Hospital Metrics TAG November 10, 2015
Welcome and Introductions 2
Agenda Overview • Updates • Year 2 data submission timeline & draft checklist • EDIE-sourced measure validation process • Review draft PPR specifications • Review stakeholder survey findings • Wrap-up 3
Updates • Year 3 CMS discussions • Committee updates – Work plan – Behavioral health learning session, 30 Oct. – Next meeting 20 November • Miscellaneous – Follow-up after hospitalization for mental illness progress reports were distributed on 27 October 4
Updates (2): Proposed new domains – highlighted areas for further exploration No. Proposed Domain Name 1 Transitions of Care** 2 Community Health Needs Assessment, Education, and Outreach 3 Patient- and Family-Focused Care** 4 Disparities Reduction 5 Youth Women and Children – Perinatal Care** 6 7 Efficiency** (move to bundled payments) Drop all current domains – use new framework 8 9 Medication side (pharmacy and safety improvements) 5
Updates (3) • CCO Metrics Update 6
Data Submission Timeline & Draft Checklist (see materials) Apprise Health Insights Elyssa Tran 7
DATA SUBMISSION TIMELINE – BASELINE • Baseline data re-submission Measure Why? Data Timeframe Due Date CAUTI NHSN specs changed Jan 1, 2015-March 31, October 16, 2015 2015 (Completed) SBIRT De-duplication Varies; need to match December 31, 2015 original submission EDIE Validation, bug, EPIC Varies; need to match February 15, 2016 issue original submission • Done via spreadsheet outside of HTPP reporting platform; send to Elyssa directly • Re-submission of baseline data on any other measures must be approved by OHA first 11/9/2015 8 Oregon Association of Hospitals & Health Systems
DATA SUBMISSION TIMELINE - PERFORMANCE • Performance period data submission Date What must be completed? Feb 15, 2016 All final data and changes submitted on Apprise reporting platform. System will be locked for review, and no additional data will be accepted. March 31, 2016 Apprise completed review and corrections of data and make final submission to OHA. Apprise received checklist with attestation of data adhering to specs, accuracy in data, and sign off from each hospital. June 30, 2016 Payments to hospitals by OHA completed. 11/9/2015 9 Oregon Association of Hospitals & Health Systems
DATA SUBMISSION TIMELINE - PERFORMANCE • Measures with Oct 1, 2014-Sep 30, 2015 performance period for all hospitals Measure Lead for data entry into Checked/approved HTPP platform by hospital by CLABSI Feb 15, 2016 Apprise (by Dec 31, 2015) Hospital Feb 15, 2016 Opioids Warfarin Hospital Feb 15, 2016 Insulin Hospital Feb 15, 2016 HCAHPS: Explain meds Hospital Feb 15, 2016 HCAHPS: Discharge Hospital Feb 15, 2016 instructions Hospital-wide readmissions Apprise (by Feb 1, 2016) Feb 15, 2016 FU mental health after OHA shared with hospitals (by March 31, 2016 hospitalization Feb 15, 2016) 11/9/2015 10 Oregon Association of Hospitals & Health Systems
DATA SUBMISSION TIMELINE - PERFORMANCE • Measures with other performance period Measure Lead for data entry into Checked/approved HTPP platform by hospital by CAUTI (Apr 1, 2015-Sep 30, Feb 15, 2106 Apprise (by Dec 31, 2015) 2015) – all hospitals Hospital Feb 15, 2106 SBIRT 1 – Screening (varies) SBIRT 2 – Brief intervention Hospital Feb 15, 2106 (varies) EDIE 1 – PCP notifications Hospital Feb 15, 2106 (varies) EDIE 2 – Development of Hospital Feb 15, 2106 care guidelines (varies) 11/9/2015 11 Oregon Association of Hospitals & Health Systems
YEAR 2 DATA SUBMISSION CHECKLIST Full Year 2 final review checklist (see draft in materials) As part of the formal submission of the Year 2 data to the OHA, hospital submissions will include a checklist Hospitals will attest to each item on the checklist as part of the formal submission This is to ensure the accuracy of the data submitted, and adherence to the official HTPP measure specifications 11/9/2015 12 Oregon Association of Hospitals & Health Systems
CAUTI BASELINE RECALCULATIONS • Final data for Jan 1, 2015-March 31, 2015 submitted by hospitals on Oct 16 to Apprise, and forwarded to OHA on Oct 30, 2015. Final Preliminary Numerator 54 Numerator 51 Denominator 65,559 Denominator 61,760 Rate per 1,000 0.82 Rate 0.83 Highest 3.79 Highest 3.79 Lowest (excluding zeros) 0.39 Lowest (excluding zeros) 0.39 # of hosp w/ zero rate 12 # of hosp w/ zero rate 14 New benchmark 1.00 New benchmark 1.10 Improvement target 3% Improvement target 3% 11/9/2015 13 Oregon Association of Hospitals & Health Systems
EDIE-sourced Measure: Baseline / Year 2 Review Process and Timelines Sara Kleinschmit, OHA Elyssa Tran, Apprise Adam Green, CMT 14
EDIE Measure Review Timeline • November 10, 2015 – CMT will make the two individual-level reports available for hospitals to review directly in EDIE . • December 10, 2015 – Last day for hospitals to respond to CMT with initial review of reports. • January 6, 2016 – For hospitals notifying PCPs outside of EDIE: Final day to send CMT a final file with any outreach occurring outside of the EDIE system for Year 1 or Year 2. CMT will not accept any numerator data for Years 1 or 2 after this date. 15
EDIE Measure Review Timeline (2) • February 1, 2016 – CMT will publish the final individual level reports for Years 1 and 2 (incorporating feedback from above . • February 15, 2016 – Deadline for hospitals to enter all Year 2 data on Apprise reporting platform. – As applicable, deadline for any hospitals resubmitting EDIE- based measure baseline ( sent separately to Apprise; not on reporting platform) • March 31, 2016 – On behalf of all hospitals, OAHHS/Apprise will officially submit all Year 2 data to the OHA (and any EDIE-sourced measure baseline revisions). 16
Special Note re: EDIE Baseline • Apprise will need to be notified separately of any changes hospitals wish to make to the EDIE-sourced measure baseline data as a result of this review process (this isn’t entered into the Apprise reporting platform). – Contact Elyssa Tran at elyssa.tran@apprisehealthinsights.com if this applies to your hospital. Note baseline data for the other HTPP measures are not eligible for resubmission as part of this review process; this review is limited to the EDIE-sourced metric. 17
Where to Find Individual Level Report in EDIE 18
Questions, Comments on Process? 19
EDIE Review Process Contacts • Questions on the individual-level HTPP reports on EDIE, contact Dylan Barker, CMT, dylan.barker@collectivemedicaltech.com • Questions on ensuring outreach to PCPs sent outside the EDIE system is included in the metrics (including questions on the specifications for the file to be sent to CMT), contact Ryan Grimmett, CMT, ryan.grimmett@collectivemedicaltech.com • Apprise Reporting Platform and Requested Changes to Baseline Submission: Elyssa Tran, Apprise Health Insights, elyssa.tran@apprisehealthinsights.com • General questions on HTPP and this process, contact Sara Kleinschmit, OHA, sara.kleinschmit@state.or.us 20
Review Draft Year 3 Potentially Preventable Readmissions Specifications see draft in supplementary materials 21
Review Stakeholder Survey Results 22
Stakeholder survey • OHA fielded this survey to inform Committee selection of domains and accompanying incentive measures for the fourth year of the program (2017), and beyond. • OHA received 58 responses from across the state. • Respondents were asked whether each of the current domains and measures should be dropped or modified for 2016; and to propose new domains/measures for the Committee’s consideration. 23
Survey respondents 24
Survey feedback on current domains and measures 25
Summary Results, Current Domains: Should [the domain] be dropped, kept but modified, or kept without changes? Keep, but Keep, no Domain Drop modify Changes Behavioral Health 10.9% (5) 23.9% (11) 65.2% (30) Healthcare-associated 4.4% (2) 24.4% (11) 71.1% (32) Infections Medication Safety 2.2% (1) 21.7% (10) 76.1% (35) Patient Experience 13.3% (6) 24.4% (11) 62.2% (28) Readmissions 4.2% (2) 42.6% (20) 53.2 % (25) Sharing ED Information 4.4% (2) 20.0% (9) 75.6% (37) 26
Summary Results, Current Measures: Should [the measures] be dropped, kept but modified, or kept without changes? Keep, but Keep, no Domain Measure Drop modify changes Follow-up after hospitalization for mental 12.5% (4) 18.8% (6) 68.8% (22) illness Behavioral Health Screening, brief intervention, & referral - 29.0% (9) 71.0% (22) for treatment (SBIRT) Adverse drug events 3.2% (1) 12.9% (4) 83.9% (26) with opioids Excessive Healthcare- anticoagulation with 10.0% (3) 10.0% (3) 80.0% (24) associated Warfarin Infections Hypoglycemia in inpatients receiving 10.0% (3) 6.7% (2) 83.3% (25) insulin 27
Recommend
More recommend
