The Family Tree of Quality Improvement

Faye Nipps, MBA, BSN, CPHQ

Objectives Clarify knowledge of the Transition of Health and Care

in America Identify three strategies to improve cardiac health through

Best Practice Intervention Packages (BPIPS) and Home Health Quality Improvement (HHQI)

Communicate assistance provided for home health agencies (HHAs) on improving influenza, pneumococcal and herpes zoster immunization rates, reducing hospital readmissions and improving medication safety

Provide resources for data-driven performance improvement from HHQI and the TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO)

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The Centers for Medicare and Medicaid Services

Family Tree of HHQI

4Note: the Million Hearts® word and logo marks are owned by the U.S. Department of Health and Human Services (HHS). Use of these marks does not imply endorsement by HHS. Use of the Marks also does not necessarily imply that the materials have been reviewed or approved by HHS.

2014 Success

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The Triple Aim – CMS QIN-QIOApproach to Clinical Quality

Goals National Patient Safety

Make care safer Strengthen person and family

engagement Promote effective communication

and coordination of care Promote effective prevention and

treatment Promote best practices for healthy

living Make care affordable

Foundational Principles Enable innovation Foster learning organizations Eliminate disparities Strengthen infrastructure and

data systems

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Our Heritage

Source: CMS QIO Program Documentary, https://www.youtube.com/watch?v=jbqUlRRmQgs

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TMF QIN-QIO

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11th Statement of Work (SOW) QIN-QIO Map

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About the QIN-QIO ProgramLeading rapid cycle, large-scale change in health quality: Goals are bolder. The patient is at the center. All improvers are welcome. Everyone teaches and learns. Greater value is fostered.

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Four Key Roles of the QIN-QIO Champion local-level, results-oriented change

› Data-driven› Active engagement of patients and other partners› Proactive, intentional innovation and spread of best practices

that stick Facilitate Learning and Action Networks (LANs)

› Create an all-teach, all-learn environment› Place impetus for improvement at the bedside level (e.g., hand-

washing) Teach and advise as technical experts

› Consultation and education› The management of knowledge so learning is never lost

Communicate effectively› Optimal learning, patient activation and sustained behavior change

TMF QIN-QIO Websitewww.tmfqin.org Provides targeted technical assistance and engages

providers and stakeholders in improvement initiatives through numerous LANs.

The networks serve as information hubs to monitor data, engage relevant organizations, facilitate learning and sharing of best practices, reduce disparities and elevate the voice of the patient.

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LANs

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Join any of the following TMFQIN.org networks and you can sign up to receive email notifications to stay current on announcements, emerging content, events and discussions in the online forums. Cardiovascular Health

and Million Hearts Health for Life –

Everyone with Diabetes Counts Healthcare-Associated Infections Meaningful Use Medication Safety

Nursing Home Quality Improvement

Patient and Family Quality Improvement Initiative Readmissions Value-Based Improvement

and Outcomes

All Are Welcome To join, create a free account at www.tmfqin.org.

Visit the Networks tab for more information. As you complete registration, follow the prompts

to choose the network(s) you would like to join. Choose the Readmission Network and set up a data

portal account to view your agencies’ readmission reports if you are in a QIN-QIO-recruited coalition.

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Care Coordination Readmission

Network

Medication Safety Network

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TMF QIN-QIOs Provide technical assistance with: Community coalition formation Root cause analyses Intervention selection and implementation plan Measurement Readmission and medication safety metrics Educational webinars Open Forum calls

Communities ACT

› East ACT› Delta ACT› North Central ACT*› Northwest ACT*

Oklahoma› Lawton› Norman› Hugo› Durant› McAlester*› Clinton*› Oklahoma City*

Missouri› West Central› Kansas City*› St. Louis*

Puerto Rico› LAZO› CUPRI*

Texas› Denton› El Paso› Lubbock› Rio Grande Valley, Upper› Rio Grande Valley, Lower› Lufkin/Nacogdoches› Temple/Waco› Sherman› Houston*› Dallas*› Ft Worth*› Laredo*

* Recruiting in 2015

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TMF QIN-QIO Goals for Care Coordination and Medication Safety Project Improve care transitions for Medicare Fee-for-Service (FFS)

beneficiaries by recruiting and working with community coalitions Improve medication safety and reduce adverse drug events (ADEs)

for Medicare FFS beneficiaries in the region Special emphasis on these sub-groups of Medicare FFS

beneficiaries:› Dual eligible› Multiple chronic conditions with multiple at-risk medications› Behavioral health issues› Alzheimer’s disease and dementia› Lower socioeconomic status and other social determinates

of health

20Source: Lynn J, Straube BM, Bell KM, Jencks SF, Kambic RT. Using population segmentation to provide better health care for all: The “Bridges to Health” model. Milbank Q. 2007;85:185-208.

Statement of Problem: Readmissions Hospitalizations consume 31 percent

of $2 trillion in total health care expenditures in the United States› 1 in 4 hospitalizations (25 percent) are

avoidable

› 1 in 5 hospitalizations (20 percent) result in 30-day readmissions

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Readmissions Network Goals Reduce hospital readmission rates in the Medicare program

by 20 percent Reduce hospital admission rates in the Medicare program

by 20 percent Increase community tenure by increasing the number

of days spent at home by Medicare FFS beneficiaries by 10 percent

Reduce the prevalence of adverse drug events, emergency department visits and observation stays or readmissions occurring as a result of the care transitions process

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What is an unplanned readmission? A hospitalization within 30 days of discharge

that was not foreseen at discharge Almost always urgent or emergencies Often signal failure of the transition from hospital

to another source of care

Quick Facts In October 2013, Medicare reduced reimbursement by up

to 2 percent for 2,225 hospitals due to excess readmissions. The payment penalty for readmissions increased to 3 percent

in October 2014. MedPAC recommendation: adjust skilled nursing facility (SNF)

payments to reduce hospital readmissions.> This proposal reduces payments by up to 3 percent for SNFs with high

rates of care-sensitive, preventable hospital readmissions, beginning in 2017.

> This will accrue $2.2 billion in savings over 10 years.> MedPAC estimates 14 percent of SNF readmissions are preventable.

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Statement of Problem: Medication Safety National estimates suggest that ADEs contribute an

additional $3.5 billion dollars to U.S. health care costs.1

Given the U.S. population’s large and ever-increasing magnitude of medication exposure, the potential for harm from ADEs is a critical patient safety and public health challenge.

ADEs are a direct result of drugs used during medical care that produce harmful events. These harmful events can include, but are not limited to, medication errors, adverse drug reactions, allergic reactions and overdoses.2,3

1Institute of Medicine Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2006.2Agency for Healthcare Research and Quality. Adverse Drug Event (ADE), in Patient Safety Network: Glossary. Available at: http://psnet.ahrq.gov/glossary.aspx.3National Action Plan for Adverse Drug Event Prevention. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 2013.

Research Shows 80 percent of patients will forget what their providers say

Almost 50 percent of what patients remember is recalled incorrectly

Health literacy costs health care systems as much as $58 billion/year

33 percent of patients are unable to read basic health care material

42 percent of patients do not understand directions for taking medications on an empty stomach

25Source: HHQI Best Practice Intervention Package: underserved populations

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Medication Safety Network Reduce ADEs by 35 percent per 1,000 screened

Medicare FFS beneficiaries by the year 2019

Monitor ADE rates by Medicare FFS beneficiaries on anticoagulants, diabetic agents or opioids by care setting, state, region and readmission rate

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What causes ADEs in the elderly?Research shows: Among older adults (65 years of age

or older), 57-59 percent reported taking five to nine medications, while 17-19 percent reported taking 10 or more.1

ADEs can occur in any health care setting, including inpatient (e.g., acute care hospitals), outpatient and long-term care settings (e.g., nursing homes).

The likelihood of ADEs occurring may also increase during transitions of care (transitions from one health care setting to another) when information may not be adequately transferred among health care providers,2 or patients may not completely understand how to manage their medications.3,4,5

1Slone Epidemiology Center. Patterns of medication use in the United States: A report from the Slone Survey. Boston, MA: 2006. 2Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker FW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-41. 3Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166(5):565-71. 4Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients’ understanding of the post-discharge treatment plan. Arch Intern Med. 1997;157(9):1026-30. 5Lindquist LA, Go L, Fleisher J, Jain N, Friesema E, Baker DW. Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications. J Gen Intern Med. 2012;27(2):173-8.

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What causes ADEs in the elderly?

7Classen DC, Resar R, Griffin F, et al. ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30(4):581-9. 8U.S. Department of Health and Human Services Office of Inspector General (OIG). Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Washington, DC., 2010 November. Report No.: OEI-06-09-00090. 9Lucado, J. (Social & Scientific Systems, Inc.), Paez, K. (Social & Scientific Systems, Inc.), and Elixhauser A. (AHRQ). Medication-Related Adverse Outcomes in U.S. Hospitals and Emergency Departments, 2008. HCUP Statistical Brief #109. April 2011. Agency for Healthcare Research and Quality, Rockville, MD. Available from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb109.pdf. 10Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277(4):307-11. 11Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277(4):301-6. 12Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-7.

Research shows: In inpatient settings, ADEs are the

single largest contributors to hospital-related complications.7 ADEs comprise an estimated one-third of all hospital adverse events,8 affect approximately 2 million hospital stays annually8,9 and prolong hospital length of stay by approximately 1.7 to 4.6 days.9,10,11

ADEs have also been identified as the most common causes of post-discharge complications (those occurring within three weeks of hospital discharge), accounting for two-thirds of all post discharge complications – more than half of which are likely preventable.12

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Hospital VBP FY 2017 Domains

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Improving Medicare Beneficiary Influenza, Pneumococcal and

Herpes Zoster Immunization Rates

Immunization Project ObjectivesImprove: Tracking Assessment and documentation Reporting

Special focus: Reducing immunization health care disparities

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Discussion QuestionInfluenza and pneumonia are ranked what number as the top 10 leading cause of death?a. 7th leading causeb. 5th leading causec. 8th leading cause

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Influenza and Pneumonia: Eighth-Leading Cause of Death

Source: CDC/NCHS, National Vital Statistics System, Mortality

34Sources: http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf;

53,282

Deaths from Pneumonia

65 years and older

Less than 65 years

90%

Deaths from Influenza

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Discussion QuestionWhat percentage of Medicare beneficiaries are vaccinated for influenza?a. 60 percentb. 54 percentc. 49 percent

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37Source: Centers for Disease Control and Prevention. (2014). Interactive mapping tool: Live-tracking flu vaccinations of Medicare beneficiaries; Williams, W. W., Lu, P-J., O’Halloran, A., Bridges, C. B., Pilishvili, T., Hales, C. M., & Markowitz, L. E. (2014). Noninfluenza vaccination coverage among adults . United States, 2012. Morbidity and Mortality Weekly Report, 63(5), 95-102

Percentage of Medicare Beneficiaries Vaccinated

Pneumoc-cocal

Influenza0

102030405060708090

100

Percentage of Medicare Bene-ficiaries Vacci-nated

54%60%

1 million cases

Varicella / Shingles

100% effective Herpes Zoster Vaccine 20% Vaccinated

Source: http://www.cdc.gov/vaccines/vpd-vac/varicella/rationale-vacc.htm

Herpes Zoster

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Influenza Vaccination

Received at Physician Of-fice

0102030405060708090

100

59%

Medicare Beneficiaries Vaccinated

0

20

40

60

80

100

54%

Source: Centers for Disease Control and Prevention. (2014). Interactive mapping tool: Live-tracking flu vaccinations of Medicare beneficiaries; Williams, W. W., Lu, PJ, O’Halloran, A., Bridges, CB, Pilishvili, T., Hales, C. M., & Markowitz, L. E. (2014). Centers for Medicare and Medicaid Services. Overview Medicare Current Beneficiary Survey. 2011a Retrieved from http://www.cms.gov/mcbs/

Discussion QuestionWhat racial/ethnic group has the lowest rates for influenza vaccinations?a. Whiteb. Asianc. Black d. Hispanic

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Zoster

Influenza

Pneumococcal

0 10 20 30 40 50 60 70 80 90 100

WhiteAsianBlackHispanic

64 %41 %

46 .%

71 %

43 .%

56 %

55 %

34 %

23 %

17 %9 %

9 %

Source: Centers for Disease Control and Prevention. (2014). Interactive mapping tool: Live-tracking flu vaccinations of Medicare beneficiaries; Williams, W. W., Lu, P-J., O’Halloran, A., Bridges, C. B., Pilishvili, T., Hales, C. M., & Markowitz, L. E. (2014). Noninfluenza vaccination coverage among adults – United States, 2012. Morbidity and Mortality Weekly Report, 63(5), 95-102

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Medicare Immunization Rates by Type, Race and Ethnicity

2019 Goals Align with the Healthy People 2020 Goals› National Absolute Immunization Rates • 70 percent influenza • 90 percent pneumonia• 30 percent zoster

1 million previously unimmunized Medicare beneficiaries will receive pneumonia immunization

90 percent of adult immunizations will be reported to the registry

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Recruitment: Health Care Providers Physician Offices Hospitals Critical Access Hospitals HHAs Pharmacies Vaccination Centers

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Recruitment: Community Community Organizations Physician Organizations State/Territory Agencies State/Territory Immunization Registries Beneficiary Representatives

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Technical AssistanceCollaborate with HHAs and provide technical assistance on: Improving cardiac health through BPIPS Improving immunization rates for influenza,

pneumococcal and herpes zoster diseases Reducing hospital readmissions Improving medication safety

Technical Assistance, cont. Educating patients, staff, physicians Standing orders and protocols Electronic health record and paper chart:

reminder/recall systems Flu-Fit Program (American Cancer Society) Improving accessibility Immunization registry reporting Policy and procedure updates

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Technical Assistance, cont. Providing evidence-based practices Sharing interventions and techniques

to increase community demand Promoting the “Immunization Passport” to

improve documentation and communication Identifying or developing educational tools

and resources

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Proposed Annual Impact 61,000 Medicare beneficiaries: Pneumonia vaccination: 5,850 Influenza vaccination: 52,950 Herpes zoster vaccination: 2,200

Coordinated Interventions

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FLU-FIT PROGRAM

IMMUNIZATION REGISTRIES

SHARED TOOLS AND BEST PRACTICES

ENHANCED VACCINATION

ACCESS

AFFINITY GROUP SESSIONS

EDUCATIONAL PROGRAMS

COMMUNITY VACCINATION CLINICS

www.HomeHealthQuality.org

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Data Individualized reports:

› Acute Care Hospitalization› Oral Medication

Management› Immunizations

Securely delivered online Updated monthly OASIS-based (raw and risk-

adjusted) Historical trends and target

setting

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Cardiovascular Health NetworkTMF QIN-QIO

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Access to resources and literature

Expert Consulting Services

Access to live online forums for networking

HHQI tools and interventions

Assistance focused on the ABCS

Cardiovascular Health Network HHAs

Benefits

http://www.tmfqin.org

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Cardiovascular Health: Let’s Get to the Heart of the Data

The Facts Heart disease and stroke

are the FIRST- and FOURTH-leading causes of death respectively for all races in the United States

Annually, heart disease and stroke cost more than $312.6 billion in health care expenditures and lost productivity

Put it into Perspective

800,000people

Weekly attendance at Disney World®

Number of Americans who

DIE from HEART DISEASE

EVERY YEAR

2,200people

Number of passengers in four loaded

jets

People who die EVERY DAY

from cardiovascular

disease

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Cardiovascular Health NetworkHHAs

We help HHAs sign up for the Cardiovascular Data Registry, developed through the HHQI National Campaign. This registry allows HHAs to track progress related to the ABCS (Aspirin therapy, Blood pressure management, Cholesterol control and Smoking/tobacco cessation).

Utilize BPIPs to provide technical

assistance

Utilize health literacy tools

to provide education

Participate in cardiac LAN Network

activities and share success stories

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Cardiovascular Health NetworkTechnical assistance: Focus on ABCS Improving health care delivery Regional open forums and LANs CMS incentive payment programs Patient/provider collaboration Tools and resources on www.tmfqin.org

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Cardiovascular Health NetworkGoals: Facilitate improvements and

best practices

Assist Providers with reporting cardiovascular PQRS reporting

Assist HHAs to report cardiovascular measures through the Home Health Cardiovascular Data Registry (HHCDR)

Improving performance on the following clinical quality measures:

> Aspirin therapy; > Blood pressure control > Cholesterol control > Smoking/Tobacco Use

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HHCDR Available to CMS-certified HHAs Helps target potential disparities in care Provides evidence of impact made by improvement efforts Most data auto-populates from OASIS-C transmissions Requires approximately two to three hours per month Option to select which measure/s to abstract: ABCS Twelve patients per measure or total discharges (whichever

is smaller)

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Do You Know Your ABCS?

The Million Hearts® word and logo marks are owned by the U.S. Department of Health and Human Services (HHS). Use of these marks does not imply endorsement by HHS. Use of the Marks also does not necessarily imply that the materials have been reviewed or approved by HHS.

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HHCDR Was the patient taking ASA? Final blood pressure?› Was HTN addressed during this episode?

Did the patient have a lipid panel in the record? Was the patient assessed for tobacco use?› Was it addressed?

Was the patient dually eligible?

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Cardio Milestones Sign up for the HHCDR Download all cardiovascular BPIPs Complete HHCDR security authentication Close at least one month of required patient data in the HHCDR Download at least one HHCDR report Abstract and close a total of six months of required patient data

for HHCDR Validate data Achieve noted improvement in one or more cardiovascular

outcomes

67http://homehealthquality.org

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BPIPs Two primary cardiovascular health BPIPs

› Aspirin as appropriate and blood pressure control › Cholesterol management and smoking cessation

Fundamental BPIPS focus on:› Blood pressure control › Smoking cessation

Include patient tools and resources Free nursing continuing education credits available

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Sign Up Today

THE DNA

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Questions?

Faye Nipps, MBA, BSN, CPHQTMF Quality Innovation Network

Phone: 501-920-4607fnipps@afmc.org

Faye.Nipps@area-b.hcqis.org

This material was prepared by TMF Health Quality Institute, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 11SOW-QINQIO-C3-15-57