QIO and ESRD Network Collaboration 2008 CMS/ESRD Networks’ Annual Meeting February 21, 2008

1. QIO and ESRD Network Collaboration2008 CMS/ESRD Networks’ Annual MeetingFebruary 21, 2008 Teresa Casey Kathleen Egan Jefferson Rowland Brian Hebbel

2. Discuss the QIO 9th SOW CKD component and the collaboration task Review the ESRD Network SOW collaborative tasks Describe an example of a QIO and ESRD Network project aimed at improving CKD care Discuss important factors for partnerships that go above collaboration Objectives for Today

3. QIO 9th Scope of Work

4. QIO 9th Scope of Work • 8. Coordination with Stakeholders The QIO may coordinate certain of its activities with those of stakeholder organizations in its state/jurisdiction working on comparable improvement efforts or interested in teaming with the QIO.

5. Prevention Task: CKD • Goal - to detect the incidence and slow the progression of CKD among beneficiaries and improve CKD care

6. CKD Numbers • Medicare population: • ESRD patients comprise 1.2 percent • CKD patients comprise 6.6 percent of the Medicare population • Together these two groups consume 27.6 percent of general Medicare expenditures in 2005 (USRDS 2007 Annual Data Atlas)

7. QIO Activities • Focus on Provider implementation of tested and proven CKD clinical practices • Target beneficiaries that are most likely to benefit from education on • Risk factors • Early identification • Treatment choices

8. QIO Activities (cont) • Utilize tools and resources available through Federal partners • Affect sustainable system change through a collaborative model

9. Quality Intervention Focus for CKD – Early Stages • Testing to detect kidney failure due to diabetes • Use of ACE inhibitor and/or ARB agent to slow progression of kidney disease

10. Quality Intervention Focus for CKD – Later Stages • AV fistula placement and maturation, where medically appropriate, for patients beginning hemodialysis • Measure reflects appropriate care and education in later stages of CKD • For example: early referral to a nephrologist

11. Required CKD Tasks • Task 1 – Clinical Quality Improvement • Task 2 – Community Collaboration

12. Community Collaboration • ESRD Networks • State/local health dept diabetes grantees • CHCs • Local chapters of kidney representative groups • State/county government and community representatives • Provider groups • Patient representatives

13. Additional Optional Tasks • Support for Companion CMS Quality Initiatives • Activities to support HIT adoption and implementation of clinical CKD components aligning with QIO CKD goals. • Reduction of disparities in care.

14. CKD Summary

16. Network Collaboration • How Do we Define Collaboration? • Where in the Contract do we have specific reference to Collaboration? • What type of Collaboration would be consistent with the intent and focus of the current contract and legislative intent

17. Define Collaboration To work jointly with others or together especially in an intellectual endeavor. To cooperate with an agency or instrumentality with which one is not immediately connected

18. Contract References toNetwork Collaboration Task 1.a The Network shall work with QIO’s and other appropriate partners to: • Promote utilization of Vascular Access quality improvement tools and activities • Achieve ESRD treatment changes at system levels • Influence effective discharge planning to enable the earliest possible placement of an internal vascular access

19. Contract References Task 1.d Facility Specific Quality Improvement Projects • Collaborate with dialysis facilities either individually or in a Group • For the purpose of development of QAIP’s to improve patient processes and outcomes

20. Contract References Task 1d continues • Facility Specific QI Projects Capacity to Respond to Local Needs based on poor performance problems • Response Activities designed in collaboration with LDO, QIO, State, other Networks and CMS

21. Contract References Task 1d Continues • Pre-approval of Project Officer for data elements outside the contract and/or collection frequency outside contract stipulations

22. Contract References Task 2.a and Task 2b Patient Education Information (Collaboration with Patients) • Written plan for making information available to patients • Determination of most effective strategies for distribution of informational materials • Identifying Partners to enhance collaboration with patients

23. Contract References Task 2.c Provider Education Information (Collaboration with Providers/Facilities) • Identifying Partners to enhance collaboration with patients • Sub-Contract with appropriate renal partners to fulfill some or all of the contract requirements

24. Contract References Task 2.d Provision of Technical Assistance Collaboration through assistance with: • Developing plans for dealing with local disasters • Developing community and patient education programs • Developing mechanisms for assessing the health related quality of life

25. Contract References Task 2.f Coalition The Network shall actively engage in efforts to support the development and/or maintenance of a strategic coalition within the renal community in the Network area through training and ongoing consultative support.

26. Contract References Task 3.e Establish an ongoing mutually beneficial working relationship with each QIO in the Network’s service area. • This working relationship shall involve regularly scheduled meetings, and a defined manner of communication • Establishment of mutually agreeable goals as well as sharing of information to assist QIO(s) in carrying out their legislative, regulatory, and/or contractual responsibilities (e.g., CKD initiatives) as permitted by statute, regulations, and CMS policy guidance.

27. ESRD/QIOCollaboration 2008-2009 • Collaboration must be consistent with the ESRD Regulatory Mandate and the current SOW. • Collaboration is tied to the care and treatment of the patient diagnosed with ESRD • Collaboration is tied to improving the quality and safety of dialysis related services provided to ESRD patients

28. ESRD/QIOCollaboration in 2008-2009 • Collaboration is tied to improving the independence, quality of life, and rehabilitation of ESRD patients • Collaboration is tied to improving the ESRD patient’s perception of care and experience of care

30. QIO/ESRD Network Special Project • Using Information Technology in Physician Offices to Identify and Care for Patients With Chronic Kidney Disease

31. Project Overview • Designed to create a framework for improving early detection and treatment of chronic kidney disease (CKD) • 15 month pilot project • MPRO • Renal Network 11 • Henry Ford Health System/Henry Ford Medical Group

32. Project Goals • Primary Identify and treat patients who are at high risk for CKD in identified primary care physician (PCP) offices with existing electronic health records (EHRs). • Secondary Improve the rate of appropriate and timely referral to a nephrologist for patients identified with stage 3 or > CKD.

33. Project Objectives • Implement a cost effective program for detecting large numbers of previously unidentified persons at high-risk for CKD • Decrease time to initiation of the National Kidney Foundation Kidney Disease Outcome Quality Initiative (K/DOQI) guidelines and recommended therapies for individuals with progressive CKD • Improve rate and timeliness of referral to a nephrologist • Achieve resultant cost savings, and more importantly, improved quality outcomes for the patient

34. MPRO’ Role • DOQ-IT experience • HIT expertise • QI expertise • Facilitate on site educational offerings • Assist practices with work flow redesign • Facilitate development of project tools • Coordinate development of CKD Care Plus screens • and help text • Provide data feedback reports: aggregate practice • level and provider level

35. Collaboration: MPRO, Renal Network 11, & HFHS • Renal Network 11 • CKD Expertise – RNs and Nephrologists • Areas of collaboration include • Defining project measures • Development of educational resources • Change package • On site physician office CKD education • Dr. Rozas; Renal Network 11, Medical Director • HFHS Primary Care Physician champion

36. Refer patients with stages 3-5 CKD to a nephrologist The CKD Special Study is designed to assist PCP offices to: Adequately assess patients with stage 1 or 2 CKD Identify CKD patients Optimally screen patients that are high risk for CKD

37. Interventions - 2 HFHS practice sites • Education sessions • Kick Off - Project overview • CKD Clinical education • New CKD screens, case studies • Resources and tools • New CKD EHR template screens & help text • Data feedback reports • Baseline and re-measurement • Work flow site visits • On site “Go Live” support

38. Successes • Physician & staff engagement • Built relationships, evolved into partnerships • Workflow time reported as neutral • Reminders not intrusive – viewed as helpful • Practices self report - CKD screens utilized • Project builds on HFHS CKD activities • Pilot is creating momentum for HFHS 2008 CKD system-wide QI initiative

39. Lessons Learned

41. Contracting • Objectives • Define “subcontracting” • Review subcontracting relationships • Review processes for subcontracting requests and approvals • Provide publicly available sources of information regarding subcontracting

42. Subcontracting

43. Processes

45. Summary

46. Contact Information • Teresa Casey (mary.casey@cms.hhs.gov) • Kathleen Egan (kathleen.egan@cms.hhs.gov) • Jefferson Rowland (jefferson.rowland@cms.hhs.gov) • Brian Hebbel (brian.hebbel@cms.hhs.gov) • Jaime Galvez (jaime.galvez@cms.hhs.gov)