Developing a QAPI Program for Cardiovascular Health Improvement

Transcription

1 Developing a QAPI Program for Cardiovascular Health Improvement Ashley Green MetaStar WiAHC Annual Conference November 5 th, 2015

2 Objectives The audience will be able to: Describe the purpose of HHQI s cardiovascular health initiative Develop a cardiovascular QAPI plan using key tools from the Cardiovascular Health Best Practice Intervention Packages (BPIPs) Evaluate the cardiovascular QAPI plan using the Home Health Cardiovascular Data Registry MetaStar represents Wisconsin in Lake Superior Quality Innovation Network. 1

3 Lake Superior QIN and HHQI 2

4 QIN-QIO Program Quality Innovation Network (QIN) - Quality Improvement Organization (QIO) 3

5 Lake Superior QIN Minnesota, Wisconsin and Michigan August 1, 2014 July 31,

6 Improving Cardiac Health & Reducing Disparities The cardiac initiative focuses on helping home health care professionals improve and measure progress on the ABCS of cardiovascular health: Aspirin as appropriate, Blood pressure control, Cholesterol management, and Smoking cessation 5

7 Acknowledgement Home Health Quality Improvement (HHQI) National Campaign 6

8 QAPI Basics 7

9 Proposed HH Conditions of Participation (CoP) Quality assessment and performance improvement (QAPI) would charge each HHA with responsibility for carrying out an ongoing quality assessment, incorporating data-driven goals, and an evidence-based performance improvement program of its own design to affect continuing improvement in the quality of care furnished to its patients. 8

10 So What is QAPI? Quality Assurance Measure quality compliance standards Assure care reaches acceptable levels Focus on provider Required and reactive Performance Improvement Improve processes to meet standards continuously Decrease problems by identifying opportunity for improvement Focus on patient Chosen and proactive 9

11 Standards of Home Health QAPI 10

12 QAPI Standards 1. Executive Responsibility Requires the HHA s governing body to assume responsibility for the agency s QAPI program Defines, implements, and maintains an ongoing and agency-wide program for quality improvement and patient safety Ensures that performance improvement efforts are prioritized and evaluated for effectiveness 11

13 QAPI Standards 2. Program Scope Shows measurable improvement in indicators for which there is evidence for improvement of health outcomes Examples: Reduction of hospitalizations and readmissions, safety, and quality of care for patients Measures, analyzes, and tracks quality indicators, including adverse patient events and other performance indicators 12

14 QAPI Standards 3. Program Data Uses quality indicator data, including measures derived from OASIS or other relevant data See the worksheet for more specifics Utilizes data to: Assess quality of care provided to patients Identify and prioritize opportunities for improvement Focuses quality assessment efforts including data collection on high priority safety and health conditions, and other goals identified by HHA Monitors the effectiveness and safety of HHA s services and quality of care 13

15 QAPI Standards 4. Program Activities Focuses on high risk, high volume, or problemprone areas of service, and considers the incidence, prevalence, and severity of problems in those areas Corrects any immediate problems that directly or potentially threaten the health and safety of patients Continues to monitor the area(s) to assure that improvements are sustained over time 14

16 QAPI Standards 5. Performance Improvement Projects (PIPs) Conducts PIPs at least annually, reflecting the scope, complexity, and past performance of the HHA s services and operations Utilizes data collection and analysis to select focus areas: Previous problematic performance issues Clear evidence of poor patient outcomes High-risk and high-volume Documents QAPI project and progress 15

17 QAPI Standards & Components for Consideration Tool was created around the proposed CoP CMS is not being prescriptive but has provided some insight into the standards HHQI is providing a draft worksheet to assist your HHA with developing your QAPI plan (not required) Keep it simple and integrate what you are already doing HHAs with Hospice may want to use their Hospice s QAPI structure 16

18 The Initiative 17

19 Million Hearts Initiative Million Hearts 18

20 Home Health Cardiovascular Improvement Initiative Aligns with national Million Hearts initiative Focuses on the ABCS of preventive cardiovascular care 19

21 Cardiovascular Health Best Practice Intervention Packages 20

22 Clinician & Patient Fact Sheets 21

23 Multimedia Tools 3-minute video by Mayo Clinic AHA s series of animated pictures with text on 15 different cardiac topics 22

24 Blood Pressure Assessment Accurate Blood Pressure Monitoring Steps for accuracy Video and article from New England Journal of Medicine Blood Pressure Accuracy & Accurately Assessing Orthostatic Hypotension 23

25 Smoking Cessation: AHA 5-Step Process Set a QUIT Date & sign a nosmoking contract Choose a method for quitting Decide if using medicatio n might help Make a plan for your QUIT Day Stop smoking on your QUIT Day AHA,

26 Performance Improvement Planning 25

27 Aspirin as Appropriate 26

28 IVD: Use of Aspirin or Another Antithrombotic Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic Percentage of patients aged 18 years or older with ischemic vascular disease (IVD) documented within the most recent 12 months while under the care of the home health agency with documented use of aspirin or other antithrombotic or anticoagulant therapy** # of Episodes with Aspirin # of Episodes without Aspirin # of Episodes with Contraindications Total Eligible Episodes Abstracted- Agency Agency Measure Compliance % Total Data Registry Measure Compliance % Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015 Total

29 Aspirin Staff Education Clinician Fact Sheet 28

30 Bulletin Board 29

31 Aspirin Patient Education Taking Aspirin to Prevent Heart Attacks (men) Taking Aspirin to Prevent Stokes (women) 30

32 Blood Pressure Control 31

33 HTN: Controlling High Blood Pressure Hypertension: Controlling High Blood Pressure Percentage of patients aged years who had a diagnosis of hypertension (HTN) documented within the most recent 12 months while under the care of the agency and whose blood pressure (BP) was adequately controlled (<140/90 mm Hg) while under the care of the home health agency # of Episodes with Controlled BP Total Eligible Episodes Abstracted- Agency Agency Measure Compliance % Total Data Registry Measure Compliance % Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015 Total

34 Controlling Blood Pressure: Follow-Up Documented Controlling High Blood Pressure: Follow-Up Documented Percentage of patients aged years who had a diagnosis of hypertension (HTN) documented within the most recent 12 months while under the care of the home health agency and a recommended follow-up plan is documented while under the care of the home health agency # of Episodes with a Follow-Up Plan Total Eligible Episodes Abstracted-Agency Agency Measure Compliance % Total Data Registry Measure Compliance % Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015 Total

35 Blood Pressure Staff Education Antihypertensive Medication Reference 34

36 Blood Pressure Staff Education Blood Pressure Accuracy & Accurately Assessing Orthostatic Hypotension 35

37 Blood Pressure Staff Education HHQI University courses Master the Maze of Blood Pressure Medications Blood Pressure Control & Smoking Cessation 36

38 Blood Pressure Staff Education Lifestyle Modifications Part 1: Weight Reduction, DASH eating Plan; and Sodium Reduction (7 min.) Lifestyle Modifications Part 2: Physical Activity, Alcohol Modification, and Smoking Cessation (7 min.) Following the DASH Eating Plan 37

39 Blood Pressure Patient Education Blood Pressure Medication Management (7 min) 38

40 Blood Pressure Patient Education How to Check My Own Blood Pressure (7 min) AHA Blood Pressure Tracker tool 39

41 My Healthy Heart Workbook Available in: English Spanish Chinese Russian Vietnamese 40

42 Cholesterol Management 41

43 Diabetes: LDL-C Control Diabetes: Low Density Lipoprotein (LDL-C) Control Percentage of patients aged 18 through 85 years with diabetes whose LDL-C was adequately controlled (<100 mg/dl) during the measurement period # of Episodes with Controlled LDL-C Total Eligible Episodes Abstracted- Agency Agency Measure Compliance % Total Data Registry Measure Compliance % Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015 Total

44 IVD: Complete Lipid Profile and LDL-C Control Ischemic Vascular Disease: Complete Lipid Profile and LDL-C Control Percentage of patients aged 18 years and older with a diagnosis if ischemic vascular disease (IVD) within the most recent 12 months while under the care of the home health agency who had each of the following documented in the patient s record: a complete lipid profile and LDL-C was adequately controlled (<100 mg/dl) Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015 Total # of Episodes with a Follow-Up Plan Total Eligible Episodes Abstracted- Agency Agency Measure Compliance % Total Data Registry Measure Compliance %

45 Cholesterol Staff Education CVH Part 2 Website 44

46 Bulletin Board 45

47 Cholesterol Patient Education 46

48 Cholesterol Patient Education CVH Part 2 Website 47

49 Smoking Cessation 48

50 Tobacco Use: Screening and Cessation Tobacco Use: Screening and Cessation Percentage of patients aged 18 years and older who were screened for tobacco use by the home health agency AND received cessation counseling/ intervention by the home health agency # of Episodes Screened and Receiving Cessation Intervention Total Eligible Episodes Abstracted-Agency Agency Measure Compliance % Total Data Registry Measure Compliance %* # of Episodes Screened for Tobacco Use Total Eligible Episodes Abstracted-Agency Agency Measure Compliance % # of Episodes Receiving Cessation Intervention Total Episodes of Screened Tobacco Users Agency Measure Compliance % Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015 Total

51 Smoking Cessation Staff Education 50

52 Smoking Cessation Staff Education HHQI University Courses Blood Pressure Control and Smoking Cessation (1.5 hrs Nursing CEs) Tobacco Effects and Smoking Cessation Medications (1.0 hrs Nursing CEs) It s HHQuitting Time: Help Your Patients Quit Smoking (1.0 hrs Nursing CEs) 51

53 Smoking Cessation Staff Education Smoking Cessation with Your Patients 52

54 Smoking Cessation Patient Education 53

55 Smoking Cessation Patient Education 54

56 Smoking Cessation Patient Education 55

57 Smoking Cessation Patient Education 56

58 Smoking Cessation Patient Education Smoking & Your Heart How to Quit Smoking 57

59 58

60 Data Access 59

61 Data Access Selecting month to abstract 60

62 Making monthly selection 61

63 1 st page in monthly registry 62

64 Top portion of Registry 63

65 Dual-Eligibility 64

66 Aspirin 65

67 Blood Pressure 66

68 Cholesterol 67

69 Cholesterol 68

70 Cholesterol 69

71 Tobacco 70

72 HHCDR Report 71

73 HHCDR Details Access HHCDR through normal Data Access portal Each month, HHA will select which measures (A, B, C and/or S) Patient demographic information will be prepopulated on the 15 th of every month All data closed by the 14 th of the month will be used to create HHCDR Report to be posted ~23 rd of the month 72

74 Additional QAPI Tools & Resources 73

75 HHQI University Pave Your Path Series Pave Your Path: Designing a Systematic Approach to Quality Improvement 4-course series in HHQI University Focuses on IHI s Model for Improvement Includes PDSA (Rapid Cycle Improvement) Collaboration with Institute of Healthcare Improvement Includes free nursing CEs 74

76 HHQI University QAPI Series Home Health QAPI Foundation course Subsequent specialized individual courses Hospitalizations Medication Management Cardiovascular Health 75

77 Next Steps Download and review the QAPI materials from HHQI. How does your current quality improvement align with QAPI? What do you need to work on to strengthen your overall QAPI Plan? Decide on an area for a Performance Improvement Plan (PIP). What does your data say? What area is high risk, high volume, or will impact your populations? What key tools and resources will you consider implementing? Download and read the CVH BPIPs Parts 1 and 2, if you select CVH as a PIP. Have you joined HHCDR already? If not join now! Are you working with your QIN/QIO? If not contact them! Which of the ABCS will you abstract and develop a PIP? 76

78 Questions? Ashley Green, Project Specialist MetaStar represents Wisconsin in Lake Superior Quality Innovation Network. 77

79 This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-TASK-YY-## MMDDYY