Hospital Metrics TAG January 12, 2016
Welcome and Introductions 2
Agenda Overview • Updates • Presentation on Potentially Preventable Readmissions Measure • Year 2 submissions • Continue review of draft Year 3 measure specifications – Sharing ED info (EDIE) – Warfarin – C-sections – Opioid – C-diff • Wrap-up 3
Updates • Year 3 CMS discussions • Committee updates – Last met 18 December • Agreed straw model (next slide) • H-TAG feedback requested: – Threshold for opioid measure (to discuss later in agenda) – Identify which medication safety measure would drop (if any) – Thoughts for hospitals without L&D – Next meeting 22 January • Discussion of Years 3 and strategies moving forward 4
Updates 5
Updates (cont) • Miscellaneous – Follow-up after hospitalization for mental illness Year 2 clarification – HTPP evaluation 6
Updates (cont) • CCO Metrics Update – Upcoming Reports – Cigarette smoking prevalence measure – January CCO Metrics & Scoring Committee meeting 7
Potentially Preventable Readmissions 8
Potentially Preventable Readmissions • Committee recommended shifting from All Cause Readmissions to Potentially Preventable Readmissions Measure beginning in Year 3 (2016) • Subject to CMS approval • Benefits: – Addresses hospital concerns regarding all-cause measure • Cons: – Uses proprietary 3M methodology 9
3M Potentially Preventable Readmissions (PPR) Overview January 2016
Overview of PPR • Developed and maintained using a panel of physicians • Chains – a series of potentially preventable readmissions related to one initial admission • Clinical Relatedness – Based on APR DRGs • Exclusions • Severity Adjustment 11
Chaining Discharged: Admitted: Admitted: Admitted: Jan 1 Jan 15 Feb 10 March 15 Heart Heart Heart Heart Failure Failure Failure Failure transfer Readmission Index Readmission Index
Clinical Relatedness Admitted: Discharged: Jan 1 Jan 15 Gastric Broken Bypass Arm Index Index
Exclusions • Patients – problems with one or more records for the same patient (i.e.. mismatched birthdates) • Admissions • Death during index stay • LAMA • Palliative care • Planned readmissions – discharge status codes are critical • Most HIV admissions • Certain metastatic malignancies • Optional – certain mental health DRGs – Excludes Schizophrenia, Depression, Bipolar disorder, etc. – Mental health diagnosis codes with substance abuse DRGs will NOT be excluded 14
Severity Adjusted Rate Accounts for differences in case-mix across hospitals • Expected rates are calculated for each DRG/SOI level • Aggregated up to an Observed to Expected Ratio • Hospital OE Ratio * State Rate = Severity Adjusted Rate Result is the hospital’s rate at the state case -mix Allows comparison across hospitals 15
Severity Adjustment Calculation State Data for APRDRG Primary 344 Calculation Severity Of Readmission At Risk State Illness Chains Admissions Rate 1 9 124 7.3% 2 71 777 9.1% 3 95 862 11.0% 4 30 165 18.2% Totals 205 1,928 10.6% Hospital XYZ- APRDRG 344 Expected Hospital Number of Expected Rate Hospital Severity State Rate Readmission At Risk Observed Rate Chains (Expected Adjusted Rate (Chains/At OE Ratio Chains Admissions (Chains/At (Hospital at Number/Hospital (Statewide Rate Risk) Severity Of risk) Risk*State At Risk) * Hospital OE Illness Rate) Ratio) 1 1 15 6.7% 7.3% 1.1 7.3% 0.92 2 5 28 17.9% 9.1% 2.6 9.1% 1.95 3 2 35 5.7% 11.0% 3.9 11.0% 0.52 4 0 0 11.0% 0.0 Totals 8 78 10.3% 10.6% 7.5 9.6% 1.07 11.3%
Questions 17
Contacts Kelly Price Senior Director, DataGen Group (518) 431-7629 kprice@hanys.org Melissa Bauer Senior Informatics Analyst, DataGen Group (518) 431-7810 mbauer@hanys.org 18
Years 1 & 2 Data Submission Timeline Reminders 19
OVERALL DATA SUBMISSION TIMELINE • Year 2: 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. 1/11/2016 20 Oregon Association of Hospitals & Health Systems
DATA SUBMISSION CHECKLIST • Year 2 final review checklist • 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; does not apply for Follow Up to Mental Health Hospitalization (OHA) and Readmissions (Apprise) • This is to ensure the accuracy of the data submitted, and adherence to the official HTPP measure specifications 1/11/2016 21 Oregon Association of Hospitals & Health Systems
YEAR 2 DATA SUBMISSION CHECKLIST EXAMPLE Measure Performance Verified that data Verified that data Verified that All verifications Data period submitted meets entered at HTPP backup completed measure reporting platform documentation specification is accurate is assembled and available if asked 1 Catheter associated Apr 1, 2015- urinary tract infections Sep 30, 2015 (CAUTI) in all tracked units 2 Central line associated Oct 1, 2014- bloodstream infections Sep 30, 2015 (CLABSI) in all tracked units 3 Adverse drug events Oct 1, 2014- due to opioids Sep 30, 2015 4 Excessive Oct 1, 2014- anticoagulation with Sep 30, 2015 Warfarin 1/11/2016 22 Oregon Association of Hospitals & Health Systems
DATA SUBMISSION TIMELINE – CAUTI • Baseline data re-submission • Timeframe: Jan 1, 2015-Mar 31, 2015 – due Oct 16, 2015 (Completed) • Performance year • Timeframe: Apr 1, 2015-Sep 30, 2015 – due Feb 15 • Seeing discrepancies between NHSN and HTPP reporting platform • Barbara and Diane will share discrepancies with hospitals during monthly calls in Jan • Hospitals need to take action and ensure correct data is on HTPP platform 1/11/2016 23 Oregon Association of Hospitals & Health Systems
DATA SUBMISSION TIMELINE – CLABSI • Baseline data • Timeframe: Oct 1, 2013-Sep 30, 2014 • No resubmission unless approved by OHA • Performance year • Timeframe: Oct 1, 2014-Sep 30, 2015 – due Feb 15 • Seeing discrepancies between NHSN and HTPP reporting platform • Barbara and Diane will share discrepancies with hospitals during monthly calls in Jan • Hospitals need to take action and ensure correct data is on HTPP platform 1/11/2016 24 Oregon Association of Hospitals & Health Systems
DATA SUBMISSION TIMELINE – MED SAFETY • Baseline data • Timeframe: Oct 1, 2013-Sep 30, 2014 • No resubmission unless approved by OHA • Performance year • Timeframe: Oct 1, 2014-Sep 30, 2015 – due Feb 15 • Self-reported by hospitals on HTPP reporting platform • Hospitals need to take action and ensure correct data is on HTPP platform 1/11/2016 25 Oregon Association of Hospitals & Health Systems
DATA CALCULATION ISSUE - HCAHPS • HCAHPS – Explain meds Q16: Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? Q17: Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? • Hospital HCAHPS Calculation Q16 ‘Always’ + Q17 ‘Always’ Q16 ‘Total’ + Q17 ‘Total’ • CMS HCAHPS Calculation Q16 ‘Always’ Q17 ‘Always’ Q16 ‘Total’ Q17 ‘Total’ 2 1/11/2016 26 Oregon Association of Hospitals & Health Systems
DATA SUBMISSION TIMELINE – HCAHPS • Baseline data • Timeframe: Oct 1, 2013-Sep 30, 2014 – due Feb 15 • Hospitals to send monthly vendor report to Elyssa or HTPP@apprisehealthinsights.com for re-calculation • Performance year data • Timeframe: Oct 1, 2014-Sep 30, 2015 – due Feb 15 • Hospitals to send monthly vendor report to Elyssa or HTPP@apprisehealthinsights.com for re-calculation • Re-submission needed for both HCAHPS measures • Apprise will re-calculate per CMS methodology and send back to hospitals for sign-off. 1/11/2016 27 Oregon Association of Hospitals & Health Systems
DATA SUBMISSION TIMELINE – HCAHPS • Sample of a vendor report 1/11/2016 28 Oregon Association of Hospitals & Health Systems
DATA SUBMISSION TIMELINE – READMISSIONS • Baseline data • Timeframe: Oct 1, 2013-Sep 30, 2014 • No resubmission – administrative data • Performance year • Timeframe: Oct 1, 2014-Sep 30, 2015 – due Feb 15 • Apprise will enter data on HTPP reporting platform by Feb 1 for hospitals to view • Hospitals need to complete review by Feb 15 • Apprise responsible for signing off on meeting measure specification and documentation 1/11/2016 29 Oregon Association of Hospitals & Health Systems
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