Hospital Metrics TAG February 14, 2017 PLEASE DO NOT PUT YOUR PHONE ON HOLD: IT IS BETTER TO HANG UP AND CALL BACK IN IF NEEDED
Welcome and Introductions 2
Agenda Overview • Updates • Year 3 data submission process and schedule • CLA BSI / CAUTI (Year 3 and 4) • Details of CMS approved Year 4 program structure • H-TAG in 2017 • Unity Center for Behavioral Health 3
Updates 4
Updates • CMS approved Oregon’s Medicaid waiver and HTPP Year 4 (more on that separately) • OAHHS opioid / readmissions education day planned for February 24, 2017 5
CCO Metrics & Scoring Committee Updates (1/2) • The Committee has removed the claims-based SBIRT measure from the 2017 incentive measure set, given additional coding complications. • The Committee encourages CCOs and practices to continue implementing SBIRT while an EHR-based measure is developed in 2017. • The Committee intends to reinstate the EHR-based measure to the incentive set for CY 2018. 6
CCO Metrics & Scoring Committee Updates (2/2) • The Committee also met on January 20 th to review their work plan for selecting 2018 measures, begin a discussion on patient experience measures, and to come to a decision about a health equity measure. • The Committee has agreed to adopt the Emergency Department Utilization measure for people experiencing severe and persistent mental illness (SPMI) as the equity measure for 2018. – Additional details about the proposal are available in the January meeting materials online. http://www.oregon.gov/oha/analytics/Pages/Metrics- Scoring-Committee.aspx 7
Health Plan Quality Metrics Committee • Purpose: to identify health outcome and quality measures that may be applied to services provided by CCOs or paid for by health benefit plans sold though the HIE or offered by the OEBB or the PEBB. • Will not oversee hospital metrics, but there will be a hospital representative on the Committee • OHA working to finalize Committee membership 8
Year 3 Close Out Process 9
Year 3 Close-out • See materials, Year 3 performance calculations document • OHA is posting an Excel document that gives an explanation of the calculations used in assessing payment, including rounding conventions, etc: http://www.oregon.gov/oha/analytics/Pages/Hos pital-Baseline-Data.aspx • It includes a copy of the template OHA uses to assess payment. Hospital can see the formulas used, etc. 10
Year 3 Close-out • See materials: Year 3 timeline • Timeline and data submission document updated to include a table with the data source for each metric (progress reporting versus final data used for payment). 11
Year 3 Close-out • Key dates – February 15 th : CMT publishes final Year 3 EDIE measure report. – February 23 rd : OHA distributes final Follow-up after hospitalization for mental illness measure progress report to all hospitals. Hospitals must respond with any additional requested changes to these reports by 3/31/2017 – March 31 st : Apprise makes official data submission to OHA an all measures but EDIE, CLABSI, CAUTI, and FU after mental illness hospitalization 12
Year 3 Close-out • Key dates (cont.) – May 12 th : OHA will distribute draft Year 3 performance reports to all hospitals – June 10 th : Hospitals will be notified of final performance and payment amounts – June 30 th : Payments issues • As for Year 2, hospitals are reminded to send their Year 3 HCAHPS documentation to htpp@apprisehealthinsights.com. • Any additional Year 3 process questions? 13
CLABSI and CAUTI reporting for HTPP Roza Tammer, MPH, CIC HAI Reporting Epidemiologist, HAI Program Hospital Metrics Technical Advisory Group (TAG) Meeting February 15, 2017, 10am-12pm
Acronyms, in order of appearance • HTPP: Hospital Transformation Performance Program • CLABSI: Central line-associated bloodstream infection • CAUTI: Catheter-associated urinary tract infection • NHSN: National Healthcare Safety Network • OHA: Oregon Health Authority • HAI: Healthcare-associated infection • OAHHS: Oregon Association of Hospitals and Health Systems
CLABSI & CAUTI reporting for HTPP • HTPP metrics include CLABSI and CAUTI data • Facilities historically report these data to – NHSN for the OHA HAI Program legislatively mandated reporting requirements – Apprise and Excel spreadsheet for HTPP participation reporting requirements (managed by OAHHS) – The OHA Office of Health Analytics uses these data to manage HTPP reimbursements • OAHHS, OHA of Health Analytics, and OHA HAI Program are collaborating to – Coordinate efforts and use resources more efficiently – Reduce burden on facility staff time – Implement a consistent process – Continue to provide progress data to facilities
All hospitals Request technical Pull quarterly CLABSI Review Edit data in Enter data assistance if needed & CAUTI data from NHSN data (incl. HTPP NHSN into NHSN during internal NHSN and enter into sent by HAI validation review period participants) Apprise platform Program Manage Export and format Provide data to facilities Export Analyze data & Provide technical Analyze & publish OHA HAI NHSN data (incl. CLABSI for internal validation (CC final data send to OHA Office assistance to facilities data in annual HAI groups & & CAUTI) from OHA Office of Health from of Health Analytics to resolve identified Program Program report data NHSN Analytics & OAHHS) NHSN (CC OAHHS) discrepancies OHA Office Staff monthly Coordinate Report quarterly progress Coordinate Publish data Technical Advisory issuance of reporting data on all biweekly of Health in annual Group (TAG) HTPP measures (incl. CLABSI & status calls HTPP report meetings payments Analytics CAUTI) to CMS with OAHHS Send OHA Office of Health Edit final data Manage Analytics quarterly OAHHS in Apprise Apprise progress data, incl. platform platform CLABSI & CAUTI SIR: Standardized infection ratio
Reporting timelines: 2017 & 2018 2017 Activities 2018 • OHA HAI Program generates data in NHSN SIRs for HTPP Year 4 baseline • OHA HAI Program prepares reports to send to hospitals 4/3 4/2 for internal validation Rates for HTPP Year 3 SIRs for HTPP Year 4 • OHA HAI Program sends CAUTI and CLABSI data to hospitals for internal validation 4/10 4/9 • Hospitals review and make any necessary changes in NHSN • Hospitals have until the COB on this date to make any necessary changes in NHSN • OHA HAI Program will generate data in NHSN at 5pm to ensure any changes made during the validation period 4/24 4/20 are included in the final data used in HTPP and HAI Program reports; changes made after this date will not be represented in HTPP or HAI Program report data 4/28 • OHA HAI Program will provide final CLABSI and CAUTI 4/30 data to the OHA Office of Health Analytics
Priority: Save facilities time & effort • Internal validation process managed by HAI Program covers both HAI Program and HTPP needs • Facilities can contact HAI Program directly for technical assistance with NHSN – Not just during the review period! • Mismatches inherent in using different data systems/export dates resolved – Data will be easier to interpret and explain – Only one data source (NHSN) makes internal validation more straightforward
Questions and discussion Contact us! OHA Office of Health Analytics Sara Kleinschmit, MSc Policy Advisor Direct phone: 971-673-3364 sara.kleinschmit@state.or.us OHA HAI Program OAHHS Roza Tammer, MPH, CIC Elyssa Tran, MPA Healthcare-Associated Infections Associate Vice President, Government Services (HAI) Reporting Epidemiologist Direct phone: 503-479-6004 Direct phone: 971-673-1074 elyssa.tran@apprisehealthinsights.com roza.p.tammer@state.or.us
HTPP Year 4 21
Final Year 4 Program Structure CMS approved an additional year of HTPP (HTPP Year 4) in January 2017. To summarize: • Limited changes to overall structure and measures (domain and payment structure, and 11 incentive measures from Year 3 continue into Year 4) • Approval of specification changes to CLABSI (shift to SIR); CAUTI (shift to SIR); and, EDIE (shift to outcome measure). • Payment amounts remain based on Medicaid discharges and days (but shift base from FFY 2012 to CY 2015) 22
Final Year 4 Program Structure • Amount in pool is consistent with Year 3 (federal match of state dollars generated by 0.5% of the Hospital Assessment Program) • Shift to calendar year: – The Year 4 measurement period is January 1, 2017 – December 31, 2017. – Any hospitals not conducting SBIRT screenings at every visit an individual patient has (instead using a ‘look back’), need to update the look back date so that staff are reminded to screen any patient who has not had an SBIRT screening from January 1, 2017, on. 23
Final Year 4 Benchmarks Improvement Target Measure Year 4 Benchmark Floor Adverse drug events due N/A (no improvement 2.0% to Opioids target) Excessive N/A (no improvement anticoagulation due to 2.0% target) Warfarin Hypoglycemia in MN method with 1 inpatients receiving 3.0% percentage point floor insulin National 90 th percentile, April / May 2016 (91.0%) MN method with 2 HCAHPS – discharge Shriners, 90 th percentile percentage point floor (TBD%) National 90 th percentile, MN method with 2 HCAHPS – medication April / May 2016 (73.0%) percentage point floor 24
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