Primaris Dorothy Andrae, MHA, BSN, RN, CPHQ Director, Clinical Review and Pt. Safety, Hospital Rural HIT Summit May 2010
Who is Primaris? <ul><li>Healthcare consulting firm  </li></ul><ul><li>Works with hospitals, physicians, nursing homes, he...
Missouri’s QIO <ul><li>Medicare population </li></ul><ul><li>Confidential </li></ul><ul><li>Information statutorily protec...
Past, Present, and Future <ul><li>Past </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>SOWs – 3 year cycles  </li...
The 9SOW <ul><li>August 2008 – July 2011 </li></ul><ul><li>Theme-oriented (not setting oriented) </li></ul><ul><li>Work wi...
9SOW Focus <ul><li>Four Themes: </li></ul><ul><ul><li>Prevention </li></ul></ul><ul><ul><li>Beneficiary Protection </li></...
Prevention <ul><li>Goal    to prevent and/or slow disease progression </li></ul><ul><li>Increase effective use of EHR/tec...
Beneficiary Protection Tasks <ul><li>Goal    to protect the rights and health of Medicare beneficiaries </li></ul><ul><ul...
<ul><li>Goal    to reduce or prevent patient harm </li></ul><ul><li>Work focused in hospital and nursing home settings </...
Patient Safety <ul><li>Work focused in hospital and nursing home settings </li></ul><ul><li>Pressure Ulcer  </li></ul><ul>...
<ul><li>www.primaris.org </li></ul><ul><li>[email_address] </li></ul><ul><li>800-735-6776 ext. 209 </li></ul><ul><li>or </...
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Primaris rural hit summit may 2010

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  • We have made great progress in the 8 th SOW. Now we will change things up a bit in the 9 th SOW. On August 1, 2008, the QIOs will begin the 9 th Scope of Work. As part of the contract requirements, QIOs will center their improvement efforts on four Themes: Beneficiary Protection, Care Transitions, Patient Safety, and Prevention. Each Theme has measurable criteria, and CMS will use close monitoring and performance improvement plans to gauge each QIO’s performance under the contract.
  • In the 9th SOW, QIOs will concentrate their efforts on facilities with the greatest opportunity for improvement on specific measures of health care quality. This was one of the Institute of Medicine’s key recommendations for improving the QIO Program—prioritizing program resources so QIOs can help providers that demonstrate the greatest need. In addition to the facilities identified by CMS, Primaris will have the opportunity to assist other facilities in Missouri if the facility requests assistance.
  • The goal of the Prevention Theme is to improve the quality and frequency of preventive health care services in order to optimize beneficiary quality of life and health care efficiencies. The Prevention theme consists of three focus areas: Core Prevention, Diabetes Disparities, and Chronic Kidney Disease (CKD).
  • In the 9th SOW, QIOs: Beneficiary Complaints Appeals Higher Weighted DRGs Referrals EMTALA In the event of a confirmed quality of care concern, QIOs must follow all CMS instructions. This includes allowing the provider an opportunity for discussion, imposing a corrective action plan where appropriate, and referring cases to the Office of Inspector General (OIG) when a QIO identifies a case in which the provider violates or fails to comply with any obligation in Section 1156(a) of the Social Security Act. Each QIO must maintain a beneficiary hotline to provide callers with information concerning Medicare beneficiary rights and responsibilities, beneficiary protections, and the various QIO programs and initiatives. The helpline must be staffed during normal business hours with the capability to record calls received outside of normal business hours. In addition, QIOs must actively promote, and support hospitals in, submission of quality data for reporting and Annual Payment Update (APU) purposes. QIOs must have a basic understanding of all measures, deadlines for submission, and the impact on the APU. QIOs will offer educational and technical assistance to providers on the use of CMS systems and reporting tools such as CART, QualityNet, and the QIO Clinical Warehouse. Finally, QIOs will continue to fulfill other responsibilities on a regular basis. These responsibilities include physician acknowledgement monitoring, where the QIOs ensure that hospitals have a physician acknowledgement statement on file for all physicians billing for services provided in the hospital. The QIOs must also work with the Beneficiary Satisfaction Survey Contractor who is surveying beneficiaries regarding their satisfaction with the QIO complaint process. The QIO is responsible for providing complete and timely information to the Survey Contractor. Finally, QIOs must provide an annual public report of all medical service reviews, using a template provided by CMS.
  • QIO activities for the Patient Safety Theme will focus on six primary topics: Reducing rates of health care–associated methicillin-resistant Staphylococcus aureus (MRSA) infections; Reducing rates of pressure ulcers in nursing homes and hospitals; Reducing rates of use of physical restraints in nursing homes; Improving inpatient surgical safety and heart failure treatment in hospitals; Improving drug safety; and Providing quality improvement technical assistance to nursing homes in need.
  • Primaris rural hit summit may 2010

    1. 1. Primaris Dorothy Andrae, MHA, BSN, RN, CPHQ Director, Clinical Review and Pt. Safety, Hospital Rural HIT Summit May 2010
    2. 2. Who is Primaris? <ul><li>Healthcare consulting firm </li></ul><ul><li>Works with hospitals, physicians, nursing homes, health plans, and home health agencies </li></ul><ul><li>URAC accredited </li></ul><ul><li>Holds Medicare quality improvement organization (QIO) contract for Missouri </li></ul>
    3. 3. Missouri’s QIO <ul><li>Medicare population </li></ul><ul><li>Confidential </li></ul><ul><li>Information statutorily protected </li></ul>
    4. 4. Past, Present, and Future <ul><li>Past </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>SOWs – 3 year cycles </li></ul></ul><ul><ul><li>Evolution – less oversight, more consulting </li></ul></ul><ul><li>Present </li></ul><ul><ul><li>9SOW to December 2010 </li></ul></ul><ul><ul><li>Work with Identified Participant (IP) Providers </li></ul></ul><ul><li>Future </li></ul><ul><ul><li>Transition to 10 th SOW and beyond </li></ul></ul>
    5. 5. The 9SOW <ul><li>August 2008 – July 2011 </li></ul><ul><li>Theme-oriented (not setting oriented) </li></ul><ul><li>Work with Providers: </li></ul><ul><ul><li>Focus on facilities with the greatest opportunity for improvement </li></ul></ul><ul><ul><li>Continue to provide assistance and resources to other providers as needed </li></ul></ul>
    6. 6. 9SOW Focus <ul><li>Four Themes: </li></ul><ul><ul><li>Prevention </li></ul></ul><ul><ul><li>Beneficiary Protection </li></ul></ul><ul><ul><li>Patient Safety </li></ul></ul><ul><ul><li>Care Transitions </li></ul></ul>
    7. 7. Prevention <ul><li>Goal  to prevent and/or slow disease progression </li></ul><ul><li>Increase effective use of EHR/technology </li></ul><ul><li>Focus on screening: </li></ul><ul><ul><li>Colorectal Cancer, Mammography </li></ul></ul><ul><ul><li>Influenza and Pneumococcal vaccination </li></ul></ul><ul><li>Three areas of focus: </li></ul><ul><ul><li>Core measures </li></ul></ul><ul><ul><li>Chronic kidney disease </li></ul></ul><ul><ul><li>Disparities </li></ul></ul>
    8. 8. Beneficiary Protection Tasks <ul><li>Goal  to protect the rights and health of Medicare beneficiaries </li></ul><ul><ul><li>Case Reviews – Medical Record reviews for quality </li></ul></ul><ul><ul><li>Quality Improvement Activities (QIAs) </li></ul></ul><ul><ul><li>Alternative Dispute Resolution (ADR) </li></ul></ul><ul><ul><li>Sanction Activities </li></ul></ul><ul><ul><li>Physician Acknowledgement Monitoring </li></ul></ul><ul><ul><li>Maintain a beneficiary hotline </li></ul></ul><ul><li>Quality Data Reporting ** </li></ul>
    9. 9. <ul><li>Goal  to reduce or prevent patient harm </li></ul><ul><li>Work focused in hospital and nursing home settings </li></ul><ul><li>Topics include: </li></ul><ul><ul><li>Physical restraints </li></ul></ul><ul><ul><li>Pressure ulcers </li></ul></ul><ul><ul><li>Surgical safety/heart failure </li></ul></ul><ul><ul><li>Drug safety </li></ul></ul><ul><ul><li>MRSA </li></ul></ul><ul><ul><li>Technical assistance to NHs in need </li></ul></ul>Patient Safety
    10. 10. Patient Safety <ul><li>Work focused in hospital and nursing home settings </li></ul><ul><li>Pressure Ulcer </li></ul><ul><li>What happens when you link hospitals and NH together? </li></ul><ul><ul><li>Prevention and treatment </li></ul></ul><ul><ul><li>Cross setting collaboration </li></ul></ul><ul><ul><li>What happens when you link hospitals and NH together? </li></ul></ul>
    11. 11. <ul><li>www.primaris.org </li></ul><ul><li>[email_address] </li></ul><ul><li>800-735-6776 ext. 209 </li></ul><ul><li>or </li></ul><ul><li>[email_address] </li></ul><ul><li>816-305-6523 </li></ul>Questions?

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