Learn How Kepro and the QIN-QIOs Work Together on Beneficiary Complaints

As a contractor for Medicare, Kepro serves as the Beneficiary and Family Centered Care Quality Improvement Organization, also referred to as a BFCC-QIO. While Kepro provides BFCC-QIO services in 29 states, the general information is relevant to everyone who has Medicare (including Medicare Advantage) and everyone who works with people who have Medicare. 

This episode is a conversation with our guests from the Quality Innovation Network Quality Improvement Organizations (QIN-QIOs). They will talk about how their organizations work with Kepro, the BFCC-QIO.

Gina Anderson RN, BSN, is a Senior Quality Improvement Facilitator at Telligen. She has worked in and supported nursing homes in a variety of roles for over 25 years including as a Director of Nursing, MDS coordinator, and a nurse consultant. In her current role, she supports healthcare providers across the Telligen region with quality improvement efforts through enhanced assistance, education, and resources. Gina has a strong compassion for building relationships with providers to improve the lives of Medicare beneficiaries.

As a Healthcare Quality Improvement Specialist at TMF Health Quality Institute for over 20 years, Melody Malone is responsible for Nursing Home Quality Improvement for multiple states, but most recently for both Nebraska and Texas. She also works on the CMS Quality Improvement Initiative (QII) with a variety of healthcare providers. In addition, she works on a special project via a HRSA Grant with the University of North Texas Health Science Center in Fort Worth. 

For more information about Kepro BFCC-QIO, please visit www.keproqio.com.

KEY TOPICS
00:30: Overview, introduction of guests, Gina Anderson and Melody Malone
03:47: Introduction of the QIN-QIO
05:37: Examples of what the QIN-QIO does
10:50: The BFCC referral process
15:20: Examples of a BFCC referral
21:05: Final thoughts

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RESOURCES

 BFCC-QIO Information for stakeholders: www.keproqio.com/partners

 BFCC-QIO Information for people who have Medicare: www.keproqio.com/bene

 QIN information: www.qioprogram.org

Music: Motivational Upbeat Corporate by RinkevichMusic
https://soundcloud.com/rinkevichmusic
Video Link: https://youtu.be/U78mgVaM12M

Transcript

Welcome to Aging Health Matters, a podcast from Kepro, a Beneficiary and Family Centered Care Quality Improvement Organization. We plan to cover healthcare topics for the Medicare population. Information in today’s show may help you or someone you know in their healthcare journey.  Thanks for joining us. Now let’s get started.

 Hello everyone and welcome to another edition of Kepro’s podcast Aging Health Matters. This is Nancy Jobe, an Outreach Specialist with Kepro, here to introduce today's topic. And as a reminder, being the Beneficiary and Family Centered Care Quality Improvement Organization for 29 states, we have three key services for people who have Medicare.

They are appeals, quality of care complaints, and Immediate Advocacy services, and more information on these topics is available on our website at www.keproqio.com. We also work with many outstanding partners to help spread information about the Medicare program and its benefits. While we greatly appreciate their partnerships, we also want to be clear that the opinions and guidance expressed by them in this podcast are solely theirs or their agencies and are not necessarily those of Kepro, CMS, or the Medicare program.

Please keep in mind that state-by-state guidance may differ as well, and today we will be talking with our guests, Gina Anderson with Telligen QIN-QIO and Melody Malone with the TMF QIN-QIO, and that is the Quality Innovation Network Quality Improvement Organizations also known as the QIN-QIOs from the states of Oklahoma, Colorado, Iowa, Illinois, Texas, Arkansas, and Mississippi are represented today.

And we're going to discuss how the QINs work with Kepro. Let's get to know our guests a little bit better. Gina, could you tell us a little bit about yourself and your position at your QIN?

 Yes, sure. Thank you so much for that introduction. My name is Gina Anderson, as you heard Nancy say, and I am a Senior Quality Improvement Facilitator here at Telligen, and it's been a privilege to work at Telligen for the past five and a half years. What is so exciting about this work is the positive outcomes that we see after we provide assistance to the healthcare systems, and those challenged areas that need improving are showing improvements.

So I am the lead of the BFCC referrals we receive from Kepro, but we do have a few others on our team that help support the healthcare providers that are referred to us. So we're all quality improvement experts ready to assist the organizations where they have those greatest needs.

 Thank you, Gina, and Melody, could you tell us a little bit about yourself and your background?

 Absolutely. Thank you, Nancy, and Gina, welcome as well. So I am a Healthcare Quality Improvement Specialist at TMF Health Quality Institute, and I've been here for over 20 years. I've worked primarily with nursing homes in quality improvement, but most recently, I've added responsibilities for the BFCC quality improvement initiative work we will be discussing today as well as I work on a special grant through HRSA, the Health Resources and Services Administration, with the University of North Texas Health Science Center in Fort Worth.

I agree with Gina that it’s so exciting to see all the positive changes that we assist facilities and providers in through the quality improvement initiative work.

So thanks a lot, and parting word is but today I'm my mom's favorite daughter. Just don't tell the other two siblings, OK?

 Alright. Melody, could you give us an idea of what is the QIN-QIO?

 Absolutely. The QIN-QIOs across the country use a variety of methods, and especially at TMF, we do as well to work with healthcare providers, so that's a wide range of hospitals, nursing homes, home health agencies, hospices, and patients and residents and their caregivers in an effort to collaborate and identify solutions to improve healthcare outcomes as well as lower costs, reduce provider burden, and increase transparency.

We may work in virtual meetings. We may do on-site visits, one-on-one calls, and our consultants work with a variety of healthcare providers across our regions that we serve. But all of our services are provided free. Through our patient and family engagement network, patients can become involved as well, and our goal there is to help educate, equip, and empower the patient and the family to become more engaged and to actively participate to improve both their health and their healthcare experience.

So we love hearing their ideas on how we can transform and design and deliver care to make it more patient centered. When people join our network at TMF, they have the opportunity to learn about healthcare topics that are of interest to them, and they can participate at their own pace and when it's convenient for them. So we invite patients and families and residents and nursing homes to become  patient and family engagement advisors with us. So I'll pass it back to you, Nancy.

 Thank you, Melody. That is quite a quite a lot on the contract with the QIN-QIO that you all serve.

 Gina, could you give us some examples as far as what Telligen is doing as a QIN-QIO?

 Yes. So Melody explained very well what the QIOs are doing, which is very similar across all of the QIO programs in the states. So I'm going to dive in a bit on what Telligen is doing to kind of give them visual picture I hope in order to see what some of this work may look like. So we are supporting healthcare systems for that improvement in quality.

So the QIOS have a strong focus on infection control and prevention, and some of the ways that Telligen supports nursing homes is to recognize their efforts and celebrate their successes through our Blue Ribbon and Vigilance and Best in Class award programs. And these programs are designed to recognize nursing home’s diligent efforts to prevent the spread of infection through staff training, promoting immunizations, having an effective emergency preparedness plan, and reducing unplanned transfers between nursing homes and hospitals. We also have a strong focus on reducing adverse drug events related to high-risk medications.

So not too long ago, Telligen completed an ECHO series. And an ECHO series is a virtual learning event, and it focused on improving the management of high-risk medications in the long-term care setting but also tying this into the care continuum system.

And then lastly, I'd like to highlight our efforts relating to reducing rehospitalizations and ED visits or emergency department visits. As the QIOs, we are available to support providers with quality improvement either individually or at a group level. For example, we've provided training on the five-star rating system. We've also established and attended healthcare coalitions in communities and brought long-term care and hospital systems together to collaborate in their efforts to improve transitions of care, and we've assisted in what we call directed plans of correction that are given by surveyor departments during a survey process, all with the intent that these efforts will help prevent patients from returning to the hospital after recent discharge. So that's a brief summary of what our work looks like. There is a lot more that I could add, but I know that we don't have that much time today to take a look at that. So I'm going to pass it back to you, Nancy.

 Gina, I have a question as you were talking. Now the items that you were talking about today, the services and the programs that you have, do all of the QINs do those programs?

The programs are specific to Telligen, but I'm sure that the other QIN-QIOs have some similar type efforts in each of the areas because I know our measures that CMS has given us are similar across all the QIOs in the states. So with that, I know that we're all working on infection control. We're all working on improving rehospitalizations and trying to improve high-risk medication management and adverse drug events. So that is similar, but what we do may look a bit different among the QIOs.

 And I would add to as well, Nancy, that I agree with Gina that they all look very similar, but the way that we go about it might be slightly different because each of our states that we operate in has unique situations and different people to work with. So we have to accommodate each individual and each provider based upon what their needs really are in order to improve or help them improve care at their level.

 Agreed. It's very individualized in a lot of cases.

 So if a listener is on here and was kind of wondering what is provided in their state, where would they look for that information to find the QIN that would be in their state?

So they can go to qioprogram. It's qioprogram.org, and they can look up the QIO for their state and then that will link them to that QIO’s website, and then they can reach out through that because we all have a way for you to contact us once you land on our websites.

 Perfect. Thank you, Melody. I appreciate that. Let’s talk about how the QIN and the BFCC-QIO work together. Medicare beneficiaries have a right to file a quality of care complaint, and once that complaint is filed with Kepro, a nurse is going to talk with the beneficiary, gather up some information, and determine whether to go forward with this quality of care complaint. And if it is determined to go forward, then the nurse is going to reach out to the provider and request medical records, and once those medical records are received and all documentation is in place, the nurse is going to send the information over to a physician reviewer. Now the physician reviewer is going to take a look at it and is going to determine whether or not professional standards of care were met. And if it is determined that those standards of care were not met, then the quality of care complaint is going to be sent to the QIN for developing a quality improvement plan. So Melody, can you tell us what happens once that referral is sent to the QIN?

 Sure, Nancy. I'm happy to address that. When we receive, and I'm the one that does this work at TMF and I have a backup colleague that backs me up when I'm out, but when I receive the referral, then I review all of the documents that you've provided to me, so I know what the case is all about. If I have a question, I give a call back and ask the question again to get clarification from you all, but then I reach out to the healthcare provider involved and again it could be any type of Medicare provider. It might be a physician or a hospital, home health agency, and so on.

I then discuss the referral with them. If they have access immediately to their documents that Kepro sent them, then we review that, and then I also explain to them the process I will follow with them to help them as they make the necessary improvements in their system. I'm always focusing them to make changes in such a way that we have sustainability in their new processes because whatever Kepro identified was somehow a break in their process.

So this is where quality improvement really begins is with a good root cause analysis. So I walk them through how to do that if they don't already know, and if they do know, then they work on that, and then we look at what their new process might be. And getting that sustainability, that's when we really make the change stick, if you will, across all that are involved because it's rare that I'm dealing with a single individual. Usually it's an organization with multiple physicians or multiple staff across their entire organization. Therefore, the changes needed have to be deep and wide in order to be sustained.

So as I'm working with them from that very first call through all the work until we close successfully the quality improvement initiative, or QII, I'm always working on getting them to focus on sustainability. So the initial goal is to get through a root cause analysis, so we're sure we're focusing on the right things. A lot of times it's real easy to take a surface issue and not really see that it's very deep, and we need to address those deeper root causes and then develop implementation strategies to address those root causes. So often times I'm coaching them on ideas of what implementation strategies might look like and then the measurement strategies that would be needed, so we can measure their progress.

Then if the provider needs any tools or resources that are topic specific, I will help them find them, if I don't already have them available on our website. We have tons of tools and resources and training videos. But sometimes I have to find something that's a one off, if you will. I do always provide them with a template of the quality improvement initiative to document their root cause analysis, their implementation plan, and then a reporting template. But they don't have to use our tool if they have something that will meet the requirements, and I always look at that If they do. Then once they've completed their root cause analysis and the plan is completed, then they go into action implementing their quality improvement strategies and report regularly their results to me. I will often provide them feedback on their data when I get those data reports in suggesting additional strategies if we're not getting closer to the goals. We'll discuss what's going on and what may be opportunities for improvement that continue. That's kind of the start to finish of the general QII or quality improvement process I follow. So back to you, Nancy.

 Thank you, Melody. Appreciate that explanation. I think a real-life story about this would be helpful. Gina, can you tell us something that you've actually worked on?

 Yes. So, Melody explained the process for supporting the referral provided to us from Kepro is very similar to Telligen’s process, and I'm sure it's very similar to many of the other QIOs that are across the states process as well. But in Telligen’s process, once we receive the referral, we do contact the provider to meet virtually, and during this meeting, we do explain the QIO program and the quality of care concerns that led to the referral. So for example, we reached out to a hospital, and we discussed their two concerns that were identified by Kepro.

The first concern was related to a patient's needs in their orthostatic blood pressure. It had not been ordered. It was not taken, so there was a definitely a concern there during that stay. There was a second concern that was related to that same patient in their pain level. While treatments were being adjusted, there was increasing of pain, and that pain relief was not acted upon, and there was no additional testing that should have occurred due to that change in pain.

So as we're continuing the conversation with the provider on these concerns, we do request that quality improvement plan and to be developed within the next few weeks. Now this plan is to include as Melody mentioned, the root cause analysis, initial interventions that they're planning to attest, and the goals that they would like to reach by the time they get to that end outcomes that they're trying to achieve. Telligen provides a quality improvement template to assist in this process, and just like Melody, they don't need to use the template, but it needs to have all the required elements within it. We're also available to meet with a provider should they have any needs during the time that they're developing a quality improvement plan.

In some cases, we do meet with them to assist with the root cause analysis, and in others, we do help with their data in that ongoing measurement. For the example that I spoke of about that hospital, they did share their quality improvement plan, and they set a goal for each of those concerns.

For the first concern, their goal was to achieve 90% compliance to improve orthostatic blood pressures and ensure that there are completed and documented. For the second concern with that pain level response, they set a goal of 90% compliance in their response activity. So once the quality improvement plan is submitted to us, at times, we do need a circle back to collect a little bit more information or follow up on what they've shared. But all in all, this plan leads to the action that they need to take.

So Telligen provides everyone that's referred to us with a plan do study act or a PDSA template to guide their quality improvement journey. Again, it's optional to use this, They may have their own tool that they can use that will help measure and look at the outcomes and the different interventions that they place.

The provider then will take action, start implementing those interventions. They test them out and measure them to ensure that they're leading the project in a positive direction. Now with this particular hospital example that I've been sharing, while they implemented some changes, they had fluctuating data. They had some high and low points, some positive and negative outcomes, so throughout the course of the project, they made adjustments. They implemented additional tasks, and they pressed forward to continue their improvement efforts, to hopefully improve that patient care and prevent those concerns from reoccurring. During our support, the hospital shared that through the project, they had learned new information that they were not aware of.

So, for example, the nurses were not aware of documenting orthostatic blood pressures in a separate field within that electronic health record, and an intervention that works on one unit does not necessarily work on other units. So some great lessons are learned during these testings of interventions and different feedback systems that they have in place. PDSA cycles continue through the monitoring period, which in this case was a full year. We monitored their data, they made adjustments in their practices, and they kept continuing to measure their effectiveness.

Now our ultimate goal is to sustain improvements. Again, just like Melody shared, our goal is sustainment, and this can be achieved by using those PDSA cycles, to ensure the right interventions are being implemented and scaled. The hospital was able to demonstrate sustainment with multiple data points by exceeding their goals. So for the first concern, to improve those orthostatic blood pressures, their aggregated data for all the units was at a 95% compliance rate. They initially started out with a baseline of 42%, so there was a lot of great improvement there.

And then their second concern, their pain level response, they met the goal and exceeded the goal of achieving 100% compliance rate. So once the goals have been met and sustainment is reached, Telligen will finalize that referral. Once it's finalized, the provider no longer needs to provide reports to Telligen, but the provider is strongly encouraged to continue monitoring their data and adjust when it's indicated.

Now we have had some providers so excited about the improvements achieved through this process, they've expressed that they want to work with us beyond this referral, so it really opens up some great doors to be able to help support them in other needs. Now with each BFCC referral, it is unique, and our support may be unique to those providers, depending on the concerns and the needs. We are always available. We have tools, resources, and provide one-to-one coaching, to help support those quality improvement efforts and improve outcomes. So with all that, I'm hoping I provided a bit of a visual of what this process looks like for those who are referred or at least a small example of that.

 Thank you, Gina. So a beneficiary might have an issue with a complaint that they want to file with  Kepro, they can see that it is taken very seriously, and there is a lot put into it from Kepro gathering the information to passing it on to the QIN-QIO who then works with that provider to find a resolution.

So that something that happened to that beneficiary does not happen to somebody else, and from what I'm hearing today, it is extremely thorough. So it is really important as a beneficiary if there is an issue that they have that they go ahead and file that quality of care complaint because we don't want to see anything happen to anybody else that might have happened to them. So I think this process is a great one as far as finding out the problem and getting a resolution at the end through the two QIOs.

I really appreciate Gina and Melody giving us part of their time today, so that we could talk about how we work together and how the process goes for those quality of care complaints, and thank you so much ladies for being so thorough in your answers. 

If you'd like more information about our services, please feel free to sign up for our newsletter as well as subscribe to our YouTube channel. Our helpline phone number, as well as a link to sign up for our newsletter, will be available in the Show Notes, and we also have several resources on our website, which is again keproqio.com. So thank you again, Gina and Melody for taking this time out and sharing all that information with us and for our listeners. And thank you for listening and please stay tuned for our next episode.