Performance Quality Measurement and Reporting for Accountable Care webinar replay
What started as a closer look at John C. Lincoln Network's 30-day Medicare readmissions for heart attack, heart failure and pneumonia kicked off a plethora of quality improvements for the Medicare Shared Savings Program, including the hiring of care transition coaches, extension of primary care hours and tightening of key gaps in care.
During HIN's webinar, Performance Quality Measurement and Reporting for Accountable Care, two experts from JCL shared how their organization modified reporting processes — from workflow changes to customizations within its EMR — to improve performance results during its 2013 reporting year.
For its transition coach program, developed to reduce Medicare 30-day readmissions, JCL hired trained military medics to help recently discharged patients transition more easily from one setting to another, explained Heather Jelonek, chief operating officer for ACOs at JCL.
"These transition coaches go into the hospitals and meet with patients when they are admitted. They get to know the patients, they develop a rapport, and they also start to prepare the patients for discharge."
After discharge, these coaches follow the patient for a minimum of 30 days to follow up on medical care, monitor blood pressure, explain medications and teach the patient about nutrition with the help of a registered dietician.
A deeper data dive also identified a trend among its Meals on Wheels beneficiaries: 85 percent of these patients were readmitted within 30 days almost always on Friday evenings. The patients did not have enough food to get them through the weekend since Meals on Wheels only delivers during the week.
This program has helped to reduce readmission readmission rates from almost 20 percent to just under 2 percent for those patients receiving Meals on Wheels and became an assessment area for the transitions coaches.
Encouraged, JCL sought to learn what additional data they needed from their system to respond to the reporting requirements for CMS's 33 quality measures. They determined their course of action for 2012 and the building requirements for 2013. According to Karen Furbush, business consultant for JCL, "we have to continually re-educate each of the practices at the hospital and the ED so that they can continue to remember what's important. And it's not just for the ACO measures, but in general for better coordinated care."
One change implemented immediately was the addition of a new message within EPIC, an ADT inbasket message that alerts the primary care physician (PCP) to schedule a follow-up visit within seven days. The PCP then reviews the message and forwards it to the medical assistant (MA) to schedule the visit. This change helped to meet one of the ACO quality measure as well as the transitional care management incentive.
Realizing that enhancements were needed for quality reporting, JCL added additional logic to its patient health questionnaire for future fall risk, aspirin usage and a depression scale. JCL also has ACO patient navigators who analyze reports to determine which patients were missing required measurement values and then schedule those patients by the end of the year as needed, noted Ms. Furbush. "We learned how to get the information out and quickly assess who hasn’t had the influenza or pneumococcal shots, or [...] a mammography or a colorectal screening. We wanted to go out and capture that information as quickly as possible because we still had three months left to be able to find that information, whether it was in a previous system or if it was in our current EMR," explains Furbush.
"We immediately tried to get on the phone to start scheduling these appointments, working through all the things that we need to do for the ACO, as well as just bringing the patient into the EMR completely," Furbush continued.
Furbush also started a weekly ACO quality reporting call to discuss a group of measures to see what kind of challenges were being faced and what was being implemented. JCL also hosted two EPIC-specific subset calls to learn how everyone was using EPIC.
Once JCL received its patient sample from CMS, it sent samples to each practice. According to Furbush, "We said [to the practices] this is what CMS said this person happens to be associated with. There are 15 categories and CMS will provide a rank of one to 616, one being the highest. You have to report on 411. We had to let them know where the patients ranked for each of the disease states and that we needed information back from them if we couldn’t get it from the EMR."
JCL continues to struggle with integration opportunities. According to Jelonek, "This includes talking to other communities and looking at HIEs as we're making an acquisition of a new practice or signing a new community physician onto the ACO. In other words, bringing everybody to the table so that we’re all speaking the same language."