PCP POD Meeting January 5, 2017 1 Agenda Call to order Richard - PowerPoint PPT Presentation

PCP POD Meeting January 5, 2017 1

Agenda • Call to order Richard Gough, MD • Quality Reporting Timeline Shelley Grant • 2017 MSSP Quality Measures Richard Gough, MD Johnson Koilpillai, MD • CY2016 Performance Results Richard Gough, MD Johnson Koilpillai, MD • 2017 Meeting Schedule Richard Gough, MD • Wrap ‐ up/Adjourn Richard Gough, MD 2

Medicare Shared Savings Program 2016 Quality Measure Reporting Timeline 3

2016 Quality Measure Reporting  FIHN provides Remote User Access Form to Practice(s)  12/01/16 thru 12/15/16  FIHN and Primaris (PQRS Vendor) confirm EHR Access with each practice  12/15/16 – 1/3/17  Patient List and Measures required received from CMS (approx. 4,216 patients)  1/3/17  FIHN and Primaris complete Audit  1/3/17 thru 3/10/17  FIHN submits Final Results to CMS 4  3/10/17

Required Practice Support • Confirm your practice manager has completed and returned the Remote Access Form! • Ensure remote access user log ‐ ins have been set ‐ up. • Ensure availability of practice staff for abstraction questions. 5

Practices Pending EHR Access • Branislav Romanic MD LLC • Frederick Center for Advanced Cardiology • Comprehensive Neurology and Sleep Medicine • Mann & Henry Podiatry • Comprehensive Neurology • Primary Medical Services, PC Services • Sajjad Aziz, MD • Urology Consultants of MD • Cardiology Associates • David Kossoff, MD PA • Syed Haque, MD • Progressive Podiatry • Kidney Center of Frederick & • Frederick Medical and Hagerstown Pulmonology • X’Cel Primary Care • Frederick Oncology • Irfan Hassen, MD Hematology Associates • Frederick Urology Associates 6

Medicare Shared Savings Program 2017 Quality Measures 7

Changes to MSSP 2017 Quality Measures 8

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Quality Scoring Points System Total Points Earned Per Domain = Overall Domain Score Total Possible Points Per Domain Overall Domain Scores are averaged and divided by number of domains (4) 1 2 to determine overall quality performance score – affects shared savings rate!

Both Attainment and Improvement in performance is taken into account when calculating our final sharing rate. Rewarded up to 4 additional points in each domain, if we demonstrate quality improvement. Not to exceed the maximum points per domain 1 3

How are benchmarks established? • 2016 and 2017 Benchmarks were established using quality data from Medicare FFS data and includes: • PQRS reported quality data by physicians and groups (2012, 2013, 2014, and 2015) • MSSP and Pioneer ACOs reported quality data (2012, 2013, 2014, and 2015) • CAHPS survey data from ACOs, PQRS, and Medicare FFS CAHPS (2012, 2013, 2014, and 2015) • Attestation, Hardship, and Meaningful Use data collected through the EHR Incentive Program (2013 and 2014) 1 4

Changes to MSSP Quality Benchmarks and Minimum Attainment • “Quality Performance Standard” (ACO must achieve to be eligible for shared savings) • Year 1 = Complete and Accurate Reporting • Year 2 and beyond = Complete and Accurate Reporting AND must score above the minimum attainment level on at least one measure in each domain. • “Minimum Attainment” • Reporting Measures = complete and accurate reporting • Performing Measures = level of 30 percent or 30 th percentile • “Quality Performance Requirement” (ACO must achieve to avoid compliance action) • Must achieve the minimum attainment level on 70% of the 1 5 measures in a domain or CMS will take compliance action. Previously ‐ achieve 70% on performance measures only

Domain: Patient/Caregiver Experience (CAHPS Survey) • ACO 1: Getting Timely Care, Appointments, and Information • (79.11% or 1.70pts) • ACO 2: How Well Your Providers Communicate • (90.11% or 2.0pts) • ACO 3: Patients’ Rating of Provider • (89.80% or 1.85pts) • ACO 4: Access to Specialists • (84.35% or 1.85pts) 1 6

Domain: Patient/Caregiver Experience (CAHPS Survey) • ACO 5: Health Promotion and Education • (55.99% or 0pts) • ACO 6: Shared Decision Making • (74.00% or 1.10pts) • ACO 7: Health Status/Functional Status • (75.78% or 2pts) • ACO 34: Stewardship of Patient Resources • (25.55% or 1.10pts) 1 7

Reminder – Patient Experience Survey is currently underway • Second paper survey mailed to non ‐ respondents • December 13 – 14, 2016 • Telephone interviews begin • January 4, 2017 • Data collection ends • February 1, 2017 • FIHN receives results • March 2017 1 8

ACO Customer Service – CAHPS Priority Recommendations (from Press Ganey) – 1. Sit at eye level when talking to patients, do not interrupt 2. Acknowledge concerns and emotions verbally ‐ “Let’s talk more about your concerns/fears”, “Let’s write down the next steps for you and your family”, “If you have questions please do not hesitate to call the office” 3. Reference information from the last visit and history D emonstrating communication between providers 4. Ask the patient to repeat instructions – teach back approach 1 9

Domain: Care Coordination/Patient Safety • ACO 8: Risk ‐ Standardized, All ‐ Condition Readmissions • ACO 35: Skilled Nursing Facility 30 ‐ Day All ‐ Cause Readmission Measure • ACO 36: All ‐ Cause Unplanned Admissions for Patients with Diabetes • ACO 37: All ‐ Cause Unplanned Admissions for Patients with Heart Failure • ACO 38: All ‐ Cause Unplanned Admissions for Patients with Multiple Chronic Conditions 20

Domain: Care Coordination/Patient Safety • ACO 43: ASC Acute Composite (PQI#91) • PQI #10 Dehydration Admission Rate/10,000 • PQI #11 Bacterial Pneumonia Admission Rate/10,000 • PQI #12 Urinary Tract Infection Admission Rate/10,000 • ACO 11: Use of Certified EHR Technology • Advancing Care Information (ACI) Practice Reported Data for ALL Providers (PCP & Specialists) 21

Action Plan – Care Coordination/Patient Safety • Manage Transitions • Register and monitor CRISP for patient alerts • Contact patients within 48 hours to schedule • Effective Care Coordination • Care Clinic • SNF Preferred Partner Arrangements 22

Action Plan – Care Coordination/Patient Safety • Early identification of patients with Ambulatory Sensitive Conditions (ASC) diagnoses • Evaluate and/or modify access to practice (i.e. same day appts, after ‐ hours, weekends). • If your practice has a coverage arrangement ensure it’s effective • Ensure there is easy access to urgent care, if unable to see patients in a timely manner. 23

Domain: Care Coordination/Patient Safety • ACO 12: Medication Reconciliation Post ‐ Discharge • ACO 13: Screening for Future Fall Risk • ACO 44: Use of Imaging for Low Back Pain 24

ACO 12: Medication Reconciliation Post Discharge Numerator Denominator Comments EHR Documentation Medication All discharges from • Exclusions – None • Document in reconciliation any inpatient facility • Exceptions ‐ None Medication conducted by a (e.g. hospital, skilled Other comment ‐ Module for quality • physician, prescribing nursing facility, or denominator is reporting – check practitioner, rehabilitation facility) based on box for registered nurse, or for patients 18 years discharges medications clinical pharmacist on of age and older seen followed by an “reconciled” or or within 30 days of within 30 days office visits, not “verified” discharge following discharge in patients – patients the office by the may appear in the **medication reconciliation is physician, prescribing denominator defined as a review of the practitioner, more than once if discharge medication list with the most recent medication list registered nurse, or there was more in the outpatient record clinical pharmacist than one providing on ‐ going discharge in the 25 care. reporting period

ACO 13: Screening for Future Fall Risk Numerator Denominator Comments EHR Documentation Patients who were Patients aged 65 • Exclusions – None NG ‐ Health screened for future years and older with Exceptions ‐ • Promotion Plan  fall risk at least once a visit during the documentation of Fall Risk panel within the measurement period medical reason for OR Social History  measurement period not screening (e.g. patient is not Lifestyle (Home ambulatory) Environment/Safety Future Fall Risk Definition ‐ if patient has had 2 or more falls in eCW ‐ Preventive the past year or any fall with injury in the past year Medicine> Screening/Special A specific screening tool is not required for this measure, Tests> Fall Risk however potential screening tools include the Morse Fall Screening Scale and the timed Get ‐ Up ‐ & ‐ Go test . OR Medicare 26 Preventative Screening Questionnaire