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In this issue: Using CAHPS® for Quality Improvement • Meet DSRIP Goals • Intended Redesign of PCMH™ Recognition ProcessNYS Medicaid Program RevisionsCAHPS® for PQRS • Criminal Attacks #1 Cause of Healthcare Data BreachesPCCC™ Standards Now AvailableDirector's Corner 
Using the CAHPS® Clinician & Group Survey for Quality Improvement—Moving Results Into Actions
You’ve taken the first step and are conducting surveys of your patients to measure their experience with
 your practice. Now what? Using the information from the CAHPS®1 Clinician & Group Survey (CG-CAHPS) can help your practice improve the quality of experiences your patients have when visiting your office. Knowing how to use the survey results allows you to review patient feedback and turn it into actionable improvements for your practice. Following some simple steps can help lead you through your efforts and ultimately improve patient experience.

Surveying patients regarding their experience, as well as incorporating findings into action items for the practice, provides opportunity to not only improve patient quality, but your practice culture as well. The first step is to make an organizational commitment to excellence in patient care, as well as having all staff fully embrace the benefits of optimizing the patient experience rating.

Once your organization is ready to embrace change, you need to determine where specific changes can or need to be made to improve the patient experience. The results of the CG-CAHPS survey are a perfect place to find areas for improvement. Looking at survey results, you can identify opportunities within your organization that should be further explored. Looking at trends in your results, comparing your organization’s results to benchmarks, and reviewing patient feedback and organizational priorities can all help you identify areas where efforts can be made for improvement. You also learn areas that are important to patients.
Based on the survey results, your leadership team should identify and prioritize opportunities for improvement. Typically the practice should focus on one area at a time. Further analysis into the opportunity should be conducted to help uncover the causes of the negative patient ratings. Observation and/or mapping of a process, analysis of administrative data tied to the process, and additional small-scale or questioning related specifically to the process can all help to uncover the root cause of the problem. 

Use multiple resources to identify opportunity ideas, including staff, patient advisory groups and the internet. Once all of the options are on the table, determine which change(s) can help you achieve your goal for improvement. Solutions should be an evaluation based on opportunities and should consider practicality, feasibility, cost and potential impact for change. When beginning to address opportunities, the practice will want to select an area where they are confident positive impact can be made. An early success will resonate with patients and motivate staff to tackle other, perhaps more different, opportunities.

Celebrate success with your staff when change implementation yields positive results in the patient experience. Engage staff and patients when a change does not improve scores to determine why it didn’t make the expected impact; identify other approaches that could help the practice along its path to improvement. This should be an ongoing effort for your organization and through it all, your patients will appreciate your focus on providing high quality patient experience. RMS Healthcare has experience working with physician practices to provide staff training opportunities, implementing new process activities and applying patient experience data.

1 The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program, is a registered trademark of the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.  
Market Research Can Help Meet DSRIP Goals

Across the country, health care and community resource providers have joined together to transform our health care delivery systems, reducing the upward cost curve of Medicaid spending while ensuring access to appropriate, quality care. States have been given the opportunity to reinvest federal savings in programs, which at the highest level, are designed to meet the triple aim objectives set by the Institute for Healthcare Improvement (IHI) of improving population health, improving patient experience of care and reducing per capita cost. One key approach being implemented here in New York State is the Delivery System Reform Incentive Program (DSRIP), which specifically targets how healthcare is provided to Medicaid patients.

New York State has structured its DSRIP initiative to promote coordinated community networks of care called Performing Provider Systems (PPS). Performing Provider Systems combine providers of hospital care, primary care and community resources that service a community’s Medicaid population. Each PPS submitted an application to New York state, identifying transformational initiatives based on its Community Needs Assessment, which would meet the primary goal of reducing avoidable hospital care by 25% over five years. This process took place in 2014. Avoidable hospital use includes reducing preventable emergency room use, reducing preventable hospital re-admissions and focusing on preventive care. Funding for eligible providers is paid throughout the five-year transformation DSRIP program and is based on the PPS’ progress in meeting milestones toward achieving stated goals. In a previous edition of the healthcare newsletter, we spoke of our experience in providing community needs assessments to Performing Provider Systems as they sought to obtain approval to participate in the State’s DSRIP. At several points over the five year period of the program, PPS must supply the State with metrics and benchmarks to assess their progress. Now that PPS' across the country are firmly entrenched in DSRIP, there are additional roles for market research firms to assist in evaluating performance or other assistance in meeting their goals. Specific research roles include community engagement activities and patient experience measurement.  

Throughout the DSRIP process, stakeholder and community engagement is critical to the overall success of the program. Stakeholders include 1) patients uninsured or insured by Medicaid, 2) healthcare workers and providers that serve the Medicaid community, 3) representatives from community resource organizations and 4) community residents with commercial health insurance. The processes used to engage these stakeholders include individual interviews (IDI’s), focus groups and surveys. One unique way to engage community stakeholders in “real time” is by using a pre-qualified, on-line panel recruited and managed by the market research firm. These methods allow for benchmarking and longitudinal tracking required to report performance against stated goals.

At the conclusion of the DSRIP program, it is expected that the health care delivery system targeting Medicaid patients, as well as ambulatory care, will provide accessible, high quality healthcare in the most appropriate setting and de-emphasize care provided in the hospital. One means of recognizing successful transformation is through receiving National Committee for Quality Assurance’s (NCQA) Patient-Centered Medical Home recognition (PCMH). PCMH recognized practices proactively engage their patients, including Medicaid covered patients, in achieving the IHI triple aim goals. To that end, it is expected that primary care practices participating in the DSRIP will become PCMH 2014 Level 3 recognized no later than DSRIP's Year 3. 

Another means is to incorporate patient experience outcome metrics through the CG-CAHPS survey tool. The survey is administered to patients to assess any disparities in the patient experience of care. Using a certified CMS vendor to administer the survey provides benchmarks and longitudinal change information needed for improving process and optimizing patient experience.

RMS - Research and Marketing Strategies, Inc., with a successful history of assisting practices in obtaining Patient-Centered Medical Home recognition, is uniquely qualified to provide assistance to a PPS. For further information on services we can offer to your PPS, please contact us at 1-866-567-5422.

NCQA Announces Intention to Redesign PCMH™ Recognition Process

The National Committee for Quality Assurance (NCQA) has announced that it is redesigning the Patient-Centered Medical Home (PCMH) recognition process to better engage practices in an ongoing assessment of compliance with PCMH standards.  

Four key goals of the newly redesigned PCMH program will be to:
  1. Strengthen the link between recognition and practice performance;
  2. Align PCMH recognition activities with other reporting requirements;
  3. Leverage the practices’ investment in health information technology; and
  4. Increase practice engagement while reducing non-value added work. 
Under consideration for the redesign are:
  1. Engaging practices in an annual "check-in," rather than submitting documentation every three years, including a demonstration of how the standards are integrated into every day practice culture and how they continue to enhance their patient-centered approach to care;
  2. Reducing the documentation burden by introducing opportunities for virtual demonstration of processes and using information generated in the course of patient care to support alignment with the standards; and
  3. Offering education and guidance to practices undergoing the transformation process including live support, enhanced on-line resources and improved customer service
Organizations which have pursued PCMH Recognition truly understand first-hand how this recognition has directly contributed to improved patient care. Practices that have had experience with the PCMH Recognition process and have worked directly with NCQA are encouraged to reach out to NCQA and provide thoughts and ideas and pertinent questions that will facilitate a successful launch of the new review platform. If you are engaged currently or have been involved in the recognition journey, visit the NCQA website and/or email NCQA at regarding your thoughts, ideas and concerns. If you would like to be regularly informed of upcoming changes, you may wish to consider enrolling in NCQA’s subscription center here.
New York State Medicaid Program to revise incentives for NCQA Recognized Primary Care practices

Effective January 1, 2016, New York State Medicaid Program is changing the Patient-Centered Medical Home (PCMH) Statewide Program Incentive payments for providers recognized by the National Committee for Quality Assurance 
(NCQA). Originally slated to take effect on April 1, 2015, the state has delayed implementation to January 1, 2016 to allow practices with Medicaid patient panels additional time to become recognized under the PCMH 2014 program (guidelines).

The State’s new policy and billing guidelines applies to both Medicaid Managed Care and Fee-for-Service (FFS) insurance programs. Payments will be reduced for those practices currently recognized under PCMH 2011 and will be significantly increased for those practices recognized under PCMH 2014

The revised policy and delayed implementation date is designed to incentivize New York State Medicaid providers to seek recognition under the more robust standards of the PCMH 2014 program. Ultimately, the Medicaid Redesign Team and State Health Innovation Plan hope to improve care, reduce per capita cost and improve population health. As a result, all incentive payments for providers recognized through Physician Practice Connections
® - Patient-Centered Medical Home™ (2008 standards) were eliminated effective April 1, 2015. Physician practices from other states should check with their state Medicaid departments for rules applying to local incentive payments. 

To review the schedule and details of the Patient-Centered Medical Home Statewide Program Incentive Payment contained within the March 2015 New York State Department of Health Medicaid Update, click here.

The Affordable Care Act mandates that all eligible professionals in practices of two or more physicians, who are receiving payment for Medicare Part B fee-for-service under the Medicare Physician Fee Schedule (MPFS), participate in public reporting of patient experience with Physician Quality Reporting System (PQRS). The goal is to have clinical and patient experience data publicly available to Medicare beneficiaries, allowing for comparison between health care providers based on clinical and patient experience quality outcomes.

Practices with 100 or more physicians have included patient experience measures for calendar year 2013, reported in 2015. Beginning this year (2015), practices with two or more physicians participating in the PQRS program must measure patient experience through use of a survey tool with the goal to publicly report patient experience as well as clinical performance measures in 2016. The number of providers within the practice dictates whether the practice must contract with a Centers for Medicare and Medicaid Services (CMS) qualified survey vendor to administer the CAHPS for PQRS survey. Practices with two to 99 providers have the option of using a certified vendor, but are not required to do so at this time. Practices with the choice of using a certified vendor should consider the advantages of using a certified vendor, particularly the quality of reporting provided by experienced certified vendors and lessening the burden of survey administration to the practice.

CMS is currently certifying vendors to conduct the CAHPS for PQRS survey on behalf of medical practices. This survey administration is similar to the process conducted on behalf of clinicians and groups, hospitals, home health agencies, in-service dialysis centers and Accountable Care Organizations. RMS - Research and Marketing Strategies, Inc. is a certified vendor for all of these CAHPS® patient measurement surveys and has applied to CMS to become a preferred vendor for CAHPS for PQRS. It is anticipated that the survey instrument will mirror the ACO-CAHPS version in terms of required number of completes, composites covered, question styles and acceptable modalities; specifically mixed mode with telephone calls to beneficiaries that do not return mailed surveys. Practices that participate in PQRS should stay tuned for details on the requirements for those participating physician groups expected from CMS in summer 2015. Interested stakeholders can watch for upcoming details in our RMS blog or the CMS website.
Criminal Attacks Now Number One Cause of Data Breaches in Healthcare

According to a recent study published by the Ponemon Institute, criminal attacks are now the number one cause of data breaches in healthcare. In the five years that the Institute has studied the privacy and security of healthcare data, there has been a significant growth (125%) in intentional criminal attacks. Types of criminal activity included spear phishing, Web-borne malware attacks and stolen computing devices. The chart that follows illustrates the multiple accessible platforms available for criminal access to valuable patient data.

Source: Ponemon Institute

This year’s report also included business associates, recognizing their role and the associated risk of sharing data in the healthcare delivery system. Security processes should include an assessment of protection available to defend against breaches covering any and all platforms, including those where any business associate has access to patient protected health information.

Despite the fact that criminal activity is now the number one cause of data breaches, the study shows that security professionals continue to concentrate on issues of employee negligence at the expense of concern for criminal attacks. Survey respondents indicated that limited resources, expertise and processes mean that healthcare organizations are not prepared to address this increased data breach risk. The findings also highlighted the astounding number of breaches healthcare organizations and their business associates experienced. Over the past five years:
  • 91% of covered entities have had a breach. Among Business Associates (BAs), 59% have had a breach and 15% had five or more in the same time period
  • 78% of healthcare organizations and 82% of BAs had a Web-borne malware attack
  • 65% of healthcare organizations and 87% of BAs had an electronic information security-based incident in the past two years and half the combined groups had paper-based incidents
The study highlighted that healthcare organizations and their business associates are at great risk of criminal activity and often lack the resources necessary to securely manage sensitive patient data. To meet this challenge, healthcare organizations need sufficient resources to adopt a comprehensive program for privacy and security assessments, training of staff and processes that ensure the security of any protected health information including shared information with business associates in the course of their business. To view the study by the Ponemon Institute, click here. RMS Healthcare can help your organization conduct comprehensive assessments and develop policies, processes and staff training programs to protect you and your patients. If you are interested in learning more, please contact Susan Maxsween, Senior Director of Healthcare Operations and Compliance or at 1-866-567-5422.
Patient-Centered Connected Care™ Program Standards Now Available

The National Committee for Quality Assurance (NCQA) Patient-Centered Connected Care™ (PCCC™) standards are now available for non-traditional practices wishing to seek recognition of their quality-driven patient care. NCQA is offering this program in response to the plethora of choices that patients have in seeking episodic care as well as the need to emphasize the importance of clinical integration and communication in the medical neighborhood. Being recognized affirms that the non-traditional practice is working within the framework of the medical neighborhood, effectively communicating and sharing patient information with primary care practices. Eligible practices include urgent care centers, onsite employee health clinics and school-and-retail-based clinics.

Sites that wish to be recognized will need to meet a minimum score across five standards. Unlike Patient-Centered Medical Home™ (PCMH™) recognition, there are no levels of recognition status; either a practice is recognized or it is not. Practices will be evaluated on five program standards including:
1.    Connecting with Primary Care
2.    Identifying Patient Needs
3.    Patient Care and Support
4.    System Capabilities
5.    Measure and Improve Performance

RMS Healthcare can assist providers in non-traditional and traditional practices in their transformation journey and/or NCQA recognition. Practices or providers interested in PCCC can purchase the standards and obtain more information from NCQA’s website.
Celebrating RMS' 13th Anniversary with a
Cinco De Mayo Bash are (from left):
Meghan House, Anna Ragonese, Bonni Nelson, Jennifer Rafferty and Heather Banks
Celebrating RMS' 13th Birthday and Cinco de Mayo!
Congratulations Sandy Baker!
RMS would like to recognize and congratulate our own Sandy Baker, Senior Director of Business Development & Corporate Strategy, for being the recipient of the 2015 House of Providence's Humanitarian Service Medallion from Catholic Charities. Sandy's dedication to the local community has earned her immense respect and we're honored to have her on our team, applauding her tremendous success!
congratulates Meghan House on her recent promotion

and Welcomes Maggy Terpstra 
and Colin Hack to the Team!

Director's Corner
Susan Maxsween, Senior Director of Healthcare Operations & Compliance

In this edition of the newsletter, we shared information on important topics in the area of protecting patient information, measuring and providing quality patient experience as well as newsworthy and upcoming developments from the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS) and New York State Medicaid Incentive Program. In addition, we spoke to the Delivery System Reform Incentive Program (DSRIP) being undertaken in several states to transform the health care delivery system to provide accessible, high quality ambulatory care; thus reducing the need for higher cost hospital care.

A common theme throughout these articles is the need for healthcare providers to transform their operations aligning with the Institute of Healthcare Improvement's (IHI) triple aim concept of improving population health, improving patient experience of care and reducing per capita cost. NCQA programs continue to evolve to improve the standards of care for primary care practices and others across the medical home neighborhood. Patients are encouraged to become more engaged in their care, including choosing their providers based on CMS-mandated, publicly-available, quality information. State Medicaid Programs, including those of New York State, continue to financially encourage eligible providers through incentives such as PCMH and DSRIP, to integrate and sustain processes which align with patient-centered care and provide appropriate, cost-effective levels of care to patients. The CAHPS Clinician & Group article offers suggestions on using patient satisfaction scores and process improvements to affect real change in patient experience.

Our team of healthcare consultants is as passionate about providing patients with high quality patient-centered care as our clients. Whether you are looking for assistance in development of HIPAA policies and procedures, measuring your patient experience or transforming your practice, we have dedicated team members that can help. Please email me at or call 1-866-567-5422 to discuss how we can assist your practice.
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