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Annual Reports

2012 Annual Report

10th SOW Annual Report of QIO Case Review Information
United States Virgin Islands
Virgin Islands Medical Institute, Inc.

I. Total # of Reviews – Provide the total number of reviews the QIO performed in CRIS by the associated review type.

Review Type

# of Reviews

Percent of Reviews (%)

Coding Validation (120 - HWDRG)

0

0.00%

Coding Validation (All Other Selection Reasons)

0

0.00%

Quality of Care Review (101 through 104 -Beneficiary Complaint)

6

40.00%

Quality of Care Review (All Other Selection Reasons)

0

0.00%

Utilization (158 - FI/MAC Referral for Readmission Review)

0

0.00%

Utilization (All Other Selection Reasons)

2

13.33%

Notice of Non-coverage (105 through 108 - Admission and Preadmission)

0

0.00%

Notice of Non-coverage (118 - BIPA)

6

40.00%

Notice of Non-coverage (117 - Grijalva)

0

0.00%

Notice of Non-coverage (121 through 124 -Weichardt)

1

6.66%

Notice of Non-coverage (111-Request for QIO Concurrence)

0

0.00%

EMTALA 5 Day

0

0.00%

EMTALA 60 Day

0

0.00%

Total

15

 

 

II. Top 10 Principal Medical Diagnoses – Provide the top 10 principal medical diagnoses for inpatient claims billed for Medicare beneficiaries.

Top 10 Medical Diagnoses

# of Beneficiaries

Percent of Beneficiaries (%)

1. 43491 - CRBL ART OCL NOS W INFRC

86

20.05%

2. 486 - PNEUMONIA, ORGANISM NOS

62

14.45%

3. 4280 - CHF NOS

60

13.99%

4. 71516 - LOC PRIM OSTEOART-L/LEG

40

9.32%

5. 27651 - DEHYDRATION

37

8.62%

6. 5990 - URIN TRACT INFECTION NOS

36

8.39%

7. 42731 - ATRIAL FIBRILLATION

31

7.23%

8. 25080 - DMII OTH NT ST UNCNTRLD

29

6.76%

9. 25070 - DMII CIRC NT ST UNCNTRLD

24

5.59%

10. 41401 - CRNRY ATHRSCL NATVE VSSL

24

5.59%

Total

429

100.00%

 

III. Provider Reviews Geographics – Provide the count and percent by Rural vs. Urban geographical locations for Health Service Providers (HSPs) associated with a completed QIO review.

Geographical Area

# of Providers

Percent of Providers (%)

Rural

5

100.00%

Urban

0

0.00%

Unknown

0

0.00%

Total

5

100.00%

 

IV. Provider Reviews Settings – Provide the count and percent by Setting for Health Service Providers (HSPs) associated with a completed QIO review.

Setting

# of Providers

Percent of Providers (%)

0 - Acute Care Unit of an Inpatient Facility

2

40.00%

1 - Distinct Psychiatric Facility

0

0.00%

2 - Distinct Rehabilitation Facility

0

0.00%

3 - Distinct Skilled Nursing Facility

0

0.00%

5 - Clinic

0

0.00%

6 - Distinct Dialysis Center Facility

0

0.00%

7 - Dialysis Center Unit of Inpatient Facility

0

0.00%

8 - Independent Based RHC

0

0.00%

9 - Provider Based RHC

0

0.00%

C - Free Standing Ambulatory Surgery Center

0

0.00%

G - End Stage Renal Disease Unit

0

0.00%

H - Home Health Agency

0

0.00%

N - Critical Access Hospital

0

0.00%

O - Setting does not fit into any other existing setting code

0

0.00%

Q - Long Term Care Facility

0

0.00%

R - Hospice

3

60.00%

S - Psychiatric Unit of an Inpatient Facility

0

0.00%

T - Rehabilitation Unit of an Inpatient Facility

0

0.00%

U - Swing Bed Hospital Designation for Short-Term, Long-Term Care, and Rehabilitation Hospitals

0

0.00%

Y - Federally Qualified Health Centers

0

0.00%

Z - Swing Bed Designation for Critical Access Hospitals

0

0.00%

Other

0

0.00%

Total

5

100.00%

 

A. Quality of Care Concerns Confirmed – Provide the number of concerns by Quality of Care PRAF Category Code and the number that were confirmed at highest level of review, for completed quality of care reviews.

Quality of Care (“C” Category) PRAF Category Codes

# of Concerns

# of Concerns Confirmed

Percent Confirmed Concerns (%)

C01 - Apparently did not obtain pertinent history and/or findings from examination

0

0

0.00%

C02 - Apparently did not make appropriate diagnoses and/or assessments

0

0

0.00%

C03 - Apparently did not establish and/or develop an appropriate treatment plan for a defined problem or diagnosis which prompted this episode of care [excludes laboratory and/or imaging (see C06 or C09) and procedures (see C07 or C08) and consultations (see C13 and C14]

1

0

0.00%

C04 - Apparently did not carry out an established plan in a competent and/or timely fashion

0

0

0.00%

C05 - Apparently did not appropriately assess and/or act on changes in clinical/other status results

0

0

0.00%

C06 - Apparently did not appropriately assess and/or act on laboratory tests or imaging study results

0

0

0.00%

C07- Apparently did not establish adequate clinical justification for a procedure which carries patient risk and was performed

0

0

0.00%

C08 - Apparently did not perform a procedure that was indicated (other than lab and imaging, see C09)

0

0

0.00%

C09 - Apparently did not obtain appropriate laboratory tests and/or imaging studies

0

0

0.00%

C10 - Apparently did not develop and initiate appropriate discharge, follow-up, and/or rehabilitation plans

2

1

50.00%


C11 - Apparently did not demonstrate that the patient was ready for discharge

0

0

0.00%

C12 - Apparently did not provide appropriate personnel and/or resources

0

0

0.00%

C13 - Apparently did not order appropriate specialty consultation

0

0

0.00%

C14 - Apparently specialty consultation process was not completed in a timely manner

0

0

0.00%

C15 - Apparently did not effectively coordinate across disciplines

0

0

0.00%

C16 - Apparently did not ensure a safe environment (medication errors, falls, pressure ulcers, transfusion reactions, nosocomial infection)

1

0

0.00%

C17 - Apparently did not order/follow evidence-based practices

0

0

0.00%

C18 - Apparently did not provide medical record documentation that impacts patient care

0

0

0.00%

C99 - Other quality concern not elsewhere classified

1

0

0.00%

Total

5

1

20.00%

 

B. Serious Reportable Events on Quality of Care Reviews - Provide the number of Quality Improvement Activities (QIAs) initiated (initial activity date within the reporting period) for all quality of care reviews with confirmed concerns. Indicate the number and percent of those QIAs that are associated with quality of care concerns you deemed to fall into the category of “Serious Reportable Events”.

# of QIAs Initiated

# of QIAs Initiated for Serious Reportable Events

Percent of QIAs Initiated for Serious Reportable Events (%)

0

0

0

 

C. Confirmed Quality of Care Concerns with Associated Interventions – Provide the number of Initial Quality Improvement Activities initiated, by Activity Type, for reviews with one or more confirmed Quality of Care concerns. Provide the percent of total activities that each comprises.

Initial Quality Improvement Activity

# of Interventions (QIAs) with this Initial Quality Improvement Activity

Percent of Interventions (QIAs) with this Initial Quality Improvement Activity

1 - Send educational/alternative approach letter

0

0.00%

2 - Perform intensified review

0

0.00%

3 - Require continuing education

0

0.00%

4 - Request/review policy/procedure

0

0.00%

5 - Request development of QIP

1

50.00%

6 - Accept provider-initiated QIP

0

0.00%

7 - Conduct informal meeting or teleconference

0

0.00%

8 - Refer to licensing board

0

0.00%

9 - Initiate sanction activity

0

0.00%

10 - Other

1

50.00%

Total

2

100.00%

 

D. Discharge/Service Termination – Provide discharge location of beneficiaries linked to discharge/service termination reviews for Selection Reasons 111 (Request for QIO Concurrence) and 121 – 124 (Weichardt Selection Reasons). Note: Data represents discharge/service termination reviews from 8/1/2011 – 4/30/2012, 8/1/2012 – 4/30/2013 and 8/1/2013 – 2/28/2014 for the first, second and third annual reports respectively. A shortened data timeframe is necessary to allow for maturity of claims data which is the source of “Discharge Status” for these cases.

Discharge Status

# of Beneficiaries

Percent of Beneficiaries (%)

01 - Discharged to home or self care (routine discharge)

0

0.00%

02 - Discharged/transferred to another short-term general hospital for inpatient care

0

0.00%

03 - Discharged/transferred to skilled nursing facility (SNF)

0

0.00%

04 - Discharged/transferred to intermediate care facility (ICF)

0

0.00%

05 - Discharged/transferred to another type of institution (including distinct parts)

0

0.00%

06 - Discharged/transferred to home under care of organized home health service organization

0

0.00%

07 - Left against medical advice or discontinued care

0

0.00%

09 – Admitted as an inpatient to this hospital

0

0.00%

20 – Expired (or did not recover – Christian Science patient)

0

0.00%

21 – Discharged/transferred to court/law enforcement

0

0.00%

30 – Still a patient

0

0.00%

40 - Expired at home (Hospice claims only)

0

0.00%

41 - Expired in a medical facility (e.g. hospital, SNF, ICF or free standing Hospice)

0

0.00%

42 - Expired – place unknown (Hospice claims only)

0

0.00%

43 - Discharged/transferred to a Federal hospital

0

0.00%

50 - Hospice - home

0

0.00%

51 - Hospice - medical facility

0

0.00%

61 - Discharged/transferred within this institution to a hospital-based Medicare approved swing bed

0

0.00%

62 - Discharged/transferred to an inpatient rehabilitation facility including distinct part units of a hospital

0

0.00%

63 - Discharged/transferred to a long term care hospital

0

0.00%

64 - Discharged/transferred to a nursing facility certified under Medicaid but not under Medicare

0

0.00%

65 - Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital

0

0.00%

66 - Discharged/transferred to a Critical Access Hospital

0

0.00%

70 - Discharged/transferred to another type of health care institution not defined elsewhere in code list

0

0.00%

Other

0

0.00%

Total

0

0.00%

 

E. Beneficiary Demographics – Provide the number of beneficiaries for whom a case review activity was started, by demographic category, and the percent of beneficiaries each category represents.

Demographics

# of Beneficiaries

Percent of Beneficiaries (%)

Sex/Gender

   

Female

9

60.00%

Male

6

40.00%

Unknown

0

0.00%

Total

15

100.00%

Race

   

Asian

0

0.00%

Black

11

73.33%

Hispanic

0

0.00%

North American Native

0

0.00%

Other

0

0.00%

Unknown

0

0.00%

White

4

26.67%

Total

15

100.00%

 

F. Quality of Care Reviews and Concerns by Intervention Type - Using a QIA started within the reporting period for the current year’s report, please provide a short description as to the type of intervention(s)/QIA(s) employed, per C.6 Technical Assistance requirements in the Contract, for three diverse or different quality categories (C1-99). Intervention/QIA types may include, but are not limited to: Educational or Alternative Approach to Care letter; Continuing Education; Assistance in Developing Policy & Procedure; Modification to Existing Policy & Procedure; Formal Quality Improvement Plan and/or Corrective Action Plan. Note: If the QIO does not have three diverse or different quality categories, please indicate such on the report.

Description 1 – Type of Intervention for Quality Category C <1-99>

The QIO has only one (1) confirmed Quality of Care Concern.


Quality Category: C10 - Apparently did not develop and initiate appropriate discharge, follow-up, and/or rehabilitation plans.

On review an improper notification to the beneficiary of the rights to a discharge appeal was found. The provider did not follow the CMS requirements for notification of the right to appeal. In addition, there was an absence of documentation throughout the hospitalization of ongoing discharge planning efforts to secure appropriate post acute-care disposition.

VIMI requested a formal Quality Improvement Plan (QIP) from the provider. A conference call was scheduled to discuss the need to develop a QIP. VIMI explained the requirements and due dates for plan development and implementation, which the provider agreed to and requested an educational activity for their staff. Our Medical Director presented the HDAN process to the provider staff. VIMI’s Manager of Beneficiary Services fielded numerous calls throughout the following week from the provider requesting further assistance. VIMI assisted the provider in developing a QIP that includes measurable indicators of improvement in provider right to appeal notifications and discharge planning documentation.

Using one example from the previously identified intervention(s)/QIA(s), describe how the intervention/QIA was determined, along with any identified “Best Practices” for the resolution of the identified quality concern.

Example from Description 1, How Interventions Determined/Best Practices

  • The focus on the IM notification process was based on the presence of the same issue with the notification process and discharge planning documentation in other case review. This indicated that the confirmed concern was not a unique occurrence.
  • Discussion with the provider and the providers request for educational review of all steps in the notification process also resulted in selection of the intervention.
  • QIO work in the C8 AIM and related knowledge of tools and techniques from the RED project related to discharge planning and documentation assists with selection of evidence based/best practices for this quality improvement initiative.

VIMI does not have any other Quality concern category identified.


G. Evidence Used in Decision-Making - Drawing upon your QIO’s case review practices, please describe the one or two most common types of evidence/standards of care criteria used to support Review Analysts’ assessments and Peer Reviewers’ decisions for Medical Necessity/Utilization Review and Appeals. Provide a brief statement of rationale for how the specific evidence/standards of care were chosen. The types of evidence/standards of care may include, but are not limited to, Local Coverage Determinations (LCD), Medicare Conditions Coverage, Medicare Conditions of Participation and National Coverage Determinations (NCD).

For QoC, describe the one or two most common types of evidence/standards of care criteria used to support Review Analysts’ assessments and Peer Reviewers’ decisions for the specific list of diagnostic categories provided in the table.
Note: The list is from other 10th SoW initiatives in which QIOs are involved. If there are any categories for which you did not conduct a QoC review during the reporting period, denote that in the table.

Review Type

Diagnostic Categories

Evidence/ Standards of Care Used

Rationale for Evidence/Standard of Care Selected

Quality of Care

Pneumonia

No QoC during this period

No QoC during this period

Heart Failure

No QoC during this period

No QoC during this period

Acute Myocardial Infarction

No QoC during this period

No QoC during this period

Pressure Ulcers

NPUAP Guidelines

Relevance to case under review. Expert status in the field.

Urinary Tract Infection

No QoC during this period

No QoC during this period

Sepsis

No QoC during this period

No QoC during this period

Adverse Drug Events

No QoC during this period

No QoC during this period

Falls

No QoC during this period

No QoC during this period

Patient Trauma

No QoC during this period

No QoC during this period

Surgical complications

No QoC during this period

No QoC during this period

Medical Necessity/Utilization Review

 

McKesson (Interqual)

One of two recognized MN or UR software programs available to the QIO at the time of review. The second program has recently become available and the QIO will utilize as needed going forward.

Appeals

 

 

Medicare Conditions of Participation

 

Medicare Claims Processing Manual

 

Medicare Benefit Policy Manual Chapter

 

Palliative Performance Scale

 

Functional Assessment Scale

 

Karnofsky Score Performance Status.

Commonly utilized standards/regulations.

 

Please provide three brief examples/case studies where case review was linked to another Aim of the QIO contract, for example, readmissions, pressure ulcers, adverse drug events, etc. Identify the evidence based criteria used to support review decisions on those cases and what influenced the selection of that criteria. Documentation should be two paragraphs or less per example/case study.

This confirmed quality of care concern is linked to C.8 Readmissions in the 10SOW. No discharge plan was developed for this patient to assist with transfer to another level of care. Therefore, the patient was discharged from an acute level of care, and re-admitted to the same facility to a lower level of care with transfer of full liability for charges to the patient. Additionally, during the initial admission there was no documentation of ongoing case management efforts to secure post-acute care placement for the patient.

In this instance, Medicare regulations were not followed as outlined in:

  • - Medicare Claims Processing Manual-Chapter 30 – Financial Liability Protections.
  • - QIO Manual Chapter 7 -7005
  • - https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HINNs.html
  • - https://www.cms.gov/Medicare/Medicare-GeneralInformation/BNI/HospitalDischargeAppealNotices.html

 

Additionally, the evidence based interventions outlined in the RED project demonstrate that early, comprehensive discharge planning throughout patient’s hospital stay increases the probability that patients are safely and seamlessly transferred to another level of care following resolution of the acute medical issue(s). These criteria support the QIO determination that early planning and consistent documentation of post discharge placement arrangements would have resulted in a more appropriate outcome.

Example/Case Study 2

No second case study identified

Example/Case Study 3

No third case study identified.

H. Effectiveness of QIAs - Please provide an analysis of how the findings in tables B, C and F can be used to support the effectiveness of QIAs conducted as part of the BFCC Aim. The QIO should provide a narrative analysis on the information provided and recommendations for how the information could be used to make a positive impact on the work done in other 10SOW Aims.

Narrative Analysis: - Using a QIP for the confirmed concern will allow a comprehensive assessment of the problem, selection of an appropriate intervention based on this assessment and a mechanism for quantifying improvement. Establishing a baseline will allow objective assessment of the extent of the problem through determination of the prevalence of improper delivery of notification of right to appeal and improper documentation of discharge planning efforts in the provider setting under review. In carrying out the QIP, root cause analysis should lead to identification to some of the factors that contribute to either failure to carry out or document proper discharge planning. This information would be critical to the C8 project given the role that proper discharge planning plays in reducing the likelihood that a patient will be readmitted. Additionally since the QIP includes a mechanism for determining measurable change in performance, it also has the potential to impact the work in C8 by demonstrating in a quantitative way what will help to improve discharge planning.