Quality Assessment and Performance Improvement Report - May 2018
There are four areas all InnovAge PACE centers are focused on monitoring and improving: falls, participant/caregiver satisfaction, serious reportable events, and grievances. The following report is a summary of our progress in each focus area.
Falls. Falls are an important issue. That’s why multi-disciplinary teams at each InnovAge PACE center are continuing to focus on falls, working through the standardized fall review process, and improving interventions. This includes investigating each fall, as well as falls risk-inducing drugs, short physical performance battery, and timed up-and-go tests to identify future fall risks and implement interventions to prevent falls.
Participant/Caregiver Satisfaction. Satisfaction surveys are distributed bi-annually by a third-party vendor, capturing 100 percent of participants and caretakers. The survey consists of 29 questions and focuses on six main areas: access to care, coordination of care, self-management support, satisfaction with services, and caregiver support. Some questions on the survey mirror questions also asked on the Consumer Assessment of Healthcare Providers and Systems survey, which enables InnovAge to benchmark answers to the community.
Serious Reportable Events. InnovAge will continue to investigate and report unusual incidents that result in adverse participant outcomes or negative media coverage related to the PACE program. We will continue to report incidents to CMS within three working days, collaborating with regulatory agencies to enhance internal quality assurance and risk management activities. InnovAge will perform internal investigations and analysis of the occurrence to identify system failures and opportunities for improvement. Once InnovAge is aware of the issue, we will immediately correct any identified problem that potentially or directly threatens the health and safety of a PACE participant.
Grievances. The grievance process is in place to provide an official forum for participants and caregivers to inform InnovAge of individual concerns about the program. At each InnovAge PACE center, a designated representative receives each grievance, and then identifies the appropriate person to resolve the issue in question. Closer monitoring of this process is displayed on the dashboard with the number of records received and how many are considered unresolved as a visual reminder that each grievance should be closed within the 30 days. Acknowledgment postcards and resolution letters are mailed to the complainant to increase communication with participants and caregivers.
California: Medication Delivery Project
This project is intended to improve timeliness of medication delivery to participants, with a goal of reducing the number of grievances related to medication deliveries by 50 percent at InnovAge California PACE – San Bernardino. InnovAge will implement standardized procedures for medication reordering, improve training on the reorder and distribution process, and implement best practices seen at other InnovAge PACE centers. The pharmacy team will develop proactive measures to ensure participants reorder medications on time, transportation will ensure all medications are delivered on time, and a detailed process for resolving any missed deliveries will be created.
Colorado: PCMH Accreditation Renewal
InnovAge’s Colorado PACE centers are working on renewing its Patient-Centered Medical Home (PCMH) recognition in fiscal year ‘18. PCMH accreditation has shown to lower costs, improve patient experiences, and lead to better health outcomes. The application process for PCMH involves providing data, workflows, and supporting documentation that show sustained and ongoing care of PACE participants.
New Mexico: Grievance Process
The grievance process is in place for participants to inform InnovAge New Mexico PACE – Albuquerque of concerns about the program or any goods and services provided. During the past four years, the Albuquerque PACE center has consistently recorded a grievance rate of 0.9 percent annually, which is substantially lower than their target goal of 2.5 percent. In the first quarter of last fiscal year, the center began to record grievances differently than they had previously based on a finding during a CMS site audit in March 2016. As part of a corrective action plan, InnovAge developed a new policy and form for recording grievances. In the current fiscal year, the Albuquerque PACE center will transition to using a new grievance log, established by CMS, (and a new target goal of less than 5 percent) to record all grievances and their outcomes.
Virginia: Day Center Safety
As the InnovAge Virginia PACE – Roanoke Valley census continues to grow, the physical space of the PACE center is becoming more crowded. During the second part of 2017, the attendance committee reviewed the number of days participants attended the center based on their medical needs, physical needs, and safety at home. During 2018, InnovAge’s Virginia PACE center is developing a tool to determine center attendance and educational programs for day center safety, such as power chair/wheelchair safety. To help address the space constraints, InnovAge will make physical changes to the center, such as wider hallway areas for traffic patterns, increased dining space, and safety exit doors.
Flu Vaccinations. Every InnovAge PACE center met the CMS goal of an 80 percent vaccination rate. All centers met InnovAge’s goal of 90 percent vaccination, except InnovAge’s San Bernardino and Aurora PACE centers.
Data and Charts: Key Performance Indicators
The following is a dashboard visualization of QAPI data to highlight key performance indicators, metrics, and initiatives.
No data was reported during Oct – Dec 16