Quality Improvement Organization Activities
Since 1984, TMF Health Quality Institute has been the Medicare Quality Improvement Organization (QIO) for Texas. As a QIO, TMF works with the Centers for Medicare & Medicaid Services (CMS) to improve patient care through cooperative efforts with the health care community.
In the 9th Scope of Work (SOW) for QIOs, which began August 1, 2008, TMF is focusing on protecting Medicare beneficiaries, promoting patient safety, encouraging preventive health care services and improving care transitions.
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Under the 9th SOW, TMF continues to carry out statutorily mandated review activities:
- Reviewing the quality of care provided to beneficiaries
- Reviewing beneficiary appeals of certain provider notices
- Reviewing potential Emergency Medical Treatment and Active Labor Act (EMTALA) violations (anti-dumping cases)
TMF is increasing efforts to link case review activities to improvements in the delivery of care by developing quality improvement activities focused on system-wide changes. TMF uses data from case review activities to identify problems related to the quality of care and design quality improvement activities to help providers correct these problems.
TMF also focuses on the following activities related to beneficiary protection:
- Beneficiary complaints and appeals
- Alternative dispute resolution
- Sanction activities
- Physician acknowledgement monitoring
- Collaboration with other CMS contractors
- Transparency through reporting
- Quality data reporting
- Communication (education and information)
TMF works with providers to implement programs to improve patient safety by combating growing issues like infection and drug safety. TMF’s patient safety activities focus on six primary topics:
- Reducing rates of health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections
- Reducing rates of pressure ulcers in nursing homes and hospitals
- Reducing rates of use of physical restraints in nursing homes
- Improving inpatient surgical safety and heart failure treatment in hospitals
- Improving drug safety
- Providing quality improvement technical assistance to nursing homes in need
The QIO focus on patient safety, also known as the CMS National Patient Safety Initiative, is designed to address areas of potential patient harm by improving health care processes and systems. TMF is working on several components from the previous SOW (surgical care, heart failure, pressure ulcers and restraints in nursing homes, drug safety), allowing us to build on the progress made with providers over the past three years. Additionally, with this new SOW the safety focus also includes new areas (MRSA, pressure ulcer prevention in hospitals, technical assistance for nursing homes in need), giving providers, in partnership with TMF, the chance to broaden the scope of patient safety-related improvement activities.
In the 9th SOW TMF is working to improve the quality and frequency of preventive health care services to optimize beneficiary quality of life and health care efficiencies. As in the other areas, prevention efforts are building on the 8th SOW. Collaborating practices work with TMF to implement care management processes using their certified electronic health records (EHRs). TMF’s goal is to impact the rates of two cancer screenings and two immunizations among Texas’ Medicare beneficiaries:
- Mammography
- Colorectal cancer screening
- Influenza immunization
- Pneumococcal immunization
Additionally, TMF is working on a program focusing on chronic kidney disease (CKD). CKD is the ninth leading cause of death in the United States. CKD affects 11% of the U.S. population over the age of 65 and those affected are at increased risk of cardiovascular disease and kidney failure. A key component of TMF’s CKD quality improvement effort is coalition building and collaboration with providers in the state as well as other partners that can support CKD efforts at the local, state and national levels.
The process by which patients move from hospitals to other care settings is increasingly problematic as hospitals shorten lengths of stay and care becomes more fragmented. Medicare patients report greater dissatisfaction in discharge-related care than in any other aspect of care that CMS measures. Within 30 days of discharge 17.6% of Medicare beneficiaries are re-hospitalized, and the Medicare Payment Advisory Commission (MedPAC) estimates that up to 76% of these readmissions are preventable. Of Medicare beneficiaries who are readmitted within 30 days, 64% receive no post-acute care between discharge and readmission.
In the 9th SOW TMF is conducting a project in the Lower Rio Grande Valley to measurably improve the quality of care of Medicare beneficiaries who transition between care settings. TMF is focusing on improving coordination of care between providers and across the continuum of care by promoting seamless transitions from the hospital to home, skilled nursing care, home health care or other providers. TMF is working with health care providers to implement interventions that result in process improvements and address issues in medication management, post-discharge follow-up, communication and coordination of care. The project will promote increased self-management of chronic disease for patients and their caregivers through education, support and a patient health care record as patients move across community health care settings.
For information on Medicare QIOs and HIPAA compliance, click here.