Past Conference 2024


2024 CMS Quality Conference

time iconApril 8, 2024 09:00

How to Begin a Medicaid and Chip Quality Improvement Project: Skills, Stories, and Resources

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Deirdra Stockmann, PhD, MUP, (Moderator)
Director,
Division of Quality and Health Outcomes, Center for Medicaid and CHIP Services,
Centers for Medicare & Medicaid Services

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Jane Taylor, MHA, MBA, ED.D.
Improvement Advisor,
Jane A. Taylor, ED.D., LLC

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Tony Richards, MPH, PMD Pro
Director,
Office of Child Welfare,
Center for Managed Care,
Bureau for Medical Services,
West Virginia Department of Health and Human Resources

Johnson A&B

Effective quality improvement (QI) begins by understanding the problem you are trying to solve. This mini plenary will discuss several tools that Medicaid and Children's Health Insurance Program (CHIP) agency staff can use to understand challenges and identify solutions for QI, as well as help identify the measures and partners needed to effect change. Participants will hear from an improvement advisor and state speaker who will describe these tools and how they applied them in their QI efforts. The class will also review new resources and tools developed by CMS to help state staff and their QI partners address other key areas of improvement in Medicaid and CHIP programs. 

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time iconApril 8, 2024 09:00

Building a Climate-resilient, Sustainable Health System in Service of the Most Vulnerable Beneficiaries

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Anita Monteiro
Director, iQuality Improvement & Innovation Group
Centers for Medicare & Medicaid Services

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Joe McCannon
Special Expert and Senior Advisor,
Agency for Healthcare Research and Quality/Office of Climate Change and Health Equity

Holiday 1-3

Climate change represents an unprecedented threat to the health of people around the world, particularly certain groups that – for reasons of long-time discrimination, disenfranchisement, and underinvestment – are much more exposed to climate-related harm. Given this, the Biden Administration created a new Office of Climate Change and Health Equity (OCCHE) to mobilize all of HHS to act in support of communities and providers across the country addressing this challenge. In this session, the OCCHE team and colleagues from CMS will describe the scope and nature of climate-related threats to health, and tools and resources to support providers and other stakeholders in tackling them, including billions of dollars in tax credits and grants from the Inflation Reduction Act and forthcoming programming from CMS.

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time iconApril 8, 2024 09:00

Enhancing Workforce Resilience & Well-Being: Rediscovering Joy in Health Care

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Lotte Dyrbye, MD, MHPE
Senior Associate Dean of Faculty and Chief Well-being Officer,
University of Colorado School of Medicine

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Lee Daugherty Biddison, MD, MPH
Chief Wellness Officer,
Director of Credentialing,
Associate Professor,
Johns Hopkins School of Medicine

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Christine Sinsky, MD
Vice President of Professional Satisfaction,
American Medical Association

Holiday 6

CMS is committed to promoting clinician well-being through our efforts to support clinicians and systems in providing high quality care, and to identify and reduce administrative burden. A systems approach to promoting well-being and resilience in health care is a cornerstone of the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience. This session will explore insights and tools from four leaders in this field who are working to strengthen and energize the health care workforce by better understanding the factors that lead to clinician burnout and promoting joy in health care. Speakers from the American Medical Association (AMA), the University of Colorado School of Medicine, Duke University Health System and Johns Hopkins Medicine will discuss the negative impact of health care worker burnout on both individuals and health care systems, and share strategies organizations can use to support well-being and resilience and create space for health care workers to stay energized and deliver excellent care.

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time iconApril 8, 2024 10:30

Welcome

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Jean Moody-Williams, RN, MPP
Deputy Director,
Center for Clinical Standards and Quality,
Centers for Medicare & Medicaid Services

Key Ballroom & Live Streamed
time iconApril 8, 2024 14:00

Guiding Dementia Care Decisions: What Matters

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Adrienne Mims, MD, MPH, AGSF
Chief Medical Officer,
Rainmakers Strategic Solutions

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Shari Ling, MD (Moderator)
Deputy CMS Chief Medical Officer,
Centers for Medicare & Medicaid Services

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Esther Oh, MD, PhD
Associate Professor of Medicine,
Psychiatry and Behavioral Sciences and Pathology,
Johns Hopkins University School of Medicine

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Tonya Saffer, MPH
Director,
Division of Healthcare Payment Models within the Patient Care Models Group,
Center for Medicaid and CHIP Services,
Centers for Medicare & Medicaid Services

Poe A&B

This is In Person Session.

Alzheimer’s Disease and Alzheimer’s Disease Related Dementias (AD/ADRD) affect as many as six million people in the United States, a number expected to more than double by 2060.  AD/ADRD are debilitating conditions that impair memory, thought processes, and function, primarily among older adults. The chance of developing dementia is not equal—Black and Latino Americans are more likely to develop AD/ADRD, as are people with risk factors such as high blood pressure, diabetes, and depression.

AD/ADRD has physical, psychological, social, and economic impacts for the person, families and caregivers, communities, and the nation. Person-centered care is effective for people living with dementia when care goals are known and used to guide nonpharmacologic and pharmacological treatment.  This session will address the importance of person-centered, patient-clinician decision making and identify ways to use the approach in dementia care planning broadly.

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time iconApril 8, 2024 14:00

Addressing Substance Use Disorder and Serious Mental Illness Through Medicaid and CHIP Demonstrations

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Sarah Sheets, MPhil
Research Analyst,
State Demonstrations Group,
Center for Medicaid and CHIP Services,
Centers for Medicare and Medicaid Services

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Leslie Hoffman, M.Ed., LSSYB
Kentucky Cabinet for Health and Family Services,
Department for Medicaid Services

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Danielle Daly, PhD, MS
State Demonstrations Group,
Center for Medicaid and CHIP Services,
Centers for Medicare and Medicaid Services

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Angela Sparrow, MSW, CSW
Behavioral Health Supervisor,
Kentucky Cabinet for Health and Family Services,
Department for Medicaid Services

Johnson A&B

This is In Person Session

This session will explore findings from section 1115 Substance Use Disorder (SUD; (#17-003 RE: Strategies to Address the Opioid Epidemic) and Serious Mental Illness (SMI; #18-011 Opportunities to Design Innovative Service Delivery Systems for Adults with a Serious Mental Illness or Children with a Serious Emotional Disturbance) demonstrations.  States conduct structured monitoring and rigorous evaluations of the demonstrations, and the Centers for Medicaid and CHIP Services (CMCS) conducts federal monitoring and evaluation of both demonstration opportunities to support identifying best practices and learning and diffusion.  CMCS will share key findings and discuss how it uses findings.  Based on data submitted to CMS through June 2022, between the baseline and Demonstration Year 3 and later, the demonstrations were associated with a 17.1 percent increase in the number of beneficiaries using SUD treatment services.  For beneficiaries with opioid use disorder (OUD), the demonstrations were associated with an increase in the share of beneficiaries receiving medication assisted treatment (MAT).  However, overdose death rates increased in 10 out of 14 states and the rate of ambulatory/preventive care use declined in 11 of 14 states.   Presenters will discuss state activities to address findings, including but not limited to strategies to increase access to MAT.  Lastly, Kentucky will share how their team uses the information to inform continuous process and quality improvement of the demonstration.

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time iconApril 8, 2024 14:00

Telehealth: Improving Access to Care for Tribes: CMS and IHS Updates

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Susan Karol, MD
Chief Medical Officer,
Division of Tribal Affairs,
Centers for Medicare & Medicaid Services

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Susy Postal, DNP, RN-BC
Chief Informatics Officer,
Indian Health Service

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Chris Fore, PhD
Director,
Indian Health Service Telebehavioral Health Center of Excellence

Peale A-B

This is In Person Session

The Indian Health Service (IHS) continues to support the expanded use of telehealth to provide patient care after the COVID-19 Public Health Emergency (PHE). This presentation will focus on an overview of the use of telehealth at the IHS and the support the Centers for Medicare & Medicaid Services (Centers for Medicare & Medicaid Services) provides. The presentation will include the accomplishments in expanding telehealth from April 2020 to the present. The various telehealth services available at the IHS will be discussed including Centers for Medicare & Medicaid Services’ support provided to rural and frontier areas. Issues in providing audio-only services will be discussed and aligned with services on the Medicare Telehealth Services List for CY 2024. Presenters will provide metrics describing the utilization of telehealth in IHS. Telehealth best practices will be discussed, and quantitative and qualitative results from IHS patient and IHS provider telehealth surveys will be addressed. Finally, patient outcomes utilizing telehealth services will be included and quality improvement options provided.

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time iconApril 8, 2024 14:00

Innovation Center Quality Pathway – A Refreshed Approach to Quality in CMMI Models

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Noemi Rudolph, MPH
Director,
Research and Rapid Cycle Evaluation Group,
Center for Medicare and Medicaid Innovation (CMMI)

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Jacob Quinton, MD, MPH
Medical Officer,
Center for Medicare and Medicaid Innovation (CMMI),
Centers for Medicare & Medicaid Services

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Susannah Bernheim, MD, MHS
Chief Quality Officer & Acting Chief Medical Officer,
Center for Medicare and Medicaid Innovation,
Centers for Medicare & Medicaid Services

Key Ballroom 1-4

This is In Person Session

The purpose of the proposed panel is to describe the CMS Innovation Center’s approach to strengthening the focus on quality, outcomes, and experience within the Innovation Center’s alternative payment models. The resulting Quality Pathway emerged from the 2021 strategic refresh and includes development of a process to certify models for expansion based on quality improvement. The panel will introduce the pathway, describing how it elevates patient outcomes and experience of care within alternative payment models and emphasizes the translation of a model’s theory of action into measurable benefits for patients. The panel will discuss how this alignment of model design and quality strategy also drives new approaches to model evaluation, and how the Quality Pathway will be used to identify when a model may be eligible for expansion based on demonstrated quality improvement in alignment with CMMI’s statutory mandate. Having addressed the conceptual basis for the Pathway, the panel will share examples of models recently under development to demonstrate how the pathway will be used at the Center. This will include insight into design choices around measure selection, implementation decisions on data collection, and evaluation considerations on methodological approach. As part of discussing implementation of the pathway, the panel will identify a number of considerations entailed in executing this new approach to model quality strategies at the Center, such as those associated with novel measure development and rigorously evaluating the impact of models on patient outcome and experience.

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time iconApril 8, 2024 14:00

Top of the List: Ensuring Transplant Readiness in Those Likely to Soon Receive an Organ Offer

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Mercedes Islas, BSN, RN
Froedtert Memorial Lutheran Hospital

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Michael Mace, MSW, LICSW
Nephrology Social Worker,
Fresenius Kidney Care

Latrobe

Assuring the transplantation of every kidney offer includes ensuring that those patients who are likely to soon receive an organ offer are prepared to accept. Froedtert Memorial Lutheran Hospital’s quality improvement activities highlighted a potential opportunity for refinement in this aspect of the pre-transplant process. Beginning in Spring 2023, the transplant team developed and executed an enhanced patient preparation called Top of the List to meet this need.  

From the perspective of a long-time dialysis social worker and transplant recipient, Mr. Mace will bring his insights on supporting patients waiting for a transplant. He will also share his experience on how to build collaborative communication and standard processes between the dialysis facility and the transplant program to ensure patients are transplant ready.

Top of the List focuses on ensuring patients based upon the OPTN allocation sequence at the top of each blood type are “transplant ready.” Froedtert’s enhancements to the process included: weekly calls to the patient from the pre-transplant coordinator, immediate review of medical records including updates from dialysis units, weekly care team meetings with multi-disciplinary review, and weekly emails to the patients’ dialysis centers to ensure timely communication on pertinent patient issues or changes in status. While outcome data is still being collected, the process shows potential to increase organ offer acceptance and simplifying activities when the offer is made.

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time iconApril 8, 2024 14:00

Home Therapy Innovation Through Culture Change

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Tammy Carmean, MBA-HM, BSN, RN,
Fresenius Home Therapies Program Manager,
Fresenius Kidney Care

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Donna Ferguson, RN, BSN
RN Charge Nurse II,
Fresenius Kidney Care

Holiday 4-5

This is In Person Session

The Mishawaka Indiana Home Therapy Team has operated on the premise that everyone deserves to attain their highest level of health and quality of life with improved dialysis treatment options. The Team aimed to cultivate a culture change and develop an effective strategy for delivering excellent kidney patient care. 

A foundational component of the team’s strategy is based on Jean Watson’s Theory of Human Caring. In tandem with Watson's theory, the team integrated Lean Six Sigma principles into the framework. 

This innovative process began in 2022 and incorporated elements into the new model, including group training, transforming traditional nursing roles, instilling an “owner versus renter” mentality, process improvement, and patient satisfaction through relationship-building practices. This foundation was designed to enhance the ability to deliver higher levels of care that improve the quality of life for every patient, every day. 

During the group training implementation, clinical staff witnessed an exceptional phenomenon. Peer-to-peer relationships blossomed, spirits lifted, and the atmosphere in the room became magical. Patients were learning from each other and forming friendships that transcended the one-on-one training. Patients and caregivers began encouraging one another and forming their own support networks. The clinic’s dynamic was transformed because of it. Within the first 10 months, the number of trained patients surpassed the clinic's entire patient population from the previous year. This model of care is transformative and can lead to meaningful human connections that enhance the quality of care and improve a patient’s quality of life.

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time iconApril 8, 2024 14:00

Using Community Health Assessments and Leveraging Community Resources to Improve Health Equity and Reduce Health Care Disparities

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Linda Griskell, MHA (Moderator)
PATH Task Order Director,
Comagine Health

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Tasha Peltier, MPH, CPH
PATH Quality Improvement Advisor and Community Engagement Advocate,
Quality Health Associates of North Dakota

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Carrie Howard, MA, CPHQ, CPPS
PATH Quality Improvement Advisor,
Stratis Health

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Julia Drishinski, BSN, RN, CPHQ
PATH Quality Improvement Advisor,
Mountain Pacific

Holiday 6

This is In Person Session

Four presenters, each a Partnership to Advance Tribal Health (PATH) team member supporting a different Indian Health Service (IHS) facility, will share their process, methods and goals for supporting a community in building a Community Health Assessments (CHA). Each presenter played a different role in the CHA process, illustrating how this work should be guided by each specific community or group and how trust, flexibility and responsiveness are keys to success in any initiative. Presenters will share their experiences, tools used, recommendations, challenges and successes for collaborating with a tribal community in building a CHA.

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time iconApril 8, 2024 14:00

Oral Health Quality Improvement in Medicaid and CHIP

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Margo Rosenbach, PhD
Vice President and Director of Health Program Improvement,
Mathematica

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Andrew Snyder, MPA, (Moderator)
Senior Policy Advisor,
Center for Medicaid and CHIP Services,
Centers for Medicare & Medicaid Services

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Natalia Chalmers, DDS, MHSc, PhD
Chief Dental Officer,
Office of the Administrator,
Centers for Medicare & Medicaid Services

Ruth

This is In Person Session

Over the past two years, CMS has made significant strides in advancing oral health across all our programs. From 2020-2023, a CMS learning collaborative focused on advancing oral health prevention in primary care. Topically applied fluoride varnish effectively prevents dental caries in children and adolescents. Because young children under 5 are more likely to see a primary care provider (PCP) than a dental provider, PCPs are uniquely positioned to support oral health prevention by offering fluoride varnish as part of primary care visits and connecting beneficiaries to dental care. The session will open with an overview of the technical assistance CMS provides state Medicaid and CHIP agencies and their quality Improvement (QI) partners to advance oral health prevention in primary care for Medicaid and CHIP beneficiaries, featuring several state QI projects from the affinity group, highlighting their strategies, partnerships, and lessons learned.

In 2022, CMS conducted its first-ever oral-focused human-centered design research in four states, interviewing nearly 100 people (i.e., beneficiaries, providers, advocates, state administrators, etc.) to understand barriers to oral health care access for the Medicaid and dually eligible population to inform policy change. In this session, The CMS Chief Dental Officer, Dr. Chalmers, will present the findings from that engagement.

CMS also convened a Workgroup to gather stakeholder feedback from experts in the field to plan strategic priorities for the next phase of our Medicaid and CHIP Oral Health Initiative. The focus is to assess gaps related to oral health and access to care for Medicaid and CHIP beneficiaries and recommend strategic priorities for the next five years. The session will conclude the workgroup process and overview of the final report and recommendations.

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time iconApril 8, 2024 14:00

Strengthening Nursing Home Emergency Preparedness: Insights from Telligen’s Online Assessment Tool and Collaborative Strategies for Resilience

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Rejie Abraham, (Moderator)
Centers for Medicare & Medicaid Services,
DCPH

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Brian Feist, BSN, RN
Senior Quality Improvement Facilitator,
Subject Matter Expert for Emergency Preparedness,
Telligen

Holiday 1-3

This is In Person Session

Emergency preparedness planning in nursing homes is crucial for safeguarding vulnerable populations, especially amid the challenges resulting from the pandemic. Staffing shortages limit the ability to focus on preparedness, with 77 percent of nursing homes facing challenges preparing for public health emergencies and natural disasters, according to a recent OIG report. To address this, Telligen developed an online assessment tool aligned with federal regulations and co-designed with nursing home partners to assist nursing homes in creating comprehensive emergency plans. This tool evaluates existing plans, procedures, and resources, focusing on evacuation plans, staff training, and essential resource availability and provides a comprehensive gap analysis for users to target their improvement efforts. Coordination with local emergency services for effective crisis collaboration is emphasized.

Upon completion, Telligen helps nursing homes identify and rectify gaps in their plans, enhancing their responsiveness to various emergencies. This session will highlight lessons learned from 368 completed assessments across a four-state region, showcase Telligen's collaboration with nursing home corporations to enhance testing, training plans, and system-level awareness for improvement, and offer best practices to foster a culture of readiness and resilience, ultimately ensuring the health and safety of residents and staff during crises.

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time iconApril 8, 2024 14:00

The True Cost of Patient Safety Events and Pursuing the Goal of Zero Harm

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Li Chen, Ph.D
Health Research Lead,
Avar Consulting

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Wendy Gary, MHA, (Moderator)
Chief Operating Officer,
Avar Consulting;
Executive Director,
BFCC-QIO;
Project Director,
BFCC NCORC

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Jacklyn Vollmer, MPH
Quality Improvement and Operations Support Specialist,
Avar Consulting

Key Ballroom 9-12

This is In Person Session

Patient safety events (PSEs) remain a persistent challenge in our healthcare system, and the Centers for Medicare & Medicaid Services (CMS) has adopted the goal of Zero Preventable Harm as part of its National Quality Strategy (NQS). This presentation will (1) discuss the prevalence of PSEs among Medicare beneficiaries, (2) analyze associated additional inpatient care and financial costs, and (3) provide insight to support CMS’ aim to promote the safest possible care for all. The Beneficiary and Family Centered Care National Coordinating Oversight and Review Center (BFCC NCORC) screens 4,000 Medicare medical records annually for PSEs, leading to follow-up actions by the BFCC-Quality Improvement Organizations (QIOs). NCORC analyzed additional days of hospitalization and payment associated with PSEs projected on a national level, by sample weighting, representing beneficiaries based on 4,000 Medicare discharges between October 2020 and December 2021. Over 5,000 PSEs were identified, and half of beneficiaries experienced at least one, with 6% being deemed preventable. PSEs were associated with nearly four additional days of inpatient care on average, totaling 32.5 million additional days nationally. This equates to $86 billion per year, or about one-tenth of all Medicare spending. Preventable PSEs cause about 5.7 million additional days of care, and over $15 billion in spending. Patient safety is the cornerstone of high-quality healthcare, yet PSEs happened in more than half of Medicare beneficiary hospitalizations, accounting for nearly 10% of all Medicare spending. These findings reinforce the urgent need for CMS’ quality agenda, and the goal of achieving zero preventable harm.

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time iconApril 8, 2024 14:00

Introduction to Merit-based Incentive Payment System (MIPS) Cost Performance Measures

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Allie Newsom, MPH
Senior Policy Lead,
Acumen, LLC

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Christopher Reinartz, (Moderator)
Division Director,
Information Systems Group,
Center for Clinical Standards and Quality,
Centers for Medicare & Medicaid Services

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Donta Henson, MS
Center for Clinical Standards and Quality,
Centers for Medicare & Medicaid Services

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Shirley Fung, MPH, MSMR,
MIPS Scoring, Data & Analytics, and Operations Lead,
Center for Clinical Standards and Quality,
Centers for Medicare & Medicaid Services

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Steven Szeliga, MS,
QPP Chief Product Owner,
ICF International, Inc.

Key Ballroom & Live Streamed

This session provides an overview of the Merit-based Incentive Payment System (MIPS) cost measure development process, measure methodologies (construction and attribution), cost measure scoring, and feedback reporting.

Cost measures are used to assess the overall cost related to providing and receiving medical care. Costs can include the direct costs of treatment, the total costs borne by a patient across all providers, follow-up care, outcomes after treatment, or some mixture of these.  Cost measures are developed and maintained in iterative processes involving in-depth input from content experts and the public, such as Technical Expert Panels, Clinical Expert Workgroups, and persons and families with lived experience related to the cost measures. CMS uses Medicare administrative claims data to calculate cost measure performance, which means clinicians don’t have to submit any data for this performance category. MIPS eligible clinicians and groups who get scored on any of the cost measures will receive category and measure-level scoring information in their MIPS Performance Feedback Patient-Level Data Reports. 

CMS will review an example of how a measure is developed, constructed, and scored. This will include defining an episode, identifying a clinician-patient relationship, determining the period of care, assigning costs of clinically related services, accounting for patient heterogeneity, calculating measure scores, and providing pertinent claims level feedback.

The session will provide insight on the methodologies CMS employs for developing and scoring cost measures, and how CMS is striving to improve the cost measures resources and data available to clinicians.

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time iconApril 8, 2024 14:00

Who Seeks Medicare Support and Advocacy Services and How Can We Address Barriers and Reduce Disparities?

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Scott Fortin, MBA
Sr. Director Communications and Outreach,
Kepro

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Carmen Villegas, RN, BSN, BCPA
Immediate Advocacy Manager,
Livanta

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Stephanie Fry, BA, CPXP
Associate Vice President,
Westat

Virtual Event Platform

In response to the President’s executive order to advance racial equity and support for underserved communities, the Department of Health and Human Services (HHS) established an equity action plan. In alignment with this plan, Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIOs) are working to identify and address barriers to equitable access and utilization of beneficiary protection, support, and advocacy services.

BFCC-QIOs offer case review services for beneficiaries who think they may be entitled to additional Medicare-covered services, or who think the quality of care they received does not meet clinical standards. Using BFCC-QIO program data, we assessed the degree to which case review services are being utilized by beneficiaries of different races and ethnicities.

Disparities in case review utilization are evident among Hispanic and Asian beneficiaries and these disparities may further contribute to existing health outcome inequalities. The concern is that these beneficiaries are still experiencing premature healthcare service termination or other quality of care issues such as gaps between government and other health providers, but are not exercising their right to review and possibly resolve these issues through BFCC-QIO program services.

BFCC-QIOs are carefully analyzing the approach and implementation strategies for their work. Seeking input from experts, stakeholders and Medicare beneficiaries, BFCC-QIOs are identifying strategies to improve access and awareness and reduce disparities in use of BFCC-QIO case review services that may contribute to poor health outcomes.

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time iconApril 8, 2024 14:00

The 2024 National Impact Assessment Report – Collecting and Using Quality Data Across 26 CMS Programs

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Robert Ziemba, PhD
Statistician,
HSAG

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Kyle Campbell, PharmD
Project Director,
HSAG

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Kendra Hanley, MS, BA
Impact Assessment Team Lead,
HSAG

Virtual Event Platform

The 2024 National Impact Assessment aggregates retrospective data from 26 CMS quality and value-based incentive programs to characterize quality and efficiency impacts associated with the use of measures. The session will focus on summarizing key findings from these comprehensive analyses that provide important insights regarding effects of the COVID-19 pandemic during the period of analysis. We will describe national measure performance trend data pre-COVID-19 (2016–2019) compared with results in the initial years of the COVID-19 public health emergency (PHE)— 2020 and 2021— and describe patient impact and costs avoided when performance for select measures improved. Data also will be presented on how the CMS measure portfolio is evolving to reduce measurement burden and address CMS quality priorities. Lessons learned from the COVID-19 PHE and proposed actions to improve the resilience of quality measurement and the health care system will be discussed. Finally, underscoring equity as a primary objective of the CMS National Quality Strategy, the session will explore patterns of disparities in quality measure scores and offer insight into underlying drivers of disparities identified through focus groups in underserved communities.

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time iconApril 8, 2024 14:00

Million Hearts 2027: Aiming for Impact with a Focus on Health Equity

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Haley Stolp
Policy and Partnership Strategist,
Centers for Disease Control Disease Control and Prevention

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Laurence Sperling, MD, FACC, FAHA, FACP, FASPC
Executive Director,
Million Hearts Initiative,
Centers for Disease Control and Prevention

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Taylor Streeter, MPH
Health Scientist,
ASRT, Inc.

Virtual Event Platform

Million Hearts® prioritized strategies for building healthy communities and optimizing care through a committed focus on specific populations experiencing inequities. This session describes how Million Hearts 2027 is addressing health equity with a review of communication assets and opportunities for engagement, an exploration of health equity-related issues for widespread use of self-measured blood pressure monitoring and cardiac rehabilitation, and an overview of new and future opportunities to reduce cardiovascular maternal health disparities.

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time iconApril 8, 2024 15:00

Behavioral Health Integration: Innovation and Advancement in Primary Care

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Elisabeth Kato, MD, MRP
Medical Officer,
Agency for Healthcare Research and Quality

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Shari Ling, MD (Moderator)
Deputy CMS Chief Medical Officer,
Centers for Medicare & Medicaid Services

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Michael Wittie
Public Health Analyst,
Office of Policy,
Office of the National Coordinator for Health Information Technology

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Rebecca VanAmburg
Social Science Research Analyst,
Center for Medicare and Medicaid Innovation,
Centers For Medicare & Medicaid Services

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Karran Phillips, MD, MSc
Deputy Director,
Center for Substance Abuse Treatment,
SAMSHA

Key Ballroom & Live Streamed

This session will bring together experts in the field of Behavioral and Physical Health Integration from CMS’s Center for Medicare & Medicaid Innovation (CMMI), the Agency for Healthcare Research and Quality (AHRQ), and the Office of the National Coordinator for Health Information Technology (ONC) to discuss innovations and lessons learned. The speakers will share what they are doing in their specific areas and engage in discussion around 5 key elements of integration: 1) team based care, 2) workforce training, education and culture, 3) community and individual needs, 4) payment and 5) infrastructure, IT and data sharing.

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time iconApril 8, 2024 15:00

What Matters Most! A Patient Led Approach to Identifying and Prioritizing Patient Reported Measures of Safety, Diagnosis and Bias

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Suz Schrandt, JD
Founder,
CEO and Chief Patient Advocate,
ExPPect

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Martin Hatlie, JD
Founding Member,
Patients for Patient Safety US

Holiday 1-3

This is In Person Session

This session will inform and engage participants in the development of Project PIVOT (Patients Involved in developing Outcomes Together), a patient-driven research initiative to identify and prioritize Patient Reported Experiences (PREs) and Patient-Reported Outcomes (PROs) that matter most to them on the issues of patient safety, diagnosis safety and health equity.

Purpose: There is heightened national awareness, including at the White House, across CMS and other DHHS agencies, and among researchers about improving patient experiences and outcomes by addressing embedded patient safety, diagnostic and health equity challenges. In the past, improvement work has incorporated traditional tools such as clinical outcome measures and satisfaction scores. There has been limited incorporation of PREs and PROs prioritized by patient/consumer community. Project PIVOT will provide an opportunity for a range of diverse patients/families, and communities, especially those who experience marginalization, to come together with measure development experts to identify and prioritize PREs and PROs that matter most to them.

Evaluation: The ultimate goal of Project PIVOT is to identify existing validated patient reported measures of patient safety and discrimination/bias and facilitate the creation of new validated measures where none exist to ensure more meaningful measurement and future research.

Outcomes:

  • Patient-identified and prioritized, existing, validated PREs and PROs
  • Patient-identified and prioritized PREs and PROs for which no validated measures exist
  • PREs and PROs that address specific challenges faced by minorities, persons with disabilities or chronic conditions, persons at risk for disparate maternal/child health outcomes, and other communities at heightened risk for disparate outcomes.

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time iconApril 8, 2024 15:00

Improving Healthcare Quality: Back to the Basics

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Anita Monteiro
Director, iQuality Improvement & Innovation Group
Centers for Medicare & Medicaid Services

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Joshua Cartwright, DHA, MHL, CPHQ, FACHDM
Associate Principal – HRC
Chartis

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David Wright, MPA
Director,
Quality Safety & Oversight Group,
Centers for Medicare & Medicaid Services

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Tom Evans, MD, FAAFP
President & CEO,
Iowa Healthcare Collaborative

Holiday 6

This is In Person Session

Recognizing the scope and complexity of health system challenges can be overwhelming. Committing to improving quality in healthcare can be exciting but daunting. What does a successful path forward look like? As the PHE taught us, it’s the basics: consistent processes, quality monitoring and most importantly, staff engagement, that are at the heart of routine or extraordinary medical responses. This session will discuss how to focus on the basic systems and foundation necessary to build any quality intervention, both organizationally and personally. This session is focused on the power of personal purpose in shaping the path forward, and our collective responsibility in making and sustaining improvements.

time iconApril 8, 2024 16:00

Medicaid and CHIP Innovations in Postpartum Care Equity

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Kristen Zycherman, RN, BSN
Quality Improvement Technical Director,
Division of Quality and Health Outcomes, Children and Adult Health Program Group,
Center for Medicaid & CHIP Services

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Adi Hirshberg, MD
Director of Obstetrical Services, Clinical Associate Professor, Maternal Fetal Medicine,
Hospital of the University of Pennsylvania, Penn Medicine

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Lindsay Standeven, MD
Assistant Professor of Psychiatry and Behavioral Sciences and Clinical Education Director,
The Johns Hopkins Reproductive Mental Health Center

Johnson A&B

This is In Person Session

This session will focus on the Equity in Postpartum Care Challenge prize competition, which rewards innovative strategies to improve postpartum care for Black or African American and American Indian or Alaska Native (AI/AN) beneficiaries enrolled in Medicaid or Children’s Health Insurance Program (CHIP). The competition emphasizes follow-up care form conditions associated with morbidity and mortality in the later postpartum period, including diabetes, postpartum depression and/or postpartum anxiety, hypertension, and substance use disorders (SUD). Two winners will speak about their winning projects and how they succeeded in scaling and spreading their ideas to improve equity in postpartum care.

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time iconApril 8, 2024 16:00

Quality Oversight of Medicaid Home and Community-based Services (HCBS) Waivers

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George Failla, Esq.
Director,
Medicaid & CHIP Operations Group,
Division of Home and Community Based Services Operations and Oversight,
Center for Medicaid and CHIP Services,
Centers for Medicare & Medicaid Services

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Susan Cummins
Technical Director,
Medicaid & CHIP Operations Group,
Division of Home and Community Based Services Operations and Oversight,
Center for Medicaid and CHIP Services,
Centers for Medicare & Medicaid Services

Peale A-B

This is In Person Session

This session will provide information about the statutory and regulatory quality requirements associated with HCBS waiver programs.  The session will outline the quality assurances states must provide, including obligations for quality monitoring and improvement.  It will also provide details about the Center for Medicaid and CHIP Services quality oversight including health and welfare site visits in states.

Click Here to View Presentation

time iconApril 8, 2024 16:00

Improving Care for People with Sickle Cell Disease:CMS & NIH/NHLBI Updates

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Teanika Hoffman, MA
CHW,
Sickle Cell Coalition of Maryland

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Shondelle Wilson-Frederick, PhD, NHLBI
Chief Engagement Officer,
National Heart, Lung and Blood Institute (NHLBI)
National Institutes of Health (NIH)

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Melissa Majerol
Cell and Gene Therapy Access Model Co-Lead,
Center for Medicare and Medicaid Innovation (CMMI)

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Jessica Lee, MD, MSHP
Acting Chief Medical Director,
Center for Medicaid and CHIP Services,
Centers for Medicare & Medicaid Services

Poe A&B

This is In Person Session

This session will focus on efforts from CMS and NIH/NHLBI to improve access, quality, and the experience of health care for individuals with Sickle Cell Disease (SCD). In 2023, CMS released a new CMS Action Plan for SCD. The Action Plan is based on listening sessions and lessons from the field as CMS is continuously gathering information on what barriers exist for individuals and providers. CMS will highlight some activities in the SCD Action Plan that address the challenges specific to CMS programs which are designed to improve health outcomes and reduce health disparities for individuals with SCD. In addition, this session will address current NIH/NHLBI efforts that are underway to advance our research and knowledge of SCD to help improve the lives of those living with this disease. Lastly, you will hear from a representative from the Maryland Sickle Cell Disease Association and her experience with SCD.

Click Here to View Presentation

time iconApril 8, 2024 16:00

Considerations for Developing New Measures in CMMI Models Highlighting Integrated Care for Kids and Emergency Triage

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Alexis Lilly, MBA
Deputy Director,
Center for Medicare and Medicaid Innovation (CMMI),
Centers for Medicare & Medicaid Services

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Chadwick Morgan, MPH
Integrated Care for Kids
Center for Medicare and Medicaid Innovation (CMMI)
Centers for Medicare & Medicaid Services

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Emily Creveling, MSW
Integrated Care for Kids Model Co-Lead,
Center for Medicare and Medicaid Innovation (CMMI),
Centers for Medicare & Medicaid Services

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Jacob Quinton, MD, MPH
Medical Officer,
Center for Medicare and Medicaid Innovation (CMMI),
Centers for Medicare & Medicaid Services

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Marvin Nichols, MHA
ET3 Model Lead,
Center for Medicare and Medicaid Innovation (CMMI),
Centers for Medicare & Medicaid Services

Holiday 6

This is In Person Session

As CMS seeks to align quality measures through the Universal Foundation, there remain important measurement gaps. The CMS Innovation Center strategically chooses to develop new measures when tied to the overarching goal of a model.  We will describe the context, importance and development of new measures for Center for Medicare and Medicaid Innovation (CMMI) alternative payment models. 

CMMI will discuss considerations for new measure development in newly announced CMMI models, as well as the approach and rationale for new measure development in current models.  This session will also highlight novel measures under the Integrated Care for Kids (InCK) and Emergency Triage, Treat, and Transport (ET3) model and the Guiding an Improved Dementia Experience model to highlight this work:

InCK:  There is evidence that interventions aimed at reducing rates of youth out of home placement (OOHP) have the potential to both improve children’s health outcomes and reduce their rates of avoidable health care utilization.  This session will provide an overview of the novel OOHP measure developed for the InCK Model. This measure reports the rate of new OOHP episodes per 1,000 attributed beneficiaries in a set geographic area.

ET3:  The ET3 Model tested an innovative new approach to paying for emergency ground ambulance services in Medicare. In order to better assess the efficacy of triage interventions, CMMI developed the Post-Triage Emergency Department (ED) Visit measure that assessed the rate at which patients return to the ED within three days of an intervention.

Participants will learn how the CMS Innovation Center evaluates opportunities to develop new quality measures and the details of recently developed measures.

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time iconApril 8, 2024 16:00

Addressing Health-Related Social Needs of Patients with Kidney Disease

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Sonya Streeter, MPP, MPH
Associate Vice President,
Westat

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Chiao Wen Lan, PhD, MPH, CPH
Social Scientist,
End Stage Renal Disease National Coordinating Center (ESRD NCC)

Key Ballroom 1-4

This is In Person Session

A critical part of advancing reform and addressing provider burden in the health care system is creating meaningful alignment among payers.  Over the last year, both Center for Medicare and Medicaid Innovation (CMMI) and the Learning and Action Networks (LAN) have announced new models and initiatives meant to generate directional alignment that balances the need for multi-payer alignment goals with payer flexibility.  This session describes how these efforts work together to generate this alignment at both the national and local levels.

Emphasizing both collaborative and individual efforts, CMMI and the LAN will highlight key initiatives and milestones generating meaningful multi-payer alignment across the healthcare market.  In both instances, these efforts adopt the principles of directional alignment, where alignment does not require identical arrangements or programs, but looks to create collaboration and alignment around core areas, such as quality measurement, and create closer alignment over time.  

Participants will learn how CMMI and the LAN are working together and with a wide range of partners to advance alignment in key areas of delivery system reform.

Click Here to View Presentation

time iconApril 8, 2024 16:00

Case Studies to Reduce Hospital-Acquired Infections Through Group Peer-to-Peer and 1:1 Customized Technical Assistance

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Donna Cohen, BSN, RN, CCM
Director Quality Programs,
Alliant Health Solutions

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Rose Langdon, BSN, MBA, CPHQ, FNAHQ
Lead Educator,
TMF Health Quality Institute

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Karen Holtz, MS, MT(ASCP), CPHQ
HQIC Education Lead,
Alliant Health Solutions

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Ann Werner, MSW, CPHQ
Director,
TMF Health Quality Institute

Holiday 4-5

In the aftermath of the COVID-19 pandemic, hospitals struggled with low performance in healthcare-associated infections (HAIs). Hospitals were overwhelmed and frustrated with their performance as a result of competing priorities due to COVID-19 and resultant staff turnover.  Health care professionals, specifically infection preventionists (IPs) struggled during and after the pandemic.

In 2023, TMF launched a series of topic-specific affinity discussion groups to address lagging performance by its supported  hospitals on specific patient safety measures. Each affinity group met monthly for three months and focused on one specific topic. We started with topics that hospitals struggled to improve, such as sepsis and pressure injuries. We provided short on-demand videos, tools and resources, and access to a subject matter expert for each group. The theme of Cultivate Your Patient Safety Environment was used across all affinity group topics.

The Alliant Hospital Quality Improvement Contractor (HQIC) applied a peer-to-peer strategy through hospital networking and one-on-one customized calls to reduce HAIs as well as improve reporting of National Healthcare Safety Network (NHSN) data. As a result of a networking call, one hospital was able to learn from a high performing hospital to significantly decrease pressure injuries. An Infection Preventionist and subject matter expert worked one-on-one with hospitals that had newly hired IPs or staff new to the role. Together, they identified gaps and implemented interventions that led to change and improvement in HAIs. Coaching packages which included best-practice interventions and links to relevant resources and professional websites were shared with hospitals. The data were monitored over time until target goals were achieved.

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time iconApril 8, 2024 16:00

Building the Foundation of a Strong Hospital Sepsis Program to Optimize Patient Care and Improve Outcomes

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Virginia Brooks (Moderator) MHA, CPHQ, FACHE
Vice President,
Health Quality Innovators

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Rebecca Boll, MSPH, CPHQ
Senior Director,
IPRO

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Charisse Coulombe, MS, MBA, CPHQ, CPPS
Director,
Hospital Quality Initiatives,
Iowa Healthcare Collaborative (IHC)

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Kendra Cooper, MSN-HCQ, RN, CPHQ
Consulting Manager,
Health Quality Innovators

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CarlaLisa Rovere-Kistner LCSW, CPHQ, CCM
Quality Improvement Specialist,
IPRO

Holiday 1-3

This is In Person Session

Hospital Quality Improvement Contractor (HQIC) use a variety of data sources to inform their ability to provide customized technical assistance. As early adopters and promoters of the Centers for Disease Control and Prevention (CDC) Hospital Sepsis Program Core Elements, Health Quality Innovators (HQI) leveraged this framework to identify hospital program needs and designed a flexible core of technical assistance to meet hospitals at various levels of sepsis program implementation. Health Quality Innovators (HQI) analyzed the NHSN 2022 Patient Safety Component—Annual Hospital Survey, specifically responses under the Sepsis Management and Practices section. Questions in the annual survey are closely tied to the CDC’s Hospital Sepsis Program Core Elements, however, Health Quality Innovators (HQI) was already using this framework with HQIC hospitals prior to the official launch of the program in August 2023. Health Quality Innovators (HQI) used the survey results to inform technical assistance planning and one-on-one coaching. IPRO also created a sepsis gap assessment to obtain an in-depth understanding of the hospitals’ needs. This gap assessment was then used to inform education needs and content for inclusion in a sepsis affinity group. In addition, IHC created and utilized low performer reports to identify the hospitals and specific components in the greatest need for technical assistance and sepsis education. All three Hospital Quality Improvement Contractors (HQICs) use Medicare FFS Administrative Claims data and site visits to measure improvement in sepsis mortality. Approximately 669 hospitals enrolled in either the Health Quality Innovators (HQI), IPRO or IHC, Hospital Quality Improvement Contractor provider engaged in a variety of interventions to reduce sepsis mortality over three years of the Hospital Quality Improvement Contractor project. These interventions included change pathways, affinity groups, action plans, office hours, educational events, podcasts, site visits and survivor stories. Several initiatives were expanded to include collaboration with additional Hospital Quality Improvement Contractors. During this session, we will highlight both Hospital Quality Improvement Contractor wide interventions as well as specific case studies describing specific systems, processes, and strategies that attributed to improvements in sepsis care and reduced mortality.

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time iconApril 8, 2024 16:00

Demonstrating Attributable Impact in Quality Improvement Through Success Stories

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McCall Glover, MPH
Data Scientist,
Booz Allen Hamilton

Key Ballroom & Live Streamed

In May 2023, the Independent Evaluation Contractor (IEC) hosted a roundtable discussion with representatives from all 12 Quality Innovation Network – Quality Improvement Organizations (QIN-QIO) contractors; the discussion aimed to understand how contractors define, measure, and report attributable impact within individual healthcare environments. Findings from the 2023 closed-door session and subsequent follow-up data were analyzed. Insights pertaining to alignment of success definitions informed the development of CMS resources to support contractors’ use of success stories to support assessment of attributable impact.

The goal of this IEC presentation is to share progress toward adequately identifying and reporting success stories in quality improvement that suggest that provider impacts may be attributable to the contractors’ support.. The IEC will present analyses from QIN-QIO-furnished qualitative data related to identified cases of observed healthcare improvement collected during the NQIIC 12th SOW, November 2019 through November 2023. Findings include QIN-QIO feedback on challenges in capturing their own success and opportunities for improving the definition of success. The IEC will discuss lessons learned and next steps to help QIN-QIOs improve the process of identifying and communicating  evidence of attributable impact.

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time iconApril 8, 2024 16:00

Chronic Pain: Getting People the Care and Services they Need

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Paige Mathew, PharmD, BCPS, BCGP
Pain Management and Opioid Stewardship Clinical Pharmacy br/>Program Manager, Department of Veterans Affairs

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Scott Lawrence, DC, CHCQM, FABQAURP
Senior Advisor,
CMS Quality Improvement and Innovation Group

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Tara McMullen, PhD, MPH
Associate Director Opioid Safety,
Veterans Health Administration

Key Ballroom 9-12

This is In Person Session

More than one fifth of American adults live with chronic pain, with about seven percent experiencing “high impact” pain. In US military veterans, chronic pain is even more common, with nine percent suffering from severe pain. Pain is a debilitating condition that negatively affects quality of life and work and is closely associated with depression, dementia, suicidality, and substance use. Pain also disproportionally impacts people who are racial and ethnic minorities, bisexual, divorced/separated, living with a disability, and have chronic conditions like arthritis and kidney disease. Nearly 80 percent of people with Medicare report chronic pain that interferes with function. Pain causes disability and social isolation, and is an ongoing burden for individuals, families, friends, caregivers, and health systems. Advancing pain care across all groups, ages, and settings is a public health imperative. Addressing pain effectively is one of the four goals of CMS’s Behavioral Health Strategy, prompting new monthly payment codes to help people with Medicare more easily access holistic care in an ongoing clinical relationship. The Department of Veterans Affairs (VA) has a long history of developing successful solutions for pain management. Its Stepped Care Model of Pain Management is one example and there is new work in pain measurement that offers potential to better tailor care. The person-centered and team-based approaches employed by the VA can serve as a model for other health systems seeking feasible, effective pain care that improves lives.

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time iconApril 8, 2024 16:00

Quality Framework for a High Reliability Organization (HRO)

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John Sellner, PharmD
Association Director of Quality and Safety,
Minnesota Hospital

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Roderick Baker
Associate Vice President of Development,
Winona Health

Latrobe

This is In Person Session

The road to becoming a High Reliability Organization (HRO) can be long and complex. The Minnesota Hospital Association (MHA) saw the desire from Minnesota hospitals and health systems to begin their HRO journeys and, using their unique process to tackle quality improvement, developed a strategic process for implementing and rolling out an HRO program. MHA created a road map for their members to use to successfully implement their own HRO program from getting started, all the way through advanced HRO implementation. MHA’s Director of Quality and Safety, John Sellner, PharmD, RPh, will present on MHA’s strategic process to tackling quality and the implementation and rollout of the High Reliability Road Map. Roderick Baker, Winona Health Minnesota will review Winona Health’s utilization of the Road Map in their HRO journey and provide recommendations to participants on how to utilize HRO resources to inform learnings and make improvements along the way.

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time iconApril 8, 2024 16:00

Resilient and Ready Together: Applying a Community Informed, Geographic Lens to our Work

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Kitichia Weeks, MA
Health Insurance Specialist/Account Manager,
Division of Health Plans Operations,
Centers for Medicare & Medicaid Services

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Thomas Bane, PhD, LMSW
Special Assistant to the Regional Administrator,
OPOLE,
Centers for Medicare & Medicaid Services

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Ashby Wolfe, MD, MPP, MPH
Regional Chief Medical Officer,
Center for Clinical Standards and Quality,
Centers for Medicare & Medicaid Services

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Susan Karol, MD
Chief Medical Officer,
Division of Tribal Affairs,
Centers for Medicare & Medicaid Services

Ruth

This is In Person Session

This session will provide an overview of the CMS Framework for Advancing Health Care in Rural, Tribal, and Geographically Isolated Communities and how it supports CMS’s overall efforts to advance health equity, expand access to quality, affordable health coverage, and improve health outcomes for all Americans. The Framework’s six priorities were identified through lessons learned and feedback from those living and working in rural, Tribal, and geographically isolated communities. CMS’s approach to operationalizing this Framework over the next five years will be informed by ongoing public engagement, as appropriate, and CMS will continue to monitor trends in health and health care that uniquely impact rural, tribal, and geographically isolated areas.

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time iconApril 8, 2024 16:00

Oral Health Quality Improvement in Medicaid and CHIP

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Margo Rosenbach, PhD
Vice President and Director of Health Program Improvement,
Mathematica

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Andrew Snyder, MPA, (Moderator)
Senior Policy Advisor,
Center for Medicaid and CHIP Services,
Centers for Medicare & Medicaid Services

Virtual Event Platform

Over the past two years, CMS has made significant strides in advancing oral health across all our programs. From 2020-2023, a CMS learning collaborative focused on advancing oral health prevention in primary care. Topically applied fluoride varnish effectively prevents dental caries in children and adolescents. Because young children under 5 are more likely to see a primary care provider (PCP) than a dental provider, PCPs are uniquely positioned to support oral health prevention by offering fluoride varnish as part of primary care visits and connecting beneficiaries to dental care. The session will open with an overview of the technical assistance CMS provides state Medicaid and CHIP agencies and their quality Improvement (QI) partners to advance oral health prevention in primary care for Medicaid and CHIP beneficiaries, featuring several state QI projects from the affinity group, highlighting their strategies, partnerships, and lessons learned.

In 2022, CMS conducted its first-ever oral-focused human-centered design research in four states, interviewing nearly 100 people (i.e., beneficiaries, providers, advocates, state administrators, etc.) to understand barriers to oral health care access for the Medicaid and dually eligible population to inform policy change. In this session, The CMS Chief Dental Officer, Dr. Chalmers, will present the findings from that engagement.

CMS also convened a Workgroup to gather stakeholder feedback from experts in the field to plan strategic priorities for the next phase of our Medicaid and CHIP Oral Health Initiative. The focus is to assess gaps related to oral health and access to care for Medicaid and CHIP beneficiaries and recommend strategic priorities for the next five years. The session will conclude the workgroup process and overview of the final report and recommendations.

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time iconApril 8, 2024 16:00

Bridging the Gaps in the Kidney Transplant Journey: Innovation Collaborations in CKD, Dialysis and Transplant

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Victoria Cash MBA, BSN, RN, CPHQ
Executive Director,
IPRO ESRD Network of the Ohio River Valley

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Ivory Harding, MS
Director,
Quality and Regulatory Affairs,
National Kidney Foundation

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Matthew Cooper MD
Chief of Transplantation,
Director of the Solid Organ Transplant Line and Professor of Surgery at the Medical College of Wisconsin,
Medical College of Wisconsin

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Sherri Morgan-Johnson RN, BSN, MHSA, FAC-COR III
Nurse Consultant,
Centers for Medicare & Medicaid Services

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Sumeska Thavarajah, MD
Medical Director,
Fresenius Kidney Care

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Charles Rice, CPhT, MTM, BBM
ETCLC National Faculty, Patient and Family Representative

Virtual Event Platform

During this patient-centered roundtable session, attendees will learn from kidney dialysis/transplant patients, the NKF, ESRD Networks, QIN-QIOs, TAQIL, and experts as they explore the complete kidney transplant journey.  

From the five CKD stages to dialysis treatment options, and the transplant process, the expert panel will highlight gaps throughout the transplant care continuum and identify potential solutions, including strategies to reduce inequities experienced by underserved communities. 

To address these identified gaps, speakers will review available partnership opportunities, new programs being tested in select communities, critical resources accessible to healthcare professionals, as well as the vital need to improve patient education that is culturally and linguistically appropriate throughout the kidney care system.

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time iconApril 8, 2024 16:00

HHS’ Call to Action on Opioid Use Disorder Treatment

Virtual Event Platform

This is In Person Session

Drug overdose deaths in the United States, driven by illicit fentanyl and other opioids, remain at historically high levels – with more than 107,000 lives lost in the past year, and millions more struggle with opioid and other substance use disorders. The opioid crisis reaches every corner of our country, from alleyways to nursing homes, and requires an immediate call to action. Federal partners, local governments, healthcare institutions, and communities are working together to provide viable solutions to combating the opioid crisis.

There is a nationwide need for education on medications for opioid use disorder (MOUD) to increase the number of practitioners eligible to manage and/or prescribe appropriate medications. Medicare providers are uniquely positioned to create the gold standard of opioid use disorder treatment by screening, diagnosing, and treating Medicare patients for opioid use disorder as routine healthcare. They can also exhibit positive attitudes to reduce stigmas associated with opioid use disorder. 

This session will consist of a panel discussion where, IPRO, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) will describe the state of the opioid crisis from a nursing home perspective and discuss how to improve patient safety in vulnerable populations. The Substance Abuse and Mental Health Services Administration (SAMHSA) will provide regulatory updates on opioid prescribing, the stigma of opioid addiction, and discuss key elements of Opioid Treatment Programs (OTPs).  Finally, the Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy (FORHP), will share opioid-related resources and funding opportunities to engage partners in rural communities.

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time iconApril 8, 2024 17:00

AI in Quality Measurements: Opportunities and Challenges in Health AI for a Resilient Health System

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Brian Anderson, MD
CEO Coalition for Health AI, Inc.

Key Ballroom & Live Streamed

This session will take a closer look at what the current state of clinical quality is in the US and the opportunities for AI to improve it, if implemented responsibly and effectively. CHAI is a community of health systems, public and private organizations, and expert practitioners of AI and data science, who have come together to harmonize standards and reporting for health AI and educate end-users on how to evaluate these technologies before adoption.

Click Here to View Presentation

time iconApril 8, 2024 17:30

Closing Remarks

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Jean Moody-Williams, RN, MPP
Deputy Director,
Center for Clinical Standards and Quality,
Centers for Medicare & Medicaid Services

Key Ballroom & Live Streamed

time iconApril 9, 2024 09:00

Quality in Motion: Acting on the Centers for Medicare & Medicaid Services National Quality Strategy

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Michelle Schreiber, MD
Deputy Director,
Quality & Value, Centers for Medicare & Medicaid Services

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Susannah Bernheim, MD, MHS
Chief Quality Officer & Acting Chief Medical Officer,
Center for Medicare and Medicaid Innovation,
Centers for Medicare & Medicaid Services

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Martin Hatlie, JD
Founding Member,
Patients for Patient Safety US

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Jessica Lee, MD, MSHP
Acting Chief Medical Director,
Center for Medicaid and CHIP Services,
Centers for Medicare & Medicaid Services

Holiday 1-5

In 2022, the Centers for Medicare & Medicaid Services (CMS) launched the CMS National Quality Strategy (NQS), a plan aimed at improving the quality and safety of health care for everyone, with a special focus on those from underserved and under-resourced communities. The CMS NQS builds on CMS’ efforts to improve health care quality for individuals across their lifespan and continuum of care by using all the Agency’s levers, including value-based payment programs and models; health and safety standards (including conditions for coverage and conditions of participation); survey and certification programs; quality measurement and public reporting; and quality improvement technical assistance. Join us to learn more about the recent publication, Quality in Motion: Acting on the CMS National Quality Strategy, and current CMS actions and accomplishments regarding equity and engagement, outcomes and alignment, safety and resiliency, and interoperability and scientific advancement.

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time iconApril 9, 2024 09:00

Care for Complex Patients: Clinical Approaches to Quality Improvement at the Intersection Substance Use Disorder, Mental Illness, and Chronic Pain

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Benjamin Springgate, MD, MPH, FACP
Professor of Medicine and Public Health,
Louisiana State University Health-New Orleans

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Chinazo Cunningham
Commissioner,
New York State Office of Addiction Services and Supports

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Karran Phillips, MD, MSc
Deputy Director,
Center for Substance Abuse Treatment,
SAMSHA

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Stefan Kertesz, MD, MSc
Professor,
University of Alabama at Birmingham Heersink School of Medicine and the Birmingham Alabama Health Care System Homeless PACT

Holiday 6

This Mini Plenary will highlight expert clinicians’ and system leaders’ approaches to healthcare delivery and quality improvement for many of the most complex patients for whom American systems care – community members with comorbid substance use disorder, mental illness, and chronic pain. Patients with this complex triad often experience unmet healthcare needs and substantially worse health and social outcomes - reflecting not only clinical complexity but also significant challenges in accessing and paying for services, variations in quality of care, and entrenched system failures to address health related social needs. Leaders with deep clinical expertise and experience working in systems to improve care for people with substance use disorders, mental illness, and chronic pain will discuss their methods to tackle challenging clinical and social scenarios, recommending practical resources and that they and their systems use to integrate approaches to quality improvement, care delivery, and social determinants of health. Master Class experts will represent federal (SAMHSA Center for Substance Abuse and Treatment (invited)), clinical academic (the University of Alabama Birmingham and Department of Veterans Affairs (invited)), and state (New York Office of Addiction Services and Supports (invited)) systems, offering diverse vantage points and practical approaches and tools to address the needs of patients with this complex triad of conditions.

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time iconApril 9, 2024 10:30

Welcome to Day 2 of the CMS Quality Conference

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Jonathan Blum
Principal Deputy Administrator & Chief Operating Officer,
Office of the Administrator,
Centers for Medicare & Medicaid Services

Key Ballroom & Live Streamed

time iconApril 9, 2024 10:40

CCSQ Priorities for 2024 and Beyond: Optimal Health for All People Across the Care Continuum

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Anita Monteiro
Director, iQuality Improvement & Innovation Group
Centers for Medicare & Medicaid Services

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Dora Hughes, MD, MPH
Acting Chief Medical Officer & Acting Director,
Center for Clinical Standards and Quality,
Centers for Medicare & Medicaid Services

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David Wright, MPA
Director,
Quality Safety & Oversight Group,
Centers for Medicare & Medicaid Services

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Tamara Syrek Jensen
Director, Coverage and Analysis Group

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Karen Tritz
Centers for Medicare & Medicaid Services
Director of the Survey & Operations Group

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Michelle Schreiber, MD
Deputy Director,
Quality & Value, Centers for Medicare & Medicaid Services

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Lisa Parker
Centers for Medicare & Medicaid Services
Director of the Clinical Standard Group

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Mark Plaugher
Centers for Medicare & Medicaid Services
Acting Director of the Information System Group (ISG)

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Jennifer Dubbs
Director, Business Operations Group
Center for Clinical Standards and Quality
Centers for Medicare and Medicaid Services

Key Ballroom & Live Streamed
time iconApril 9, 2024 11:05

Patient Safety Fireside Chat w/ CCSQ’s Acting Chief Medical Officer & Director and the Deputy Director of Quality and Value

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Michelle Schreiber, MD
Deputy Director,
Quality & Value, Centers for Medicare & Medicaid Services

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Dora Hughes, MD, MPH
Acting Chief Medical Officer & Acting Director,
Center for Clinical Standards and Quality,
Centers for Medicare & Medicaid Services

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Arjun Srinivasan, MD
Deputy Director
Program Improvement in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC)

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Craig A. Umscheid, M.D., MS
Director,
Center for Quality Improvement and Patient Safety (CQuIPS)
Agency for Healthcare Research and Quality (AHRQ)
Department of Health and Human Services

Key Ballroom & Live Streamed

The Centers for Medicare & Medicaid Services (CMS) is committed to improving performance on key patient safety metrics through the application of CMS levers such as quality measurement, payment, health and safety standards, and quality improvement support. This session is a conversation with CMS Senior Leadership and Federal partners to renew our collective commitment to patient safety. We will be discussing progress that has been made, as well as challenges faced, since the 2023 CMS Quality Conference. Additionally, the panel will speak to a call to action for our healthcare community so that together we can achieve our patient safety goals.

time iconApril 9, 2024 11:35

Welcome Remarks from the Centers for Medicare and Medicaid Services Chief Dental Officer

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Natalia Chalmers, DDS, MHSc, PhD
Chief Dental Officer,
Office of the Administrator,
Centers for Medicare & Medicaid Services

Key Ballroom & Live Streamed

time iconApril 9, 2024 11:45

Remarks from HHS Inspector General Christi A. Grimm on Quality in HHS Programs

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Christi A. Grimm
Inspector General,
Office of Inspector General,
Department of Health and Human Services

Key Ballroom & Live Streamed

time iconApril 9, 2024 13:30

Advancing Multi-Payer Alignment and Specialty Care Integration through the Health Care Payment Learning and Action Network (LAN)

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Kate Davidson LCSW
CMMI,
Centers for Medicare & Medicaid Services,
Director of the Learning and Diffusion Group (LDG)

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Mark McClellan M.D., PhD
Director,
Margolis Center for Health Policy at Duke University

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Dr. Helen Burstin MD, MPH, MACP
CEO,
Council of Medical Specialty Services

Key Ballroom 1-4

A critical part of advancing reform and addressing provider burden in the health care system is creating meaningful alignment among payers.  Over the last year, both Center for Medicare and Medicaid Innovation (CMMI) and the Learning and Action Networks (LAN) have announced new models and initiatives meant to generate directional alignment that balances the need for multi-payer alignment goals with payer flexibility.  This session describes how these efforts work together to generate this alignment at both the national and local levels.

Emphasizing both collaborative and individual efforts, CMMI and the LAN will highlight key initiatives and milestones generating meaningful multi-payer alignment across the healthcare market.  In both instances, these efforts adopt the principles of directional alignment, where alignment does not require identical arrangements or programs, but looks to create collaboration and alignment around core areas, such as quality measurement, and create closer alignment over time.  

Participants will learn how CMMI and the LAN are working together and with a wide range of partners to advance alignment in key areas of delivery system reform.

Click Here to View Presentation

time iconApril 9, 2024 13:30

Improving Health Equity by Addressing Health-related Social Needs in Medicaid and CHIP

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Jessica Lee, MD, MSHP
Acting Chief Medical Director,
Center for Medicaid and CHIP Services,
Centers for Medicare & Medicaid Services

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Christopher Chen, MD, MBA, FACP
Medical Director,
Medicaid Washington State Health Care Authority

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Ruben Soliz, MPH
Federal Relations Lead and Health Policy Advisor
Arizona Health Care Cost Containment System

Key Ballroom & Live Streamed

This session will explore recently released CMS guidance on health-related social needs (HRSN) and how states are implementing housing and nutritional supports to improve the quality of care and health outcomes. In November 2023, CMS issued an Informational Bulletin on how states can address health-related social needs (HRSN) in Medicaid and the Children’s Health Insurance Program (CHIP), and framework of services and supports considered allowable under specific authorities, including section 1115 demonstrations. CMS has approved 1115 demonstrations for HRSN services in states including Arizona and Washington. Presenters from these state Medicaid programs will describe how they have implemented housing and nutritional supports, integrating with existing social and housing services, as well as how they are measuring associated changes in health care utilization and quality, and health outcomes.

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time iconApril 9, 2024 13:30

Working with Managed Care Plans to Improve Quality in Medicaid and CHIP:
Lessons from the Infant Well-Child Affinity Group

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Emily Stauffer Rocha, MBA, MSN, RN, NE-BC, CHCQM,
Director of Clinical Innovation,
Texas Health and Human Services Commission

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Crystal O'Reilly BSN, RN
AVP,
Quality and Care Management Affairs,
Cook Children's Health Plan

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Susan Ruiz, BA
EPSDT/Children’s Health Subject Matter Expert,
Division of Quality and Health Outcomes,
Children and Adult Health Program Group,
Center for Medicaid & CHIP Services

Peale A&B

With more than 70% of Medicaid and Children's Health Insurance Program (CHIP) beneficiaries enrolled in managed care, states can have a significant impact on improving health services delivery and outcomes for their Medicaid and CHIP beneficiaries by working with their managed care plans (MCPs) on quality improvement (QI) initiatives. State staff from Texas Health and Human Services developed an approach to coordinating MCP QI efforts around a common state aim statement. Each MCP chose and implemented an improvement project to complement the state aim, and the state created a structure to enhance peer learning and impact. Participants will hear from a state speaker about their approach and from a participating MCP that ran its own supportive QI project. This session will also review resources developed by Centers for Medicare & Medicaid Services to help state Medicaid and CHIP staff and their MCP QI partners implement a similar approach.

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time iconApril 9, 2024 13:30

Update on the Medicare Value-based Strategy

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Michelle Schreiber, MD
Deputy Director,
Quality & Value, Centers for Medicare & Medicaid Services

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Purva Rawal, PhD
Chief Strategy Officer at the CMS Innovation Center
Centers for Medicare and Medicaid Services

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John Pilotte
Director of the Performance-based Payment Policy Group (P3)
Center for Medicare at the Centers for Medicare & Medicaid Services

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Sophia Sugumar (Moderator) MSHM
Program Policy Lead,
Division of Electronic and Clinical Quality,
Centers for Medicare & Medicaid Services

Key Ballroom 9-12

The panel presentation will provide an update to the Medicare Value-Based Care Strategy. The presentation will specifically focus on progress along the three objectives of the Strategy—Alignment, Growth and Equity—as well as future priorities and vision.

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time iconApril 9, 2024 13:30

Awareness to Action: Using a Structurally Competent Approach to Overcome Biases

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Keith Norris MD
Distinguished Professor of Medicine,
UCLA Division of General Internal Medicine and Health Services Research

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Ken Teasley
Patient Facility Representative br/>NCC Legacy PSME
CAB, Harlem Wellness Center- MT. Sinai

Johnson A&B

Health disparities continue to persist among patients with End Stage Renal Disease (ESRD). Marginalized racial and ethnic minority and low socioeconomic populations have a disproportionate burden of involuntary discharges (IVDs) and other disparities, such as lack of access to transplantation and higher unplanned hospital readmissions. Structural competency for equitable kidney care is an approach in which healthcare professionals recognize and respond to health and illness as the downstream effects of broad social, political, and economic factors. It serves as an equity framework for overcoming disparities and bias in healthcare. Applying this approach in kidney care can play a significant role in reducing health disparities and advancing health equity. The ESRD National Coordinating Center (NCC) developed a three-module structural competency training for kidney professionals to address health inequities. The training provides specific, evidence-based interventions and strategies to address the structural drivers of kidney care inequities, including IVDs.

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time iconApril 9, 2024 13:30

Optimizing Opioid Stewardship in 2024: How the Compass Program is Changing Clinical Care for Patients on Chronic Opioid Therapy

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Jen Brockman, MHA, BSN, RN, CPPS,
Chief Clinical Program Officer & OPSS Project Director,
Iowa Healthcare Collaborative

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Don Stader, MD, FACEP
OPSS Medical Director & Addiction Medicine Specialist,
Stader Opioid Consultants

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Laurie Fisher, MD
Family Medicine Physician & OPSS Cohort,
Town Plaza Family Practice

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Rachael Duncan, PharmD, BCPS, BCCCP
OPSS Coach,
Stader Opioid Consultants

Ruth

This presentation will examine the implications of historical prescribing practices on patients receiving Chronic Opioid Therapy (COT) and assess the subsequent changes in prescribing patterns, patient access, and associated risks. This presentation will feature a panel from the Compass Program, including an addiction medicine physician, a pharmacist, a nurse, and a family medicine physician participant. The panel will discuss several of the core pillars of the Compass Program and how they are being implemented within the participant cohort to change clinical practice and improve patient outcomes. They will discuss resources to support opioid-sparing management of acute pain to reduce opioid exposure, utilizing nonopioid pharmacologic agents and nonpharmacologic therapies. For patients maintained on chronic opioid therapy (COT), the panel will discuss risk management strategies to increase patient safety including rotation to safer agents, providing naloxone, using patient-specific tapering strategies, and minimizing co-prescribing of other sedating agents. Lastly, the panel will discuss the critical need for primary care providers and family medicine physicians to help reduce overdose mortality trends by offering treatment of OUD with buprenorphine products, supported by resources, 1-on-1 coaching, and education from the Compass Program.

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time iconApril 9, 2024 13:30

Who Seeks Medicare Support and Advocacy Services and How Can We Address Barriers and Reduce Disparities?

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Scott Fortin, MBA
Sr. Director Communications and Outreach,
Kepro

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Carmen Villegas, RN, BSN, BCPA
Immediate Advocacy Manager,
Livanta

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Stephanie Fry, BA, CPXP
Associate Vice President,
Westat

Holiday 4-5

In response to the President’s executive order to advance racial equity and support for underserved communities, the Department of Health and Human Services (HHS) established an equity action plan. In alignment with this plan, Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIOs) are working to identify and address barriers to equitable access and utilization of beneficiary protection, support, and advocacy services.

BFCC-QIOs offer case review services for beneficiaries who think they may be entitled to additional Medicare-covered services, or who think the quality of care they received does not meet clinical standards. Using BFCC-QIO program data, we assessed the degree to which case review services are being utilized by beneficiaries of different races and ethnicities.

Disparities in case review utilization are evident among Hispanic and Asian beneficiaries and these disparities may further contribute to existing health outcome inequalities. The concern is that these beneficiaries are still experiencing premature healthcare service termination or other quality of care issues such as gaps between government and other health providers, but are not exercising their right to review and possibly resolve these issues through BFCC-QIO program services.

BFCC-QIOs are carefully analyzing the approach and implementation strategies for their work. Seeking input from experts, stakeholders and Medicare beneficiaries, BFCC-QIOs are identifying strategies to improve access and awareness and reduce disparities in use of BFCC-QIO case review services that may contribute to poor health outcomes.

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time iconApril 9, 2024 13:30

Expanding Access to Quality and Affordable Oral Health and Behavioral Healthcare

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Jessica Maksut PhD
Technical Director,
Office of Minority Health;
Centers for Medicare & Medicaid Services

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Carla Shoff PhD,
Senior Advisor to the Chief Dental Officer,
Office of the Administrator;
Centers for Medicare & Medicaid Services

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Lorel Burns DDS, MS
Assistant Professor,
NYU College of Dentistry

Poe A-B

Over the past two years, CMS has made significant strides in advancing oral health across all our programs. CMS has developed a set of cross-cutting initiatives that engage teams across our organization to drive the goals highlighted by the strategic pillars and enhance focus on critical components of our work. These initiatives are high-level, multi-year priorities for CMS that bring our centers and offices together to leverage their expertise and strengthen collaboration. The CMS Chief Dental Officer will describe the launch and work under the Oral Health Cross-Cutting Initiative. Access to oral health services promotes health and wellness and allows beneficiaries and consumers to achieve the best health possible. States have the flexibility to determine what dental benefits are provided to adult Medicaid enrollees. While most states offer at least emergency dental services for adults, less than half of the states currently provide comprehensive dental care. There are no minimum requirements for adult dental coverage. More than 1 in 4 (26%) adults in the United States have untreated tooth decay. Over the last ten years, dental pain has been a top reason for opioid prescribing upon discharge from the ED, thereby contributing to the overdose crisis. There is a bi-directional link between oral health and substance use disorder. This session will focus on the outcomes of two studies that analyzed Medicaid enrollment and claims data. These studies examine oral health needs, disparities, and access to dental services for Medicaid adults with substance use disorders, as well as the impact of the COVID-19 public health emergency, state coverage policies, and socio-demographic factors on adults' access to dental services.

Click Here to View Presentation

time iconApril 9, 2024 13:30

Lessons from Human Centered Design Informing Policymaking: Substance Use Disorders and Oral Health

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Morgan Taylor
Lead Human Center Design Specialist,
Office of Burden Reduction & Health Informatics (OBRHI)

Latrobe

The Customer Focused Research Group (CFRG) within the Office of Burden Reduction and Health Informatics (OBRHI) will present on their Behavioral Health and Oral Health Human-Centered Design Customer Engagements. Human-Centered Design (HCD) is the process CMS uses to understand the people for which they write policies; and create programs and services. CFRG will share the qualitative research aimed at understanding how to ensure equitable access to oral health care without stigma. Each respective engagement revealed many insights in addition to an opportunity to co-create illustrations with external customers to highlight and raise the customers’ voice in supporting those suffering with substance use disorders.

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time iconApril 9, 2024 13:30

The 2024 National Impact Assessment Report – Collecting and Using Quality Data Across 26 CMS Programs

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Robert Ziemba, PhD
Statistician,
HSAG

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Kyle Campbell, PharmD
Project Director,
HSAG

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Kendra Hanley, MS, BA
Impact Assessment Team Lead,
HSAG

Holiday 6

The 2024 National Impact Assessment aggregates retrospective data from 26 CMS quality and value-based incentive programs to characterize quality and efficiency impacts associated with the use of measures. The session will focus on summarizing key findings from these comprehensive analyses that provide important insights regarding effects of the COVID-19 pandemic during the period of analysis. We will describe national measure performance trend data pre-COVID-19 (2016–2019) compared with results in the initial years of the COVID-19 public health emergency (PHE)— 2020 and 2021— and describe patient impact and costs avoided when performance for select measures improved. Data also will be presented on how the CMS measure portfolio is evolving to reduce measurement burden and address CMS quality priorities. Lessons learned from the COVID-19 PHE and proposed actions to improve the resilience of quality measurement and the health care system will be discussed. Finally, underscoring equity as a primary objective of the CMS National Quality Strategy, the session will explore patterns of disparities in quality measure scores and offer insight into underlying drivers of disparities identified through focus groups in underserved communities.

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time iconApril 9, 2024 13:30

Breaking Barriers: Enhancing Language Access in Health and Human Services

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Maria Moreno MPH
Program Manager
Sutter Health

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Genevieve Babecki
Language Access Coordinator,
HHS/Office of Civil Rights

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Lina Rashid
Senior Policy Advisor,
Centers for Medicare and Medicaid Service/Center for Consumer Information and Insurance Oversight

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Anita Pinder
Director,
Centers for Medicare & Medicaid Services/Office of Equal Opportunity & Civil Rights

Holiday 1-3

Approximately 68 million people in the United States speak a language other than English at home, and of those, 8.2% speak English less than very well. Individuals with limited English proficiency (LEP) do not speak English as their preferred language and have a limited ability to read, write, speak, or understand English. A lack of meaningful language access can lead to inequitable access to health and human services. Research indicates that adverse events affect patients with LEP more frequently, are often caused by communication problems, and are more likely to result in serious harm compared to those that affect English-speaking patients. Providing language access decreases barriers to equal access to health and human services. During this session, you will hear from three leaders working to ensure language access. They will share insights from the federal perspective with a focus on policy and communications, as well as from one large health system and their 20-year experience with language services.

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time iconApril 9, 2024 13:30

Innovation Center Quality Pathway – A Refreshed Approach to Quality in CMMI Models

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Susannah Bernheim, MD, MHS
Chief Quality Officer & Acting Chief Medical Officer,
Center for Medicare and Medicaid Innovation,
Centers for Medicare & Medicaid Services

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Noemi Rudolph, MPH
Director,
Research and Rapid Cycle Evaluation Group,
Center for Medicare and Medicaid Innovation (CMMI)

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Jacob Quinton, MD, MPH
Medical Officer,
Center for Medicare and Medicaid Innovation (CMMI),
Centers for Medicare & Medicaid Services

Virtual Event Platform

The purpose of the proposed panel is to describe the Centers for Medicare & Medicaid Services Innovation Center’s approach to strengthening the focus on quality, outcomes, and experience within the Innovation Center’s alternative payment models. The resulting Quality Pathway emerged from the 2021 strategic refresh and includes development of a process to certify models for expansion based on quality improvement. The panel will introduce the pathway, describing how it elevates patient outcomes and experience of care within alternative payment models and emphasizes the translation of a model’s theory of action into measurable benefits for patients. The panel will discuss how this alignment of model design and quality strategy also drives new approaches to model evaluation, and how the Quality Pathway will be used to identify when a model may be eligible for expansion based on demonstrated quality improvement in alignment with CMMI’s statutory mandate.

Having addressed the conceptual basis for the Pathway, the panel will share examples of models recently under development to demonstrate how the pathway will be used at the Center. This will include insight into design choices around measure selection, implementation decisions on data collection, and evaluation considerations on methodological approach. As part of discussing implementation of the pathway, the panel will identify a number of considerations entailed in executing this new approach to model quality strategies at the Center, such as those associated with novel measure development and rigorously evaluating the impact of models on patient outcome and experience.

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time iconApril 9, 2024 13:30

Advancing Oral Health Equity Through Quality Improvement Measures

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Meagan Khau, MHA (Moderator)
Director,
Data and Policy Analytics Group,
Office of Minority Health,
Centers for Medicare & Medicaid Services

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Kimia Imani, MS
DDS/PhD Student,
University of Washington School of Dentistry

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Kaylie Magidson, DDS
Pediatric Postdoctorate Student,
New York University College of Dentistry

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Beau Meyer, DDS, MPH
Associate Professor,
The Ohio State University College of Dentistry

Virtual Event Platform

Oral health is a crucial component of overall well-being. States are mandated to provide dental care for children under Medicaid and the Children's Health Insurance Program (CHIP). However, a 2023 report revealed that only 46% of Medicaid-insured children and teens had a dental check-up in 2018. The COVID-19 pandemic further hindered access to dental services, with a 20% reduction in treatments for children. This decrease in access to preventive and necessary dental care has led to a higher reliance on emergency services and the need for antibiotics to treat advanced dental issues and their complications. The pandemic also necessitated a shift towards less invasive treatments, like silver diamine fluoride (SDF). Healthcare systems aiming to enhance patient experience often encounter significant obstacles, indicating the necessity to modify behaviors and practices throughout various organizational levels and sectors. However, they can also benefit from applying well-established principles and methods for quality improvement (QI).

This session will delve into the findings from three joint studies analyzing enrollment and claims data from the Transformed Medicaid Statistical Information System (T-MSIS). These studies aim to understand how Medicaid-enrolled children used oral health services during 2019, 2020, and 2021. The data reveals patterns over time and highlights significant variations based on geography and demographics. Notably, there has been no substantial change in the rates and duration of antibiotic prescriptions for dental issues. Nevertheless, there is a marked increase in the use of silver diamine fluoride and a growing number of emergency department visits for non-traumatic dental problems, especially among children with special healthcare needs. These trends highlight numerous opportunities for quality improvement efforts at various levels and areas within the dental care system.

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Click Here to View Presentation

time iconApril 9, 2024 13:30

Telehealth: Improving Access to Care for Tribes: CMS and IHS Updates

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Susan Karol, MD
Chief Medical Officer,
Division of Tribal Affairs,
Centers for Medicare & Medicaid Services

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Susy Postal, DNP, RN-BC
Chief Informatics Officer,
Indian Health Service

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Chris Fore, PhD
Director,
Indian Health Service Telebehavioral Health Center of Excellence

Virtual Event Platform

The Indian Health Service (IHS) continues to support the expanded use of telehealth to provide patient care after the COVID-19 Public Health Emergency (PHE). This presentation will focus on an overview of the use of telehealth at the IHS and the support the Centers for Medicare & Medicaid Services (CMS) provides. The presentation will include the accomplishments in expanding telehealth from April 2020 to the present. The various telehealth services available at the IHS will be discussed including CMS’s support provided to rural and frontier areas. Issues in providing audio-only services will be discussed and aligned with services on the Medicare Telehealth Services List for CY 2024. Presenters will provide metrics describing the utilization of telehealth in IHS. Telehealth best practices will be discussed, and quantitative and qualitative results from IHS patient and IHS provider telehealth surveys will be addressed. Finally, patient outcomes utilizing telehealth services will be included and quality improvement options provided.

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time iconApril 9, 2024 14:30

Improving Outcomes in Organ Donation and Transplantation: The Organ Transplant Affinity Group (OTAG) Action Plan

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Jean Moody-Williams, RN, MPP
Deputy Director,
Center for Clinical Standards and Quality,
Centers for Medicare & Medicaid Services

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Suma Nair, PhD, MS, RD
Associate Administrator,
Health Services Bureau,
Health Resources and Services Administration

Key Ballroom & Live Streamed

There is no denying that that there is much work to be done to improve the transplantation system as there are over 100, 000 patients waiting for organ transplants, as of October 2023.

In September 2023, a federal collaborative, led by the Centers for Medicare & Medicaid Services (CMS) and the Health Resources and Services Administration (HRSA), called the Organ Transplantation Affinity Group (OTAG), launched with a goal of strengthening accountability, equity, and performance to improve access to organ donation, procurement, and transplantation for patients, donors, families and caregivers, and providers.

Join this listening session to learn about and provide feedback on OTAG’s mission to strengthen federal oversight and support of the organ transplantation system.

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time iconApril 9, 2024 14:30

The Age-Friendly Health Systems Movement: How Focusing on Quality and Safety for Older Patients Builds Resilience

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Terry Fulmer, PhD, RN, FAAN
President,
The John A. Hartford Foundation

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Leslie Pelton, MPA
Vice President,
Institute for Healthcare Improvement

Holiday 1-3

Learn about the Age-Friendly Health Systems movement and how it leads to improved outcomes for older adults and health system resilience. Presenters will share actionable opportunities, implementation successes and programs for specific settings.

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time iconApril 9, 2024 14:30

Healthcare and Public Health Cyber Security: Keeping Patients Safe and Secure

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Brian Mazanec, PhD
Deputy Director,
Office of Preparedness,
Department of Health and Human Services

Holiday 4-5

The Healthcare and Public Health (HPH) sector continues to experience increasingly sophisticated cyberattacks that exploit complex hospital infrastructures, underfunded cybersecurity functions, and numerous vulnerable legacy medical devices. These cyberattacks against the sector are growing both in numbers and severity. ASPR, in its Sector Risk Management Agency (SRMA) role and with active involvement from stakeholders across the Department of Health and Human Services (HHS), proactively confronts these growing cyber threats and strengthens the HPH sector’s cybersecurity posture. In December, HHS published a roadmap outlining how the department will level up to this challenge to make our healthcare system more resilient and prepared for cyber threats. In January, aligned with the first pillar in this new roadmap, HHS—through ASPR—published HPH Cybersecurity Performance Goals to further help healthcare organizations implement these high-impact cybersecurity practices.

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time iconApril 9, 2024 14:30

Improving Healthcare Quality: Beginning with the End in Mind

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Anita Monteiro
Director, iQuality Improvement & Innovation Group
Centers for Medicare & Medicaid Services

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Timmy T. Nelson
Patient Advocate/Outreach Advisor,
UPS (retired)/Network 4, Quality Insights,
Chester County Community Foundation

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Sven T. Berg, MD, MPH
Chief Executive Officer,
Quality Insights

Holiday 6

Data-driven quality improvement is the foundation of healthcare transformation. The ability to visualize the end goals, outcomes and results, strategically leverage healthcare data, then design a quality improvement process/intervention to deliver outcomes is what separates the highly effective quality improvement professionals from those that are not. This session focuses on the practices and interventions quality improvement professionals can use on a daily basis to help them relate the small decisions to the bigger picture and ensure that what’s produced eventually will be valuable.

time iconApril 9, 2024 15:30

Advancing Oral Health Equity Through Quality Improvement Measures

speaker headshot

Meagan Khau, MHA (Moderator)
Director,
Data and Policy Analytics Group,
Office of Minority Health,
Centers for Medicare & Medicaid Services

speaker headshot

Kimia Imani, MS
DDS/PhD Student,
University of Washington School of Dentistry

speaker headshot

Kaylie Magidson, DDS
Pediatric Postdoctorate Student,
New York University College of Dentistry

speaker headshot

Beau Meyer, DDS, MPH
Associate Professor,
The Ohio State University College of Dentistry

Latrobe

Oral health is a crucial component of overall well-being. States are mandated to provide dental care for children under Medicaid and the Children's Health Insurance Program (CHIP). However, a 2023 report revealed that only 46% of Medicaid-insured children and teens had a dental check-up in 2018. The COVID-19 pandemic further hindered access to dental services, with a 20% reduction in treatments for children. This decrease in access to preventive and necessary dental care has led to a higher reliance on emergency services and the need for antibiotics to treat advanced dental issues and their complications. The pandemic also necessitated a shift towards less invasive treatments, like silver diamine fluoride (SDF). Healthcare systems aiming to enhance patient experience often encounter significant obstacles, indicating the necessity to modify behaviors and practices throughout various organizational levels and sectors. However, they can also benefit from applying well-established principles and methods for quality improvement (QI).

This session will delve into the findings from three joint studies analyzing enrollment and claims data from the Transformed Medicaid Statistical Information System (T-MSIS). These studies aim to understand how Medicaid-enrolled children used oral health services during 2019, 2020, and 2021. The data reveals patterns over time and highlights significant variations based on geography and demographics. Notably, there has been no substantial change in the rates and duration of antibiotic prescriptions for dental issues. Nevertheless, there is a marked increase in the use of silver diamine fluoride and a growing number of emergency department visits for non-traumatic dental problems, especially among children with special healthcare needs. These trends highlight numerous opportunities for quality improvement efforts at various levels and areas within the dental care system.

Click Here to View Presentation

time iconApril 9, 2024 15:30

HHS’ Call to Action on Opioid Use Disorder Treatment

speaker headshot

Robert Accetta, RPh, BCGP, FASCP
Senior Pharmacist,
IPRO QIN_QIO

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Megan Meacham, MPH
Director,
Rural Strategic Initiatives Division,
Health Resources and Services Administration (HRSA)

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Wanda Pamphile, PharmD, MPH
Senior Health Insurance Specialist,
Centers for Medicare & Medicaid Services

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Karran Phillips, MD, MSc
Deputy Director,
Center for Substance Abuse Treatment,
SAMSHA

Key Ballroom 1-4

Drug overdose deaths in the United States, driven by illicit fentanyl and other opioids, remain at historically high levels – with more than 107,000 lives lost in the past year, and millions more struggle with opioid and other substance use disorders. The opioid crisis reaches every corner of our country, from alleyways to nursing homes, and requires an immediate call to action. Federal partners, local governments, healthcare institutions, and communities are working together to provide viable solutions to combating the opioid crisis.

There is a nationwide need for education on medications for opioid use disorder (MOUD) to increase the number of practitioners eligible to manage and/or prescribe appropriate medications. Medicare providers are uniquely positioned to create the gold standard of opioid use disorder treatment by screening, diagnosing, and treating Medicare patients for opioid use disorder as routine healthcare. They can also exhibit positive attitudes to reduce stigmas associated with opioid use disorder. 

This session will consist of a panel discussion where, IPRO, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) will describe the state of the opioid crisis from a nursing home perspective and discuss how to improve patient safety in vulnerable populations. The Substance Abuse and Mental Health Services Administration (SAMHSA) will provide regulatory updates on opioid prescribing, the stigma of opioid addiction, and discuss key elements of Opioid Treatment Programs (OTPs).  Finally, the Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy (FORHP), will share opioid-related resources and funding opportunities to engage partners in rural communities.

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time iconApril 9, 2024 15:30

Using School-based Services to Improve Behavioral Health Service Delivery to Children in Medicaid and CHIP

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Kate Ginnis MSW, MPH
CMCS Senior Advisor for Youth Coverage
Centers for Medicare and Medicaid Service
Medicare & Medicaid Services

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Kate Yager MA
Director of Medicaid
Chicago Public Schools

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Sergio Obregón M.Ed.
Bureau Chief for Medical Eligibility and Special Programs, Division of Eligibility
Illinois Department of Healthcare and Family Services

Johnson A&B

It is a focus of the Biden-Harris Administration to make it easier for states to support schools in providing critical health care services, especially mental health services, for millions of students across the nation. The Bipartisan Safer Communities Act helped pave the way for the Medicaid guidance Delivering Services in School-Based Settings: A Comprehensive Guide to Medicaid Services and Administrative Claiming announced in May 2023 as a significant overhaul of school Medicaid billing. The new guidance is designed to streamline the process of school-based billing and increase students’ access to healthcare at school. This session provides an overview of the flexibilities provided in the guide, including allowing state Medicaid agencies to change the way that services are paid for in schools, as well as which providers can bill for services in schools. This session will highlight intra-state coordination between a State Medicaid Agency and Local Educational Agency (LEA) to leverage school-based services to improve behavioral health service delivery to children in Medicaid and CHIP and how they are measuring the improvements (e.g., increasing claiming and delivery of behavioral health services). This session will highlight how states can ease the administrative burden for schools so that more services can be paid for by Medicaid/CHIP—bringing more money into the schools for health services—and by extension allowing for more services.

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time iconApril 9, 2024 15:30

Building Capacity to Improve HIV Viral Suppression Data Among Medicaid Beneficiaries

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Bashirat Olayanju, MPH,
Director, Health System
NASTADs Integration

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Marlene Matosky MPH, RN,
Chief - Clinical and Quality Branch
Health Resources and Services
Administration

speaker headshot

Parker James, MPP,
Policy Analyst
The Hilltop Institute

Peale A&B

The HIV viral suppression measure included in CMS’ Adult Core Set (HVL-AD) offers a unique opportunity to promote inter-program, intra-state collaboration to share data and develop joint and/or complementary policies to drive high-impact, sustainable improvement for Medicaid beneficiaries living with HIV. NASTAD was funded by the Health Resources and Services Administration (HRSA) HIV/AIDS Bureau (HAB) to support building the capacity to calculate and report the HVL-AD measure to CMS, through the implementation of a quality improvement collaborative. Calculation of the HVL-AD measure uniquely utilizes multiple data sources in addition to claims data, including clinical and laboratory data received by public health programs. Panelists for this session will discuss how the use of multiple data sources across both Medicaid and public health programs, served as the catalyst for inter-agency collaboration, in which they will focus on recent experiences initiating HVL-AD reporting and use the data from a participating state in the collaborative. Panelists will highlight the process of inter-agency engagement, their team accomplishments and lessons learned particularly highlighting collaboration strategies. The session will offer insights into what it takes to create the conditions for both enabling collaboration as well as how that collaboration has led to the strategic use of the data plan engagement strategies that will support the improvement of health outcomes for Medicaid beneficiaries living with HIV.

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time iconApril 9, 2024 15:30

Aligning Quality Measures and Program: The CMS National Quality Strategy in Action

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Jessica Lee, MD, MSHP
Acting Chief Medical Director,
Center for Medicaid and CHIP Services,
Centers for Medicare & Medicaid Services

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Douglas Jacobs, MD, MPH
Chief Transformation Office
Center for Medicaid and CHIP Services;
Centers for Medicare & Medicaid Services

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Susannah Bernheim, MD, MHS
Chief Quality Officer & Acting Chief Medical Officer,
Center for Medicare and Medicaid Innovation,
Centers for Medicare & Medicaid Services

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Michelle Schreiber, MD
Deputy Director,
Quality & Value, Centers for Medicare & Medicaid Services

Key Ballroom & Live Streamed

Increasing alignment and coordination across CMS quality programs and initiatives focuses our attention on high priority clinical areas and amplifies the impact of CMS actions. The CMS National Quality Strategy serves as a guide for collaboration as we concentrate our efforts to advance health equity, address maternal morbidity and mortality, streamline the CMS quality measurement portfolio, and improve the delivery of safe care. Join us to hear the current activities and accomplishments of programs across CMS as we work to get closer to the high-quality, safe, equitable, and resilient health care system envisioned for all individuals.

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time iconApril 9, 2024 15:30

Million Hearts 2027: Aiming for Impact with a Focus on Health Equity

speaker headshot

Haley Stolp
Policy and Partnership Strategist,
Centers for Disease Control Disease Control and Prevention

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Laurence Sperling, MD, FACC, FAHA, FACP, FASPC
Executive Director,
Million Hearts Initiative,
Centers for Disease Control and Prevention

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Taylor Streeter, MPH
Health Scientist,
ASRT, Inc.

Holiday 1-3

Million Hearts® prioritized strategies for building healthy communities and optimizing care through a committed focus on specific populations experiencing inequities. This session describes how Million Hearts 2027 is addressing health equity with a review of communication assets and opportunities for engagement, an exploration of health equity-related issues for widespread use of self-measured blood pressure monitoring and cardiac rehabilitation, and an overview of new and future opportunities to reduce cardiovascular maternal health disparities.

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time iconApril 9, 2024 15:30

Bridging the Gaps in the Kidney Transplant Journey: New Collaboration in CKD

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Victoria Cash MBA, BSN, RN, CPHQ
Executive Director,
IPRO ESRD Network of the Ohio River Valley

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Ivory Harding, MS
Director,
Quality and Regulatory Affairs,
National Kidney Foundation

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Matthew Cooper MD
Chief of Transplantation,
Director of the Solid Organ Transplant Line and Professor of Surgery at the Medical College of Wisconsin,
Medical College of Wisconsin

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Patrick Gee Ph.D
Founder,
iAdvocate

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Sherri Morgan-Johnson RN, BSN, MHSA, FAC-COR III
Nurse Consultant,
Centers for Medicare & Medicaid Services

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Sumeska Thavarajah, MD
Medical Director,
Fresenius Kidney Care

Key Ballroom 9-12

During this patient-centered roundtable session, attendees will learn from kidney dialysis/transplant patients, the NKF, ESRD Networks, QIN-QIOs, TAQIL, and experts as they explore the complete kidney transplant journey.  

From the five CKD stages to dialysis treatment options, and the transplant process, the expert panel will highlight gaps throughout the transplant care continuum and identify potential solutions, including strategies to reduce inequities experienced by underserved communities. 

To address these identified gaps, speakers will review available partnership opportunities, new programs being tested in select communities, critical resources accessible to healthcare professionals, as well as the vital need to improve patient education that is culturally and linguistically appropriate throughout the kidney care system.

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time iconApril 9, 2024 15:30

Supporting Equity at Scale Across HQIC-enrolled Hospitals

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Laura Benzel, MS, BS, CCSGB,
Project Director, Health Equity Lead,
IPRO

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Natalie Graves MPH,
Director, Research & Implementation,
Convergence Health Consulting

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Nicole Ford MBA, CPHQ,
Project Manager,
Healthcare Association of New York State

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Rosa Abraha MPH,
Health Equity Lead,
Alliant Health Solutions

Ruth

IPRO and Alliant Health Solutions deployed multiple assessments and conducted technical assistance to understand the current health equity needs of Hospital Quality Improvement Contractors (HQIC) supported hospitals. The responses revealed that hospitals are most concerned about and need support for preparing for the new CMS health equity reporting requirements. In response, IPRO and Alliant Health Solutions developed multiprong approaches to support hospital health equity implementation, including Learning and Action Networks (LAN) with subject matters experts, affinity groups, one-on-one technical assistance, SDOH resources, discharge tools, a dynamic six-step model for hospital health equity implementation, and a bite-sized learning video series on health literacy, cultural and linguistically appropriate standards (CLAS). Additionally, Alliant Health Solutions worked with a hospital in Georgia, which prompted dedicated monthly health equity office hours co-led by the Alliant Health Solutions health equity lead and a representative from the Georgia hospital. 

In addition, the HANYS and Convergence HQIC teams will describe organizational approaches to addressing and advancing health equity. HANYS will describe their experience developing and administering a health equity gap analysis assessment and how hospitals have used the tool, identified gaps, and taken action by addressing & implementing practice recommendations across all 7 assessment categories. The Convergence HQIC team will describe the approach to equity that focuses on building reliable, culturally sensitive processes for implementing a Social Drivers of Health (SDOH) screening program in hospitals across a variety of settings.

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time iconApril 9, 2024 15:30

Medicare Beneficiaries Hospital Readmissions: Prevention and Cost Evaluation

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Stephanie Hursey, MSN, MHA, CCM (Moderator),
Contract Officer Representative,
Centers for Medicare & Medicaid Services, DCPH

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Vanessa Andow, CPHQ, CPPS, FACHE,
Project Director,
TMF Health Quality Institute

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Sadiq Bouda Abdulai, PhD
Senior Data Analyst,
Quality Insights

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Jill Manna BA, PMP.
Quality Improvement Specialist,
TMF Health Quality Institute

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Grace Bolanos Sewell, MA, CCLS, CPHQ
Quality Improvement Specialist,
TMF Health Quality Institute

Holiday 6

Attend this presentation to hear about the work Quality Insights and TMF Health Quality Institute, two Quality Innovation Network-Quality Improvement Organizations, have done around hospital readmissions.

The first part of this session will focus on how standardization of communication can reduce or prevent unnecessary hospital readmissions across the continuum of care. Since 2019, the TMF Quality Innovation Network-Quality Improvement Organization healthcare quality improvement specialists, along with health care providers and partners in the community of El Paso, Texas, identified poor communication among the health care providers in the community that resulted in high readmission rates. To combat these rates, the community developed a Nurse-to-Nurse Report to standardize communication among the health care providers in the community that treat the same patients being readmitted. 

The second part of this session will compare parametric and nonparametric cost estimates for hospital readmissions.  Using Medicare claims data from Pennsylvania and West Virginia spanning 2017-2022, we estimate how much more, on average, Medicare beneficiaries with selected index diagnoses cost when readmitted within 30 days, compared to those not readmitted, after controlling for demographics and comorbidities. This estimation is accomplished via a robust machine learning variable importance framework. This approach avoids the assumptions associated with parametric methods, and thus enhances accurate valuation."""

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time iconApril 9, 2024 15:30

Infusing Technology and Innovation to Reduce Burden and Improve Services for Medicare Beneficiaries

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Wendy Gary, MHA, (Moderator)
Chief Operating Officer,
Avar Consulting;
Executive Director,
BFCC-QIO;
Project Director,
BFCC NCORC

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Josh Dominick, MPA,
Director, Business Intelligence
Kepro

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Jed Shakarji,
Data Analyst II,
Avar Consulting

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Brian Salzer, MS, PMP
Data Science Team Lead,
Avar Consulting

Holiday 4-5

Rapidly advancing technology, access to data, and secure ways to communicate with an increasingly tech-savvy cross-section of the American population has changed how we think about protecting Medicare beneficiaries and the Medicare Trust Fund. Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIOs) are adopting strategies to improve access and efficiency while reducing burden for all parties.

In their scope of improving the effectiveness, efficiency, economy and quality of services provided to Medicare beneficiaries, BFCC-QIOs review case documentation, medical records, and/or Medicare claims for more than 400,000 records annually. BFCC-QIOs also produce detailed documentation for providers and Medicare beneficiaries to summarize findings for beneficiary-initiated quality of care reviews. Continuously looking to improve quality, BFCC-QIOs identified ways to streamline processes, resulting in improved outcomes and beneficiary- and family-centered services. 

To support providers, BFCC-QIOs are implementing cutting edge technologies such as artificial intelligence and machine learning to create efficiencies in case review and documentation processes; these have resulted in reduced burden, improved patient-safety and improved standardization. To support beneficiaries, BFCC-QIOs utilize these tools to ensure appropriate implementation of plain language in documentation intended for beneficiaries and families. Finally, to support the Medicare Trust fund, BFCC-QIOs developed approaches to streamline records review and more efficiently use physician review time for identification of cases that are likely to be misaligned with CMS policies.

While technology cannot replace the need for human review, input, and interactions, BFCC-QIOs have identified ways to maximize efficiencies and use administrative, clinician, and beneficiary time when it is most valuable.

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time iconApril 9, 2024 15:30

Expanded Access to Quality and Affordable Oral Health and Behavioral Healthcare

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Jessica Maksut PhD
Technical Director,
Office of Minority Health;
Centers for Medicare & Medicaid Services

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Carla Shoff PhD,
Senior Advisor to the Chief Dental Officer,
Office of the Administrator;
Centers for Medicare & Medicaid Services

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Lorel Burns DDS, MS
Assistant Professor,
NYU College of Dentistry

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Natalia Chalmers, DDS, MHSc, PhD
Chief Dental Officer,
Office of the Administrator,
Centers for Medicare & Medicaid Services

Virtual Event Platform

Over the past two years, CMS has made significant strides in advancing oral health across all our programs. CMS has developed a set of cross-cutting initiatives that engage teams across our organization to drive the goals highlighted by the strategic pillars and enhance focus on critical components of our work. These initiatives are high-level, multi-year priorities for CMS that bring our centers and offices together to leverage their expertise and strengthen collaboration. The CMS Chief Dental Officer will describe the launch and work under the Oral Health Cross-Cutting Initiative. Access to oral health services promotes health and wellness and allows beneficiaries and consumers to achieve the best health possible. States have the flexibility to determine what dental benefits are provided to adult Medicaid enrollees. While most states offer at least emergency dental services for adults, less than half of the states currently provide comprehensive dental care. There are no minimum requirements for adult dental coverage. More than 1 in 4 (26%) adults in the United States have untreated tooth decay. Over the last ten years, dental pain has been a top reason for opioid prescribing upon discharge from the ED, thereby contributing to the overdose crisis. There is a bi-directional link between oral health and substance use disorder. This session will focus on the outcomes of two studies that analyzed Medicaid enrollment and claims data. These studies examine oral health needs, disparities, and access to dental services for Medicaid adults with substance use disorders, as well as the impact of the COVID-19 public health emergency, state coverage policies, and socio-demographic factors on adults' access to dental services.

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time iconApril 9, 2024 15:30

The True Cost of Patient Safety Events and Pursuing the Goal of Zero Harm

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Li Chen, Ph.D
Health Research Lead,
Avar Consulting

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Jacklyn Vollmer, MPH
Quality Improvement and Operations Support Specialist,
Avar Consulting

Virtual Event Platform

Patient safety events (PSEs) remain a persistent challenge in our healthcare system, and the Centers for Medicare & Medicaid Services (Centers for Medicare & Medicaid Services) has adopted the goal of Zero Preventable Harm as part of its National Quality Strategy (NQS). This presentation will (1) discuss the prevalence of PSEs among Medicare beneficiaries, (2) analyze associated additional inpatient care and financial costs, and (3) provide insight to support Centers for Medicare & Medicaid Services’ aim to promote the safest possible care for all. The Beneficiary and Family Centered Care National Coordinating Oversight and Review Center (BFCC NCORC) screens 4,000 Medicare medical records annually for PSEs, leading to follow-up actions by the BFCC-Quality Improvement Organizations (QIOs). NCORC analyzed additional days of hospitalization and payment associated with PSEs projected on a national level, by sample weighting, representing beneficiaries based on 4,000 Medicare discharges between October 2020 and December 2021. Over 5,000 PSEs were identified, and half of beneficiaries experienced at least one, with 6% being deemed preventable. PSEs were associated with nearly four additional days of inpatient care on average, totaling 32.5 million additional days nationally. This equates to $86 billion per year, or about one-tenth of all Medicare spending. Preventable PSEs cause about 5.7 million additional days of care, and over $15 billion in spending. Patient safety is the cornerstone of high-quality healthcare, yet PSEs happened in more than half of Medicare beneficiary hospitalizations, accounting for nearly 10% of all Medicare spending. These findings reinforce the urgent need for Centers for Medicare & Medicaid Services’ quality agenda, and the goal of achieving zero preventable harm.

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time iconApril 9, 2024 16:30

Chartering the Course to Zero Harm

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Tejal Gandhi, MD, MPH, CPPS
Chief Safety and Transformation Officer,
Press Ganey

Key Ballroom & Live Streamed

This session will explore the broader definition of harm beyond physical safety, and the importance of addressing inequities to achieve zero harm. Dr. Gandhi will share strategies and tactics to show how leading organizations are innovating and transforming a culture and leveraging high reliability to build engaged, resilient care teams that deliver safe, high-quality care and the optimal patient experience.

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time iconApril 9, 2024 17:00

Closing Remarks

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Jean Moody-Williams, RN, MPP
Deputy Director,
Center for Clinical Standards and Quality,
Centers for Medicare & Medicaid Services

Key Ballroom & Live Streamed

time iconApril 10, 2024 10:00

Welcome

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Jean Moody-Williams, RN, MPP
Deputy Director,
Center for Clinical Standards and Quality,
Centers for Medicare & Medicaid Services

Holiday Ballroom & Live Streamed

time iconApril 10, 2024 10:05

Lessons Learned from the Forefront: Resident Socialization, Staffing Stabilization, and Facility Support

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Lenise Cummings-Vaughn, MD, CMD
Medical Officer,
Center for Clinical Standards and Quality,
Centers for Medicare & Medicaid Services

Holiday Ballroom & Live Streamed

As the newest Medical Officer to join CMS, Dr. Lenise Cummings-Vaughn will share her insights and lessons learned as a Hub leader for the AHRQ ECHO National Nursing Home COVID Action Network and the themes that emerge including balancing patient needs for socialization with infection control, resource management, staffing stabilization, burn out, and education on best practices and quality assessment and improvement.

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time iconApril 10, 2024 10:30

The Moving Forward Coalition Promotes Strengthening Resident Councils

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Anna Fisher, CADDCT, CDP, CMDCP, CDSGF, QCP
Education Consultant/Nurse,
Hillcrest Health Services

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Mairead Painter, BSW
Long Term Care Ombudsman,
State of Connecticut

Holiday Ballroom & Live Streamed

This session will demonstrate how one of the committees that is part of the Moving Forward Coalition assembled residents, care partners, advocates, and researchers to develop a step-by-step Resident Council Guide for nursing home residents, staff, and community members. We will describe how the guide is currently being piloted and tested in 4 nursing homes and what we hope to learn from this pilot. We will discuss the importance of a resource guide and its use to assist nursing homes to implement, sustain, and continually enhance an effective, person-centered Resident Council.

Click Here to View Presentation

time iconApril 10, 2024 11:00

Supporting the Neighborhood Enrichment Team (NET) to Enhance the Nursing Home (NH) Experience

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Patricia Gagliano, MD
Task Order 1 Lead and Vice President,
IPRO’s Healthcare Quality Improvement Department

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Melanie Ronda, MSN, RN, LTC-CIP, CPHQ
Task 3 Lead,
Infection Preventionist and a Director in IPRO’s Healthcare Quality Improvement Department,
IPRO QIN-QIO

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Jennifer Wieckowski, MSG
Senior Executive Director,
Health Services Advisory Group

Holiday Ballroom & Live Streamed

The NET program enriches the lives of NH residents by recruiting community partners to actively engage in activities that bring value to residents. The NET program evaluates the impact and feasibility of the community taking an active role to improve resident experiences and quality of life.

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time iconApril 10, 2024 11:30

Using Data to Increase Nursing Home Participation

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Nicole Haas, MPH, CPH, CPHQ
Quality Improvement Initiative Manager,
Alliant Health Solutions

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Dee Kaser, RN, CDCES
Quality Improvement Advisor,
Great Plains

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Stephanie Meduna, RN, BSN
Quality Improvement Advisor,
Great Plains

Holiday Ballroom & Live Streamed

Part 1: Since April 2020, Quality Improvement Organizations have received Targeted Response Quality Improvement Initiative (TRQII) referrals from CMS for nursing homes identified as needing assistance with infection control, COVID hot spots, and low vaccination rates. Great Plains QIN operationalizes a multi-faceted best practice approach to facilitate engagement and action leveraging all encounters with nursing homes to improve infection control practices and vaccination uptake.

Part 2: This session will focus on applying high reliability concepts to team members and throughout quality projects to increase nursing home participation in targeted response quality improvement initiatives."

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time iconApril 10, 2024 13:00

The Quality Improvement Journey: Recertification of Laguna Honda Hospital and Rehabilitation Center (LHH)

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Barb Averyt, MHA
Senior Executive Director,
Health Services Advisory Group

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Troy S. Williams, MSN, RN, CPHQ, CPHRM
Laguna Honda CMS Recertification Co-Incident Commander,
Chief Quality Officer,
San Francisco Health Network, San Francisco Department of Public Health

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Keith Chartier, DrPH, MPH
Executive Director,
Health Services Advisory Group

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Jim Bossemeyer
Acting Director, Division of SF/Seattle Survey & Enforcement
Centers for Medicare & Medicaid Services

Holiday Ballroom & Live Streamed

This presentation will feature insights from the San Francisco Department of Public Health's Chief Quality Officer, HSAG representatives and CMS, offering a comprehensive understanding of the recertification journey of San Francisco's Laguna Honda Hospital and Rehabilitation Center (LHH), the 2nd largest public run skilled nursing facility in the United States. Attendees will gain valuable insights into the strategies employed for successful culture change and sustainability, providing a compelling narrative of resilience, collaboration, and innovation in addressing healthcare challenges.

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time iconApril 10, 2024 13:30

Innovations In Training and Training Evaluations

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Crystal Morse, MS HSA, CSW, CCM
Senior Account Manager,
Mountain Pacific Quality Health

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Laura Myerchin Sklaroff, MA, EdD
Director,
Systemwide Quality Improvement Evaluation,
Comagine Health

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Callie Perkins, BSN
Wyoming Account Manager,
Mountain Pacific Quality Health

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Ann Jensen, MPH, CPH
Healthcare Data Analyst,
Comagine Health

Holiday Ballroom & Live Streamed

Part 1 – Mountain Pacific Project Firstline team co-created an interactive, team and skills-based activity that provided innovative learning for health care professionals. The Escape Room is a “fun and effective way to learn,” while improving the team culture. Part 2 - Comagine Health QIN-QIO designed and implemented a two-part model to evaluate participant and facility level learning collaborative outcomes over time for single cohorts and across cohorts to access impact and growth. Strategies for learning collaborative evaluation, highlighting an example focused on a Hypertension SMBP learning collaborative will be shared.

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time iconApril 10, 2024 14:00

Creative Employee Engagement

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Tina Sandri, MHSA, LNHA, QCP, RYT-200
Chief Executive Officer,
Forest Hills of DC

Holiday Ballroom & Live Streamed

During this unprecedented SNF employee shortage, employee retention is paramount. Forest Hill of DC’s efforts led to a front-page story in the NTY, an AHCA Program of the Year, and the District of Columbia’s first CNA apprenticeship program.

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time iconApril 10, 2024 14:30

Fireside Chat with CMS Division of Nursing Home

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Colleen Frey
Director,
Division of Community and Population Health,
Centers for Medicare & Medicaid Services

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Eimee Casal, BSN, RN, LNHA
Quality and Safety Branch Manager,
Division of Nursing Home,
Centers for Medicare & Medicaid Services

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Shequila Purnell-Saunders
Director,
Division for Chronic and Post Acute Care,
Centers for Medicare & Medicaid Services

Holiday Ballroom & Live Streamed

Eimee Casal, Division of Nursing Homes, Colleen Frey, Division of Community and Population Health, and Shequila Purnell-Saunders, Division of Chronic and Post Acute Care of the Center for Clinical Standards and Quality at the Centers for Medicare and Medicaid Services will discuss several recent and forthcoming initiatives impacting nursing home providers, residents, and families."

time iconApril 10, 2024 15:00

Closing Remarks

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Jean Moody-Williams, RN, MPP
Deputy Director,
Center for Clinical Standards and Quality,
Centers for Medicare & Medicaid Services

Holiday Ballroom & Live Streamed

Posters

Poster # 1

Associations between oral health and general health among Medicare beneficiaries

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Oral and general health are important parts of a person's overall wellbeing. This analysis used data from the Center for Medicare and Medicaid Service (CMS)'s 2021 Medicare Current Beneficiary Survey (MCBS) to show how physical wellbeing is associated with oral health among community-dwelling Medicare beneficiaries. The analysis examined three oral health outcomes: loss/removal of all natural teeth, difficulty eating due to mouth/teeth issues, and chronic toothache or jaw pain.
The MCBS data showed that beneficiaries aged 65 years and younger were more likely than age-eligible beneficiaries to have oral health problems. In terms of both self-reported general health and specific chronic conditions, oral health problems were associated with physical health problems in both the under-65 and 65+ age groups. Physical limitations with activities of daily living were also associated with each of these three oral health outcomes, especially difficulty eating. The relationships between oral health and general health are likely to be complex, without a unidirectional causal pathway that applies across all cases. It is possible that improving general health could lead to better oral health outcomes, and also that better oral health would improve general health.

Poster # 2

Trends and Concurrence of Opioid Prescribing Among Medicare and Medicaid Beneficiaries, 2019-2021

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Dentistry is a common source of opioid exposure, especially among children. For Medicare and Medicaid beneficiaries, alternative methods of prescription payment, such as cash, private insurance or assistance programs, influence both access to prescription medications and pharmacoequity. Research investigating the effects of these alternative payment methods on opioid prescribing patterns is limited. This study finds alternative methods of opioid prescription payment, such as cash, private insurance and  assistance programs, account for about 20% of all opioid prescriptions to Medicare and Medicaid beneficiaries. Further, rates of opioid concurrence are strongly linked to days’ supply of the opioid prescription and provider specialty.

Poster # 3

Using Intentional Measure Stratification as a Tool for Identifying and Addressing Health Disparities in North Carolina Medicaid

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In 2021, North Carolina (NC) Medicaid launched Standard Plans as the primary vehicle for managed care, serving around 1.8 million beneficiaries through five prepaid health plans. Health disparities within this population are measured and tracked using a set of standardized stratified reporting elements including age, race, gender, ethnicity, primary language, Long-Term Services and Supports (LTSS) status, disability status, transitions to community living, and geography. NC Medicaid learned that utilizing singular race categories, including multiracial, led to a relative under-reporting of race groups with high rates of multiracial identifications, such as American Indian/Alaskan Native. In response, NC Medicaid developed binary comparison stratification methodologies, including binary Black or African American and a binary American Indian/Alaska Native stratum. This intentional stratification methodology is essential in accurately measuring, tracking, and addressing health disparities within the NC Medicaid population. This poster will cover NC Medicaid’s stratified reporting methodology and highlight three ways it is used to address health disparities: 1. Disparity identification within the Standard Plan population for key quality measures of interest and intentional target setting to encourage improvements for the population of interest. 2. The Standard Plan Withhold Program’s Childhood Immunization Status (CIS) – Combination 10 disparity sensitive measure. 3. Stratification elements used in the Annual Health Equity report to publicly track and analyze disparities for the entire NC Medicaid population.

Poster # 4

Data Directed Technical Assistance: Using Real Time Data to Improve Resident Outcomes

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The Data Directed Technical Assistance (DDTA) project utilizes real time nursing home (NH) EHR data for quality improvement based on the current state, rather than relying on older data. The EHR data is available in a dashboard for on-the-spot use by the NH Quality Improvement Specialist (QIS), highlighting the count/rate of infection (orders) by month for NHs with trending over time. The dashboard generates the monthly referral list of the top 20 NHs by highest rate for urinary tract infection (UTI) starting in 8-23 using 7-23 data and pneumonia starting in 11-23 using 9-23 data. A project specific portfolio provides the QIS with 40 infection specific evidence-based resources which support the implementation of Action Plans with goals that include education, prevention, and antibiotic stewardship. A total of 157 NHs are reviewed for infection monthly. The referral numbers for NHs with UTI rates >10% are: 7-23: 11, 8-23: 8, 9-23: 11, 10-23: 21; and NHs with pneumonia rates >3%: 7-23: 14, 10-23: 19. A total of 355 contacts have been completed to date for UTI and pneumonia, with 252 resources provided. Outcome results for participating NHs will be available in 2024.

Poster # 5

Reducing Readmissions: A Gap to Goal Approach

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Medicare-Fee-For Service beneficiaries experienced 1.7 million readmissions within 30 days in 2015. Of those, an estimated 1 million are thought to be preventable at a cost of $14 billion to Medicare. Looking at claims data through May 2023, in November 2023 IPRO used a gap-to-goal analysis to identify nursing homes that had increased from their hospital readmission baseline.  

The IPRO team developed a comprehensive, multifaceted approach to provide technical assistance to these facilities. The Quality Improvement Specialists (QIS’s) began an email campaign, highlighting tools, resources, and invitations to virtual meetings to discuss facility-specific readmission drivers. 

42 Nursing homes responded and met with QIS to discuss:

readmission

root cause analysis

mitigation strategies  

current state (staffing, facilities-specific challenges, hospital concerns, etc.)

IPRO shared its comprehensive collection of resources targeted to NH specific needs. These include:

a newly developed readmission tracking log 

educational materials 

courses offered on IPRO Learn, an asynchronous learning management platform

Poster # 6

Utilization of Dental Services by Medicare Beneficiaries Living in the Community and Dental Out-of-Pocket Expense, 2021

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This analysis uses data from the Medicare Current Beneficiary Survey (MCBS) to look at utilization of select dental services and out-of-pocket expenses associated with dental care. The estimates are presented for Medicare beneficiaries living in the community in 2021 - overall and by type of dental coverage.

Poster # 7

A Strategy to Assess Nursing Home Readmission Gaps: HSAG Care Transitions Assessment

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The HSAG Care Transitions Assessment helps skilled nursing facilities (SNFs) identify gaps and opportunities for improvement in their care transitions processes. The assessment tool contains nine evidence-based action items in three focus areas for improvement. HSAG assists SNFs in completing the assessment, analyzes results, and provides tools and resources to address the identified opportunities to improve care coordination and reduce preventable hospital readmissions.

Poster # 8

Comagine Health: Guiding SMBP Program Implementation

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To help overcome the complexity and cost of setting up self-measured blood pressure (SMBP) programs in an outpatient clinic setting, Comagine Health launched a 12-month learning collaborative with 12 outpatient clinics in Idaho, New Mexico and Washington. In this collaborative, practices receive coaching, group learning, opportunities for collaboration and technical assistance to facilitate implementation. Data reports are provided to participants prior to each collaborative as a way to quickly see their current status, track their progress through the course of the program, and as a conversational tool in discussions with administrators. Halfway through the collaborative, there are 64 trained staff with 88 enrolled patients with hypertension.

Poster # 9

Comagine Health: Innovations in Opioid Use Disorder Care

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Overdose deaths, specifically those related to opioids, remain a concern and are increasing. To empower health care providers to better diagnose and treat opioid use disorder (OUD), Comagine Health launched a six-part learning series on innovations in caring for people with OUD, featuring subject matter experts and people with lived experience. Overall, feedback from the sessions has been largely positive with many attendees expressing intentions to incorporate lessons learned into their practice.

Poster # 10

Comagine Health: Improving Partnerships by Inviting Feedback

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Comagine Health conducted a guided interview study with 22 nursing home leaders to investigate how QIN-QIOs can better support their facilities. Overall, the study found that nursing home leaders are aware of Comagine Health, the facilities would like more in-person technical assistance, the facilities would like to hear from Comagine Health in both synchronous and asynchronous methods depending on the content, and nearly all barriers to implementation of quality improvement practices were related to workforce challenges.

Poster # 11

Quality Payment Program Clinician Champions Project 2024

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Since its inception in 2016, the role of the QPP Clinician Champions has been to provide feedback for consideration in CMS tools and resources developed for the Quality Payment Program, as well as to provide real-time feedback regarding the implementation of Alternative Payment Models in communities of practice nationwide.

Poster # 12

Comagine Health: Using Quality Data to Close Gaps in Care

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This poster summarizes the efforts of Comagine Health and the Keystone Center for Geriatrics (Keystone). Keystone was not routinely screening patients diagnose with hypertension (HTN) for Chronic Kidney Disease (CKD). Comagine Health supported Keystone by creating a bi-directional IT portal for the clinic to enter their patient data. From July to December 2023, Keystone tripled the rate of patients with HTN who received full CKD labs.

Poster # 13

Quality Insights: Improving Care in WV and PA Nursing Homes

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This poster provides details and visual graphics related to a course and a workshop the Quality Insights Nursing Home Team offered in 2023 – “Staffing Solutions for Nursing Homes” and “Nursing Home Opioid Strategy: Appropriate Use and Screening.”

Poster # 14

Quality Insights: Improving Communities in WV and PA

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This poster provides details about various initiatives from the Quality Insights Partnership for Community Health team, such as wellness workshops and chronic disease educational sessions.

Poster # 15

Nursing Home Infection Prevention Training Implementation

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According to the Centers for Disease Control and Prevention (CDC) 1-3 million infections occur in long term care facilities annually. Alliant Health Solutions QIN-QIO recognizes the importance of improving infection prevention (IP) training in nursing homes and how crucial it is for safeguarding the health and well-being of residents, who are often at high risk for infections. Alliant Health Solutions develops, collaborates and delivers local level trainings that complement the national trainings developed by CMS to maximize resources and avoid duplication. The local training allows QIN-QIOs to address important national topics with a focus on local needs and to leverage local relationships and stakeholder engagement. The Nursing Home IP Training Implementation Initiative, focuses on providing support to nursing homes, a multi-state approach to increase the number of IP trained front-line staff.

Poster # 16

Assessment of Targeted Response for COVID-19 Vaccination​

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This poster presents the findings from the Independent Evaluation Contractor’s (IEC) analysis assessing the Network of Quality Improvement and Innovation Contractors (NQIIC) program’s Quality Innovation Network – Quality Improvement Organizations (QIN-QIO)  contractors’ attributable impact on increasing nursing home resident COVID-19 vaccination rates through utilization of tailored, customized interventions designed to mitigate issues of vaccine access and hesitancy and improve data reporting among QIN-QIOs.

Poster # 17

Reducing Hospitalizations With On-Site Technical Assistance

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Thirty-two dialysis facilities with high rates of hospitalization and emergency department (ED) usage among their patients were identified in Alaska, Washington, Oregon and Montana. Fourteen interventions were offered as best practices for the facility to choose from, including creating awareness of the link between physician rounding and hospitalizations and enabling patient empowerment through facility-patient communication.

Poster # 18

Improvement Sprints: Collaborating Across the Care Continuum

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Through the steps of gap analysis, action plan, implementation, and sustainability and maintenance, and using the resource, "Dialysis Facility Sepsis Screening Tool" the Midwest Kidney Network partnered to lead rapid improvement cycles to enhance patient quality outcomes across three topics (i.e., sepsis screening, early identification, and intervention). Data is pending.

Poster # 19

Quality Measure Reports to Drive Nursing Home Improvement

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Great Plains QIN developed and disseminates Quarterly Nursing Home Quality Measure Reports that display performance trend graphs of individual nursing home’s data compared to state and national trends. The reports include 17 quality measures, including the influenza and pneumococcal vaccination quality measures. GPQIN utilizes a standardized process to identify nursing homes who are low performers for readmissions, ED visits, Clostridioides difficile infection (CDI), and other infections. GPQIN contacts low performing nursing homes and sets up a meeting with the nursing home team and provides quality improvement technical assistance through a multi-faceted approach. These interventions have contributed to reduced CDI hospitalizations for Short-Stay nursing home residents from a baseline rate of 70.53 to 32.29 (RIR 54.2%) and Long-Stay residents from 15.2 baseline rate to 5.45 (RIR 64.1%) within a 12-month period.

Poster # 20

Organ Procurement Organization Quality Intervention Special Innovation Project

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Forty (40) organ procurement organizations (OPOs) were provided with data-driven technical assistance and quality interventions to increase organ donation and transplantation rates.

Poster # 21

Advancing Organ Donation and Transplantation Through Collaborative and Complementary Programs

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The End Stage Renal Disease (ESRD) Treatment Choices Learning Collaborative (ETCLC) and the Organ Procurement Organization (OPO) Quality Intervention Special Innovation Project (SIP) work in tandem to produce results for increased deceased donor kidneys, increased KDPI >/= 60 kidneys recovered, and completed root cause analyses and enhanced interventions implemented.

Poster # 22

SOS: Sharing Out Suggestions for Compliance

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Mountain Pacific, a Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) uses compliance-related issues as an opportunity to educate nursing homes quickly and efficiently in the form of weekly “SOS: Sharing Out Suggestions for Compliance” toolkits. The Mountain Pacific team listened to the needs of nursing home leadership to identify and reduce deficient practice and enhance the quality of care. These bite-sized, just-in-time learning toolkits provide real-life citation examples, compliance recommendations and resources, resulting in expedited, proactive responses; averting deficient practice and enhancing the quality of care for nursing home residents. One nursing home leader shared about the toolkits: “This is one of the emails I always open and pay attention to. It helps us maintain compliance.” Data suggests a reduction in these focused F-tags since sharing the toolkits. This email-based and online microlearning can be deployed across nursing homes and provide an opportunity to partner and collaborate with surveyors.

Poster # 23

Improving Dialysis Patient Outcomes Under the ESRD QIP: The Impact of Timely Medication Reconciliation

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Beginning in 2020, the End-Stage Renal Disease Quality Incentive Program (ESRD QIP) added a reporting measure to track monthly dialysis facility performance of MEDICATION RECONCILIATION (MedRec), a formalized process where healthcare professionals compare a patient’s prescribed and actual medication regimen, for each beneficiary in their care. Dialysis facilities with the most MedRecs within one week of hospital discharge had the fewest 30-day readmissions.

Poster # 24

Empowering ESRD Patient Decision Making Through Mobile Connectivity

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Mobile applications bridge the gap in underserved communities without access to broadband services, actively connecting patients with critical healthcare resources. Mobile connectivity ensures timely access to information, support services, and personalized decision-making tools. Improving patient lives with tools that support complex decision making and effective engagement in their healthcare.

Poster # 25

Telligen’s Enhanced Technical Assistance Helped an ACO Surpass Goals for A1c Measure Improvement

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Since January 2023, Telligen has provided enhanced technical assistance (TA) to an organization within an Accountable Care Organization (ACO) in Oklahoma on their Quality Payment Program (QPP) diabetes measure. After completing a root cause analysis (RCA) with Telligen, the organization identified a care gap where lab results are often missing from the electronic health record (EHR) if they are performed at an external facility. Labs were often completed but missing or charted incorrectly. Telligen provided TA to connect the organization with the Diagnostic Lab of Oklahoma to collaborate on ways to improve their process for uploading lab results to the EHR, so they are counted. This involved working with IT departments to correct existing data pathways and install a plug-in to create a new direct pathway for uploading results from the lab to the organization’s system. Integrating outside lab sources into the organization’s EHR is critical for sustainable success. Telligen helped to close the care gap by improving the communication between the different care providers.

Poster # 26

Improving an Evidence-Based Medication Review Program with Technical Efficiencies and Cost Savings

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Health Quality Innovators (HQI) facilitates the Blue Bag Initiative (BBI), a long-standing intervention that supports medication reviews and reconciliation at hospital discharge and in the community. Through the BBI program, 15,333 patients have received a Comprehensive Medication Review with 10,544 patients identified with a potential Adverse Drug Event. These reviews showed cost-savings of $3.33M - $4.88M attributable to avoidable adverse drug events. This program includes data collection and reporting by participants. The collection process, which took three weeks to complete, involved multiple people and steps and a monthly report for participants. HQI developed a new automated, secure data collection and report portal which streamlined report generation to 24 hours and resulted in QIN team time savings of 17 hours per month and QIN cost savings of $7,800 per year.

Poster # 27

Strategies for Ensuring Dialysis Patients Maintain Access to Care in Today's Challenging Climate

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All dialysis patients have a right to quality care, to be treated with respect and dignity, and to be recognized as an integral part of their healthcare team. Patients have rights to privacy, information that can help them make healthful decisions about their care, clinic policies and services, and how to file a grievance without fear of losing services if care expectations are not being met. Patients also have responsibilities to learn and ask questions, follow their treatment plan, be respectful of other patients and dialysis staff, and maintain financial responsibility for their treatment. When facilities do not adequately advocate for patient rights, and patients do not fully understand or maintain their responsibilities, it can result in the challenging situation of a patient being at-risk for involuntary discharge.

Poster # 28

Increasing Depression Treatment Among Dialysis Patients

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The HSAG End Stage Renal Disease (ESRD) Networks worked with dialysis facilities to increase the percentage of patients who were screened and received treatment for depression.

Poster # 29

Innovative Recognition Programs: Safeguarding Nursing Homes in the Wake of COVID-19 & Beyond

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The COVID-19 pandemic underscored the crucial importance of emergency preparedness, infection control and effective vaccination strategies for nursing home residents, visitors and staff. Nursing home staff confront overwhelming staffing challenges with many areas experiencing shortages. In response to these challenges, Telligen has initiated two successful nursing home recognition programs that are strategically designed to engage partners, boost staff morale, increase COVID-19 vaccinations and identify gaps in care. In the fall of 2021, Telligen introduced the Blue Ribbon in COVID-19 Vigilance award. It is presented to nursing homes that meet resident and staff up-to-date vaccine criteria and have policies, processes and ongoing staff education to prevent the spread of COVID-19. The award includes a ready-to-use marketing toolkit, designed to help awardees publicly share their successes. Since the Blue Ribbon in COVID-19 Vigilance was created, 682 nursing homes have met the criteria and received the award. In 2023, the B.E.S.T. in Class recognition award was introduced. It raised the bar and challenged participants to sustain robust infection prevention practices and training, complete a gap analysis for their emergency preparedness plans, receive the Blue Ribbon in COVID-19 Vigilance award for three quarters and meet the criteria for preventable emergency department visits. All awardees are recognized on the Telligen website, receive a ready-to-use marketing toolkit, an invite to be featured on Telligen’s podcast and a personally-delivered framed certificate. As of January 2024, 26 nursing homes have received the B.E.S.T. in Class award.

Poster # 30

Patient Resources: A Journey for Creating Materials by Patients for Patient

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The End Stage Renal Disease National Coordinating Center (ESRD NCC) National Patient and Family Engagement Learning and Action Network (NPFE-LAN) brings patients and families together to offer peer support and create resources that help patients understand their care options to make informed healthcare decisions and improve their health outcomes.

Poster # 31

ETCLC Patient and Donor Family Representatives: Sharing Invaluable Lived Experience to Increase Organ Donation & Kidney Transplantation

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Patient and Donor Family Representatives (PFRs) continue to play an integral role in ESRD Treatment Choices Learning Collaborative (ETCLC) quality improvement activities. Their engagement informs transplant programs, organ procurement organizations, and donor hospitals about the needs, expectations, and recommendations of transplant candidates, recipients, and donor families.

Poster # 32

KCER National Exercise Week: Ensuring Disaster Preparedness, Response, and Recovery for the Kidney Community

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Each year, KCER hosts a National Exercise Week to help End Stage Renal Disease (ESRD) Networks test and evaluate the effectiveness of their preparedness policies, plans, and procedures, and improve the overall response to emergencies and disasters impacting the kidney community. Stakeholders— including dialysis patients and representatives from emergency management, public health, healthcare coalitions, dialysis facilities, and state survey agencies—are invited to participate in the exercise.

Poster # 33

Data-Driven Predictors for Smoking Cessation

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Smoking among Medicare beneficiaries is prevalent, and an impactful opportunity for health intervention. However, the ubiquity of over-the-counter smoking cessation products renders Medicare claims a challenging data source to leverage for targeted interventions. Among the thousands of beneficiaries who smoke, Mountain Pacific tracks those in our states who smoke or pursue smoking cessation. Counts of claims that include smoking ICD-10 codes or smoking cessation HCPCs codes may not be representative of true smoking cessation trends, but they may be used to identify populations who are particularly successful at pursuing smoking cessation or, more importantly, less likely to pursue smoking cessation. To identify populations who may benefit from targeted interventions, we use descriptive statistics to identify beneficiary characteristics that are associated with pursuit of smoking cessation and incorporate them into multiple logistic regression modeling using monthly claims as panel data. Using claims from 2019 through August of 2023, North American Native beneficiaries in our states are about 9.0% less likely to pursue smoking cessation compared to non-North American Native beneficiaries [95% CI, -0.126, -0.056], and black beneficiaries are about 8.5% more likely than non-black beneficiaries to pursue smoking cessation [95% CI, 0.023, 0.147].

Poster # 34

Game Changers & Innovators: ETCLC Organizations Increasing Transplants and Improving KPDI ≥60 Recoveries

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Participating organizations in the ESRD Treatment Choices Learning Collaborative (ETCLC) increased the number of deceased donor kidneys transplanted by 3.8% and kidney donor profile index (KDPI) ≥ 60 kidneys recovered by transplant by 16.9%.

Poster # 35

Equity in Action: An Inclusive, Culturally and Linguistically Appropriate Services Implementation Action Plan for the End Stage Renal Disease

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Why CLAS in the ESRD community? The U.S. Department of Health and Human Services Office of Minority Health developed the National CLAS standards. ESRD affects a diverse group of people, and implementing CLAS standards is an essential step in improving health outcomes for all.

Poster # 36

Innovative ESRD Quality Reporting System (EQRS) Transplant Waitlist Dashboard

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The EQRS added an exciting new dashboard feature to improve communication and collaboration between transplant centers and dialysis facilities.

Poster # 37

Rural-Urban Differences in Dental Opioid Prescribing Among Adolescent/Young Adult and Adult Medicaid Beneficiaries

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Previous studies have primarily shown that overall opioid prescription rates are higher in rural areas. Our findings provide additional perspective by demonstrating that the likelihood of receiving a dental opioid prescription in an urban vs rural setting can significantly vary depending on beneficiary-level factors such as sex, age, and race and ethnicity. For example, for NH black adults, the odds of receiving a dental opioid prescription were significantly greater in urban areas, but for adolescents/young adults, the odds were significantly less in urban areas. These findings suggest that successfully addressing disparities in dental opioid prescribing must be sensitive to both individuals and their surrounding environment. County-level predictors showed consistent effects across both adolescents/young adults and adults, but opposite effects were observed between areas with a higher percentage of NH black residents (higher odds) and a higher percentage of Hispanic residents (lower odds). This finding suggests that race and ethnicity are not only significant at a beneficiary level but also at a population level. When considering the impact of county-level factors across urban and rural areas, we found that the protective effect of residential stability is significantly greater in rural areas. Studies have shown that residential stability is more common in rural settings, with better health outcomes mediated through communal benefits such as greater social cohesion and community support. Our findings suggest that these social benefits may also facilitate a lower likelihood of receiving a dental opioid prescription.

Poster # 38

Equity in Action: An Inclusive, Culturally and Linguistically Appropriate Services Implementation Action Plan

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Why CLAS in the ESRD community? The U.S. Department of Health and Human Services Office of Minority Health developed the National CLAS standards. ESRD affects a diverse group of people, and implementing CLAS standards is an essential step in improving health outcomes for all.

Poster # 39

Michigan Dental Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Survey- Trends Monitoring for Quality Improvement in Oral Health

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The Michigan Department of Health and Human Services (MDHHS) contracted with an External Quality Review Organization (EQRO) administered the Agency for Healthcare Research and Quality’s (AHRQ’s) Dental Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Survey instrument in 2022 for the adult population in the Comprehensive Health Care Program (CHCP). A CAHPS® survey in 2023 with a sample of 1,350 members was selected from the 9 Managed Care Health plans aged 19 years or older who were currently enrolled and were continuously enrolled at least 11 of the 12 months from November 1, 2021, to October 31, 2022, and had a paid or denied dental claim in the measurement period. The results were analyzed to identify the key drivers which impacted the consumer satisfaction and compared to those enrolled in Health plans from 2019-2020 and 2020-2021 and trends and statistical significance and strategy for improvement are discussed.

Poster # 40

Multi-State Opioid Collaborative Improves Naloxone Co-Prescribing and Addresses Days Supply of Opioids from Emergency Department

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With the number of drug overdose deaths increased by 16% from 2020 to 2021, decreasing opioid adverse drug events and deaths is a priority for the Mercy Health MSSP Accountable Care Organization (ACO). To support Mercy Health in addressing opioid utilization and misuse, the Health Quality Innovation Network and Mercy Leadership co-facilitate the Mercy QIO Opioid Collaborative along with two other Quality Innovation Network-Quality Improvement Organizations, Telligen and TMF. This Collaborative meets monthly to engage 404 clinics and 33 hospitals in the ACO’s service area which spans across Missouri, Oklahoma and Arkansas. The Collaborative’s focus is to develop and disseminate tools, resources, best practice advisories, and patient and provider education on opioid best practices to the ACO’s providers and patients in all three states.

Poster # 41

Improving Nursing Home Resident COVID-19 Vaccination Rates

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In January 2023, HQI launched a robust vaccination campaign in response to the Biden Administration COVID-19 Winter Preparedness Plan. The campaign, “Take Aim at a Healthy New Year,” focused on improving vaccination rates among nursing home residents. Informational packages designed for hesitant residents and families were provided to ombudsman programs in HQI’s four-state service area. HQI also partnered with the American Society for Consultant Pharmacists to provide long-term care staff with strategies to increase resident booster rates. Through this campaign, nursing homes across the service area achieved a 7.16% relative improvement rate of COVID-19 vaccinations among residents.

Poster # 42

Community Health Disparities Reduction Partnership (CHDRP) Initiative

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Superior Health launched the CHDRP Initiative in May 2023 to invest in projects in Wayne County (Michigan), Ramsey County (Minnesota), and Milwaukee County (Wisconsin). Grant funds awarded support one project in each county promoting health equity and improving care for residents, including Medicare beneficiaries. These projects are unique because they are co-designed by trusted partners and community members who reflect the populations that interventions are serving. This poster will share the approach to creating and launching this initiative in hopes that it is replicated in other communities.

Poster # 43

Strengthening Nursing Homes Emergency Preparedness Response: Supporting Tabletop Exercise Requirements

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The Centers for Medicare & Medicaid Services (CMS) requires long-term care facilities to address emergency preparedness as indicated in the State Operations Manual Appendix Z Requirement for Long-term Care Facilities F0039 (483.73). Superior Health Quality Alliance offers facilitated, virtual, tabletop exercises that meet the CMS requirement for one annual, full-scale, community-based exercise to all enrolled nursing homes.

Poster # 44

Superior Health Quality Alliance Presents: Engaging Home Healthcare Agencies to Reduce Patient Emergency Department Use

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This poster session provides information on two interventions “Timeliness of Care” and the “Call Us First” toolkit developed by Superior Health’s Home Healthcare Agency Workgroup. The Workgroup developed the two interventions to assist with reducing emergency department use for home healthcare patients living in the community.

Poster # 45

Leveraging Quality Measurement to Address Health Equity: Implementation of the MassHealth Healthcare Quality and Equity Initiative

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Measure stratification is a key component of the Healthcare Quality and Equity Initiative (HQEI), part of the MassHealth Medicaid and CHIP Section 1115 waiver. The HQEI program focuses on three domains: Demographic and Health-Related Social Needs Data, Equitable Quality and Access, and Capacity and Collaboration. Entities participating in the program (including acute care hospitals and accountable care organizations) are incentivized to collect self-reported race, ethnicity, language, disability, sexual orientation, and gender identity (RELD-SOGI) data in a standardized format state-wide. This data collection effort will enable organizations and MassHealth to stratify priority quality measures within each care setting to identify potential disparities among sub-populations. The ability to stratify quality measures will help inform opportunities to close gaps in care among sub-populations which can then be addressed through such mechanisms as multi-stakeholder collaboration, program incentives, and performance improvement projects.

Poster # 46

Mobile Vaccination Clinic Effect on Hospitalizations With a Positive COVID-19 Test in Michigan

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Superior Health Quality Alliance identified a gap in mobile vaccination clinic coverage in Michigan along with higher rates of hospitalization with a positive COVID-19 test among the unvaccinated population in nursing homes. We partnered with Visit Health to provide free mobile vaccination clinics to nursing homes and monitor our progress toward increasing up to date rates and decreasing hospitalization with positive COVID-19 test rates.

Poster # 47

Improving Maternal Health Through Care Review

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According to the Maternal Mortality Report released by the Georgia Department of Public Health (DPH) for 2018-2020, there were 30.2 pregnancy-related deaths per 100,000 live births. The leading causes of death were hemorrhage, mental health conditions, cardiomyopathy, cardiovascular and coronary conditions, embolism, preeclampsia, and eclampsia. Of the pregnancy-related deaths, 89% reportedly had at least some chance of being prevented. To improve maternal care outcome among Medicaid beneficiaries statewide, the Department of Community Health (DCH) developed a Clinical Practice Guidelines (CPG) audit process and related tools for the purpose of reviewing care provided to pregnant and postpartum persons. The tools were informed by most current standards and recommendations established by ACOG and the American Family Physician (AAFP). This maternal care review initiative will require CMOs to conduct quarterly medical record reviews to gain insight into practice and support providers in their delivery of care. The process was launched as a trial run in October 2023. DCH expects this care review process will identify gaps in practice and allow for adoption of remedial actions which in turn will lead to improved care and lower the rate of maternal morbidity and mortality in Georgia.

Poster # 48

Analyzing Grievance Cases for Return on Investment Monitoring Results and Estimating Return on Investment

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Alliant Health Solutions (AHS) ESRD Network 8 and 14 serve over 120,000 patients and over 1,200 dialysis facilities and transplant centers in four states. ESRD Networks have experienced an increase in patient involuntary discharges and access to care cases. With these increases, the AHS Network patient services staff have created a tool and dashboards to track and monitor these cases and demonstrate the number and percentage of access to care cases the Network has been able to avert.

Poster # 49

Community Providers and Local Students - CMS/NQIIC Innovation Project

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The Community Providers and Local Students (PALS) innovation project was tasked with developing a pilot student engagement program to improve the quality of care for vulnerable Medicare beneficiaries residing in underserved nursing homes (identified using CMS priority zip codes). Medical, pharmacy, and nursing students were recruited from universities in Houston, Texas, including one Historically Black College or University (HBCU). The team partnered with nursing home administrators and social workers to identify and recruit socially isolated and lonely residents. Student volunteers learned about Aging Topics, Health Equity, Social Isolation, Loneliness and Connection (SILC), and Empathetic Communications. Each student was paired with a nursing home resident for 6 on-site sessions that incorporated the EAR (Educate-Assess-Respond) Framework to guide students on assessing SILC, and on how to respond using ""social prescribing"". Storytelling exercises and “Hey, You” conversation prompts were used to promote intergenerational relationships. PALS sponsored two cohorts that aligned with student university summer and fall schedules. Having two cohorts allowed the PALS team to apply feedback and refine the program for the second cohort. Using pre/post-assessments, resident screenings, and student journaling following each session, the PALS team monitored the program’s impact on all participants. Results support that PALS had a positive impact on the SILC of participating residents. Students enjoyed the program and were empathetic to the vulnerability of nursing home residents and the associated loss of health, independence, and social connection. Finally, nursing home partners would like this program to continue.

Poster # 50

IP3 Leverages Emerging and Traditional Platforms to Educate NH Infection Preventionists

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The COVID-19 pandemic underscored the critical role played by Infection Preventionists (IPs) in Long Term Care roles. In many cases, nurses were tasked with IP roles in addition to other responsibilities. In response, IPRO QIN-QIO developed the IP3 Office Hours – Infection Prevention for Infection Preventionists by Infection Preventionists. These weekly online sessions allow IPs to address questions related to regulation and guidance. Attendees select the topics they would like to address the following week. We provide research and discuss how the facilities can operationalize the topic. The conversation is fluid and may shift based on the needs of the attendees. To keep the IP's engaged throughout the week, IPRO created a private Facebook page for colleagues. To support LTC IPs who wish to become certified, the group features a study-focused “Question of the Week.” This popular feature encourages IPs to begin studying for the certification exam of their choice. The program has been successful in engaging the IPs in problem solving. Attendees at weekly office hours use the chat to ask questions and share strategies with their peers. Since launching in February 2022:

• More than 1,000 IPs have attended weekly office hours.

• 2C5257 IPs regularly participate in the dedicated Facebook Group.

Poster # 51

Early and Periodic Screening, Diagnostic, and Treatment: National Environmental Scan Results

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In 2022, the Center for Medicaid and CHIP Services’ (CMCS) was tasked by the Bipartisan Safer Communities Act with “review[ing] State implementation of the requirements for providing early and periodic screening, diagnostic, and treatment services [EPSDT]… [and] identify[ing] gaps and deficiencies with respect to State compliance with such requirements.” The EPSDT benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services. As a first step to addressing Congresses’ request, CMCS, through a contract with NORC at the University of Chicago, conducted an environmental scan of state resources to see how they described EPSDT and the related services. This poster will share the results of the national environmental scan.

Poster # 52

Beneficiary and Family Centered Care Quality Improvement Organizations: A Hub of Support Services for Medicare Beneficiaries

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To protect Medicare beneficiaries and the Medicare Trust Fund, the Centers for Medicare & Medicaid Services (CMS) established Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs). BFCC-QIOs help Medicare beneficiaries exercise their right to high-quality health care by providing assistance when beneficiaries have a concern about their care. BFCC-QIOs provide a process for appeals if patients feel they are being discharged from a facility or Medicare-covered service before they are medically ready, investigate complaints made by beneficiaries and general quality of care concerns, and provide immediate advocacy services to resolve concerns in situations when the beneficiary complaint process is unlikely to reach complete resolution. From June 2019 through April 2023, the BFCC-QIOs completed more than 1 million hospital discharge and service termination appeals for Medicare beneficiaries, conducted almost 20,000 quality of care reviews, and facilitated more than 40,000 immediate advocacy cases. This poster introduces BFCC-QIO services and provides a sense of the magnitude of this important program.

Poster # 53

Opioid Utilization Among Hospitalized Beneficiaries

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The opioid crisis has been a pressing national problem since the late 1990s, resulting in opioid-related overdoses and deaths, and nearly $80 billion per year in associated costs. The Beneficiary and Family Centered Care National Coordination and Oversight Review Center (BFCC NCORC) assessed national opioid prescribing patterns among hospitalized Medicare beneficiaries using data from a clinical review of 4,000 patient records. Analyses indicated several socio-demographic and healthcare facility characteristics that are associated with increased rates of opioid use among Medicare beneficiaries. Data also suggested that new opioid initiation among beneficiaries was associated with increased patient safety events (PSEs) in hospitals. Contrary to national trends suggesting a recent decline in opioid prescribing, NCORC’s findings indicate that opioid use among Medicare beneficiaries did not decline between 2018 and 2021. Opioid use patterns varied significantly by age group with younger beneficiaries living in more disadvantaged areas being more likely to be prescribed opioids.

Poster # 54

The Relationship Between Health Equity and Patient Safety Among Medicare Beneficiaries

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The Beneficiary and Family Centered Care National Coordination and Oversight Review Center (BFCC NCORC) conducted a special study looking at racial disparities in patient safety events (PSEs). Commensurate with other studies in the literature, this investigation did not observe a significantly higher risk of PSEs in Black beneficiaries compared to White beneficiaries. Based on our analysis, it appears that the similarity in PSE rates between Black and White beneficiaries may be attributed to the shorter life expectancy of the Black population in the U.S. The NCORC sample, mirroring the national distribution of Medicare beneficiaries, contained a larger proportion of younger Black beneficiaries with lower PSE rates, thereby lowering the overall average PSE rate. Conversely, the smaller number of older Black beneficiaries, who had notably higher PSE rates, had less impact on the overall average PSE rate due to their limited representation. Other than the difference in age distribution, PSE rates did not vary significantly by diagnosis-related group (DRG) or health literacy score for either White or Black beneficiaries, suggesting that healthcare providers treated Medicare beneficiaries equally with no significant variation amongst disadvantaged populations.

Poster # 55

Leveraging NC HealthConnex for Digital Quality Measurement

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Providers face increasing administrative burdens related to paperwork, documentation, and data sharing agreements. Over the last few decades, reliance on technology and data sharing systems has come at a high-cost, both monetarily and on overall provider well-being. Unfortunately, this increase in documentation and technology has not been met with a stepwise increase in meaningful, comprehensive, or timely data related to beneficiary health outcomes. The question becomes, how can we accurately and meaningfully understand the quality of care that is being provided to beneficiaries, without adding to provider burden? To answer this question, North Carolina (NC) Medicaid has partnered with the NC Health Information Exchange Authority (HIEA) to leverage the state-designated health information exchange, NC HealthConnex. The long-term vision for this work is to transition to digital quality measures (dQMs), relying on NC HealthConnex as a central, data aggregator that will ingest and transform data from various sources. Not only does this movement align with CMS’ goal of transitioning all quality measures used in reporting programs to dQMs, but dQMs inherently solve many of the challenges experienced under the current system. This poster will outline NC Medicaid’s strategy and workplan to (1) reduce the administrative burden associated with sending and reporting data to multiple data sources, (2) provide near real-time quality measure data to providers, practices, health plans, and other permissioned entities to promote whole-person care, and (3) create an environment for information to be pulled in from various sources in a standardized and accurate format.

Poster # 56

The Cost of Patient Safety Events to Medicare

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Patient safety events (PSEs) and medical errors remain a persistent challenge in our healthcare system. In a random sample of 4,000 medical records, the Beneficiary and Family Centered Care National Coordination and Oversight Review Center (BFCC NCORC), found that over 50% of hospitalized beneficiaries experienced at least one PSE, and over 5,000 total PSEs were identified, with 6% deemed preventable. PSEs were associated with almost four additional days in the hospital on average, totaling over 32 million additional days nationally. This equates to approximately $86 billion dollars per year, or about one-tenth of all Medicare spending. Preventable PSEs were associated with about 5.7 million additional days of hospital care and over $15 billion dollars in spending. Patient safety is the cornerstone of high-quality healthcare, yet in this analysis, PSEs occurred in more than half of Medicare beneficiary hospitalizations, accounting for nearly 10% of Medicare spending. These findings reinforce the urgent need for the Centers for Medicare & Medicaid Services (CMS)’ National Quality Strategy (NQS) goal of achieving zero preventable harm.

Poster # 57

TMF HQIC Collaborates with University of Arkansas for Medical Sciences (UAMS) Reduces 30-day Sepsis Mortality Rate with New Clinical Pathway Standard

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In 2020, UAMS found that the risk-adjusted mortality index for patients diagnosed with sepsis was significantly higher than other top performing academic medical centers. They created a Sepsis Quality Improvement (QI) Team co-led by a critical care physician, the med-surg nursing director and a process improvement analyst for a strategic approach to address the statistic that more than half of inpatients who died had sepsis. The team expanded on its existing emergency department sepsis workflow to create a detailed inpatient clinical pathway for timely identification and treatment of sepsis. The TMF HQIC team provided frequent check-ins through virtual meetings with UAMS sepsis QI team to assess progress in the development of the pathway and provided useful resources. That team launched the pathway protocol in November 2021 and since implementation, UAMS has seen a 20.74% relative improvement rate in its 30-day sepsis mortality rate. They learned that early identification of sepsis is key to improved patient outcomes and the inpatient clinical pathway allows them to do that.

Poster # 58

Using an All-Cause Harm Prevention Model to Improve Care in HQIC Hospitals

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This poster describes IPRO’s Circle of Safety All-Cause Harm Prevention Model, designed to support all-cause harm prevention in the HQIC eight core patient safety areas. The model integrates Patient and Family Engagement (PFE) and Health Equity as essential components to harm reduction. Based on the model, IPRO created three resource tools that address how best practices can be used in each harm area to engage patients, reduce disparities, and reduce overall harm. The poster describes how the resource tools can be accessed from IPRO HQIC’s resource library.

Poster # 59

Co-Prescribing Benzodiazepines and Opioids in Acute Care Discharged Patients

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Using a data-driven approach, Health Services Advisory Group (HSAG) Hospital Quality Improvement Contract (HQIC) worked with enrolled hospitals with consistently high rates for co-prescribing of opioids and benzodiazepines at patient discharge. HSAG provided technical assistance to hospitals including performing a gap analysis to identify the common root causes for this practice. Interventions, tools, and resources were developed to assist hospitals on process changes aimed at reducing this high-risk prescribing practice. As a result, HSAG HQIC was able to reduce the rate of patients who were co-prescribed opioids at discharge from 14.09 percent down to 7.71 percent.

Poster # 60

Missouri Hospital Fights Back Against Opioid Crisis

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Through the HQIC program, HQI has helped hospitals strengthen opioid stewardship programs, including using coaching calls with data analysis, providing evidence-based tools, peer-to-peer support, implementing EMR prompts, and updating policies with new opioid pain guidelines. This poster highlights one hospital’s journey to reduce opioid prescribing and interventions that led to a 59% relative improvement rate.

Poster # 61

MAKING HEALTH EQUITY A REALITY: A data-driven approach to reducing health disparities

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In 2022, MediSys completed HANYS’ Health Equity Gap Analysis to assess the application of health equity best practices. Following the health equity gap analysis, MediSys appointed a health equity leader, created a health equity and inclusion committee, and implemented targeted performance improvement strategies to promote health equity across the organization. One of the strategies is to create and improve upon service line projects to reduce health disparities among at-risk populations. The Violence Elimination and Trauma Outreach (VETO) program is designed to support gunshot wound (GSW) patients through intensive case management, counseling, and referrals to wraparound services. An exploratory analysis of the trauma registry revealed that GSW patients were overwhelmingly Black or African American, male, uninsured or Medicaid-insured, and at greater risk for violent reinjury than non-GSW assault patients. According to the two-year pilot evaluation, VETO program graduates had a lower trauma recidivism rate than non-graduates. MediSys plans to replicate the success of the VETO program across the healthcare system by promoting a data-driven approach to health equity.

Poster # 62

KEEPING OUR PATIENTS SAFE: Three strategies to reduce inpatient falls

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During the fiscal year of 2023, Guthrie Corning Hospital experienced an increase in the number of inpatient falls each month on the two med-surg units. The hospital recognized the need to focus on keeping patients safe by using evidence-based strategies to reduce falls. The first intervention was the introduction of the fall champions to each unit. The champions encouraged the units to use three methods to reduce falls: “Ready, Steady, Balance” form to provide falls education, daily audits of fall prevention tactics, including bed/chair alarm, and increasing the use of the remote sitter program has not only supported fall reduction but also has decreased the number of physical personnel needed. For the first five months of FY 2024 Guthrie Corning reduced the number of inpatient falls on the med-surg units by 30%. To date, there have been zero falls with major injury.

Poster # 63

GIVING ALL A VOICE TO IMPROVE PATIENT SAFETY

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This poster describes the Partnership to Advance Tribal Health (PATH) support for Indian Health Service (IHS) facilities and tribal communities and clinics in regularly administering staff perception surveys on patient safety, compiling and analyzing data, and outcomes, discussing results with facility leadership and staff, helping create data displays to support transparency and providing action plan coaching.

Poster # 64

Compass Opioid Stewardship Certificate Program

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The Compass Opioid Stewardship Program, developed by the Iowa Healthcare Collaborative (IHC) and funded by CMS, is a nationwide initiative responding to the SUPPORT Act. It aims to enhance clinicians’ understanding of opioid stewardship, providing diverse support such as self-paced education modules, podcasts, and live events. Participants benefit from a comprehensive toolkit, individualized coaching, and fulfillment of quality improvement requirements, contributing to responsible opioid prescribing and fostering a culture of patient safety. The program encourages active participation and flexibility, allowing clinicians to tailor their involvement to meet individual needs.

Poster # 65

Leveraging the CAHPS Health Plan Survey to Identify and Address Health Disparities Based on Rurality and Race

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North Carolina (NC) Medicaid has taken new steps to better identify health disparities by adding new and updated measure stratifications to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan survey. Rural and urban stratifications have been added to the CAHPS survey analysis to determine if there are disparate experiences of care depending on the geographic region members reside in. It is hypothesized that members residing in rural areas will have lower experiences of care across key domains compared to their urban counterparts due to not having the same level of healthcare access. Using CDC methodologies to designate counties as either rural or urban, significant differences across CAHPS measure domains will be highlighted. Based on these results, NC Medicaid intends to use the data to inform quality initiatives and programs that aim to decrease disparities based on rurality. Additionally, NC Medicaid has updated strategies for analysis based on race for the CAHPS survey. Previously, race was analyzed by comparing members across racial demographic categories to their White counterparts. Moving forward, self-identified race will still be used, but members that have identified their race will be compared to their opposite. For instance, results for White respondents will be compared to non-White respondents, results for Black respondents will be compared to non-Black respondents, and so on. The adoption of this new analysis strategy is a more appropriate and statistically valid way of assessing if members’ experience of care is different due to their racial identity. As such, these comparisons will continue to look for evidence of differing experiences by race and ethnicity demographics to address racial disparities in health and healthcare delivery.

Poster # 66

Nevada 2022 Congenital Syphilis Case Review Findings and Recommendations

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Annual congenital syphilis (CS) cases have been increasing nationwide, including in Nevada, with 65 infants born with CS in Nevada in 2022. About 50% of all births are covered by Medicaid in Nevada, so we wondered how many mothers with CS were insured by Medicaid and of those, how many were receiving adequate prenatal care including appropriate screening, diagnosis, and treatment and what other healthcare system touchpoints mothers had where an intervention could have occurred to prevent these cases of CS. The Nevada Department of Health and Human Services (DHHS) Office of Analytics conducted analyses to investigate these questions and reviewed results with DHHS stakeholders and subject matter experts to identify areas for targeted interventions to reduce and hopefully eliminate future CS cases. Medicaid eligibility and claims data were linked with vital records and sexually-transmitted-disease surveillance data to explore questions surrounding health care coverage and prenatal care including services, diagnoses, and treatment patterns; other datasets such as SNAP and TANF eligibility and WIC and Child Welfare services were linked and explored to identify additional system touchpoints or areas of intervention for the mothers. Key findings included that about 70% of the mothers were enrolled in Medicaid and 61% had some level of utilization in the months preceding childbirth. Utilization data were not exclusive to prenatal care and reflected the spectrum of available Medicaid services. Only 45% of the mothers with infants with CS received any prenatal care, and of those, only 26% had adequate prenatal care indicated on the birth record, suggesting a gap in appropriate screening and diagnosis. In most congenital syphilis cases (83%), the mother was not diagnosed early enough to adequately treat. Recommendations were developed to build future interventions to occur at the patient, provider, community, and public health systems levels including recommendations for Nevada Medicaid.

Poster # 67

Advancing Health Equity with Native Hawaiians

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Mountain Pacific partnered with the Alu Like patient and family advisory council (PFAC) on health education for Native Hawaiians targeted in Kapolei, Nanakuli and Waimanalo on O’ahu. Native Hawaiians continue to face cultural, financial, social and geographic barriers, preventing them from fully utilizing existing health services. Working with Mountain Pacific as a PFAC, the Alu Like Ke Ola Pono Na Kupuna program benefited from shared learning, and collaborative interactions between Mountain Pacific and the Native Hawaiian patients and their families has increased. Hypertension, diabetes and heart failure resources and tools were localized and made easier to understand for all communities. Social connections developed over the last 10 years provide an additional safety net critical to keeping kÅ«puna (elders) healthy in their communities. Says the Alu Like team, “Continuing our relationship with Mountain Pacific, who are knowledgeable and dependable, ensures sustainability for the health and well-being of the Native Hawaiian people and the Alu Like programs.” The final measures for the eight-month Alu Like blood pressure management program were taken in October 2023, with 30 kÅ«puna completing the program and collectively dropping their systolic measures by 12 points, their diastolic measures by 4 points and their pulse by 5 points.

Poster # 68

Patient Safety: Using Data and Resources for Harm Reduction in SNF/PALTC with a Regional Stakeholder Collaborative

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The analysis of Medicare beneficiary admissions to hospitals or Part D prescription dispensing claims indicates that the scope of the crisis has not abated. Beneficiaries requiring a hospital admission who are diagnosed with an opioid overdose or OUD, or experiencing opioid overdose, once stabilized, need placement options for post-acute or extended care services. Patients who have OUD and need the level of care provided by SNF/PALTC facilities face challenges to entry. IPRO assessments identified 29% of nursing homes occasionally, rarely, or never use opioid risk mitigation strategies including naloxone, nearly 20% of nursing homes did not have naloxone in their emergency medication kits, and 40% of nursing homes desired education on naloxone. This places Nursing Home residents at increased risk for opioid overdose deaths by both prescription drugs and non-prescribed substances. IPRO convened LTC stakeholders for advocacy, and created the Nursing Home Naloxone Policy & Procedure Toolkit with editable policies and procedures to assist nursing homes in responding to opioid induced respiratory depression events (overdoses). Additional action plan items include providing data-driven technical assistance to nursing homes emphasizing naloxone, medications for OUD, and alternatives to opioids, and disseminating best practices developed by IPRO and other evidenced-based resources through nursing home corporate leadership to facilitate rapid spread and scale.

Poster # 69

Beacon of Hope

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A supportive and effective healthcare system can assist those on their journey to recovery. Navigating the challenges of substance use can be difficult for individuals. The visual was derived from various interviews with key interested parties to understand barriers to accessing prevention, treatment, and recovery services for individuals with Substance Use Disorders (SUD).

Poster # 70

Pathways to Recovery

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Support teams are critically important to meet people where they are and let them know they have options. The journey to recovery is not the same for everyone. The visual was derived from various interviews with key interested parties to understand barriers to accessing prevention, treatment, and recovery services for individuals with Substance Use Disorders (SUD).

Poster # 71

Story of Sam

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Sam is on their journey to recovery. Through Sam’s story, we can better understand the person’s perspective as they move through the substance use recovery process. The visual was derived from various interviews with key interested parties to understand barriers to accessing prevention, treatment, and recovery services for individuals with Substance Use Disorders (SUD).

Poster # 72

Barriers to Oral Health Care

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Patients and providers report encountering various barriers to receiving and providing quality care under Medicaid, a joint federal/state program administered by states under broad federal guidelines. Oral health is a cross-cutting priority for CM, and patients, providers, and state governments all have a role to play in improving oral health. This visual summarizes interviews with interested parties to better understand experiences of barriers to oral health care.

Poster # 73

Compare Tool: Procedure Volume, Facility Affiliation, MIPS Performance, and APM Participation

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Medicare hosts a tool that provides a web-based, single-source search-and-compare experience for people with Medicare and their caregivers to find information about doctors, clinicians, and other healthcare providers and settings. The Provider Data Catalog (PDC) provides researchers and other interested parties direct access to view and download data used on profiles.

Poster # 74

Implementing Procedure Volume Reporting on Medicare.gov Compare Tool

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CMS released procedure volume data on physician profile pages on Medicare.gov in January of 2024. This poster will focus on the process of adding procedure volume on the Medicare.gov compare tool (a planned enhancement, subsequently supported by statute), including concept origination; research to define the procedure categories and count a unique procedure; design, plain language, and consumer testing; the regulatory process (including authorization to include Medicare Advantage encounters); launch; and related public announcements.

Poster # 75

Setting eCQMs on FHIR

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Progression to Electronic Clinical Quality Measures (eCQMs) and Digital Quality Measures (dQMs) with HL7 Fast Healthcare Interoperability Resources (FHIR®)

Poster # 76

Optimizing Quality of Care for Medicare Beneficiaries and Enhancing the Protection of the Medicare Trust Fund

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This poster examines how Kepro has collected and analyzed clinical data from appeals. From this data, Kepro is improving processes, enhancing the quality of care delivery to Medicare beneficiaries, and protecting the integrity of the Medicare Trust Fund.

Poster # 77

Kepro BFCC-QIO Internal Quality Improvement Program

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This poster examines the internal quality improvement program at Kepro. It looks at Kepro’s problem-solving method, the lean/six-sigma approach, and the program’s innovations.

Poster # 78

Elevating Quality: The Power of Patient Voices in Healthcare

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Creating an Optimal Environment for Quality Healthcare for Individuals, Families and Communities

Poster # 79

What are QIOs and how do they help Medicare beneficiaries? A look inside Kepro’s BFCC-QIO program

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This poster examines the role of the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). It looks at the services provided by the BFCC-QIO, statistics related to those services, and ways Kepro interacts with Medicare beneficiaries, partners, and providers.

Poster # 80

#BeAwareForBetterCare: A Toolkit for Healthcare Professionals

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Disparities in care continue to affect people from certain racial and ethnic minority groups despite ongoing efforts. Advancing health equity is one of the pillars of the Centers for Medicare & Medicaid Services (CMS) National Quality Strategy. Health equity means the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, or gender identity. This poster presents the #BeAwareForBetterCare social media toolkit to raise awareness of the importance of health equity for all people.

Poster # 81

Livanta Claim Review: Improving Accuracy, Reducing Errors, Protecting the Medicare Trust Fund

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As the national claims review contractor, Livanta evaluates two main types of claims paid under Medicare Part A with high potential for errors: hospital inpatient admissions of short duration and claims in which hospitals paid under the Prospective Payment System (PPS) re-submitted inpatient claims for a higher payment than what they had billed initially. This poster illustrates the significant achievements that the Livanta claim review team has accomplished over two years of reviewing short stay claims and higher weighted diagnosis-related group reviews (HWDRG) claims.

Poster # 82

Creative Initiatives to Yield High Survey Response Rates

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This poster outlines the BFCC-SC efforts to raise Experience Survey response rates.

Poster # 83

How BFCC-QIOs Engage Medicare Beneficiaries through Immediate Advocacy

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This poster describes the Immediate Advocacy (IA) premise and process and discusses outcomes with quantitative and qualitative data.

Poster # 84

Improving Efficiency with Risk Scores Generated from Public Datasets

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The Beneficiary and Family Centered Care National Coordinating Oversight and Review Center (BFCC NCORC) reviews 4,000 Medicare claims annually as a part of the patient safety surveillance system. Physician and nurse reviewers screen the medical records to identify patient safety events (PSEs), however this is a time intensive approach and almost half of the sampled cases do not have a PSE. To improve efficiency in identifying medical records with PSEs, the BFCC NCORC developed a predictive model to calculate risk scores using public datasets, such as the U.S. census and hospital ratings. Compared to the random sampling approach, the risk-based sampling method using this new model may identify as many as 1,100 additional cases with PSEs, when reviewing the same amount (4,000) of medical records. This analysis suggests that using predictive modeling may be a more efficient method for identifying medical records with PSEs compared to using physician and nurse reviewers.

Poster # 85

Lessons Learned: How a hospital-community partnership can reduce hospital readmissions

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Learn how a hospital and community partners worked together to reduce hospital readmissions with assistance from their QIN-QIO, TMF Health Quality Institute.

Poster # 86

Reducing Disparities in Use of Support and Advocacy Services for Medicare Beneficiaries

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Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) offer support and advocacy services to Medicare beneficiaries through their case review services. Analysis of the socio-demographic characteristics of Medicare beneficiaries using BFCC-QIO services identified that some groups of beneficiaries are using services at a much lower rate than others. Hispanic and Asian beneficiaries are the least likely to appeal a hospital discharge or service termination, file a quality of care complaint, and use immediate advocacy compared to beneficiaries of other racial and ethnic groups. To address possible barriers to use of support and advocacy services, the BFCC National Coordinating Oversight and Review Center conducted targeted interviews with community service providers and stakeholders in several Hispanic and Asian communities. Stakeholders indicated that beneficiaries may be less likely to use services due to language and literacy barriers, processes that require seniors to navigate complicated technology, and cultural taboos related to aging and help seeking. Stakeholders recommended engaging family and caregivers to increase awareness of BFCC-QIO services, using messaging tailored to underserved Hispanic and Asian beneficiaries, and partnering with trusted organizations to improve equitable access to BFCC-QIO services.

Poster # 87

Closure of Dialysis Clinics in 2022 and 2023: An Unprecedented Trend in ESRD Care

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Quarterly public reporting of select data under the National Forum of the End-Stage Renal Disease (ESRD) Networks include number of operating dialysis facilities and transplant centers as well as persons receiving dialysis treatment under the ESRD program starting from the third quarter of 2021. We used these quarterly data to examine ESRD dialysis clinic growth trends over time and their relationship with dialysis patient growth trends during the post-COVID-19 pandemic era.

Poster # 88

The Effect of Value-Based Purchasing Programs on Reducing Adverse Hospital Outcomes and Improving Overall Hospital Performance

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Purpose: This evaluation focuses on three CMS Value-Based Purchasing programs: the Hospital Value-Based Purchasing Program, the Hospital-Acquired Condition Reduction Program, and the Hospital Readmissions Reduction Program. Research topics include (1) changes in adverse outcomes assessed by the programs and (2) the impact of ownership changes on subsequent performance. Description: Performance measures included adverse outcomes (e.g., readmissions and hospital-acquired infections) and program scores. Research questions were addressed through multivariable linear regression, with difference-in-difference methodologies utilized as appropriate to identify causal effects. Evaluation: Main findings are: 1) cross-program total annualized adverse outcome counts decreased from 390,026 in FY2019 to 285,832 in FY2023, although these totals mask slight increases in Hospital VBP Safety and HACRP adverse outcomes in more recent years overlapping with the COVID-19 Public Health Emergency; 2) HRRP-eligible hospitals did not experience larger improvements in readmissions than their peers; and 3) there was no consistent performance trend associated with ownership change. Outcomes: Increases since FY2022 in adverse outcomes tracked by the Hospital VBP and HACRP programs pose challenges to CMS’s three-part aim to support better care for individuals, better health for populations, and lower cost. Further, difference-in-difference methods found that HRRP-eligible hospitals did not achieve greater reductions in readmissions than HRRP-ineligible hospitals. Furthermore, changes to the market environment that hospitals operate in may have implications for quality of care. Findings suggest changes in hospital ownership are associated with differences in performance. However, the direction and magnitude of these differences depend on the type of owner change and the outcome.

Poster # 89

Virginia Medicaid Core Set Development and Reporting

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The poster will cover the development process of the 2024 Mandatory Child and Adult Behavioral Health Core Set measures in Virginia including challenges and lessons learned.

Poster # 90

Behavioral Health (BH) Quality Measures: A CMS Measures Inventory Tool (CMIT) Search Use Case

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The CMS Measures Inventory Tool (CMIT) is the repository of record for information about the measures which CMS uses to promote healthcare quality and quality improvement. CMIT includes measure info details across 26 quality reporting programs, CMMI models, and Medicaid. CMIT does not contain measure performance data, which is available on various CMS public reporting websites. CMS uses CMIT to assess where there are measurement gaps and to facilitate enhancing completeness in assessing quality across all Behavioral Health conditions.

Poster # 91

Updated Guide for Reducing Disparities in Readmissions Provides Resources to Support Actions

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This poster shares the updated 2024 Guide for Reducing Disparities in Readmissions, from the CMS Office of Minority Health. It provides background data about the impact of hospital readmissions on enrollees, families, caregivers, and the health system at large. Social determinants of health (SDOH) such as health care access and quality, economic stability, the neighborhood and build environment, social and community context, and education access and quality often drive readmissions. The Guide shares steps to reduce disparities, as well as proven strategies health systems, hospitals, providers, and community-based organizations can use to improve care and reduce disparities. Links to over forty resources provide a wide range of help and tools.

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