The QIN-QIO shall develop a plan for facilitating the measurement of performance at multiple levels (e.g., individual physician level and group practice level).

Task D.1.8. Address Gaps in Quality of CareUsing CMS quality reporting value based payment program, and PQRS data, QIN-QIOs shall identify gaps in quality of care and shall assist participating providers with the development of interventions to address identified gaps.

Task D.1.9. Physician Feedback Reporting Program As stated in Task D.1.7 and where applicable (and if requested by physicians or physician groups), QIN-QIOs shall use the QRUR and other feedback to identify and support physicians in quality and efficiency of care improvement projects, in accordance with all applicable statutory laws, regulations, and guidance. This might also include the identification of opportunities to identify drivers of high cost care and their causes, in addition to improving care coordination. QIN-QIOs shall provide reporting on cost growth using quality data available through Value Modifier, QRUR and other relevant data.

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Task D.1.10. Learning and Action Networks (LANs)QIN-QIOs shall use LANs to spread promising practices and solutions for improving quality and efficiency of care based on performance on the quality and cost composite measures and other information provided in the CMS hospital, ASC, IPF, and PPS-Exempt Cancer Hospital quality reporting or value based payment programs , and QRURs of the Value Modifier Program. Spread shall be across multidisciplinary groups (e.g., at the community level – including civic leaders, public health and healthcare systems leaders). QIN-QIOs shall support subsection (d) and CAH hospitals, PPS-exempt cancer hospitals, ASC’s, and IPF’s participating in CMS quality reporting or value based payment programs, and physicians and physician groups participating in the Value Modifier by identifying and meeting with local organizational stakeholders that perform work related to the applicable CMS quality reporting or value based payment programs , and Value-Based Modifier program. In addition, QIN-QIOs shall support (if only by technical assistance) communities, organizations and institutions that participate in potential pilots of value-based purchasing programs. (Value-based purchasing pilots refer to potential projects in healthcare settings not currently included in the Hospital VBP and Value-Based Modifier Program (e.g., home health agencies, ambulatory care centers, etc.).

Task D.1.11. Alignment and Coordination with related CMS Programs (including VBP Programs)

QIN-QIOs shall demonstrate alignment with other CMS incentive based programs for the Medicare program, including but not limited to the Community-Based Care Transitions Program, Hospital Acquired Condition Reduction Program,, and Hospital Readmissions Reduction Program, the EHR incentive Program (including Regional Extension Centers: RECs), Accountable Care Organizations, and ESRD Quality Improvement Program (ESRD-QIP) to identify areas where synergies can occur and implement interventions that improve quality.

Specifically, the QIN-QIO shall:a. Work with other designated CMS contractors (such as but not limited to the VIQRC

or RECs, to develop, maintain and/or revise standard processes and documentation for data collection, transmission, and analysis to support the CMS quality reporting and Hospital And Physician value based payment programs for:

1) Specified program measures;2) Potential new program measures; 3) Additional domains as directed by CMS; and 4) Participate in all scheduled conference calls with CMS-designated contractors.

Report summarizing activities quarterly.b. Act as liaison between CMS and physicians to provide two-way data and information

sharing; 1) to inform monitoring and evaluation activities, and 2) to help improve quality, access, and efficiency of beneficiary care. In essence, be available to inform quality improvement activities with insights from lessons learned in performing this Task.

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Task D.1.12. Physician Data Collection While understanding the characteristics of who is actively (currently) submitting data electronically to receive a payment modifier is important to successful performance of this Task, it is equally imperative to understand the characteristics of those physician groups that have yet to submit data electronically. To this end, we expect that the QIN-QIO shall collect the following data and use analysis of this data to achieve the Task’s goals and drive quality improvement within the QIN-QIO and with physicians:

a. Demographic data on physician groups that do not have an electronic health record system and physician groups with an EHR that are not submitting data electronically to CMS – demographic data would include presence of EHR system, size of the organization, per capita spending, net revenue and link/association/affiliation with a hospital system;

b. Demographic data on each physician group’s patient population (race/ethnicity, income, age, gender, and family size);

c. Data that highlights whether a physician group has systems in place to assess quality improvement efforts;

d. Data that highlights how physicians/physician groups submit data (GPRO, Registries, Claims) to PQRS for the VM program;

e. Data that highlights how/if physician groups use QRUR to address quality of care and reduction in health disparities; and

f. Data that assesses physician experience with the VM program.

Because of the significant and synergistic opportunities to improve EHR capabilities for these groups, especially as it relates to electronic reporting on quality data, the QIN-QIO shall work with the RECs (as outlined in Task A.4) to collect the aforementioned data and to identify those groups that will benefit from the services of the RECs in updating EHR capabilities. Data collected under this section should be provided in the program progress reports (see section D.1.6.1.c.4 of this Task).

Task D.1.13. Monitoring and Reporting Requirements See Part 4 of this TO, Core Requirements Applicable to All Task Orders.

Task D.1.14. Sustainability PlanIn addition to the requirements outlined in Part 4 of this TO, Core Requirements Applicable to All Task Orders, the QIN-QIO shall identify areas in its processes related to this TO that have a potential to hinder success in carrying out the Task, and shall provide a plan for surmounting these potential hindrances. Areas to consider shall include, but are not limited to, quality data or EHR vendor software updates, presence or absence of EHR inadequate outreach tools used to identify eligible physician groups, competing Federal, State, Local government and private value and incentive initiatives, and limitations in QIN-QIO staffing capacities. If the QIN-QIO is coordinating this plan with other key stakeholders (including Regional Extension Centers) this information shall be included. This plan shall be submitted to CMS for approval in accordance with the Schedule of Deliverables.

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Section E. Schedule of DeliverablesThe contractor shall provide all deliverables for- Task D.1 – Quality Improvement through Value-Based Payment, Quality Reporting, and the Physician Feedback Reporting Program in accordance with Attachment A, Task Order 001 Schedule of Deliverables.

Section F. Measurement, Evaluation and PerformanceThe QIN-QIO will be monitored on a quarterly basis regarding progress towards achieving the CMS-designated evaluation measures. See Attachment B, Task Order 001, Evaluation Measures Tables for Task D.1 – Quality Improvement through Value-Based Payment, Quality Reporting, and the Physician Feedback Reporting Program measures. Also, see Section C.6, Contractor Performance Measurement in the base contract.

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Task D.2: QIN-QIO-Proposed Projects that Advance Efforts for Better Care at Lower Cost

Section A. Overview and BackgroundCMS reserves the right to request that QIN-QIOs submit Special Innovation Projects after contract award. CMS is looking for innovative ways to support national healthcare quality and realizes that beneficiaries are kept healthy and active, one beneficiary at a time. Medicare beneficiaries are integral to their communities, which include supportive family, healthcare institutions, organizations, professionals, and concerned citizens. The focus on a beneficiary’s health should not only be at the point of care. A beneficiary’s health each day is also determined by the sum of community efforts, be they effective or deficient, to maintain the beneficiary’s health.

CMS will use Special Innovation Projects (SIPs) to support QIN-QIOs in their respective services areas to work with communities to improve healthcare quality and efficiencies. Specifically, SIPs are initiatives, efforts, and programs rooted in the QIN-QIO area. SIPs are recommended to CMS, through the QIN-QIO, by community advocates, organizers, and groups engaged with local health issues. The SIP is intended to address a health issue the community finds acute but is less visible to high-level federal analytics.

Section B. General Desired OutcomesUnder this task, QIN-QIOs shall identify new models of service delivery that hold the promise of delivering the three-part aim of better health, better healthcare, and lower costs through improved quality for Medicare enrollees. Successful models shall include plans to rapidly develop and/or deploy the requisite workforce to support the proposed model.

Section C. Personnel Requirements1. Designation of Key Personnel-- For this Task, the following position(s) are determined as

Key Personnel:a. See Part 2., Personnel Requirements in this TO.

2. Other Recommended Personnel and Qualifications – Unique to This Task a. Task Lead

1) In addition to the standard qualifications for Task Lead, the Task Lead must have five years of progressive management experience in community projects, developing and directing a variety of staff including professionals, community workers and stakeholders (e.g., organizers, social workers, educators).

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Section D. Task D.2 Requirements

Task D.2.1. Proposing Special Innovation ProjectsProposed projects should support the work of the 11th SOW by providing fresh and original models of healthcare quality improvement methods. An innovation project is defined, in part, as work that CMS approves for the QIN-QIO to perform that is not defined under the SOW. A proposed project should further the goal(s) of the QIN-QIO Program, as articulated in §1862(g) and Part B of title XI of the Social Security Act, as well as the foundational principles for the QIN-QIO Program listed in Appendix A of the Base Contract. An innovation project might not be limited to just Medicare beneficiaries, provided that any additional non-Medicare information/activities are essential to the project and that the focus of the project is directly related to benefiting Medicare beneficiaries, including but not limited to racial and ethnic minority and dual-eligible beneficiaries.

CMS is particularly interested in SIPs that address quality and value improvements in these domains:

a. How hospital value-based purchasing data is used to improve the quality of health and health care and lower health care costs.

b. The impact of patient and family engagement in beneficiary-centered care to improve the health and health care of Medicare beneficiaries.

c. Geographic challenges to care such as in urban and, rural areas where travel for beneficiaries is difficult resulting in reduced, access to care;

d. The health effects of demographic differences in individuals and populations, for example age, sex, race, ethnicity, gender, disability and other issues which underlie poor health;

e. Multiple chronic diseases with numerous care givers who may not communicate resulting in emergency room visits, readmissions, depression, and reduced quality of life;

f. Dual-eligible beneficiaries who may receive more care or less care depending upon their relationships with their community advocates and care givers;

g. Economic challenges to care, especially those beneficiaries of low income, and poor housing who may have additional problems such as poor nutrition due to food deserts;

CMS, at a time of its choosing, will invite letters of recommendation, or call letters for SIPs, especially where measures and values of issues noted above fall lower or higher than 1.28 standard deviations (40% below or above) the national means where such deviation indicates poor performance, poor quality, or other substandard index. An acceptable call letter will result in a SIP Task Order being issued by CMS. The QIN-QIO(s) will submit a proposal which shall be considered for award under the SIP Task.

The QIN-QIO shall develop a SIP proposal that includes, but may not be limited to, the following:

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a. Implementation of a proof of concept , through which a previously untested innovation is tested on a small scale to demonstrate its feasibility for addressing an identified problem or to determine whether it works to solve/address an identified problem;

b. Implementation of an innovation or improvement approach , to provide information for decision-makers about structural, contextual and process factors that play a critical role in increasing (or reducing) the chances that a proven evidence-based innovation (or a modification of that proven innovation),will work in a given setting; and

c. Spread, or the taking to scale, of one or more proven innovations or delivery system improvements, including the active, wide dissemination of information about what works, accompanied by concrete guidance on how to maximize the likelihood of successful implementation and sustainability. Increasing knowledge about strategies used to promote the systematic uptake of research findings and other evidence-based practice by providers and other decision-makers is an important objective as well.

d. Efforts that promote prevention and improve population health, including broad-based coalitions that address systemic community challenges that impact health (challenges may address access to care, linkages to community-based social services, community violence, obesity, mental health, etc.) and other non-clinical prevention efforts (i.e., take place outside of the “clinical-setting”).

e. All of the requirements in Part 4 of this TO, Core Requirements Applicable to All Quality Improvement Task Orders.

Task D.2.2. Other Provisions of SIP ProposalsSIP proposals shall include an emphasis on: quantitative and qualitative evaluation, including testimony from stakeholders, participants, and beneficiaries; furthering the quality strategies that fulfill the purposes of the QIO statute and regulations; scalability; and innovative of design. CMS will look for sustainable projects which could be melded into subsequent QIO SOWs. Proposals perceived as research involving human subjects shall not be considered and will be returned to the offeror.

SIP proposals must demonstrate innovation, efficient and economical use of resources, development of new training and educational materials, and the ability to spread the effects of an innovation or improvement approach to other populations and regions. All software used for the innovation project shall be Commercial-Off-the-Shelf (COTS) software and no software shall be developed by QIN-QIOs for the projects. All software shall be interoperable (see Attachment J-8 Glossary of Terms and Acronyms) with existing systems. Therefore, all data collection, measures, registers, etc. shall be readily and easily integrated, mapped, and transferred into other CMS existing systems.

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Task D.2.3. Interim and Quarterly ReportsAfter award of a SIP Task, the QIN-QIO shall submit quarterly, interim and/or final reports to the COR and GTL. These reports are to be included or attached to the QIN-QIO’s regular reports to the COR as determined by the COR. The SIP report(s) shall be a brief summary of the project, including an outline of accomplishments, barriers, and issues for CMS action. The report shall be formatted and written in Times Roman 12 point type without italics or bold font; however, underlining may be used. All charts and graphs shall follow Tufte Guidelines (http://www.edwardtufte.com/tufte/ ) and shall be in black and white without any other color.

Task D.2.4. SIP Final ReportsThe SIP reports are key to replicating and sustaining valuable projects. All SIP final reports shall be held to the following standards and a QIN-QIO not meeting these standards in the final report shall lose eligibility to participate further in this Task. The final report is to be written in Times Roman 12-point type without italics or bold font; however, underlining may be used. All charts and graphs shall follow Tufte Guidelines (http://www.edwardtufte.com/tufte/ ) and shall be in black and white without any other color.

The final report shall contain all of the following item headings in the order below:

1. Title page shall show the QIN-QIO name, address, phone, email, project name, and project number.

2. Contents page will show all of the items in order below with pages indicated

3. Executive summary or abstract

4. The purpose of the project

5. Project team members with an organizational chart

6. Questions the project attempted to answer

7. The project setting including the community, the population, etc.

8. Level of community support for the project

9. All data used during the project

10. The trend of the project measures over the time of the project

11. All interventions suggested

12. All interventions tried

13. All interventions that would have been tried if not for some resource or other problem

14. What worked and did not work

15. Possible long term solutions to the problem

16. What the QIN-QIO would do differently if it had to do the project over again.

17. Evidence of the successes and failures of the project related to the questions noted above that the project attempted to answer; this shall include personal testimony as well as data.

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18. Description of how the program can be replicated in other communities and states with links and citations of appropriate training materials.

19. A project summary suitable for the lay reader; that is, suitable for someone with a ninth grade education who has no knowledge of technical terms.

20. References

21. Appendices

The QIN-QIO shall submit the Draft Final Report 14 days prior to the end of the period of performance of the SIP. The Final Report shall be submitted on the last day of the period of performance of the SIP and biannually thereafter.

Section E. Schedule of DeliverablesThe QIN-QIO shall provide all deliverables for Task D.2 – QIN-QIO -Proposed Projects that Advance Efforts for Better Care at Lower Cost Schedule of Deliverables in accordance with Attachment A, Task Order 001 Schedule of Deliverables.

Section F. Measurement, Evaluation and PerformanceMeasurement, evaluation, and performance frameworks shall be established as part of the technical approach for the SIP proposals under CMS review. Also, see Section C.6, Contractor Performance Measurement in the base contract.

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E. Other Technical Assistance Projects

Task E.1: Quality Improvement Initiatives

Section A. Overview and BackgroundThe QIN-QIO is in a position to provide technical assistance to providers and practitioners to help them improve the quality of their care. As defined in 42 CFR 476.1, a Quality Improvement Initiative (QII) means any formal activity designed to serve as a catalyst and support for quality improvement that uses proven methodologies to achieve these improvements. The improvements may relate to safety, healthcare, health and value and involve providers, practitioners, beneficiaries, and/or communities. CMS has interpreted the regulatory language to include that a QII is any formal plan designed to assist a provider(s) and/or practitioner(s) in identifying the root cause of a concern, develop a framework in which to address the concern and improve a process or system.

A QII may consist of system-wide and/or non-system-wide changes and may be based on a single, confirmed concern or multiple confirmed concerns.

The QIN-QIO must consider all aspects of the care reviewed when evaluating methods to improve care, and shall employ data analysis techniques to identify potential opportunities for improvement. In addition, QIN-QIOs shall consider the impact of changes within, as well as across, settings. QIN-QIOs may work with one, several, or all providers and/or practitioners involved to improve the level of the provider’s and/or practitioner’s performance; however, QIN-QIOs may not share information among providers and/or practitioners without the specific consent of the providers and/or practitioners.

The QIN-QIOs and Beneficiary and Family Centered Care (BFCC)-QIOs are to collaborate and follow the instructions in Chapter 5 of the QIO Manual in the development of QIIs. The BFCC-QIO shall make recommendations to the QIN-QIOs for conducting QIIs associated with quality of care issues. QIIs may be the recommended result of any BFCC-QIO case review function.

QII assistance may also be necessary for referrals by the QIN NCC, Value Incentives and Quality Reporting Center contractors, practitioner and/or provider requests for assistance, or other approved sources. For example, a referral may occur when data reveal that a provider may benefit from assistance based on the analysis of a total performance score for value based purchasing or for systemic improvement in beneficiary safety due to survey and certification findings.


a. To assist providers/practitioners with conducting root cause analysis. b. To assist providers/practitioners in developing processes to improve the quality of

care provided to patients. 2. The specific targets and time periods for these goals are listed in the Evaluation Measures

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Table for this Task.

Section C. Personnel Requirements 1. Designation of Key Personnel—


Section D. Task E.1 Requirements

Task E.1.1. QII Referralsa. The QIN-QIO shall accept recommendations and referrals from the BFCC-QIOs, the QIN

NCC, VIQRC contractors, practitioner and/or provider requests for assistance, or other approved sources for technical assistance to providers, physicians, and other practitioners when a need is identified for Quality Improvement Initiative(s) based on a confirmed quality of care concern.

b. The QIN-QIO shall assist provider(s)/practitioner(s) when technical assistance is requested directly from the provider/practitioner or recommended by the BFCC-QIO, the QIN NCC, VIQRC contractors, or other approved sources.

c. The QIN-QIO shall coordinate with the requestor to analyze findings for the referral. d. For BFCC referrals, the QIN-QIO shall coordinate with the BFCC NCC to analyze

findings from the CMS-designated case review system, other information from review activities, and provider performance measures to:

Identify trends and patterns; Identify needs for technical assistance related to CMS measures across settings to

help providers and/or practitioners meet standards (especially those most challenged to succeed) and;

Provide technical assistance that addresses the specific needs that the QIO has identified, and which promotes evidence-based medical practice and beneficiary-centered care principles to improve quality of care and outcomes to beneficiaries.

e. The QIN-QIO shall develop measurable interventions in collaboration with provider(s)/practitioner(s)/physician(s) practice and address systemic confirmed concerns.

f. The QIN-QIO shall provide assistance to healthcare provider(s) and/or practitioner(s), (especially those most challenged to succeed). Such assistance shall be about how best to employ successful interventions and proven methods to improve healthcare quality and lower costs for the Medicare Program.

g. If, during the course of the QIN-QIO work (i.e., other tasks in the QIN-QIO Task Order), the QIN-QIO identifies problems or concerns that could impact the quality of care that Medicare Beneficiaries are receiving, the QIN-QIO, working with its designated practitioner , shall consider the need to request that the provider and/or practitioner initiate and complete an improvement plan to correct the problem. If an improvement plan is warranted, at the time the QIN-QIO requests initiation of the improvement plan, the QIN-QIO shall alert its CMS COR in writing of the request and the reason it was warranted. A request for an improvement plan must be data based and state clearly the

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issue(s) that warrants improvement. The improvement plan must include the goals/objectives to be achieved, the process/measurements/tools to be used to assess the issue(s) and to measure improvement, and the time frame for accomplishing the improvement plan, including monitoring/documenting improvement. The action to improve the quality of care described in the provider’s/practitioner’s plan must be sustainable.

h. The QIN-QIO shall post tools and resources used in successful interventions on its QIN-QIO website within 30 days of COR/GTL approval.

Task E.1.2. QII DevelopmentFollowing the instructions in the Chapter 5 of the QIO Manual, the QIN-QIO is to work with the practitioner(s) and/or provider(s) to develop a QII. The QIN-QIOs must ensure that all QIIs are cost-effective. The results of QIIs shall be reproducible without necessitating excessive time and/or monetary expenditures. The QIN-QIO shall assist the practitioner(s) and/or provider(s) in leveraging all opportunities for improvement. In addition, the QIN-QIO shall work with both the administrative and the medical staffs (e.g., a hospital quality assurance committee) when providing information and developing, implementing, and monitoring QIIs. The QIN-QIO shall investigate if the practitioner/provider has been recruited into any of the QIN-QIO Learning and Action Networks (LAN). When deemed appropriate, the practitioner/provider shall be requested to participate in the applicable LAN.

The initial planning of a QII must be finalized within 30 calendar days of receipt of the referral/recommendation/request with a QII Plan. The QII Plan shall be developed in accordance with the Task Order Work Plan requirements in Section C.6.4.1 of the Base Contract and submitted to the COR for approval. For level of effort planning purposes, the QIN-QIO shall plan on three QIIs per state within its QIN-QIO area. The implementation of a QII may be delayed an additional 30 calendar days after the QII is completed to obtain sufficient baseline data from which improvements can be measured. The QIN QIO shall collaborate with the referring entity to determine if periodic reviews should be conducted during the implementation of interventions to gauge whether potential improvements are being realized and sustained.

When a QII is determined to be unsuccessful, the QIN must work with the practitioner(s) and/or provider(s) to identify reasons why the plan was unsuccessful and revise the plan as appropriate.

Task E.1.3. QII ReportThe QIN-QIO shall submit a quarterly report with detailed progress on the initiation, development, implementation and conclusion for each QII. The report shall include the identification of successful interventions (e.g., tools and resources) used in each of the QIIs. Also, the report shall include the details of any unsuccessful QIIs based on practitioner(s) and/or provider(s) unwillingness to participate or instances where the QIN-QIO decided not to initiate a QII. A representative from the QIN-QIO shall be prepared to discuss the progress of their QII efforts with the COR on an as-needed basis.

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Section E. Schedule of DeliverablesThe contractor shall provide all deliverables for Task E.1.Technical Assistance – Quality Improvement Initiatives in accordance with Attachment A, Task Order 001 Schedule of Deliverables.

Section F. Measurement, Evaluation, and PerformanceSee Attachment B, Task Order 001, Evaluation Measures Tables for Task E.1. Technical Assistance – Quality Improvement Initiatives. Also, see Section C.6, Contractor Performance Measurement in the base contract.

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11th SOW QIO-QIE Task Order SOW · Web viewSee Attachment B, Task Order 001, Evaluation Measures...

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Transcript of 11th SOW QIO-QIE Task Order SOW · Web viewSee Attachment B, Task Order 001, Evaluation Measures...