QIO 8th Scope of Work Polly Warner, Chief Review Officer UR Workshops, November 2005

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QIO 8th Scope of WorkPolly Warner, Chief Review
OfficerUR Workshops, November 2005

• The enclosed material was prepared and assembled
  by Northeast Health Care Quality Foundation
  (NHCQF), the Medicare Quality Improvement
  Organization (QIO) for Maine, New Hampshire and
  Vermont, under contract with the Centers for
  Medicare Medicaid Services (CMS), an agency of
  the U.S. Department of Health and Human Services.
  The contents presented do not necessarily
  reflect CMS policy.
  1105-318

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QIO 8th Scope of Work

• Contract period 8/1/05-7/31/08
• Quality Improvement Tasks
• Nursing homes
• Home health agencies
• Physician offices
• Part D Benefit
• Hospitals
• Beneficiary Protection Tasks

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Nursing Homes

• Improve clinical performance
• High risk pressure ulcers
• Physical restraints
• Depression symptoms
• Pain
• Promote person directed care and organizational
  culture change to improve resident and staff
  satisfaction and decrease CNA/LNA turnover

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Home Health Agencies

• Reduce acute care hospitalizations
• Improve performance on OASIS measures (bathing,
  transferring, management of oral medications,
  pain, ambulation/locomotion, dyspnea, urinary
  incontinence, status of surgical wounds)
• Increase assessment and use of immunizations
• Promote use of telehealth technologies

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Physician Practices

• Improve effective management of chronic diseases
• Diabetes
• Heart disease
• Improve reliability of delivery of preventive
  services
• Cancer screening (mammography)
• Adult immunizations
• Promote use of electronic clinical information to
  improve clinical performance (DOQ-IT)

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Part D Benefit

• Work with physicians, pharmacists and
  Prescription Drug Plans to develop quality
  improvement projects to improve safety in the
  delivery of prescription drugs

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Hospitals

• Improve clinical performance
• Improve the Appropriate Care Measure (ACM)
  results for AMI, HF and pneumonia
• Promote adoption of standard processes of care
  for the Surgical Care Improvement Project (SCIP)
• Surgical site infection, cardiovascular
  complications, venous thromboembolism, ventilator
  associated pneumonia, promote use of fistulas for
  hemodialysis

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Hospitals

• Hospital Reporting and Validation
• Improve validity, timeliness and completeness of
  Annual Payment Update (APU) measure submission
• Encourage submission of full Hospital Quality
  Alliance (HQA) measure set

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Hospitals

• Evaluate the use of Computerized Physician Order
  Entry (CPOE)
• Assess and improve patient safety climate

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Beneficiary Protection

• Beneficiary Complaint Response Program
• Beneficiary Appeals
• Other Case Reviews
• Quality Improvement Plans
• Hospital Payment Monitoring Program (HPMP)

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Beneficiary Complaint Response Program

• Promote beneficiary satisfaction with the
  complaint process and outcomes
• Many settings with Medicare covered services
• Flexibility to use case review, mediation or
  other alternative dispute resolution options to
  handle complaints

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Expedited Beneficiary Appeals

• Appeals of notices of noncoverage issued in the
  hospital inpatient setting
• Appeals of notices of noncoverage issued in other
  settings
• SNFs, including SNF swing beds
• HHAs
• Hospices
• CORFs

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Other Reviews

• Retrospective notice of noncoverage review
  (general acute care hospitals only, cases with
  patient liability only)
• Hospital requested higher weighted DRG review
• EMTALA review
• Referrals from CMS, FI, OIG, etc.

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Quality Improvement Plans

• QIPs may relate to quality concerns, billing
  errors, coding issues, admission decisions,
  issuance of notices of noncoverage the whole
  spectrum of QIO review

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HPMP

• Measure, monitor and reduce incidence of improper
  FFS inpatient payments
• Monthly random sample reviewed to estimate
  national and state payment error rates

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PEPPER Changes 3rd Quarter Fiscal Year 2005

• Utilization target areas
• New target area
• 3 day SNF qualifying stays
• Deleted target areas
• One day stay transfers
• Same day readmissions
• Revised target area
• DRGs 239/243/253 now just DRG 243, Medical Back
  Pain

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PEPPER Changes (cont.)

• Coding target areas
• New target areas
• Complication/comorbidity pairs
• DRG 089 Simple Pneumonia
• Deleted target area
• DRG 475 Respiratory Diagnosis with Ventilator
  Support

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PEPPER (cont.)

• National PEPPER training Web based
• Maine
• November 10, 2005 1200-100 pm
• New Hampshire and Vermont
• November 15, 2005 1200-100 pm
• Contact www.pepperinfo.org for additional
  information, registration, recorded sessions

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Other Resources

• Top 20 DRG Report
• Data reports on request
• Updated Compliance Manual
• Web Site
• www.nhcqf.org - Review Services
• Helpline
• 1-800-772-0151 ext 165 (Review Services)