Annual Reports

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.

 

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”.

 

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

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 10^th 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:

 

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.