There were only 160 hospitals nationwide that participated in the CMS voluntary hybrid readmission measure pilot and Memorial Health Care Systems was one of them. Taunya Schlueter is a clinical analyst at Memorial Health and was instrumental in implementing the hybrid measure pilot program for her hospital. Today she shares with us what that process looked like and why it was important for her hospital to participate.
|Name: Taunya Schlueter BA, RN
Job Title: Clinical Analyst, Information Technology
Hospital: Memorial Health Care Systems
The hybrid readmission measure isn’t required for submission to CMS until 2023, why was it important for your hospital to participate in the voluntary submission period in 2018?
Actually, at the time we made the decision to participate, we weren’t even sure if these hybrid measures would ever become a requirement. At Memorial Health we put a high value on patient care, and for us that means using every tool at our disposal to validate the excellent patient care we provide our patients.
The hybrid readmission measure data was something we wanted to see. We assumed we were already collecting all of the information on these patients in our EHR, but this gave us the opportunity to see where there were gaps. It also gave us the chance to understand what this new risk stratification model would tell us about our patient population.
And of course, our hospital prides itself on being ahead of the curve and this was one way we could do that.
Can you tell us about the process of getting the hybrid measure set up?
The set up was super easy. We already had the Medisolv ENCOR software, which is where the hybrid measure was going to be captured and reported. My Medisolv consultant Pam Feeler guided me through the entire process. Pam gave me all of the details including which core clinical data elements would need to be mapped, what it would look like in the Medisolv software and what we would be focusing on during the pilot.
So, I went into our EHR, found where these core clinical data elements were located and mapped them according to the specification Pam provided me. We had to get all of this set up before the start of the pilot program so that during the pilot we would be capturing the data we needed for this measure.
The mapping part didn’t take very long, maybe a few days. If I ran into any issues, Pam helped me troubleshoot. Then Pam validated it to make sure it was pulling in and we were ready!
When did the pilot program take place?
It ran January 1 through June 30 of 2018.
During that time what did you have to do to monitor your performance?
It did require ongoing monitoring of our data. Using the Medisolv software, ENCOR, I could see which patients were in the denominator or in the numerator. With Medisolv you can narrow it down to those that are just in the denominator and furthermore you can see why they didn’t get into the numerator. From there you can figure out what’s going on with those patients, whether it was, for instance, a compliance or a mapping issue. Then you can fix it.
But honestly, it wasn’t a lot of work to do that monitoring. Mostly because we didn’t have a lot of people that didn’t meet the numerator. Like I said, we were capturing most of these core clinical data elements in our EHR already. And that was proved with our submission performance. We ended up with a 95% when we submitted. That was awesome to see.
So, speaking of submission, what did the submission process look like for you?
The submission process was really easy. Pam notified me that the submission process was going to start. She sent me a screenshot of our final results and together we confirmed the data looked right. Then Pam submitted the data on our behalf. That was it. Then this year, we received our hospital specific report back from CMS with our results.
Does your hospital plan to participate in the 2021 voluntary reporting period?
Yes, we do. In general, I think the hybrid readmission measure offers a better way of risk adjusting our population. And monitoring the measure performance during the pilot was a good way for us to confirm that we were capturing those super important items like patients’ baseline vital signs such as blood pressure and heart rate.
I think the more detail you have to accurately get a picture of your patients the better. And I think the hybrid measures will give us a better picture.
Do you have any advice to other hospitals thinking about setting up the hybrid measure?
My first suggestion is not to take it lightly. You should really understand how this information will be used to help your hospital, if at all. Once you understand why it will be helpful and how it will be used, then go and talk with your admin and staff. You need to be ready to explain it to them and get buy in before you begin.
I also think it’s important to have an expert who is skilled in the set-up of the hybrid measure. For us, having our Medisolv consultant was extremely helpful. Pam was amazing. She is always there whenever I need her. Anytime I have questions, even if it’s a quick meeting, she’s there. We meet monthly too to make sure things are looking good.
Any other comments before we go?
I think Medisolv has a wonderful product. I walked into this position brand new. I had a lot of medical background and some knowledge of the CMS measures from a clinical perspective, but less about the technical side of things. Pam was great at helping me to learn all of the eCQMs not just the hybrid measure. The thing I value most about Medisolv is that I have someone who can guide me through the entire process and help me figure out what will work best for our hospital technically and clinically which subsequently helps our providers, patients and staff.
It’s awesome that Medisolv has this product because I don’t know how other hospitals do it. Pam helps me use our hospital’s eCQM results to better our patient care. It has really made my life a lot easier.
To learn more about CMS’ new hybrid readmission measure, check out these other blog posts, e-books and videos from Medisolv: