Past Conference 2023

Click on the title to view the recordings.

Agenda

May 1, 2023 11:00 am

Welcome

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

May 1, 2023 11:05 am

Opening Address

Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services

May 1, 2023 11:15 am

HHS Priorities for Resilient Communities and Quality Healthcare

Andrea Palm
Deputy Secretary
U.S. Department of Health and Human Services

May 1, 2023 11:25 am

Restoring Trust In Science To Build Resilient Communities

Dr. Lee A Fleisher, MD
Chief Medical Officer and Director of the Center for Clinical Standards and Quality
Centers for Medicare & Medicaid Services

Dr. Robert Califf
Commissioner
U.S. Food and Drug Administration

Dr. Rochelle Walensky, MD, MHP
Director
Centers for Disease Control and Prevention & Administrator
Agency for Toxic Substances and Disease Registry

The COVID-19 pandemic has impacted us all in one way or another and America’s healthcare workforce has certainly felt the weight of this public health emergency. While there is no doubt that the pandemic exposed vulnerabilities in our healthcare system; it also presented opportunities for innovation and creative solutions. Researchers worked continuously to answer fundamental questions about the virus, and transmission all while clinicians and physician scientists were testing therapeutics and vaccines. As we document lessons learned from the darkest days of the pandemic to prepare for future emergencies, it's apparent that medical science is facing a credibility crisis. Join this dynamic panel of clinical and government experts for a discussion about the factors behind public distrust, how COVID exacerbated the distrust and where we go from here to rebuild resilient communities.

May 1, 2023 11:50 am

A Path to an Equitable and Thriving Healthcare System: Advancing Health Equity Across CMS Programs

Dr. LaShawn McIver
Director
Office of Minority Health
Centers for Medicare & Medicaid Services

The healthcare system continues to respond to emerging threats and persistent challenges that impact the communities served by CMS programs. An equitable resilient health care system can recover from those challenges and thrive during troubling circumstances. It is imperative that we build resilience in our health equity infrastructure to support thriving communities. Over the next 10 years, through the CMS Framework for Health Equity, the agency is committed to operationalize health equity across all its programs.

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May 1, 2023 12:10 pm

Advancing Patient Safety through Patient and Family Engagement

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

Susan E. Sheridan, MIM, MBA, DHL
Founding Member, Patients for Patient Safety
& Director, Patient Engagement Emeritus
Society to Improve Diagnosis in Medicine

Dawn Edwards
Kidney Disease Warrior

The COVID-19 public health emergency put enormous stress on the health care system and disrupted many normal activities in hospitals and other facilities. Unfortunately, these stressors have caused safety problems for both patients and staff. Join this session for an intimate conversation with a dynamic panel of patients —focused on their experiences and the importance of restoring standards to rebuild a healthcare system in which safety is embedded in every step of the process with a renewed focus on the voices of the patient, family and caregivers.

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Breakout Sessions

May 1, 2023 12:35 pm

Dr. Meena Vythilingam (Moderator)
Senior Mental Health Advisor
Office of the Assistant Secretary for Health
Department of Health and Human Services

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

Dr. Yngvild Olsen
Director
Center for Substance Abuse
Substance Abuse Mental Health Services

Marsden McGuire, M.D., M.B.A.
Director, Continuum of Care and General Mental Health
Office of Mental Health and Suicide Prevention Department of Veterans Affairs

Jessica Walker, Ph.D., L.P.
National Clinical Suicide Prevention Telehealth Coordinator
Office of Mental Health and Suicide Prevention
Department of Veterans Affairs

CMS’ Behavioral Health Strategy outlines goals to support the whole emotional and mental well-being of a person, and promote person-centered behavioral health care. This is aligned with the HHS Roadmap for Behavioral Health Integration, which aims to coordinate behavioral health work across HHS operating divisions. Rising numbers of Americans living with mental disorders including substance use disorders (SUD) and suicidality appears to have been exacerbated by the COVID-19 pandemic, making the integration of behavioral and physical health an urgent need. This session will address these concerns, focusing on best practices for mental health and SUD services and supports across HHS and the Department of Veterans Affairs (VA), each with a unique perspective on the subject matter and people impacted.

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May 1, 2023 12:35 pm

Dr. Terrence O'Malley
Corresponding Faculty
Harvard Medical School

Lorraine Wickiser, RN
Nurse/Consultant/RN Centers for Medicare & Medicaid Services

Beth Connor, RN
Health Insurance Specialist
Centers for Medicare & Medicaid Services

Brenda Akinnagbe
Policy Analyst
Office of the National Coordinator
Centers for Medicare & Medicaid Services

Dr. Constantine Lyketsos, MD, MHS, FACLP, FACPsych, FACNP, FAPM, DFAPA
Elizabeth Plank Althouse Professor & Vice Chair of Psychiatry,School of Medicine
Johns Hopkins University
&
Chair of Psychiatry,
Johns Hopkins Bayview Medical Center

Elizabeth Palena Hall, MIS, MBA, RN
Health Insurance
Centers for Medicare & Medicaid Services

Advancing electronic health data exchange is crucial to communicate the needs of individuals for care planning and care coordination, and enables person centered care/data to follow the person across the trajectory of their care, including acute care, post-acute care, behavioral Health. One of the goals of the Improving Medicare Post-Acute Care Transformation Act (IMPACT) is to support the exchange of key health data important for care planning, such as cognitive status, functional status, and special services, treatments and interventions, as well as improve quality of care and health outcomes, enhance coordination of care, and to support person centered goals. Panel members from CMS, ONC, and industry will examine opportunities and gaps within the healthcare interoperable ecosystem and discuss the broader topic of standardized data and its role in promoting Health.

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May 1, 2023 12:35 pm

Samantha Richardson (Moderator)
Director
Governance and Impact Analysis
Centers for Medicare & Medicaid Services

Darlene Fleischmann
Technical Advisor for Policy
Centers for Medicare & Medicaid Services

In September 2022, CMS released the Make Your Voice Heard [RFI], which sought public comment on a variety of topics. Response to this RFI was robust, included extensive stakeholder insight from more than 4,000 specific comments received from approximately 900 respondents. Commenters included a broad range of our stakeholders, individuals and organizations, across the health system. The data we received identified specific challenges and pain points for beneficiaries and clinicians, including health equity and access to care, workforce experiences, behavioral and mental health services, and the impact of Telehealth as a result of the COVID-19 PHE waivers and flexibilities. The RFI commenters also shared diverse suggested recommendations for improvement in such areas as accessing care and advancing health equity. This session will also explore details and key findings specific to understanding the insight we received.

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May 1, 2023 12:35 pm

Dr. Christine Blake-Smith, DO
Family Medicine Physician
Portland West Family Practice

Jennifer Brockman, MHA, BSN, RN
Chief Clinical Program Officer
Iowa Healthcare Collaborative

Rachel Duncan, PharmD, BCPS, BCCCP
Clinical Pharmacist
Iowa Healthcare Collaborative
Stader Opioid Consultants

Dr. Don Stader, MD, FACEP
Founder and President
Iowa Healthcare Collaborative
Stader Opioid Consultants

Opioid stewardship programs are designed to reduce opioid overuse, misuse, and abuse, ultimately helping prevent addiction while treating pain effectively. During this presentation, panelists will address the unique challenges surrounding opioid stewardship experienced by rural providers as well as strategies used to ensure successful implementation of opioid stewardship practices. The moderator and panelists will discuss methodologies and strategies to help attendees better understand opioid stewardship, how to address local challenges, and discuss implementation strategies to improve sustainability.

May 1, 2023 12:35 pm

Dr. Chiao Wen Lan (Moderator)
Social Scientist
Health Services Advisory Group

Dr. Shika Pappoe
Regional Medical Officer
Strive Health

Dr. Deidra Crews
Professor of Medicine
Johns Hopkins University School of Medicine

Dr. Dinushika Mohottige
Assistant Professor
Icahn School of Medicine at Mount Sinai

Health disparities continue to persist among End Stage Renal Disease patients (ESRD), and the causes of them are complex and interrelated. In addition to the structural barriers impeding patients’ access to care, patients’ complex health-related social needs also affect their short-term and long-term health outcomes. Data from the ESRD Quality Reporting System were analyzed to investigate issues related to accessing care, in conjunction with the measures of social determinants of Health to identify areas needing targeted interventions. Data show that patients residing in under-resourced neighborhoods experience barriers to care, including reduced access to home dialysis programs and decreased transplant waitlisting. Disparities persist throughout the kidney transplantation process, including wait time as well as receipt of transplant. Strategies to advance health equity in the ESRD community require multilevel interventions. Research suggests that equity training, including cultural humility training and structural competency, could strengthen the capacity of health care providers to recognize and respond to structural issues at various levels. Evidence-based interventions to reduce health disparities in underserved populations, as well as case studies from the most disadvantaged neighborhoods, can provide a roadmap with innovative approaches to coordinate care and advance health equity in the ESRD community.

May 1, 2023 12:35 pm

Melanie Brown, PhD, MPH
Technical Director
Disabled and Elderly Health Program's Group
Centers for Medicare and Medicaid Services

Brian MacDaid
Director
Division of Quality Assurance
Office of Long-Term Living Bureau of Quality Assurance & Program Analytics
Pennsylvania Health and Human Services

In this session, the Center for Medicaid and CHIP Services (CMCS) and a representative from Pennsylvania Health and Human Services (PA HHS) will discuss progress related to strengthening home and community-based services (HCBS) and advancing health equity in Medicaid.  The session will cover current efforts related to quality measurement, measure development, publicly reporting on HCBS quality, and quality activities to promote equity. The session will close with a discussion between the CMCS and PA HHS representatives covering the topics of data stratification, gaps in measures, involving stakeholders in designing measures, and others.

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May 1, 2023 12:35 pm

Dr. Jessica Maskut
Technical Director
Data and Policy Analytics Group
Office of Minority Health
Centers for Medicare and Medicaid Services

Dr. Nancy Chiles Shaffer
Technical Director
Data and Policy Analytics Group
Office of Minority Health
Centers for Medicare and Medicaid Services

Meagan Khau
Director
Data and Policy Analytics Group
Office of Minority Health
Centers for Medicare and Medicaid Services

Abdugheni Ubul
Health Statistician
Office of Minority Health
Centers for Medicare and Medicaid Services

This session from CMS’ Office of Minority Health (OMH) will provide updates on the status of CMS health equity data and several of the tools that utilize the data to assess the landscape and identify disparities. The panel will review 1) the recently released CMS OMH white paper "The Path Forward: Improving Data to Advance Health Equity Solutions", which includes the current state of health equity data, progress to date, and future actions for improvement; 2) an update to the Health Equity Summary Score (HESS) and the HESS Dashboard, recently piloted for Medicare Advantage Plans to be able to view their performance on addressing health disparities; and 3) the Mapping Medicare Disparities (MMD) Tool, which is an interactive map that can be utilized to identify areas of disparities between various subgroups of Medicare beneficiaries.

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May 1, 2023 12:35 pm

Stacy Harper, RDH, MPH
Health Insurance Specialist
Center for Medicare and Medicaid Services

Thelma Baker, MSHA, RHIA,CPHQ
Chief Operating Officer and Principal Consultant
Health Quality Innovators

Donald Dipette, MD, FACP, FAHA
Distinguished Professor
University of South Carolina School of Medicine

Vicky Kolar, EMT-P, CPHQ
Quality Specialist
CCME (a partner with Health Quality Innovators) South Carolina QIN-QIO

Karen Southard, RN, MHA, CPHQ
State Program Director
CCME (a partner with Health Quality Innovators) South Carolina QIN-QIO

Over 50% of adults in the US have hypertension, while only one in four have high blood pressure under control. The US Surgeon General issued a Call to Action for Hypertension Control in 2020. Across a QIN-QIO service area, hypertension control reflected the national statistics which continued to decline in 2021, further contributing to chronic conditions impacting the quality of life for Medicare beneficiaries. This decrease created an urgency to help providers evaluate current treatments and implement impactful changes.

In June 2022, HEARTS In America (HEARTS) was introduced, an international evidence-based program developed by the World Health Organization and led by the Pan American Health Organization. HEARTS targets hypertension control through standardized treatment protocols while reducing health disparities.

Through a peer-to-peer interactive learning virtual platform, a root cause analysis was performed regarding variations in treatment of hypertension. Over six months, the QIN-QIO engaged 550 participants in biweekly events discussing the initiative, critical drivers of hypertension, treatment protocols, and implementation.

Primary Care participants in SC implemented HEARTS in five communities with a potential impact of 116,667 beneficiaries. Several providers are implementing the HEARTS modules, based on their identified population. The outcomes target increased Blood Pressure Control, improved provider workflow through team-based care, and reduction in disparities.

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May 1, 2023 12:35 pm

Min Lu
CCSQ ServiceNow Tech Lead
Information Systems Group
Division of Shared Services and User Experience
Centers for Medicare & Medicaid Services

Jay Vancil
CCSQ ServiceNow Operation Lead
Information Systems Group
Division of Shared Services and User Experience
Centers for Medicare & Medicaid Services

CCSQ Support Central portal provides our healthcare community with the advanced-level program and technical support to help customers meet CMS quality reporting requirements – it includes quick links and the ability to track or submit a ticket; you can also sign up for newsletters, so you never miss a beat. Our customer-focused interface is designed to meet you where you are. In 2022 we added the ability to schedule a callback and live chat with the CCSQ Service Center. Come join us to learn more and meet our automated assistant Chat and Resource Line (C.A.R.L.).

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May 1, 2023 12:35 pm

Dr. Michelle Schreiber, MD
Deputy Director
Center for Clinical Standards and Quality
Centers for Medicare & Medicaid Services

Erin Grace, MHA
Deputy Director
Center for Quality Improvement and Patient Safety
Agency for Healthcare Research and Quality

Arjun Srinivasan, MD
Associate Director
Healthcare Associated Infection Prevention Programs
Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention

First, Do No Harm – this statement from the Hippocratic Oath is as relevant today as it was thousands of years ago. It is the imperative for all who work in healthcare, to have as a first priority keeping individuals safe and free from preventable harm. Over two decades have passed since the reports on “To Err is Human” and “Crossing the Quality Chasm” which described the gaps in quality and safety. Multiple initiatives have been developed and implemented over the years to improve in these areas – some with success. For example, healthcare associated infections had significantly declined pre-pandemic. However, despite some success, there remain significant opportunities to improve safety, as noted in the recent OIG report (May 2022) and NEJM article (January 2023) which demonstrate nearly a quarter of hospitalized patients still experience harm.
Track: During the Covid-19 pandemic, safety metrics showed a significant decline, including a 40% worsening of healthcare acquired infections, and a rise in skilled nursing facility falls and pressure injuries. In November, 2022, HHS and Secretary Becerra called together a group of leading healthcare CEO’s and patient advocates to re-commit to patient safety. We call upon all who work in healthcare to re-evaluate, re-design, and re-energize initiatives to reduce preventable harm. In this session we will trace the history of safety performance in healthcare, identify key strategies for achieving improvements, and discuss key strategies that CMS (and other federal agencies) could use to best support patient safety.

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Engagement Opportunity | May 1, 2023 01:20 pm

Listening Sessions

May 1, 2023 02:20 pm

Jenny Keroack
Senior Policy Advisor
Office of Climate Change and Health Equity
Office of the Assistant Secretary for Health
U.S Department of Health & Human Services

John Balbus, MD
Acting Director
Office of Climate Change and Health Equity
Office of the Assistant Secretary for Health
U.S Department of Health & Human Services

Aparna Bole, MD
Special Expert
Agency for Healthcare Research and Quality & Community Resilience
Lead Office of Climate Change and Health
Equity Office of the Assistant Secretary for Health
U.S. Department of Health & Human Services

Joe McCannon
Senior Advisor
Agency for Healthcare Research and Quality
and Community Resilience Lead
Office of Climate Change and Health Equity
Office of the Assistant Secretary for Health
U.S. Department of Health & Human Services

The cumulative impacts of climate change represent the greatest threat to global public health of the coming decades, putting vulnerable communities at great risk and buffeting a healthcare system already at the limits of its capacity. This session from the HHS Office of Climate Change and Health Equity will describe this challenge, documenting the impacts of climate change on every dimension of Quality
as well as potential solutions. The presenters will introduce existing resources to support rapid action by health care organizations, including the tax incentives, grants and technical assistance made available by the Inflation Reduction Act, HHS agencies and other federal departments.

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May 1, 2023 02:20 pm

Dr. Michelle Schreiber, MD (Moderator)
Deputy Director
Center for Clinical Standards and Quality
Centers for Medicare & Medicaid Services

Doug Jacobs, MD, MPH
Chief Transformation Officer
Center for Medicare
Centers for Medicare & Medicaid Services

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

Aditi Mallick, MD
Chief Medical Officer
Center for Medicaid and CHIP Services
Centers for Medicare & Medicaid Services

In 2022 the Centers for Medicare & Medicaid Services (CMS) debuted the CMS National Quality Strategy, a set of goals to raise the bar for a resilient, high-value health care system with a mission and vision aimed at promoting quality outcomes, safety, equity, and accessibility for all individuals. As the healthcare quality ecosystem continues to evolve at a rapid pace, we continue to coordinate our quality activities and efforts to reach our goals and measures our success with objectives and targets.
Track: After a year of listening and incorporating your feedback, we invite you to join us for an update on the CMS National Quality Strategy and the work we are doing to align quality measures across CMS as a part of the Universal Foundation.

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May 1, 2023 02:20 pm

Elisabeth Myers, MBA
Deputy Director
Office of Policy
Office of the National Coordinator for Health
Information Technology

Matthew Rahn
Acting Director
Standards Division
Office of the National Coordinator for Health Information Technology

Kyle Cobb, MS
Branch Chief
Office of Technology
Office of the National Coordinator for Health Information Technology

The Office of the National Coordinator for Health Information Technology (ONC) developed the United States Core Data for Interoperability (USCDI) as a standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange. ONC established an expansion process for USCDI that creates a “rising floor” over time based on input from industry and federal partners and consideration of various factors such as impact, feasibility, and standards maturity. Subsequently, ONC launched USCDI+, a service that ONC provides to USCDI+ partners, in collaboration with their key stakeholders, who need to establish, harmonize, and extend the use of interoperable datasets that advance beyond the core data in the USCDI to meet agency or use-case specific programmatic requirements. USCDI and USCDI+ support efforts to share health data more rapidly to ensure effective and equitable care across the United States. As part of the USCDI+ initiative, ONC and CMS are collaborating around the identification of a core data set to support quality measurement. Join ONC presenters as they discuss how USCDI+ Quality can advance goals of interoperability and quality improvement across CMS programs and how ONC is working with partners to address gaps in quality measurement data standards across the health care ecosystem. 

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Breakout Sessions

May 1, 2023 03:10 pm

Dr. Arkaprava Deb (Moderator)
Medical Officer
U.S. Department of Health and Human Services

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

Dr. Yngvild Olsen
Director
Center for Substance Abuse
Substance Abuse Mental Health Services

Marsden McGuire, M.D., M.B.A.
Director
Continuum of Care and General Mental Health
Office of Mental Health and Suicide Prevention
Department of Veterans Affairs

Jessica Walker, Ph.D., L.P.
National Clinical Suicide Prevention Telehealth Coordinator
Office of Mental Health and Suicide Prevention
Department of Veterans Affairs

CMS’ Behavioral Health Strategy outlines goals to support the whole emotional and mental well-being of a person, and promote person-centered behavioral health care. This is aligned with the HHS Roadmap for Behavioral Health Integration, which aims to coordinate behavioral health work across HHS operating divisions. Rising numbers of Americans living with mental disorders including substance use disorders (SUD) and suicidality appears to have been exacerbated by the COVID-19 pandemic, making the integration of behavioral and physical health an urgent need. This roundtable discussion will be a continuation of the conversation started in the educational session, “Best Practices in Mental Health and Substance Use Disorders Services.” Hear more from the presenters on taking the best practices shared earlier and integrating them into practice at all levels.

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May 1, 2023 03:10 pm

Wendy Gary, MHA
Chief Operating Officer
Avar Consulting Executive Director
BFCC-QIO Operations Project Director
BFCC NCORC

Brian Preslopsky
Vice President
Avar Consulting Analytic Director
BFCC NCORC

Stephanie Fry
Senior Study Director
Westat Deputy Director
BFCC NCORC

First, Do No Harm – this statement from the Hippocratic Oath is as relevant today as it was thousands of years ago. It is the imperative for all who work in healthcare, to have as a first priority keeping individuals safe and free from preventable harm. Over two decades have passed since the reports on “To Err is Human” and “Crossing the Quality Chasm” which described the gaps in quality and safety.

Multiple initiatives have been developed and implemented over the years to improve in these areas – some with success. For example, healthcare associated infections had significantly declined pre-pandemic. However, despite some success, there remain significant opportunities to improve safety, as noted in the recent OIG report (May 2022) and NEJM article (January 2023) which demonstrate nearly a quarter of hospitalized patients still experience harm.

Track: During the Covid-19 pandemic, safety metrics showed a significant decline,including a 40% worsening of healthcare acquired infections, and a rise in skilled nursing facility falls and pressure injuries. In November, 2022, HHS and Secretary Becerra called together a group of leading healthcare CEO’s and patient advocates to re-commit to patient safety. We call upon all who work in healthcare to re- evaluate, re-design, and re-energize initiatives to reduce preventable harm. In this session we will trace the history of safety performance in healthcare, identify key strategies for achieving improvements, and discuss key strategies that CMS (and other federal agencies) could use to best support patient safety.

Click here to view presentation

May 1, 2023 03:10 pm

Andrew Snyder (moderator)
Health Insurance Specialist
Center for Medicaid and CHIP Services
Centers for Medicare & Medicaid Services

Sarah Holland, MS
CEO
Virginia Health Catalyst

Michele Griguts, DDS
Dental Director
New York State Medicaid

Irene V. Hilton, DDS, MPH, FACD
Dental Consultant
National Network for Oral Health Access

This session will focus on a blend of CMS work with partners and communities to improve oral health. Presentations include discussions on the two Oral Health Integration tools used by Medicaid Oral Health Integration Learning Collaborative participants. This will be followed by a discussion on the New York State Dental Insurance Policy team’s participation in the CMS Quality Improvement Collaborative
Advancing Prevention and Reducing Caries in Medicaid. This session will review strategies for stakeholders to affect change and public acceptance of challenges. The final presentation will focus on the training and technical assistance strategies used to assist over 1,000 health center dental practices to implement and improve on the HRSA UDS Sealants Measure and the role of quality improvement in identifying strategies to increase sealant rates and mitigate the impact of COVID-19.

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May 1, 2023 03:10 pm

Temi Olafunmiloye
Manager Health Equity
Health Quality Innovators

Dr. Bruce Spurlock
President and CEO
Cynosure Health

How do we approach health equity in a way that's attainable across hospital settings? This session will feature an in-depth look at the variety of methods used by hospitals of all sizes, types, and available resources to identify and address equity and the role in improving outcomes among the patients we serve.

First, Health Quality Innovators (HQI) will share their process of partnering with hospitals to remove barriers to action on health equity, especially those in communities with low racial and ethnic diversity. HQI creates reports using the Area Deprivation Index and the Social Vulnerability Index to supplement and contextualize available claims and provider data. These reports help to raise awareness of SDOH that may contribute to disparities. HQI will be sharing tools and resources that have resulted in hospitals implementing equity-based interventions such as the use of Z codes to capture patient-level SDOH screening results, and collaboration with outside funders to support identified needs

Second, Cynosure Health will provide a practical overview of the new CMS Final Rule requiring hospitals to screen patients for Social Drivers of Health (SDOH) that will feature: (1) Hospital-tested resources and tips, including how to build trust with patients to promote understanding and engagement; (2) Steps for building action plans to support your community’s well-being, such as how to engage patients, families, and community members in the screening and referral processes; and (3) How to interpret data in support of your existing quality and safety reporting efforts. In addition, insights will be shared from hospital champions from across the various stages of the implementation of a SDOH screening process.

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May 1, 2023 03:10 pm

Lisa Stocks RN, MSN, FNP (moderator)
National Faculty Co-Chair
ESRD Treatment Choices Learning Collaborative

Enver Akalin, MD
Montefiore Medical Center
Professor of Medicine and Surgery
Medical Director
Kidney Transplant Program

Joseph R. Scalea, MD
Director of Kidney Transplantation and Transplant Quality
Vice Chair of Innovation and Commercialization
Professor of Surgery
Medical University of South Carolina

Heather Wertin, MPH, BSN, RN
Program Manager
Abdominal Organ Transplant
Barnes-Jewish Hospital

The End Stage Renal Disease Treatment Choices Learning Collaborative (ETCLC), established in the Fall of 2021, brings together more than 80% of the transplant centers, more than 90% of Organ Procurement Organizations and two of the largest donor hospitals in each of the eleven (11) donor service areas (DSA) in the US. The aims of this national collaborative include: 1) increasing deceased donor kidney transplants; 2) decreasing the national discard rate of all procured kidneys; and 3) increasing the percentage of recovered kidneys greater to or equal to 60 Kidney Donor Profile Index (KDPI) for transplant.

Track: Over the past year, members of the ETCLC community, comprised of 25 Quality Improvement teams, have shared best practices during monthly quality improvement meetings. These best practices have reduced discards through surgical decision making, efficient communication, and effective institutional practice.

During this session, the presenters will provide practices employed to honor the “yes” mindset for accepting marginal kidneys and working closely with individual kidney transplant candidates to increase utilization of >60-year-old and Donation after Circulatory Death (DCD) kidneys and contribute to reducing the kidney discard rate.

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May 1, 2023 03:10 pm

Ashley Sirianni, DNP, FNP-BC
Medical Director
South Carolina Department of Health and Human Services

Tim Nix, MA, LPC
Director of Child Health and Well Being
South Carolina Department of Social Services

Jessica Lee (Moderator)
Medical Officer
Division of Quality and Health Outcomes
Center for Medicaid and CHIP Services
Centers for Medicare & Medicaid Services

Kathleen Domm, MD, FAAP
Foster Care Medical Director
Select Health of South Carolina

The Center for Medicaid and CHIP Services (CMCS) partners with states to share promising practices and provide technical assistance to drive improvement in care for Medicaid and CHIP beneficiaries. This session will focus on the CMCS Foster Care affinity group and how South Carolina's Medicaid program utilized partnerships to work towards sustainable improvements. CMCS will facilitate a panel discussion with representatives from South Carolina’s Medicaid agency, foster care agency, and a managed care organization.

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May 1, 2023 03:10 pm

Darci Graves, MPP, MA, (moderator)
Co-chair
Rural Health Council
Centers for Medicare & Medicaid Services
&
Technical Advisor Office of Minority
Health Centers for Medicare & Medicaid Services

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

Dr. Susan Carol, MD
Captain
U.S. Public Health Service & Chief Medical Officer
Division of Tribal Affairs
Centers for Medicare & Medicaid Services

Rodney Waltersdorff
Deputy Director
Emergency Preparedness & Response Operations

Resilience is the dynamic and demonstrable outcome of an individual, family, or community’s ability to cope with uncertainty, access needed resources, and adjust or bounce back in an often hazardous environment.

Rural, tribal, and geographically isolated communities face unique challenges, but also have unique strengths that allow them to be resilient and resourceful as they seek to recover from a variety of disasters.

This moderated discussion will highlight resiliency and resourcefulness across Entities (e.g., federal, state, local, tribal, and territorial) who have had to prepare for, mitigate, and overcome challenges related to natural disasters (e.g., earthquakes, fires, disease outbreaks) and human-made disasters (e.g., oil spills, lead poisoning, climate change), so that health and health care disparities for rural, tribal, and geographically isolated communities are not caused or worsened.

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May 1, 2023 03:10 pm

Charlotte Gjerloev, BSN, RN
Project Director
IPRO/Qlarant

Toni Kettner, BSN, MHN, NHA, CPHQ
Quality Improvement Advisor
Superior Health Quality Alliance

Mei Wang, PhD
Division of Community and Population
Health iQuality Improvement and Innovation Group
Centers for Medicare & Medicaid Services

The QIN-QIOs’ Real-Time Medical Systems Quality Improvement Collaborative seeks to leverage nursing home data using innovative health information technology (HIT) solutions that respond to the Centers for Medicare & Medicaid Services directive that QINs incorporate advances in HIT to improve healthcare quality. This innovative work uses electronic medical record (EHR) agnostic software to pull live EHR data into real time alerts, reports, and dashboards, on a secure portal. The data is updated regularly throughout the day, and accessible to the care team (clinicians and pharmacists) and QINs.

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May 1, 2023 03:10 pm

Bethany Gabbard, PhD
Senior Data Analyst
TMF Health Quality Institute

Jill Manna, BA, PMP
Director of Analytic Resources
Quality Insights

Anita Thomas, PharmD
Technical Advisor
Division of Community and Population Health iQuality Improvement and Innovation Group
Centers for Medicare & Medicaid Services

Knitasha V. Washington, DHA, FACHE
President & CEO
ATW Health Solutions

In this session we will review and discuss QIN-QIO efforts to advance health equity using customized data dashboards and interactive tools to assess relationships across equity measures and social determinates of health.
Track: Attention to social risk factors has become increasingly important and evidence supports that the proportion that social risk factors play is a pivotal role in poor health outcomes. Adverse social conditions include food insecurity, housing instability, and transportation challenges. Efforts to address these problems in the past few years have witnessed increased collection of data on social determinants of health (SDOH).

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May 1, 2023 03:10 pm

Kenneth Howard
Director
Division of Engineering and Architecture
Information Systems Group
Centers for Medicare & Medicaid Services

In this session, learn more about Center for Clinical Standards and Quality's (CCSQ) vision of “bringing users to the data”. To avoid data duplication, security, and transparency issues, CCSQ looks to enhance current architecture and processes that provide users a “one-stop-shop” to data and analytics tools. Bringing users to this solution and its data, instead of sending the data out to users, will strengthen data accountability, data Quality
and data transparency. Join this session to learn more about this important effort.

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May 1, 2023 03:10 pm

Samantha Levy
HCD Researcher
Agile Six Applications Inc.

Kiel McLaughlin
Senior UX Researcher
Agile Six Appications Inc.

Sophia Sugumar
Health Insurance Specialist
Centers for Medicare & Medicaid Services

This session will look back at the last three years as the Quality Payment Program (QPP) worked towards the implementation of the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs). During this session we will explore how interactive research sessions with QPP site users, including clinicians and their staff, led to an improved understanding of users’ needs and experiences in the program. We will also cover how these insights ultimately laid the groundwork for the MVP Learning Experience, which aims to assist clinicians in their transition to MVPs. We will also discuss how interested parties may continue to engage with the QPP Human Centered Design (HCD) Team in the future.

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May 1, 2023 03:10 pm

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

Samuel "Le" Church, MD, MPH, CPC-I, FAAFP
Local Medical Director
Aledade, Inc.

Ali Khan, MD, MPP, FACP
Chief Medical Officer
Value-Based Care Delivery
Oak Street Health

The power of targeted data analysis to guide understanding of health and disease disparity will be reviewed. The application of this knowledge to direct targeted high yield strategies and interventions across large provider networks will be explored with recommendations for best practices. Specific target areas include cardiovascular disease and event reduction through team-based hypertension control as well initiatives to prevent the progression of chronic kidney disease.

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May 1, 2023 04:00 pm

Patient Safety Actions

Dr. Michelle Schreiber, MD
Deputy Director
Center for Clinical Standards and Quality
Centers for Medicare & Medicaid Services

May 1, 2023 04:15 pm

Healing with Intention

Dr. Rana Awdish, MS, MD, FACP, FCCP
Henry Ford Health

May 2, 2023 11:00 am

Welcome to Day 2

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

May 2, 2023 11:05 am

The Medicare Value-Based Care Strategy: Alignment, Growth and Equity

Dr. Lee A Fleisher, MD (Moderator)
Chief Medical Officer and Director of the Center for Clinical Standards and Quality
Centers for Medicare & Medicaid Services

Elizabeth "Liz" Fowler, PhD, JD
Deputy Administrator and Director
Center for Medicare and Medicaid Innovation
Centers for Medicare & Medicaid Services

Dr. Meena Seshamani, MD, PhD
Deputy Administrator and Director
Center for Medicare
Centers for Medicare & Medicaid Services

As the nation’s largest health care payer, responsible for more than one in five dollars spent on health care within the United States, Medicare plays a key role in transitioning the health care system away from fee-for-service, which incentivizes quantity of care, and towards value-based care, which incentivizes high-quality care and smarter spending. This session will focus on CMS’ efforts to remain committed to advancing value-based care, by focusing on three strategic priorities of alignment, growth, and equity in a way that best meets the needs of people with Medicare, who deserve high-Quality equitable care.

May 2, 2023 11:25 am

Welcoming Remarks from the Center for Medicare and CHIP Services

Dr. Dan Tsai
Deputy Administrator and Director
Center for Medicaid and CHIP Services
Centers for Medicare and Medicaid Services

Medicaid and the Children’s Health Insurance Program (CHIP) cover 90 million Americans, including over 41 million children. These programs are administered by the states under broad federal guidelines. In this session, you will hear from Daniel Tsai, Deputy Administrator and Director Center for Medicaid and CHIP Services about federal quality measurement and improvement initiatives, and how CMS is partnering with states to facilitate coverage and access, equity, and innovation and whole-person care, including behavioral Health for our beneficiaries.

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May 2, 2023 11:45 am

Welcoming Remarks from the Center for Medicare and Medicaid Chief Dental Officer

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

The CMS Chief Dental Officer will discuss the vision for oral health programs across the Agency, including how dental-medical integration is essential for advancing health equity, improving clinical outcomes, and improving oral health for all beneficiaries.

May 2, 2023 11:55 am

Improvement Still Matters

Dr. Donald Berwick, MD, MPP, FRCP, KBE
President Emeritus and Senior Fellow
Institute for Healthcare Improvement

May 2, 2023 12:05 pm

Refresh, Restore, and Refocus: Goal Concordant and User Centered Care

Dr. Shari Ling
Deputy Chief Medical Officer
Center for Clinical Standards and Quality
Centers for Medicare & Medicaid Service

May 2, 2023 12:10 pm

Advancing Health Equity Across the Country

ADM Rachel L. Levine, MD
Assistant Secretary for Health
U.S. Department of Health & Human Services

Breakout Sessions

May 2, 2023 12:25 pm

Dr. Chiao Wen Lan (Moderator)
Social Scientist
Health Services Advisory Group

Dr. David E. Henner, DO
Division Chief of Nephrology
Medical Director of Dialysis
Berkshire Medical Center , Pittsfield, MA President, National Forum of ESRD Network

Sunil Patel, MD
Director
Kidney Pancreas Program
University Medical Center Transplant Center, Las Vegas, NV

Shrona Alpough, RN, BSN
Facility Administrator
DaVita Renal Center of Port Arthur

David Tyrell, BS, RN
Clinical Director/Transplant Administrator
University Medical Center Transplant Center, Las Vegas, NV

Christa Abel, LCSW, MSW
Renal Social Worker
Berkshire Medical Center, Pittsfield, MA

Patients living in disadvantaged neighborhoods are more likely to encounter barriers to care, including transportation challenges, food insecurity, and housing instability. Dialysis facilities and transplant centers play a critical role in reducing health disparities among underserved patients. The End Stage Renal Disease (ESRD) National Coordination Center analyzed ESRD Quality Reporting System (EQRS) data and the Area Deprivation Index to identify facilities serving patients living in the most disadvantaged neighborhoods. Dialysis facilities above the national average for transplant waitlists were interviewed to identify best practices. These facilities will share lessons learned, what worked for patients, barriers faced, and the solutions implemented to advance health equity. This includes equity-promoting strategies to reduce disparities, including screening and identifying health-related social needs, providing culturally tailored patient education, and connecting patients to community-based resources. Lessons learned from Technical Assistance Quality Improvement and Learning (TAQIL) and the ESRD Treatment Choice Learning Collaborative (ETCLC) have identified a key driver to transplantation is waitlist management. One successful transplant center, which has more than tripled the number of kidney transplants in recent years, will share its assertive approach to improving communication with dialysis facilities and patient education. It has focused on maintaining “transplant ready” status and overall improved health and well-being as a top priority for patients on the waitlist.

May 2, 2023 12:25 pm

LT John Watts, PharmD
U.S. Public Health Service & Analyst Office of Burden
Reduction & Health Informatics
Centers for Medicare & Medicaid Services

Like throwing a stone into a lake, we create ripples on the surface and displace the water below. What happens when that stone is health care policy, and those ripples and displacement are both burden reduction and unattended consequences? In this discussion, we review the Office of Burden Reduction and Health Informatics’ efforts on predicting and measuring those ripples and displacements.

In 2022 OBHRI developed an Impact Analysis Methodology, which scores every regulatory action and policy released by CMS for potential burden reduction and policy-related impacts. This innovative methodology creates baseline quantitative and qualitative assumptions of burden totality using regulatory impact analysis, stakeholder feedback, and media sensing technology.

The methodology uses data to compare current burden perceptions, evaluates burdens estimated in the regulations, and then augments the quantitative data with qualitative, experiential anecdotes. The qualitative data prompts efforts to then review targeted data sources to add quantitative data to either support or challenge the qualitative burden perceptions.

This discussion will provide details on the methodology developed to bring clarity to the burden totality perceived by stakeholders and beneficiaries, beyond dollars and hours.

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May 2, 2023 12:25 pm

Dr. Shari Ling (Moderator)
Deputy Chief Medical Officer
Centers for Medicare & Medicaid Services

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

Joe Montminy
Dementia Advocate

Dr. G. Michael Harper, MD, ADSF, FACP
President
American Geriatrics Society & Professor UCSF School of Medicine & Physician San Francisco Veterans Affairs Medical Center

In the United States, Alzheimer’s Disease and Alzheimer’s Disease Related Dementias (AD/ADRD) affects as many as 5 million people and roughly 13.2 million older Americans are projected to have AD/ADRD by 2050. Alzheimer's Disease and related Dementias (AD/ADRD) are debilitating conditions that impair memory thought processes, and functioning, primarily among older adults. AD/ADRD has physical, psychological, social, and economic impacts not only for the individual but also for their families, and society as a whole.

Care management can be 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 patient-clinician decision making as well as identify ways to improve patient-clinician decision making in dementia care planning.

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May 2, 2023 12:25 pm

Stephanie Fry, BA
Senior Study Director
Westat
&
Deputy Director
BFCC NCORC

Scott Fortin, MBA
Senior Director
Communications and Outreach
Kepro

Matthew Stofferahn, MD
Medical Director
Livanta

David Bercham, MSW
Senior Associate
Rainmakers Strategic Solutions
&
Director
BFCC-Survey Center

  • Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) help to improve the effectiveness, efficiency, economy and quality of services provided to people with Medicare. Learn how BFCC-QIOs are using data to identify trends and focus services to best meet the needs of Medicare beneficiaries and their care partners.
  • Kepro, a national case review BFCC-QIO, will discuss the changing landscape and describe how they are adapting to provide excellent customer service and information to a new generation of beneficiaries. They will share how they recognized the changes in the market due to volume fluctuations and differences in the ways beneficiaries and families have started to interact with them.
  • Livanta, also a national case review BFCC-QIO, will describe their collaboration with Quality Improvement Network (QIN) QIOs to transform beneficiary care concerns into sustainable quality improvement initiatives. After detecting a shortfall in concern referrals, they identified an opportunity to strengthen relationships with QIN partners and increase provider access to technical assistance services. Their presentation explores the root causes of the shortfall, detailed efforts to increase collaboration and appropriate provider referrals, and reports on the progress that has been made.
  • The Survey Center, a contractor collecting beneficiary experience data through a survey of individuals who directly received case review services from BFCC-QIOs, will talk about using the beneficiary voice to inform service delivery in a beneficiary-centered fashion. They will share some key elements that drive positive beneficiary experience.

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May 2, 2023 12:25 pm

Stella "Stace" Mandl, BSW, BSN, RN, PHN (Moderator)
Deputy Office Director
Office of Burden Reduction and Health Informatics
Centers for Medicare & Medicaid Services

Morgan Taylor
Technical Advisor
Customer-Focused Research
Group Office of Burden Reduction and Health Informatics
Centers for Medicare & Medicaid Services

Ted Long, MD, MHS
Senior Vice President Ambulatory
Care and Population Health
New York City Health + Hospitals & Executive Director Test & Treat Corps

Neeraj Gandotra, MD
Chief Medical Officer
Substance Abuse and Mental Health Services Administration

Sarah Lenz Lock, JD
Senior Vice President
Policy & Brain Health AARP

Jeane Garcia-Davis, MSN/MPH, RN
Associate Director
Science & Policy Office of the Surgeon General

Stakeholder engagement activities leveraging Human-Centered Design methods by the Office of Burden Reduction were conducted to understand the problem spaces in care delivery related to Behavioral Health and Chronic Pain. While separate engagements, the two projects revealed a common theme specific to the impact stigma has on perceptions and therefore access to care, treatment and recovery.

This panel discussion will include a case study on how Human-Centered Design methods were leveraged for CMS’ stakeholder engagements to holistically understand the barriers encountered by individuals accessing behavioral health services for the prevention, treatment, and recovery from substance use disorder (including effective pain treatment), and the barriers encountered by those seeking access to covered treatment for chronic pain. Discussions will delve into issues raised through the stakeholder engagement work; including the impacts abstinence models have on vulnerable populations and the biases endured by individuals coping with and treating chronic pain. Through the lens of providers and patients, the discussion will illuminate the pervasiveness of stigma; the expansive impacts it has for those who seek care, and those who provide care, as well as efforts through communities and education to mitigate the barriers that stigma creates.

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May 2, 2023 12:25 pm

Dr. Carla Shoff, PhD (Moderator)
Senior Advisor to the Chief Dental Officer
Centers for Medicare & Medicaid Services

Dr. Jill Boylston Herndon, PhD
Owner
Key Analytics and Consulting, LLC

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

Mary Foley, MPH
Executive Director
Medicaid|Medicare|CHIP Services
Dental Association

This session will contain three presentations focusing on advancing health equity through oral health quality improvement. The presentation will highlight the impact of the COVID-19 pandemic on the health disparities in the prevalence of dental conditions and access to dental services. The Oral Health Equity Self-Assessment Tool can decrease oral healthcare inequities and increase access and use of dental services. A dashboard has been created that can dynamically generates state and national oral healthcare quality measure reports.

May 2, 2023 12:25 pm

Anita Monteiro (Moderator)
Director iQuality Improvement and Innovation Group
Centers for Medicare & Medicaid Services

Steve Burrows
Founding Member
Patients for Patient Safety US

Carole Hemmelgran, MS
Founding Member
Patients for Patient Safety US

Armando Nahum
Founding Member
Patients for Patient Safety US

Soojin Jun, BCGP, CPPS, CPHQ
Founding Member
Patients for Patient Safety US

In this session Patients for Patient Safety US will share practical solutions for safer care that have their genesis in the stories of patients and their family members. The solutions we offer have been shaped by each speaker’s sense of having a calling to be an activist for patient safety, to partner effectively so that change happens, to re-invigorate patient safety and health equity as intrinsically connected priorities for all patients, and to restore trust. The session will explore preventable harm beyond complications and healthcare acquired conditions to include diagnostic failure or delay, failure to rescue, bias, moral harm, emotional harm, fiscal harm, and the intergenerational impact of unsafe care on parents, siblings and children. Revival in its essence is about renewal, recommitment and rebirth. The solutions we seek are achievable if there is the will to recommit to transparency, being responsible, and valuing the lived experience of patients and families as we co-create solutions together. With this session, Patients for Patient Safety US welcomes patients, providers, policymakers and change agents of all stripes who seek a safe and resilient healthcare system grounded in dedication to first, and fundamentally, do no harm. Join us at the Patient Safety Revival!

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May 2, 2023 12:25 pm

Stephen Esquivel-Pickett, PhD
Economist State Demonstrations Group
Center for Medicaid and CHIP Services
Centers for Medicare & Medicare Services

Joshua Bougie
Health Insurance Specialist, Division of State Coverage Programs
Centers for Medicare & Medicaid Services

Amy Pulda
Homelessness Services
Manager Wisconsin
Department of Health Services

Gary Sing
Mass Health Senior Director of Strategic Initiatives
Office of Payment and Care Delivery Innovation

State Medicaid agencies have significant flexibility to design programs to comprehensively address the health of their beneficiaries, including addressing unmet health-related social needs. This session will examine Health Services Initiatives in the Children’s Health Insurance Program and innovative new Medicaid demonstration projects that address food insecurity and housing instability. The Center for Medicaid and CHIP Services (CMCS) will present measurement and evaluation approaches and challenges. Representatives from the states of Massachusetts and Wisconsin will reflect on operational challenges, and how the efforts in these areas can serve as best practices for the future and result in improved delivery of equitable health care.

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May 2, 2023 12:25 pm

LeTonya Smith, CRNP
Health Insurance Specialist
Division of Community and Population
Health iQuality Improvement and Innovation Group
Centers for Medicare and Medicaid Services

Tammy Geltmaker, RN, BSN, MHA, CPHQ
Progam Director
QSource

Don Gettinger, BS
Quality Improvement Advisor
QSource

Tara Hatfield, MHA, BSN, CPHQ
Education Outreach Coordinator
QSource

This session will share CMS QIN-QIO lessons learned in partnership development and CLAS education, especially with populations at risk for health disparities, and opportunities to spread best practices.
Track: In June 2022, a QIN-QIO looked at ways to provide CLAS Standards support. Conversations with Partnerships for Community Health (PCH) identified the need for this assistance, especially for those pursuing NCQA accreditation. A QIN-QIO provided CLAS presentations to all 12 PCHs and learning sessions for the Indiana Rural Health Association. Individual meetings have been conducted with six organizations to explain CLAS and offer technical assistance. CLAS-related materials have been developed and disseminated. One common gap identified is access to translated resources from trusted sources. To address this need, a QIN-QIO is building new partnerships with community health workers and Su Casa, a local community hub for the Latinx population, and is leveraging existing opportunities with the Minority Health Coalition. Through Su Casa, A QIN-QIO was able to get three of our most-requested resources translated to Spanish and disseminated them at a community health fair in one of the Partnerships for Community Health (PCH) communities.

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May 2, 2023 12:25 pm

Floyd Eisenberg, MD, MPH, FACP
Senior Standards Advisor ICF

Standard updates significantly improve electronic clinical quality measures (eCQMs) and digital quality measures (dQMs) ability to aggregate outcomes about patient-centered care and patient engagement, areas challenged by insufficient and disparate capture and nomenclature for essential data elements. The Office of the National Coordinator for Health Information Technology (ONC) standardized definitions and data capture by publishing United States Core Data for Interoperability (USCDI) with social determinants of health (SDOH) criteria, functional and cognitive status, and physical activity. HL7 and ONC collaborate to support data capture and aggregation with US Core observation profiles to allow use of any screening/risk tool. Results enabled with these structured formats using standard code systems include food insecurity, functional status, cognitive status, and social risks. Quality Improvement Core (QI-Core®) builds on US Core, providing profiles to author eCQMs and dQMs quality measures consistent with how health systems share data for routine clinical care. Defining frailty (i.e., functional status and physical activity) is a current challenge seen in expressing eCQMs.
Track: Future work with a nascent Health Level Seven International (HL7) Fast Health Interoperability Resources (FHIR) Accelerator for Devices promises to capture data from ambulatory devices for trending patients over time (e.g., glucometer) and enable aggregate analysis of populations with respect to changes in trends over time. This presentation will review standards updates used in eCQMs and dQMs relevant to clinical outcomes and risk adjustment to improve data quality.

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May 2, 2023 12:25 pm

Tabia Henry Akintobi, PhD, MPH
Professor and Chair of Community Health and Preventive Medicine &
Associate Dean of Community Engagement & Principal Investigator &
Director of the Prevention Research Center & Director Evaluation and Institutional Assessment,
Morehouse School of Medicine

Shirley E. "Bella" Borghi
Executive Director and Vice Chairman Hispanic Health Coalition of Georgia

Saadia Khizer, M
Director Vaccine Trials Unit
Morehouse School of Medicine

The COVID-19 pandemic has presented an unanticipated watershed movement where data is being leveraged to reprioritize and sustain community-engaged research to advance health equity in Georgia.
Track: The Garnering Effective Outreach and Research in Georgia for Impact Alliance (GEORGIA) - Community Engagement Alliance (CEAL) Against COVID-19 Disparities Project (hereafter called GEORGIA CEAL) was funded as part of a 21-state organization network to conduct urgent community-engaged research and outreach focused on COVID-19 awareness and education to address misinformation and mistrust and promote and facilitate inclusion of diverse racial and ethnic populations in clinical trials along with vaccination uptake.

The GEORGIA CEAL Community Coalition Board, adapted from the Morehouse Model, leveraged networks supporting mixed method data collection strategies that included: surveys administered at two time-points in 34 counties (characterized by low vaccination and testing rates, and the Social Vulnerability Index); and interviews/focus groups.

Blacks/AA were 0.48 less likely to get vaccinated (p=0.003), and those with insurance and those who trusted their doctors/healthcare providers were more likely to get vaccinated (OR: 2.75, p=.001 and OR: 2.81, p=.0072, respectively). Qualitative findings highlighted historical and sociocultural factors driving vaccination mistrust and decision-making and informed a social media dashboard with real-time monitoring and analytics to identify/share credible communication resources.

Results reflect not only the acquisition of community wisdom towards advancing effective communication among marginalized communities in Georgia but the application of findings to communications and education approaches resulting in the vaccination of over 65,000 Georgians and an increased proportion of Black and Latinx participants in vaccine trials, amidst justified hesitancy during the pandemic.

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May 2, 2023 12:25 pm

Purva Rawal, PhD (Moderator)
Chief Strategy Officer
Centers for Medicare and Medicaid Services

Liz Fowler, JD, PhD
Director
Centers for Medicare and Medicaid Innovation

Noemi Rudolph, MPH
Acting Director
Research and Rapid Cycle Evaluation Group
Centers for Medicare and Medicaid Innovation

Kate Davidson, LCSW
Director Learning and Diffusion Group
Centers for Medicare and Medicaid Innovation

Julita Mir, MD
Chief Medical Officer
Community Care Cooperative

This session will 1) provide an overview of the CMS Innovation Center’s impact on the value-based care landscape, 2) share examples of how Innovation Centers models have impacted key dimensions of health system transformation through retrospective reviews of evaluations and learning system work, as well as panelist experiences, and 3) discuss how the CMS Innovation Center will assess the impacts of its models on health system transformation moving forward.

The CMS Innovation Center was created in 2010 as a result of the Affordable Care Act (ACA) of 2010. It has since tested over 50 innovation models with the goal of improving quality and outcomes for beneficiaries while reducing costs.

In 2021, the Innovation Center underwent a strategic refresh, which resulted in a renewed vision to innovate equitable outcomes through high-Quality
person centered care.

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Engagement Opportunity | May 2, 2023 01:10 pm

Listening Sessions

May 2, 2023 02:10 pm

Dr. Sean Michael (Moderator)
Regional Chief Medical Officer,
Centers for Medicare & Medicaid Services

Arjun Venkatesh, MD, MBA, MHS
Chair, Department of Emergency Medicine, Yale School of Medicine

Eric Wei, MD, MBA
Senior Vice President and Chief Quality Officer
New York City Health + Hospitals

Martin Reznek, MD, MBA
Professor and Execute Vice Chair for Clinical Operations and Education
Department of Emergency Medicine,
UMass Chan Medical School/Umass Memorial Health

Although respiratory illness isn’t the cause of overcrowded emergency departments (EDs), the COVID-19 pandemic highlighted a reality present for decades: A resilient system, including one that can cope with surges in demand, requires deliberate alignment of incentives. One predictable consequence of healthcare economic incentives is the widespread practice of “boarding” people in EDs.

Boarding has a nexus to every element of the CMS National Quality Strategy and is associated with a multitude of harms including increased mortality, medical errors, readmissions, hospital acquired infections, guideline non-adherence, and physical violence. The consequences are well-described, but the practice continues because the economic and regulatory milieu continue to incentivize it. This panel of experts—representing perspectives from urban and rural hospitals, emergency care research, and quality improvement science—will examine why and begin to reimagine a more resilient and equitable design. This moderated roundtable will briefly survey the substantial body of topical literature, more closely examine the economic drivers, and discuss policy levers such as quality measurement, certification standards, payment dynamics, and other systematic approaches. Patients are put at risk not out of malice, but as a predictable consequence of how a complex system responds to incentives. By identifying and examining those incentives, we can improve outcomes, build resilience, and enhance safety.

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May 2, 2023 02:10 pm

Quality Care: Integrating Physical and Mental Health

Dora Hughes, M.D., M.P.H. (co-Moderator)
Chief Medical Officer
Center for Medicare & Medicaid Innovation
Centers for Medicare & Medicaid Services

Dr. Shari Ling (co-Moderator)
Deputy Chief Medical Officer
Center for Clinical Standards and Quality
Centers for Medicare & Medicaid Services

Anand Parekh, MD, MPH
Chief Medical Advisor
Bipartisan Policy Center

Kedar Mate, MD
President and Chief Executive Officer
Institute for Healthcare Improvement

CMS’ Behavioral Health Strategy outlines goals to support the whole emotional and mental well-being of a person, and promote person-centered behavioral health care, and aligns with the HHS Roadmap for Behavioral Health Integration.  This plenary provides insights into the transformational opportunities to achieve better health outcomes through the delivery of integrated physical and mental health care services and supports.  Speakers will discuss multi-level policy opportunities to enable integrated physical and mental health care delivery, and describe a systems-level framework for a learning health system for continuous improvement of health outcomes for people with mental and physical health needs

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May 2, 2023 02:10 pm

Anita Monteiro (Moderator)
Director Quality Improvement and Innovation Group
Centers for Medicare & Medicaid Services

Michael Connors
Division Director - Division of Quality Contracts
Office of Acquisition and Grants Management (OAGM)
Centers for Medicare & Medicaid Services

CMS is providing the key elements of programmatic vision and acquisition related to the planned QIO 13th Scope of Work. Learn more about how CMS intends to position the QIO Program to provide quality improvement assistance within a changed health system.

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Breakout Sessions

May 2, 2023 03:00 pm

Scott Lawrence, DC (Moderator)
Deputy Director
Division of Practitioner Services Center for Medicare
Centers for Medicare & Medicaid Services

Linda Porter, PhD
Director
Office of Pain Policy and Planning
National Institutes of Health

Cindy Steinberg
Director of Policy and Advocacy
U.S. Pain Foundation

Jan Losby, PhD
Branch Chief
Division of Overdose Prevention
Centers for Disease Control and Prevention

The HHS 2019 Pain Management Best Practices Inter-Agency Task Force Report outlined multiple approaches to pain management that should be leveraged based on each person’s unique situation to achieve successful pain care.

It is essential to apply a comprehensive, person-centered approach to the diagnosis and treatment of pain that allows for multiple therapeutic modalities alongside thoughtful and individualized care coordination. The uptake of this approach is an increasingly urgent concern; nearly 80 percent of Medicare beneficiaries report experiencing chronic pain that interferes with function and quality of life.

Physician shortages also have serious implications for people living with pain across geography, underserved populations, and care settings. Our goal is to increase access to high quality pain care in the nation’s health care system. This session will outline collaboration across several HHS operating divisions to issue updated prescribing guidance, create new payment pathways for treatment, and make it easier for clinicians to find screening tools.

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May 2, 2023 03:00 pm

Samantha Richardson (Moderator)
Director
Governance and Impact Analysis Group
Centers for Medicare & Medicaid Services

LCDR Réna McClain, PharmD
Senior Health Insurance Specialist
Office of Burden Reduction and Health Informatics
Centers for Medicare & Medicaid Services

During the fall of 2022, OBRHI developed a set of survey questions to obtain data related to burden and provider experiences, including variations in care delivery experiences of rural vs. non-rural providers, and providers of historically underserved populations , including challenges pertaining to the use of telehealth as a care delivery service and patient risks and needs related to social determinants of health. Survey topics included: 1) screening for and addressing patients’ social needs and risks; 2) patient challenges using video-enabled telehealth; 3) factors impacting time spent with patients; and 4) scope of practice flexibilities established during the COVID-19 public health emergency. The survey was distributed nationally to providers who practice in office-based settings and serve Medicare/Medicaid beneficiaries.

This discussion will convey insights from the survey results, including the experiences and perceptions of providers who deliver care to underserved patient communities including individuals that are members of racial and ethnic communities and providers practicing in ZIP Codes with higher poverty levels.

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May 2, 2023 03:00 pm

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

Dr. Steffany Chamut, DDS, MPH, FICD
Instructor in Oral Health Policy and Epidemiology
Harvard School of Dental Medicine

Colleen Lampron, MPH
Collaborative Director
National Network for Oral Health Access

Monica McKee, MPH, RDH
Vice President
Ancillary Clinical Services
Oklahoma City Indian Clinic

This session will showcase three examples of quality improvement in oral health integration. Research using the Minimum Data Set 3.0 Resident Assessment Instrument can be used to identify oral health problems and malnutrition among Medicare beneficiaries residing in Nursing Homes.
Track: Health centers are improving outcomes for patients with diabetes by using a shared measurement system for their collaborative. An Integrated Dental Hygiene Program for expecting mothers led to early intervention, medical-dental integration, and continuity of care. Results from their 4-month study will be shared.

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May 2, 2023 03:00 pm

Cheri C. Wilson, MA, MHS, CPHQ
Program Director
Diversity Inclusion, and Health Equity
Johns Hopkins Health System

Dr. Alexandria Beranger
National Director
Quality & Patient Experience
ChenMed

The presentation will describe how two healthcare organizations used CLAS Standards to provide high quality care.

The Johns Hopkins Medicine Office of Diversity, Inclusion, and Health Equity; Language Services; and academic–community partnerships operationalized to develop a health equity focus based upon the three domains of the National Culturally and Linguistically Appropriate Services (CLAS) Standards in Health and Health Care (National CLAS Standards) to support the organization’s COVID-19 response and to provide a framework of health equity initiatives for other academic medical centers.

ChenMed, a value-based care health care organization, operates more than 120 centers in 15 states, where primary care physicians are transforming care of the neediest populations. Including reducing in-patient hospitalizations by 30 to 50 percent, and shrinking ER visits by as much as 75 percent.

This presentation will describe how strategic physician recruitment, career development and robust operational support solutions, reduce physician burnout, and help medical practices on the pathway to full-risk.

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May 2, 2023 03:00 pm

Marilyn Reirson, MS
Program Director
Partnership to Advance Tribal Health

CAPT Cynthia Gunderson, PharmD
Chair National Committee on Heroin
Opioids, and Pain Efforts (HOPE)
Indian Health Service

Jane Brock, MD, MPH
Clinical Director
Partnership to Advance Tribal Health

Impacting opioid overdoses in Indian Country requires collaboration on harm reduction education, data, resources and interventions. Under the CMS American Indian Alaska Native Healthcare Quality Improvement (AIHQI) Task Order, the Partnership to Advance Tribal Health (PATH) aligns Indian Health Service (IHS) strategic priorities and CMS contract goals to drive improvement in patient care.

Collaborating with the IHS National Committee on Heroin Opioids and Pain Efforts (HOPE Committee) has proven invaluable in guiding PATH’s opioid work. HOPE is comprised of dedicated IHS health professionals, like physicians, pharmacists, rehabilitation professionals, behavioral health providers, nurses, and engineers serving tribal communities across the nation. They work to promote appropriate and effective pain management, reduce overdose deaths from heroin and prescription opioid misuse and improve access to culturally appropriate treatment. With a shared goal of decreasing the harm caused by opioids on tribal communities, PATH and HOPE developed a workplan for multi-disciplinary and innovative approaches on opioid stewardship, screening strategies and harm reduction efforts.

The teams co-created materials for an IHS opioid dashboard, training videos, an opioid stewardship template, as well as offered opioid dashboard office hours and educational events on substance use screening. HOPE provides insights and guidance on PATH materials and contract work, while PATH offers creative, administrative, and logistical support for HOPE. By aligning with and amplifying the work of an existing IHS team, PATH efforts for harm reduction in Indian Country are more meaningful, more impactful and more sustainable.

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May 2, 2023 03:00 pm

Dr. Michelle Schreiber, MD (Moderator)
Deputy Director
Center for Clinical Standards and Quality
Centers for Medicare & Medicaid Services

Carole Hemmelgran, MS
Founding Member
Patients for Patient
Safety US

Martin Hatlie, JD
Founding Member
Patients for Patient
Safety US

COL Steven Coffee, MA
Founding Member
Patients for Patient
Safety US

Patients and family members who have experienced unsafe care are now activated in calling for a reprioritization of Patient Safety as a top policy concern. Failures in responsible reporting, accountability, transparency, and patient/family engagement still occur more than 20 years after the To Err is Human call to action. In 2021 a National Academy of Sciences report observed that progress in patient safety was at a “standstill” in the United States and that continuing in the current trajectory would not produce better results.

Covid-19 underscored the gaps in patient safety, health equity and health system resilience overall. Concerned that patient safety has drifted off the national agenda for many organizations and government agencies, a group of patient advocates came together to form Patients for Patient Safety US (PFPS US), a branch of the World Health Organization network of patients, family members, healthcare professionals and policymakers passionate about achieving safe healthcare across the globe. As an advocacy group, we have engaged interested government agencies, healthcare systems and community partners to collaborate in raising patient safety and health equity to the national, state and local level again as top health policy priorities.

In this session, founders of PFPS US will present an agenda of actionable interventions to drive transparency, accountability and oversight, and patient and family engagement as patient safety and health equity improvement change engines.

Click here to view presentation

May 2, 2023 03:00 pm

Stephanie Hutchinson, MBA (Moderator)
Executive Director
ESRD Network 16,
Comagine Health

Jessica Joseph, MBA
Senior Vice President for Scientific Operations,
National Kidney Foundation

Matthew Rivara, MD
Associate Professor of Medicine,
University of Washington

The National Kidney Foundation (NKF) initiated a successful Chronic Kidney Disease (CKD) ECHO in 2019 helping health systems identify at-risk populations for kidney disease and utilizing the ECHO program to deliver pre-emptive prevention education.
Track: The National Kidney Foundation and Comagine Health forged a partnership in 2021 to provide this program within the Network framework as a national outgrowth from the NKF work on CKD. Piloted with Network 16 in 2021-22, it has now expanded to include 4 Networks (NW 2, 5, 11, and 16) with the curriculum which will encompass 2022-2023. The goal of this session is to introduce the initial Network Home Dialysis ECHO to the kidney community.

Click here to view presentation

May 2, 2023 03:00 pm

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

Krista Lynch
Analytics, Research, and Measurement Administrator

Larry Mull
Associate Director
Business Intelligence Solutions
Division of Health Benefits
North Carolina Department of Health & Human Services

Kimberly Proctor, PhD

Chief Data Officer
Data and Systems Group
Center for Medicaid and CHIP Services
Centers for Medicare & Medicaid Services

This session will explore data visualization tools used by the Center for Medicaid and CHIP Services and state Medicaid and CHIP agencies to understand beneficiary health and drive quality improvement, including data dashboards, run charts, and visual tools for communicating quality information to interested parties. The session will focus particularly on how data visualization is being used to identify health disparities and promote health equity.

Click here to view presentation

May 2, 2023 03:00 pm

Joel Andress, PhD
Senior Digital Quality Measurement Program Lead
Centers for Medicare & Medicaid Services

Bridget Calvert
Senior Digital Quality Measurement Implementation Lead
Centers for Medicare & Medicaid Services

The CMS and ONC 2020 interoperability rules created formal processes for advancing standards and implementation by encouraging innovation with data exchange and Fast Healthcare Interoperability Resources (FHIR®) application programming interface (API) technology. Pending progress in interoperability creates an opportunity to move to leverage standardized data, FHIR® solutions, and modernize quality measurement processes.

Along these lines, in 2020, CMS announced a goal of transitioning to full digital quality measurement. This panel will discuss key CMS activities to achieve digital quality measurement, focused on leveraging data standards, and exploring quality measure redesign to leverage advances in technology.

May 2, 2023 03:00 pm

Cheryl Franklin, MD, MPH
Associate Professor
Department of Obstetrics and Gynecology
Morehouse School of Medicine & Executive and Founding Director Center for Maternal Health Equity Morehouse School of Medicine

Natalie Hernandez, PhD, MPH
Associate Professor and Executive Director
Morehouse School of Medicine

Kaitlyn Hernandez-Spalding, MPH
Research Assistant II
Morehouse School of Medicine

Black women are about 3 to 4 times as likely to die from a pregnancy-related cause compared to white women and more than 80% of these deaths are preventable. This talk will highlight the role of a historically Black medical school in its fight against inequities in severe maternal morbidity and mortality.

The presentation will highlight the work of the Center for Maternal Health Equity at Morehouse School of Medicine (MSM) in pursuing equity through interdisciplinary translational research, inter-professional training, outreach, education, community engagement, policy and advocacy, and respectful health care. The presentation will feature two specific projects from MSM investigators that are addressing maternal health inequities focused on “maternal near misses” and the two pandemics of structural racism and COVID-19 on Black maternal health.

Click here to view presentation

May 2, 2023 03:00 pm

Anita Thomas, PharmD
Technical Advisor
Division of Community and Population Health iQuality Improvement and Innovation Group
Centers for Medicare & Medicaid Services

Mary Ford, RN, MPH
Division of Community and Population Health Quality Improvement and Innovation Group
Centers of Medicare & Medicaid Services

Sheila McLean, MBA, LNHA, CPHQ
Senior Consulting Manager
Vice President Health Quality Innovators

Allison Spangler, BSN, RN, RAC-CT, QCP
Consulting Manager
Health Quality Innovators

Teresa Lubowski, Pharm. D., B.S., CPHQ,
Director
Drug Safety

Valerie Reger, LPN
Quality Assurance Technician
New Jersey Department of Health

In this session, two CMS QIN-QIOs will present on nursing home patient safety quality improvement interventions using data and innovative approaches to identify and track outcomes.Nursing Home Hand Hygiene Electronic Data collection /visualization/analysisA QIN-QIO collaborated with the New Jersey Department of Health (NJDOH) to create and disseminate an automated hand hygiene competency and observation project for nursing homes (NH) in New Jersey.

56 NHs were included in this intervention. The goal was to use an automated process to assess hand hygiene adherence, utilizing real-time data for education and reporting. NH teams used REDCap to collect data electronically on cell phones, tablets, or iPads to decrease paper data collection. Utilizing Tableau for data visualization provided a "real-time" dashboard and access to customized reports. NH teams have access to their data and can filter by competency, observation, type of staff, unit, shift, quarter, and bed size and compare data to other participating NHs using a facility identifier for confidentiality.

Hand hygiene observations were correctly completed for up to 86 % of observed instances and incorrectly completed for up to 5% of observed instances. Reducing Sepsis-Related Hospital Readmissions and Emergency Department Visits through a Fast-Track Educational Sprint Series:In late spring 2022, QIN-QIO nursing home quality improvement advisors identified that hospital readmissions and emergency department (ED) visits were high across the entire service area. Through further analysis of Part-A claims, the QIN-QIO team identified sepsis as the number one diagnosis for readmissions and ED visits across the four state service area.

In response, the team launched a “Sepsis Sprint Series” learning and action event in June 2022. This weekly series offered practical recognition tools and best practices or “how to’s” enabling nursing home participants to immediately share and implement what they learned to reduce readmissions and ED visits due to sepsis.

Click here to view presentation

May 2, 2023 04:00 pm

Resiliency through Design Thinking: A Fireside Chat with Stacey Chang

Dr. Lee Fleisher (Moderator)
Chief Medical Officer and Director of the Center for Clinical Standards and Quality
Centers for Medicare & Medicaid Services

Jonathan "Jon" Blum
Principal Deputy Administrator
and Chief Operating Officer,
Centers for Medicare & Medicaid Services

Stacey Chang
Former Founding and Executive Director
Design Institute for Health
University of Texas at Austin

Join Dr. Lee Fleisher, Jon Blum and Stacey Chang for an intimate conversation about design thinking and its linkage to resilience. Stacey Chang serves as the executive director of the Design Institute for Health at the University of Texas at Austin. It is a first-of-its-kind institution, dedicated to applying design approaches to solving systemic health care challenges as an integrated part of both an operating health system, and a medical education and training program. Working with invested stakeholders in the health ecosystem, and harnessing the resources of the university, the Institute is focused on creating human-centered solutions in clinical and community environments—all with the intent to improve people’s health outcomes and health care experiences.

May 2, 2023 04:30 pm

Closing Plenary

Dr. Lee Fleisher
Chief Medical Officer and Director of the Center for Clinical Standards and Quality
Centers for Medicare & Medicaid Services

May 3, 2023 12:00 pm

Opening Address

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

May 3, 2023 12:05 pm

Infection Prevention and Control: The Cornerstone of a Resilient Healthcare System

Dr. Nimalie D. Stone, MD, MS
Senior Advisor for Long term Care Partnerships
Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention

Dr. Michael Wasserman, MD, CMD
Geriatrician
Chair, Public Policy Committee
California Association of Long-Term Care Medicine

Angela Vassallo, MPH, MS, CIC, FAPIC
Infection Prevention and Epidemiology Expert
Angela Vassallo, LLC
Board member, Association for Professionals in Infection Control and Epidemiology

Dr. Swati Gaur, MD, MBA, CMD, AGSF
Chief Medical Officer, Senior Care Office
Medical Director, Post-Acute Care
Northeast Georgia Health System

This presentation is specific for infection preventionist to learn and share implementation best practices in nursing home Infection Prevention Control (IPC)

Click here to view presentation

May 3, 2023 12:35 pm

Increasing Vaccination Rates in Nursing Homes and Communities of Color

Gary Puckrein, PhD
President and Chief Executive Officer
National Minority Quality Forum

Joe Silva, ScM
PhD student
Brown University

Chad Worz, PharmD, BCGP, FASCP
Chief Executive
American Society of Consultant Pharmacists

The National Minority Quality Forum (NMQF), in working with the Centers of Disease Control, has created options to continue to build on partnerships and methods created during this pandemic to improve minority health. NMQF is seeking to expand a successful disparities reduction vaccine model established in Baltimore by Dr. Terris King in partnership with the Johns Hopkins International Vaccine Center and Baltimore Cities Health Department. This model improved vaccination rates by 13%. While efforts to address the impact of disparities on vaccination rates in nursing homes is important, this must only serve as an entry point into addressing the broader issue of poor quality that has and will continue to be related to disparities in nursing homes across the country. This workshop will present successful models and allow for the discussion of future approaches to enhancing vaccination rates not only in nursing homes, but across all communities of color.

May 3, 2023 01:05 pm

The Public Health Emergency is Ending. Now What?

Michelle Veach (Moderator)
Life Safety Engineer
Center for Medicare and Medicaid Services

Elizabeth Sholar, NHZ, MSH
Director of Health Services
Vicar’s Landing

Jen Salter, MS, LNHA, CPHRM
Director of Operations
Century Care Management

This session will focus on Emergency Preparedness and Resilience for long-term care including information and resources to help members respond to an emergency in a timely, organized, and effective manner

Click here to view presentation

May 3, 2023 01:35 pm

Break

May 3, 2023 01:40 pm

Quality Assurance and Performance Improvement (QAPI) – Making it Work

CAPT Hyosim Seon-Spada, DNP, USPHS
Survey, and Long-term Care Branch Manager
Centers for Medicare and Medicaid Services

Jennifer Wieckowski, MSG
Senior Executive Director
Health Services Advisory Group
Centers for Medicare & Medicaid Services (CMS) Quality Innovation Network

Nursing homes are required to develop, implement, and maintain an effective, comprehensive, and data-driven Quality Assurance & Performance Improvement (QAPI) program to improve the quality of life and quality of care delivered to nursing home residents. This session will provide an overview of QAPI, discuss challenges and opportunities in the QAPI process, describe expectations for governing boards, and describe effective program implementation for nursing homes. Attendees will be given access to tools and resources to assist nursing homes in developing an effective QAPI program, which is the foundation of a strong quality improvement program. Nursing homes can use these tools as they problem-solve, address new challenges, and strive to embed sustainable QAPI principles and performance improvement projects (PIPs) into their day-to-day work and culture.

Click here to view presentation

May 3, 2023 02:10 pm

Age Friendly Health Systems

Alice Bonner
Senior Advisor for Aging
Institute for Healthcare Improvement

Harvey Wells
Resident
The Cedars, Portland, ME

This session will review how nursing homes can join the Age-Friendly Health Systems (AFHS) movement to improve health outcomes for older residents while improving workflow for nursing home teams. An overview will be provided of the AFHS 4Ms Framework – what Matters, Medication, Mentation, and Mobility – and a nursing home resident receiving age-friendly care will share experiences. Examples will be given from participating sites, two other nursing home initiatives will be introduced, and participants will learn practical next steps on how to collaborate with others to promote age-friendly nursing home care.

Click here to view presentation

May 3, 2023 02:40 pm

Building a Stronger Long-term Care System That’s Equitable

Heidi Magladry, RN
Skilled Nursing Facility Quality Reporting Program
Coordinator
Centers for Medicare and Medicaid Services

Alexandre Laberge, PhD, PT, MBA
Senior Policy Advisor PAC VBP Program
Centers for Medicare and Medicaid Services

Colleen Frey, RN, MSN, CPHQ
Acting Director
Division of Community and Population Health
Centers for Medicare and Medicaid Services

Alpha Wilson
Technical Advisor
Centers for Medicare and Medicaid Services

This session will focus on the Federal levers and authorities to advance equity in long term care including:

  • IMPACT Act
  • SNF VBP Proposed Rule
  • Culturally Competency and Patient Centered Care Proposed Rule
  • Standardized data

Click here to view presentation

May 3, 2023 03:10 pm

Building a Resilient Workforce that Enhances Patient Care

JoVonn H. Givens, MPH
Task Order Director
Alliant Health Solutions

Attendees will have the opportunity to learn more about workforce resiliency and the importance of engaging their staff. The concept of behavioral science will be reviewed and how this can be used to understand people’s behaviors. Furthermore, practical examples of ways to increase resiliency and engagement from leadership and peers will be shared.

Click here to view presentation

May 3, 2023 03:40 pm

Closing Plenary

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

Christopher Jones

Ashby Wolfe

Dr David Nilasena

Dr Doug Jacobs

Dr Michelle Schreiber

Dr Marcel Salive

Scott Cooper

Stephanie Mercado

Susannah Bernheim

Thomas Lee

Directors Corner Dr. Bertagnolli

Dr Michelle Schreiber

Jonathan Perlin

Jean Moody Williams

Directors Corner Dr. Sandbrink

Dr Sean Michael

Stella Stace Mandi

Posters

POSTER # 1

Make Your Voice Heard Results of the 2022 CMS Request for Information

In September, 2022, CMS Office of Burden Reduction & Health Informatics posted a Request for Information, titled Make Your Voice Heard, that sought public input on barriers to accessing healthcare and related challenges. During the 60-day comment period, CMS received over 4,000 comments from individual stakeholders and organizations. This poster provides an overview of responses by topic area and highlights samples of the burdens and recommendations shared by stakeholders.

POSTER # 2

Office of Burden Reduction and Health Informatics (OBRHI)

We are a team composed of empathetic designers working daily to improve the lives of those CMS serves. Our team brings formidable skills, deep curiosity, and a commitment to our work. We build trust with stakeholders to transform messy healthcare challenges into thoughtful accessible healthcare delivery and inspire change. We elevate the customers voice and infuse their perspective into CMS' policies, programs, and operations, which supports 9 of CMS 13 strategic cross-cutting initiatives. We would love feedback on how we define our customer and specifically if there are others we should include. Please email feedback to suzanne.martin-devroye@cms.hhs.gov Thank you!

POSTER # 3

Early Intervention and Monitoring of Timeliness of Medical and Dental Visits in Foster Care Children using Data Visualization

Michigan is currently working on a Plan do Study Act (PDSA) Quality Improvement cycle, in alliance with the CMS Affinity group to improve the timeliness of initial medical and dental visits and developmental screening /psychosocial behavioral assessment metrics in foster care children. The participating HLOs are expected to follow-up with the foster care parent for scheduling initial medical visits and dental visits within 2 business days and a follow-up within 5 days. Michigan will monitor the ongoing improvement to meet the goal by developing a data visualization tool using Run charts, to assess and modify the PDSA cycle as needed.

POSTER # 4

Oral Health and Access to Dental Care Among Medicare Beneficiaries

The poster uses data from the Medicare Current Beneficiary Survey to understand Medicare beneficiaries' experiences with oral health issues, preventive oral health behaviors, and access to dental care.

POSTER # 5

Dental Coverage Status and Utilization of Preventive Dental Services by Medicare Beneficiaries

This poster uses data from the Medicare Current Beneficiary Survey to look at dental coverage and utilization of preventive dental services among community-living Medicare beneficiaries in 2019.

POSTER # 6

Health Literacy: A Prescription for Patient Empowerment

Many people do not fully understand the medical information behind their healthcare decisions. Research shows that nearly 25% of chronic kidney disease patients experience limited health literacy. Health literacy is how well someone can find, understand, and use health information. The End Stage Renal Disease National Coordinating Center (ESRD NCC) National Patient and Family Engagement Learning and Action Network (NPFE- LAN) created resources to help patients understand their care options better to make informed healthcare decisions. Benefits may include improved health literacy, compliance to treatment, patient-provider communication, mental health, patient satisfaction, and health outcomes.

POSTER # 7

Waitlist Management: Right Patient, Right Kidney, Right Time

Throughout the transplant journey, several members of the transplant team may be involved as the patients move through the transplant center's system with the goal of receiving a kidney transplant. Once a transplant center receives the referral from the dialysis center or the nephrologist office, a transplant team member may contact the patient to begin the evaluation process. Ongoing education and periodic diagnostic evaluations ensure that the right patient is ready for the right kidney at the right time.

POSTER # 8

Top Waitlisted Patient Reviews

During year one of the ESRD Treatment Choices Learning Collaborative, Augusta University Health Solid Organ Transplant Program initiated a waitlist management improvement project, centered on increasing the number of deceased donor kidneys transplanted. Each month, the multi-disciplinary team receives a list of approximately 30 top waitlisted patients (active/status 1 and inactive/status 7). Each list is updated monthly and worked from the top down. The transplant program has incorporated top waitlisted patient reviews into normal operations and will continue to use a data-driven approach to ensure candidate readiness. Augusta's results demonstrated 27% of active patient reviews were transplanted within 6 months.

POSTER # 9

Swimming Upstream Pathways To Advance Health Equity in Kidney Care

Disparities persist in End-Stage Renal Disease (ESRD) patient outcomes, and disadvantaged populations bear a disproportionate burden of disease incidence and mortality. Patients living in disadvantaged neighborhoods are more likely to encounter barriers to care. To close the gap of disparities, there is a need to ensure equitable access to care. Facilities can adopt and implement equity promoting strategies, such as social workers connecting patients to relevant community-based resources and following through with referrals, to meet non-medical social needs.

POSTER # 10

Superior Health Readmission Sprint

This QIO/ESRD collaboration to improve transitions across the care continuum was developed with a goal of reducing readmissions for Medicare beneficiaries in both the QIO and ESRD Networks. Using an improvement sprint with 31 hospitals and 17 dialysis facilities, Superior Health implemented multiple interventions including four learning webinars (e.g., gap analysis, evidenced-based resources), a Transitions of Care Assessment, a toolkit of resources, and the use of a social networking site to share challenges and best practices, and promote networking across care systems and specialties. Next steps will include 1:1 coaching calls, assisting with follow-up needs, and tracking progress.

POSTER # 11

Process Improvement to Auditing and Tracking ESRD Grievances

To increase visibility, transparency, and identify gaps related to grievances, Alliant Health Solutions (ESRD Networks 8 and 14), created tool to track and document cases in the Patient Contact Utility (PCU) and ensure all cases are edited and in compliance with the contract requirements. The tool, which captures the number of grievances and access to care cases opened and closed each month, also uses an alert system when a case is nearing a deadline by changing colors and counting days to the closure of a case. Overall, the tool ensures effective strategies are employed to increase satisfaction in case resolutions.

POSTER # 12

Patient Resources: Toolkits Created BY Patients FOR Patients

The Forum of ESRD Networks' Kidney Patient Advisory Council (KPAC) has developed multiple patient resources to support the ESRD patient community. These toolkits created BY patients FOR patients include key topics such as grievances (e.g., patient rights, what to do when you are unhappy with your dialysis center), depression (e.g., demands of dialysis, coping with anxiety and depression, types of help available), financial help resources (e.g., medical bills, job seeking, going back to school, public/private resources), and transplantation (e.g., navigating the process, patient stories, risks/rewards, questions to ask your care team.)

POSTER # 13

Patient Navigators: Facilitating Improvements in the Kidney Transplant Journey

The ESRD Transplant Choices Learning Collaborative (ETCLC) engages people living with kidney disease and donor family members to share their lived experiences. Together, patients, donor families, transplant centers, organ procurement organization, and donor hospitals, implement initiatives to improve the number of patients who seek placement on the kidney transplant waitlist, increase patient knowledge of high Kidney Donor Profile Index (KDPI), and improve the number of patients who accept and receive a kidney transplant. Additionally, the patients and families are developing tools and resources to reach people in their transplant journey.

POSTER # 14

Patient Engagement Beyond Borders

The rate for lower limb amputations related to diabetes in zip code 29203 (South Carolina) was double the state average from 2016 - 2020, and a large portion of residents in that zip code experience food apartheid. Dialysis centers are also common in this zip code since vascular pathology is often followed by kidney disease and other health issues. One Virginia man, and Network 5 patient subject matter expert, has gone beyond borders to fight disparities in 29203. His work includes providing education, harnessing digital technology, partnering with Network 6 regarding diabetic foot checks, and identifying food share opportunities.

POSTER # 15

Partnering to Advance Health Equity

African Americans, Hispanic Americans, and Native Americans are more likely to have kidney failure than the general population. Racial minorities have a higher risk of progressing to end stage renal disease more rapidly and are also less likely to receive a kidney transplant. To combat these issues, ESRD Networks 10, 11, and 12 partnered for a regional collaboration to advance health equity. Interactive learning sessions focused on defining health equity and cultural competency, discussing social determinants of health, engaging underrepresented communities, and applying intercultural strategies. Next steps will identify leaders, create strategies, and spread concepts.

POSTER # 16

Mental healthcare was not designed for everyone

Clinical approaches to mental health are built on decades of research lacking representation from people of color and diverse communities. Providers are traditionally not equipped with tools to effectively address the psychological and sociological impacts of culturally diverse experiences in society and in the workplace. One solution is to offer a best-in-class special network that includes a culturally responsive model focused on recruitment (e.g., licensed masters and doctoral-level providers), training (e.g., case conceptualization), and growth (e.g., clinical rounds, case reviews). Results indicate that only 11% of participants drop off after their first session, which is historically 20-57%.

POSTER # 17

Increasing Incident Patient Starts to a Home Modality

Factors emerging during COVID that reduced access to outpatient dialysis for patients in Oregon and Washington. An estimated 450 patients in the two states boarded in hospitals for several months while awaiting access to outpatient dialysis. Comagine Health ESRD Network 16 convened a coalition of hospital administrators, discharge planners, dialysis providers, and ESRD educators to find ways to facilitate urgent-start dialysis. The coalition identified key barriers and developed strategies to support more timely access to dialysis for patients. Solutions were implemented at two hospital chains and decreased the number of boarding patients to pre-pandemic waiting levels.

POSTER # 18

HSAG ESRD Networks Improve PFE in QAPI and Life Planning

HSAG (ESRD Networks 7, 13, 15, 17, and 18) successfully worked with facilities to increase patient and family engagement (PFE) in Quality Assurance and Performance Improvement (QAPI) and the use of life planning for patient goals. This effort identified dialysis facility areas of improvement (e.g., making QAPI easily accessible to patients, understanding the difference between life plans and plan of care). Strategies implemented included targeting facilities for data- driven 1:1 technical assistance, utilizing resources created by patients for patients, and spreading best practices (e.g., breaking down larger life goals into smaller, more achievable pieces), which resulted in significant improvement in PFE.

POSTER # 19

Waitlist Management The Hot List” Approach

Organ discard rates are rising despite changes to the kidney allocation system, which were intended to improve organ utilization. With more than 88,000 people awaiting a kidney transplant, it is vital that every viable organ be transplanted. NYU Langone Health created the “Hot List” approach to increase utilization of hard- to-place organs. The “hot list” of patients refers to all patients added to the waitlist who are ready for transplant. All patients on the waitlist are aware of every option to be transplanted quickly, and appropriate candidates for each organ type are approached with the option to accept the organ offer.

POSTER # 20

Forum of ESRD Networks Toolkits: Valuable Resources for Patients and Providers

As part of its mission to support ESRD Networks and dialysis facilities, the Forum has created toolkits that are regularly updated to provide freely disseminated information to dialysis facilities and those that they serve (providers and patients). Based upon utilization data, it appears that the toolkits are becoming increasingly utilized by the nephrology community. Feedback from the ESRD Networks and members of the dialysis community help direct future toolkit projects with an ongoing effort to focus on specific areas of unmet need as determined by the CMS statement of work and patient and provider goals of care.

POSTER # 21

Disaster Resources Created by Patients for Patients

The involvement of patient subject matter experts (SMEs) in the National KCER Patient and Family Engagement Learning and Action Network (N- KPFE-LAN) ensures that the patient voice is incorporated into all KCER activities and encourages a patient perspective for emergency and disaster preparation. N-KPFE-LAN members collaborated to create several patient-centered resources during 2022 and 2023, including a KCER communication plan to capture vital information, a dialysis patient evacuation resource, and a guide to create a dialysis patient go-bag with basic items needed in the event of an emergency.

POSTER # 22

Decreasing Kidney Non-Use Through Kidney Allocation Process Improvement

The Midwest Transplant Network (MWTN) operates progressively regarding donor selection and routinely pursues sub-optimal donors. It identified the opportunity to improve post- recovery with the allocation process. To decrease discards, MTWN utilized retrospective and ongoing data collection, implemented a structured process for making expedited open offers, created a list of transplant centers likely to accept sub-optimal kidneys, held in-depth weekly reviews of each donor case, and conducted weekly Organ Utilization meetings to discuss each donor case in which organs were not used. Strategies implemented resulted in the non-use rate of kidneys decreasing by 3% at the end of 2022.

POSTER # 23

Prevention, Early Detection, Treatment and Recovery for Substance Use Disorders: Reducing Avoidable Readmissions for Substance Use and Mental Health Treatment

In Pennsylvania, the number of fatal drug overdoses has steadily increased since 2012. To address the impact of this epidemic, the Department of Human Services (DHS), Office of Mental Health and Substance Abuse Programs (OMHSAS) partnered with the Medicaid Behavioral Health Managed Care Organizations (BH-MCOs) to implement its Performance Improvement Project (PIP). The PIP focuses on clinical interventions, American Society of Addiction Medicine (ASAM) Criteria implementation and concurrent pharmacotherapy and counseling in SUD treatment. This poster highlights statewide performance and interventions implemented by BH-MCOs that have attributed to these improved rates.

POSTER # 24

A New Tool to Monitor Integrated Physical and Behavioral Health Key Performance Indicators at North Carolina Medicaid

North Carolina Medicaid has piloted a dashboard to track key performance indicators among integrated care, which prioritizes whole-person care coordination for physical, behavioral, and social drivers of health. The metrics are disaggregated to understand disparities by race, ethnicity, county, and between standard and tailored plans. Standard plans offer integrated physical health, care coordination, and behavioral health services, whereas tailored plans offer services for significant mental health needs, intellectual/development disabilities, traumatic brain injuries, and substance use disorders (SUD). Data sources for the dashboard include claims and encounters data, along with data collected from the 1115 SUD waiver.

POSTER # 25

Utilizing Health Net's Disparity Dashboard to Identify and Address Perinatal Health Inequities in Los Angeles County for Black Birthing People

Health Net is committed to promoting birth equity and addressing the maternal care disparity gap for Black birthing people. To identify maternal care disparities, Health Net's disparity dashboard was utilized as a comprehensive data analysis tool. The dashboard's data shows the disparity for the prenatal and postpartum HEDIS measures present in the Black Medi-Cal population, living in South Los Angeles County. The dashboard also interlays the segmentation of data by race, ethnicity, language, socioeconomic, and provider characteristics for a comprehensive overview of the disparity. This allows for a focused and comprehensive barrier analysis at the member, community, and provider levels.

POSTER # 26

Interactive Data Website Used to Improve Healthcare Quality in Texas Medicaid

The Texas Healthcare Learning Collaborative (THLC) Portal displays healthcare quality measure results and other performance data on Texas's Medicaid programs. The THLC Portal is publicly available at https://thlcportal.com and designed to provide information to stakeholders and the public. This poster describes the functionality of the portal and how it is used for quality improvement.

POSTER # 27

The Role of Data Visualization in Evaluating the Advanced Medical Home (AMH) Program in North Carolina Medicaid

North Carolina Medicaid has adopted the Advanced Medical Home (AMH) program for delivering care management. The AMH program requires prepaid health plans (PHPs) to delegate certain functions to providers who are certified as AMHs. These measures are used by the PHPs to develop performance targets and VBPs for their providers. NC Medicaid utilizes Tableau dashboards to effectively communicate measure set performance across AMH tier, provider size, and geographic location. Visuals from these dashboards are essential components of presentations to internal and external stakeholders and demonstrate the outcomes of the first six months of AMH performance under managed care.

POSTER # 28

Use of Data Visualization Tools to Transform Virginia Medicaid Quality Data

The Virginia Department of Medical Assistance Services (DMAS) has developed a variety of data visualization tools to make quality data more accessible for audiences. DMAS QPH Units' data visualizations are focused on CMS Adult and Child Core Set measures by utilizing the NCQA HEDIS® measures demonstrated by Tableau dashboards. DMAS has aligned the dashboard benchmark performance requirements to the 2023-2025 Quality Strategy. The strategy encompasses the Performance Improvement Project (PIP) deliverables including; quality of care and identifying opportunities for improvement. The dashboard consists of seven HEDIS® categories utilized by DMAS and can be accessed at Managed Care HEDIS Dashboards.

POSTER #29

Data Visualizations Reveal Disparities with the Utilization of Telehealth Among Medicaid Beneficiaries

Access to telehealth services is critical as they decrease barriers to preventive and primary care. A combination of claims, encounter, and self-reported data (via the Consumer Assessment of Healthcare Providers and Systems [CAHPS®] Survey) collected by NC Medicaid and an External Quality Review Organization (EQRO) reveal disparate outcomes among the utilization of telehealth services. These visualizations illustrate how demographic factors may influence the likelihood of utilizing telehealth services and being offered these services. NC Medicaid utilizes data visuals to inform decision-making among internal and external partners, monitor utilization, and evaluate the adequacy and effectiveness of services.

POSTER #30

Ensuring Beneficiary-Centeredness In Capturing The Beneficiary Experience

This poster presents how the Beneficiary and Family Centered Care Survey Center (BFCC-SC) administers the Experience Survey to Medicare beneficiaries who have gone through the complaints and appeals processes with the BFCC-Quality Improvement Organizations. The BFCC-SC describes the Experience Survey processes of training, administration, analysis, and feedback and the associated outcomes.

POSTER #31

Antipsychotic Medication Use in Long-term Care

Kepro BFCC-QIO Communications
The Centers for Medicare & Medicaid Services (CMS) and Kepro collaborated to perform an in-depth review of focus studies and survey reports to take a closer look at skilled nursing facilities (SNFs) and determine if antipsychotic drugs are being appropriately and safely used for Medicare beneficiaries.

POSTER #32

Ensuring Accurate Medicare Part A Payment Through Review and Education

Although Beneficiary and Family Centered Care - Quality Improvement Organizations (BFCC-QIOs) like Livanta routinely provide case review services on behalf of Medicare beneficiaries, claim review services are additional activities provided by Livanta and funded by the Centers for Medicare & Medicaid Services (CMS). Claim review services represent an important activity of advancing Medicare's triple aim of better health, better care, and lower costs. This poster summarizes findings from Year One of this national contract, including the amount of improper payment amounts. https://www.livantaqio.com/en/ClaimReview/index.html https://livantaqio.com/en/ClaimReview/Regions.html

POSTER #33

CLAS Implementation Plan

The TMF Quality Innovation Network-Quality Improvement Organization Health Equity Improvement Strategy builds awareness of health disparities through educational programs, and uses stratified data to identify health disparities and provide technical assistance to health care providers and stakeholders. Key to this strategy is leveraging tools and resources that support the delivery of equitable, patient-centered care, such as the National Culturally and Linguistically Appropriate Services standards. Effective cross-cultural communication skills Admissions Guide for Partnership for Community Health members Admissions Guide for Partnership for Community Health members (Spanish) Diabetes Zone Tool Diabetes Zone Tool (Spanish for Puerto Rico)

POSTER #34

Linking Data to Advance Health Care Quality and Equity

Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIOs) provide a range of services to Medicare beneficiaries. One of these services includes supporting beneficiaries when they need to appeal a health care provider's decision to discontinue services or discharge them from the hospital. The National Coordinating & Oversight Review Center (NCORC) links appeals data from the BFCC-QIO program with other Medicare and socio-demographic data to better understand and improve healthcare services for Medicare beneficiaries.

POSTER #35

Livanta Facilitates Quality Improvement through Inter-Agency Coordination

Livanta conducts quality of care reviews to determine whether the quality of services provided to beneficiaries met professionally recognized standards of healthcare. Some quality of care reviews are referred to the Beneficiary and Family Centered Care – Quality Improvement Organization (BFCC-QIO) from other Medicare contractors. Through this process, Livanta's independent physician reviewers determine if the care provided met the professionally recognized standards of medical care. When a confirmed quality of care concern exists, Livanta refers the case, as appropriate, to the respective Quality Innovation Network (QIN)-QIO contractor for ongoing monitoring and/or educational assistance to ensure that improvements are sustained by providers. https://www.livantaqio.com/en/Beneficiary/Quality_Of_Care

POSTER #36

Medication for Opioid Use Disorder (MOUD) in the Primary Care Setting

Comagine Health conducted a six-state monthly educational webinar series featuring faculty presenter Mandy Sladky, advanced practice nurse, to assist primary care sites in the development or expansion of MOUD treatment services in primary care settings. Participants were challenged to address the clinical and system support evidence- based practices that result in effective MOUD treatment delivery, as well as the longstanding issue of stigma in health care culture toward people with struggling with substance use disorder.

POSTER #37

Building Quality Improvement Capacity in Long- Term Care Centers

This poster presents a unique partnership between Comagine Health and the University of Washington to offer a quality improvement (QI) certification program to nursing home staff. The curriculum offered a broad overview of QI approaches designed to build capacity for successful implementation of QI projects in the nursing home setting.

POSTER #38

Applying Cost Benefit Analyses to Quality Improvement Initiatives

Stakeholders interested in understanding the costs and benefits of quality improvement initiatives should harness appropriate data and evaluation methods to develop quantifiable estimates of intervention value. In this session, we describe how Telligen's delivery of Targeted Response support to 745 referred nursing homes for COVID-19-related initiatives yielded demonstrable benefits including 22,240 resident infections prevented, 8,229 hospitalizations avoided, and 1,815 resident deaths averted. We estimate a Return on Investment (ROI) (92.4, indicating that for every dollar spent by CMS saved $92.40 in healthcare costs) by contextualizing CMS' investment with an accounting of resident outcomes following nursing home staff completion of quality improvement plans. We will describe our data collection activities, consisting primarily of secondary data wrangling and published literature reviews, which minimized respondent burden and generated reliable values. Among several options for understanding effectiveness, we delineated a propensity score model to identify a control group of nursing homes. For clarity on using these data, we enumerate the calculations in our difference-in-difference model and examine the robustness of our ROI estimate by considering data and methodological concerns. Following this session, participants will be able to identify key data components and methods in cost benefit analyses that may be applied to other initiatives.

POSTER #39

Is your Nursing Home Ready for an Emergency?

QIN-QIOs were activated to assist nursing homes and communities in building capacity for emergency preparedness. This support includes offering self-assessments for managing emergencies, assistance with developing and updating actionable emergency plans, and support with operationalizing plans. As a result, Telligen developed an online Emergency Preparedness Assessment tool for long-term care facilities to assess their emergency preparedness plan (EPP). This tool is designed to evaluate emergency readiness, identify gaps within a current EPP, and provide real time feedback. Prior to launching the tool, we vetted it with nursing home leaders to assess usability and value. One nursing home administrator commented, “The assessment is a good measuring stick in identifying critical elements in the plan, to ensure they have been met and successfully implemented, as well as addressing those areas that need improvement.” To date, 67% of enrolled nursing homes have reviewed their EPP. Additionally, to secure engagement, we incorporated completion of the assessment into our nursing home recognition program, to recognize nursing home's efforts to strengthen emergency preparedness and protect the most vulnerable. In this session, the Telligen QIN-QIO will provide an overview of our emergency preparedness assessment tool, discuss common gaps identified, and strategies we've deployed to address identified gaps.

POSTER #40

Social Determinants of Health - The Heart of CLAS

Identifying and addressing health equity requires organizational commitment and implementation of CLAS standards. Telligen QIN QIO is committed to incorporating health equity as a foundational element across all our work, in every effort, across every community. Using the CMS Framework for Health Equity to inform action, Telligen developed a CLAS Standard framework to support our partners with the tools, resources and interventions needed to provide respectful, inclusive and equitable care. Our CLAS framework provides a hands-on guide our partners can use to implement incremental, measurable short-term and long- term goals using quality improvement methodologies. We begin by establishing organizational commitment to advance health equity, then conduct an organizational assessment and offer enhanced technical assistance, including monitoring for sustainability. This poster demonstrates how our framework supports providers and communities with advancing health equity. Source: A Practical Guide to Implementing the National CLAS Standards: Centers for Medicare and Medicaid Services, Office of Minority Health, 2016

POSTER #41

Addressing Health Equity through a Targeted Focus on Culturally and Linguistically Appropriate Services

Every level of health care treats and serves diverse populations. Minorities of racial and ethnic origin with limited English proficiency and individuals who have trouble hearing or may be deaf, are more vulnerable to poor health outcomes when confronted with poor communication. Health care professionals can provide more effective communication and language assistance by delivering Culturally and Linguistically Appropriate Services in the community to ensure all patients receive high quality, equitable care. This poster highlights HQIN-provided interventions and examines the impact on improving communication with Medicare beneficiaries in areas with low health literacy or those with disabilities and/or language barriers.

POSTER #42

Managing Opioid Use Disorder in the Emergency Department (MOUD in the ED)

Comagine Health implemented an ECHOâ„¢ series focused on building best practice programs for management of opioid use disorder in the Emergency Department. Topics included neuroscience of addiction, screening, patient education, naloxone co-prescribing, buprenorphine pharmacology and initiation, social determinants of health, peer specialist support, and harm reduction. Participants conducted a gap analysis of their current program, assessed barriers, created action plans, and received ongoing technical assistance. ED toolkits disseminated included patient education packets, buprenorphine initiation, harm reduction, and Naloxone co-prescribing protocols. Fifteen facilities and one healthcare system are working to fully implement MOUD in their ED. Nine facilities developed mature programs.

POSTER #43

Mapping Medicare Disparities Tool

The MMD Tool is an interactive map identifying geographic areas of disparities between subgroups of Medicare beneficiaries. The MMD Tool contains and visualizes health outcome measures for disease prevalence, costs, hospitalization for 60 specific chronic conditions, emergency department utilization, readmissions rates, mortality, preventable hospitalizations, and preventive services. It is an excellent starting point to understand and investigate geographic and racial and ethnic differences in health outcomes.

POSTER #44

Making the Connection: Helping Hospitals Apply the Five Patient and Family Engagement Best Practices to All-Cause Harm Reduction

The five Patient & Family Engagement Best Practices foster partnerships between patients, clinicians, and staff to reduce harm by encouraging meaningful conversations and actions that can increase patient safety. IPRO HQIC piloted a tool that identifies how each PFE Best Practice can be used to engage patients in actions that contribute to harm reduction or prevention; how hospitals can identify patients at greatest risk of any harm to prioritize partnership at the point of care; and how harm measurements of concern for the hospital may be the focus of partnership in hospital operations.

POSTER #45

Prevalence of Self-Reported Kidney Disease in Older Adults by Sexual Orientation

Existing research identifies disparities in chronic kidney disease (CKD), however, little is known about chronic kidney disease in lesbian, gay, bisexual and transgender (LGBT) older adults. In summary, we found that LGBT+ older adults reported higher rates of kidney disease than their heterosexual counterparts. These results underscore the importance of addressing the interaction between CKD risk factors and the social and medical marginalization of older LGBT+ adults. These findings also support increased access to screening for CKD risk factors, preventative education, culturally responsive and affirming care, and addressing other societal drivers of health disparities in older LGBT+ adults.

POSTER #46

2022 Compass HQIC Reducing Readmissions ASPIRE+ Method

Readmissions continue to be an area of focus for HQIC hospitals. Standardization of best practice approaches varies by state and by hospital. Reducing readmissions requires a multifocal approach with critical appraisal to recognize high utilization of populations in rural hospitals. ASPIRE+ Method assists teams in how to identify a subpopulation(s) to take specific, practicable, action-oriented steps forward that demonstrate improvement through reducing readmissions. Utilize the ASPIRE + Method to promote hospital use of data and evidence-based structures to reduce readmissions using an equity lens.

POSTER #47

A HAPI Prevention Program: Eliminating Hospital Acquired Pressure Injuries

Preventing hospital acquired pressure injuries (HAPIs) in healthcare has been a challenge for many years and aging patient populations and increasing comorbidities and acuities have intensified these challenges. When this project was first launched, they implemented two-person skin assessments that were to be completed twice per week. They quickly learned that this was not enough to be successful. This led to the creation of the validation process, which allowed leaders to hold staff accountable to the expectations. HAPI prevention is now part of the unit's culture and staff remain engaged in the prevention process.

POSTER #48

Improving Sepsis Care in A Critical Access Hospital

Sepsis is a life-threatening condition where there is systemic organ dysfunction secondary to an infection. More than 210,000 people die nationally from this condition and the critical access hospital environment is not immune. Data is reported to the Hospital Quality Improvement Contractor measuring compliance with an evidence-based 3-hour bundle that has been shown to decrease mortality associated with the disease. Data for both a 3- and 6- hour bundle is also reported to CMS. The goal is to provide consistent and high-quality care to patients with sepsis including both those who are admitted to the Sturgis Hospital and those who are transferred to a higher level of care by following the CMS Management Bundle.

POSTER #49

Opioid Prescriber Safety and Support Program

Clinicians across the nation continue to face one of the most devastating public health crises in decades: the overuse and abuse of prescription and illicit opioids. Opioid-related adverse drug events, physical dependence, development of opioid use disorder (OUD), and opioid overdose have become an increasingly common part of medical practice. In response to the CMS Opioid Prescriber Safety and Support (OPSS) Task Order, the Iowa Healthcare Collaborative (IHC) has developed the national Compass Opioid Stewardship Program. This program supports providers through education and outreach to improve prescribing practices and increase the use of non-opioid pain management therapies.

POSTER #50

Care Partner Program: Reducing Readmission

This poster provides an overview of one hospital's journey to implement a care partner program. EQIC's Care Partner framework supports utilization of an individual appointed by the patient who is included as a member of the care team accepting mutually-agreed upon patient care responsibilities during and between episodes of care. Utilizing the framework, the team developed a new workflow and process to help patients designate a Care Partner upon admission. As a result of these interventions, the readmission rate at this hospital decreased by 29% from baseline, to a rate of 6.23. Patient satisfaction scores improved in key areas.

POSTER #51

Continued Focus Improves Readmissions Efforts

This poster features the results of a 10-part Readmissions Affinity Series HQI hosted from January 2022 through May 2022. The interactive sessions delivered practical and feasible readmission reduction strategies. Early results and feedback indicate this series was successful in helping hospitals implement these strategies to reduce readmissions. The Hospital-Wide, All-Cause 30-Day Readmissions chart compares rates between series participants, non-participants, and discovery participants (five hospitals who committed to attending the series and sharing their experiences with the group). Another run chart highlights a hospital's results. Tool Links: Ideas that Work - Circle Back The Readmissions Interview Seeing Sepsis Stoplight Tool

POSTER #52

COVID-19 and Increased CLABSI in Acute Care Settings

The COVID-19 pandemic placed unprecedented stressors on the healthcare system. Large volumes of high acuity patients, staffing shortages, and lacking resources resulted in significant drift from standard work designed to reduce line usage and mitigate central line blood stream infections (CLABSI). The pandemic resulted in an exponential increase in device utilization and lack of maintenance care leading to more CLABSI than reported in over a decade. This poster highlights the successful interventions used by HSAG HQIC to reduce CLABI in the inpatient hospital setting.

POSTER #53

Alaska Flex Readmission Reduction Collaborative: Targeting Health Literacy & Social Determinants of Health

Readmissions are associated with unfavorable patient outcomes and high costs. To reduce readmissions, the Alaska team launched a learning collaborative using the ASPIRE model for whole person transitional care. Ten rural and tribal hospitals participated. The collaborative discovered the top diagnoses for readmissions at all hospital types was sepsis. The top diagnosis at critical access hospitals was alcohol related disorders. The group saw a reduction in readmissions across hospital types and discovered opportunities for future work including improving access to behavioral health services. The collaborative will continue into 2023.

POSTER #54

Freestone Medical Center: Improve Compliance with Sepsis Bundle in a Rural Hospital Inpatient Prospective Payment System (IPPS)

The care team at Freestone Medical Center had a lower than expected level of compliance with the Sepsis Core Measure Bundle, especially during patient transitions between hospital units. The hospital implemented training on using the bundle and added a new sepsis-screening tool for use by emergency department staff in the electronic medical record. These actions resulted in increased bundle compliance, and a decrease in 30-day sepsis mortality.

POSTER #55

Lessons Learned from the Introduction of Peer Recovery Services into the Maternal Opioid Misuse (MOM) Model

The incorporation of peer-support services provided by people with lived experience with substance use disorder (SUD) is an integral part of seven MOM Models. This poster presents lessons learned from MOM Models that implemented peer recovery services during the first year of model implementation. Lessons learned cover a variety of areas, including the recruitment and identification of peer support staff to provide model services, and the challenges and successes MOM Model awardees and their partners encountered when incorporating people with lived SUD experience into their clinical teams.

POSTER #56

Early Intervention and Monitoring of Timeliness of Medical and Dental Visits in Foster Care Children using Data Visualization

Michigan is currently working on a Plan do Study Act (PDSA) Quality Improvement cycle, in alliance with the CMS Affinity group to improve the timeliness of initial medical and dental visits and developmental screening /psychosocial behavioral assessment metrics in foster care children. The participating HLOs are expected to follow-up with the foster care parent for scheduling initial medical visits and dental visits within 2 business days and a follow-up within 5 days. Michigan will monitor the ongoing improvement to meet the goal by developing a data visualization tool using Run charts, to assess and modify the PDSA cycle as needed.

POSTER #57

Come to the Data- CCSQ Data & Analytics

Establish standards and governance to drive visibility, quality, access control, usage, lineage, and security of data and resources

POSTER #58

2023 CCSQ Support Central

The CCSQ Support Central website was created to provide our customer base with an advanced level of technological support to help them meet CMS reporting requirements. The user-friendly interface is intended to serve as a resource hub where customers can submit tickets, track existing tickets including status and resolution notes, send comments directly to the agents working on your ticket, and reopen resolved tickets. Updates for 2023 include Call Scheduling, Live Chat and sms verification.

POSTER #59

Transplant: Innovation Driving Success

The IPRO ESRD Program, including Networks 1, 2, 6, and 9, utilized multiple innovative solutions to drive improvement in waitlist and kidney transplantation. Key strategies included the use of technology (e.g., online portals, IPRO Learn), collaborations (e.g., health equity organizations, Chronic Kidney Disease educators), best practice sharing (e.g., simplified health literacy evaluation tools for transplant), and patient-to-patient engagement (e.g., peer mentorship program, Patient Expo). IPRO's kidney transplantation and wait listing rate was higher than the national average during the past year and IPR0 is transplanting as well as adding more patients to the waitlist this year than last which supports another strong performance year.

POSTER #60

Strategies to Address Barriers in PFE for Quality Measure Development

Jennifer Bitterman Jennifer.bitterman@rainmakerssolutions.com

Person and Family Engagement (PFE) is pivotal for creating healthcare quality measure tools that are impactful and meaningful to patients and families. Measure development contractors (MDCs) benefit from strategies to encourage patients and families from diverse backgrounds to participate on technical expert panels, work groups, and focus groups to provide their lived experience as data for improved quality measures. The Person and Family Engagement Network (PFEN) is an innovative network of patients and families that resolves barriers to participating on MDC projects by educating patients and families about their role and impact as partners in healthcare improvement while simultaneously supporting MDCS on best practices for engaging patients and families for quality data.

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POSTER #61

CMS Introduces Telehealth Indicator, Continues Phased Public Reporting of Doctor and Clinician Performance

Noy Birger nbirger@acumenllc.com

Background information on public reporting goals. Feature on new telehealth indicator, which will enable patients and caregivers to identify clinicians whose offices they may not always need to travel to in order to receive care. This information will likely be useful to patients who have transportation/mobility challenges, or live far from care providers. Summary of information reported for PY 2021 vs. past years. Summary of reporter volume for PY 2021 vs. past years.

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POSTER #62

eCQI Resource Center listens to our users

Rhonda Schwartz Rhonda.Schwartz@icf.com

The Electronic Clinical Quality Improvement (eCQI) Resource Center website is the centralized hub for stakeholders engaged in electronic clinical quality improvement and is the source of truth for the specifications for electronic clinical quality measures (eCQMs) used in CMS programs. Since its creation in 2015, the Centers for Medicare & Medicaid Services (CMS) and the eCQI Resource Center team have worked to provide a user-friendly website with the most up-to-date information pertaining to the standards, tools, and technical requirements of eCQMs in CMS quality reporting programs. The eCQI Resource Center poster will highlight several enhancements to the eCQI Resource Center requested by end users including a measure compare feature (ability to view versions of eCQMs side by side), the improved eCQI Tools and Key Resources, eCQM navigation and filtering, Digital Quality Measures, and value set information. The eCQI Resource Center is constantly under review and seeks to update the information to remain current on evolving standards, tools, and terminologies to support eCQI. The poster will highlight ways to become involved with the eCQI Resource Center User Group, a volunteer forum of eCQI Resource Center users that use the site to obtain resources necessary for eCQM development, implementation, reporting, and education on key eCQM and eCQI concepts and standards.

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POSTER #63

Moving from United States Core Data for Interoperability (USCDI) to real-world data capture for support of electronic clinical quality measures (eCQMs) and digital quality measures (dQMs) requirements for patient-centered care.

Floyd Eisenberg feisenberg@iparsimony.com

USCDI advances standardized data capture to support eCQM and dQM requirements for patient-centered care. Recent examples include clinical test results, social determinants of health (SDOH), sexual orientation/gender identity (SOGI), functional & cognitive status, and physical activity. However, detailed specifications for capturing and sharing such data require interoperability standards with terminology bindings to allow common understanding across care settings. The Health Level 7 (HL7®) US Core® Road Map 2022 and Quality Improvement Core (QI-Core®) provide a direct pathway to USCDI concepts, commonly used data elements, and QI-Core profiles for authoring eCQMs and dQMs. HL7’s US Core project team evaluates each USCDI version requirement in Fast Healthcare Interoperability Resources (FHIR®) to achieve operational interoperability. US Core ballots six months after each USCDI publication (January 2023 for USCDI v3). Further, QI-Core updates the following September after each US Core version. Thus, QI-Core updates annually providing profiles for authoring quality measures consistent with the method information technology systems share the data for routine clinical care. HL7 Accelerators (e.g., Gravity, CARIN Alliance, Argonaut) further engage their communities in developing and using these standards. This poster will review the balloting and publication processes to clarify how change moves from proposal to real-world data capture for increasing eCQM and dQM effectiveness.

POSTER #64

Findings from the OY2 Hospital Evaluation Study: The Combined Effects of HVBP, HACRP, and HRRP on Measured Outcomes

This poster presents a summary of findings from a 2022 evaluation of impacts from three CMS programs (Hospital Value Based Purchasing [HVBP] Program, Hospital Acquired Condition Reduction Program [HACRP], and Hospital Readmission Reduction Program [HRRP]) from FY2018 to FY2022 payment determination years. The study evaluated (1) reductions in adverse outcomes targeted by the programs over time, (2) variation in performance across hospitals, and (3) performance improvement after penalty. The study was conducted by the Value, Incentives, and Quality Reporting Program (VIQR) Monitoring and Evaluation (M&E) Project.

POSTER #65

CMS Care Compare and Provider Data Catalog: Key Enhancements to Available Quality and Provider Data

In September 2020, the Centers for Medicare and Medicaid Services (CMS) launched a streamlined redesign of the eight existing healthcare compare tools that were available on Medicare.gov, resulting in two new tools, Care Compare and the Provider Data Catalog. There have been significant enhancements to the quality and provider data available to patients on Care Compare and PDC, increasing transparency and making it easier to find information that is important when shopping for healthcare. We review some of the enhancements by provider type, that have been implemented since the launch of the new tools.

POSTER #66

Addressing the Opioid Crisis and Increasing Patient Safety

Congress enacted the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) of 2018 to address the nationwide opioid crisis. Section 2003 of the Act mandates electronic prescribing for controlled substances (EPCS), including opioids, under Medicare Part D prescription drug plans. EPCS enhances patient safety through identity checks, safety alerts, medication menus, electronic history files, and medication recommendations that lower the risk of fraud, errors, and potentially harmful interactions. The CMS EPCS Program began measuring compliance with the law on January 1, 2023. An overview of the program requirements and timeline are included.

POSTER #67

Highlights of the CMS Measures Management System (MMS)

Highlights of the CMS Measures Management System (MMS)

POSTER #68

Coordinating the Kidney Transplant Community to Improve Outcomes through Actionable Collaboration

Julie Moss, Gayla McClain, Katrina Dinkel

The ESRD Treatment Choices Learning Collaborative (ETCLC) centers around three National Aims: Increasing deceased kidney transplants, decreasing the discard or un- transplanted kidney rate, and increasing the percentage of high-KDPI kidneys recovered for transplant. The collaborative represents more than 400 organizations, including 80% of Transplants Centers, 93% of Organ Procurement Organizations, and two of the largest Donor Hospitals in each Donor Service Area. Together, the ETCLC drives improve through the use of QI Teams, change package strategies, pacing events, case studies, and the sharing of lived experience by patients and donor families.