KENTUCKY REGIONAL EXTENSION CENTER

QPP Year 8 Webinar February 13: QPP Reporting Options

QPP Year 8 Webinar February 13: QPP Reporting Options

QPP Year 8: ALL ABOUT QPP REPORTING OPTIONS*
Tuesday February 13, 2024 @ 12PM ET

CMS’s Quality Payment Program continues to evolve each program year. In the current landscape, there are more avenues than ever available for reporting your Eligible Clinician’s data. All these choices can be overwhelming, and make it challenging to determine the best reporting method for your practice.

Join our team of experienced advisors as we dive into the intricacies of QPP reporting options for both Program Year 2023 (PY23) & Program Year 2024 (PY24).

We will guide you through the diverse options of data collection and submission methods for each Performance Category, and review the different levels of submission for MIPS. This will give you the facts to make informed decisions that align with your practice’s goals, and shed light on essential considerations for the various MVP reporting levels.

Already a QPP client or interested in becoming one? As a client, you receive exclusive access to our analysis of all aspects of the Quality Payment Program. To speak with the team on how we can best support you, feel free to contact us HERE.

Open to the public webinars will be available in 2024, highlighting major updates and implications for eligible clinicians and practices.

Mark your calendars for “All About QPP Reporting Options” on Tuesday, February 13 at 12pm EST.

Contact YOUR Experts at the Kentucky REC for all your QPP, MIPS/MVP, and APM Track questions. We are here to help. Call us at 859-323-3090.

*This webinar is for Kentucky REC contracted QPP clients only. If you are interested in this topic and would like to learn more about becoming a client, please contact us at (859) 323-3090 or email us at KYRec@uky.edu. We aim to be your trusted healthcare advisor!

Kentucky REC 2023 Premier Partner – Kentucky DPH

Kentucky REC Premier Partner Award: Kentucky Department for Public Health

The Kentucky Department for Public Health, and Sue Thomas-Cox especially, has had a long, successful history of collaboration with the Kentucky REC. Together we support technology innovation, performance improvement and health care transformation for health care systems and organizations across Kentucky.

Our most recent partnership to improve chronic disease outcomes would not have been possible without the confidence, trust and mutual respect between the Kentucky Department for Public Health and the Kentucky REC. Kentucky REC currently works with the Department for Public Health on numerous grant projects including Colorectal Cancer, Heart Disease and Stroke, Diabetes Management, Diabetes Prevention, Asthma, and Community Health Workers. Each of these projects strive to improve health outcomes and address barriers for patients in Kentucky.

Sue Thomas Cox is the BRANCH MANAGER of the CHRONIC DISEASE PREVENTION/HEALTH PROMOTION, Kentucky Department for Public Health, Division of Prevention and Quality Improvement. She has been instrumental in the success of all of our work with DPH. Congratulations to the Kentucky Department for Public Health as our Premier Partner!

Kentucky REC 2023 Client Quality Awards

Kentucky REC advisors are proud to work with many organizations on quality improvement programs and initiatives such as the Quality Payment Program and Patient Centered Medical Home and Specialty Practice. Awardees were chosen by their advisor team and presentations were made at our Annual Conference. We awarded the following organizations in 2023 for their exemplary performance.

The Heart of the Patient Award: Excellent Dedication to Patient-Centric Care

The Heart of the Patient Award:  Excellent Dedication to Patient-Centric Care & the Patient-Centered Medical Home – Little Flower Clinic

Little Flower Clinic achieved initial PCMH recognition in 2017 with the Kentucky REC’s assistance from one of our PCMH Certified Content Experts (PCMH CCE).  Since then they have provided high-quality patient-centered care for their community; while realizing improved health outcomes and workflow efficiencies for their patients and staff.

This past Spring they completed and passed their Annual Reporting requirements and received the NCQA Distinction in Behavioral Health. This distinction assists Primary Care practices to better integrate behavioral healthcare into their organization and acknowledges organizations that excel in this area.

Not only did Little Flower Clinic accomplish all of the previous mentioned accolades, but they also underwent an NCQA audit, passing with flying colors, while dealing with the devastating flood in their area. During that time, Little Flower Clinic had several staff members’ homes destroyed, with no electric or phone service for a period of time, and they continued to provide for their patients and community with food, water, clothing and hygiene items.

The Kentucky REC would like to recognize and award Little Flower Clinic with the PCMH client award for their work in the PCMH model of care and extraordinary commitment to their patients.

 

Outstanding Achievement Award: Commitment to Quality Improvement & QPP-MIPS

J. David Outland’s practice is a single provider dermatology clinic in Western Kentucky that has submitted to the Quality Payment Program as a MIPS Eligible Clinician since the inception of the program.

Dr. Outland’s staff first began participation in the QPP through the use of claims submission. As the program requirements changed and became increasingly more complex, Dr. Outland contacted the Kentucky Regional Extension Center for assistance in navigating this complexity. Dr. Outland and his staff have successfully navigated the program using a registry and without the use of an electronic health record system.

The practice continues to achieve a perfect score each year and receives the maximum payment adjustment available. We believe that recognizing this practice for the hard work required to assure data entered into the registry is accurate, validated and meets his practice goals is important and their work is exemplary.

The efforts of Dr. Outland and his staff proves that other clinics of similar size and settings can be successful in avoiding payment reductions while also complying with CMS’s reporting requirements for the Quality Payment Program.

The Kentucky REC would like to recognize and award J. David Outland with the QPP-MIPS IA Small Practice award for their steadfast work in Quality Improvement and the QPP/MIPS track, and their overwhelming commitment to their community and patients.

 

Kentucky REC 2023 Client HIPAA Awards

Kentucky REC HIPAA Security advisors are proud to work with many organizations on compliance with the HIPAA Privacy Rule. Awardees were chosen by the HIPAA advisor team and presentations were made at our Annual Conference. Below are the organizations chosen in 2023 for their exemplary performance.

5 Star HIPAA Security Excellence Award - Large Organization

Ephraim McDowell Regional Medical Center consistently demonstrates excellence in upholding the HIPAA Security Rule, prioritizing the protection of their patient’s health information. With a steadfast dedication to enhancing security compliance, EMRMC conducts annual security risk assessments, promptly addresses identified vulnerabilities, and reinforces safeguards as needed.

The compliance team diligently develops, implements, and provides training on new policies and procedures whenever necessary. Collaborating seamlessly, the IT and Compliance teams at EMRMC remain vigilant in monitoring the organization’s existing security measures while actively researching and adopting improved solutions. The commitment to security is deeply ingrained in EMRMC’s culture, evident throughout its extensive network of facilities, encompassing three hospitals and over 20 clinics.

 

5 Star HIPAA Security Excellence Award - Small Organization

Health First Community Health Center consistently demonstrates an exceptional commitment to safeguarding their patients’ electronic protected health information, surpassing industry standards.

During annual security risk assessments, the team at Health First consistently challenges themselves with the question, “How can we enhance our practices further?” Their security risk management team diligently provides comprehensive documentation for all required safeguards directed by the HIPAA Security Rule. Furthermore, they actively involve their workforce and leadership team in continuous security training initiatives, including engaging in a CISA-led tabletop exercise focused on cybersecurity attacks.

It is remarkable to hear clients express anticipation for the Security Risk Assessment (SRA) every year, and Health First’s team consistently shares their excitement, eagerly showcasing the improvements they have made since year after year. Their genuine enthusiasm for learning about HIPAA Security is commendable, setting them apart in their dedication to staying ahead of evolving security measures.

 

5 Star HIPAA Security Excellence Award

 

Kentucky REC 2023 Client Hospital Awards

Kentucky REC advisors are proud to work with numerous Kentucky hospitals on the CMS Promoting Interoperability Program. Awardees were chosen by the advisor team and presentations were made at our Annual Conference. Below are the organizations chosen in 2023 for their exemplary performance.

Distinguished Large Hospital System Award - ARH

The Healthcare System of Appalachia, ARH is ranked as one of the Top 10 Employers in Kentucky by Forbes Magazine. They are a not-for-profit health system operating 14 hospitals: Barbourville, Hazard, Harlan, Highlands, Mary Breckinridge, McDowell, Middlesboro, Morgan, Our Lady of the Way, Paintsville, Summers County, Tug Valley, and Whitesburg in Kentucky; as well as Beckley in West Virginia.

We began advising ARH on the Medicare PI Program at the beginning of 2021. We scheduled regular, recurring calls for the PI team and dug into the work- providing education, drilling-down on program details, and monitoring reports. We’ve watched them work together as a team and improve their performance tremendously. We’re proud to report that for the past two years, ARH has successfully attested to the Medicare PI program for all 14 hospitals. This year, they are on track to do the same with near perfect scores. We are so proud of them, their performance, and their teamwork! Congratulations, ARH!

Hospital Legacy Award - Russell County Hospital

Russell County Hospital is a twenty-five-bed community hospital that has served the residents of Russell Springs, KY and surrounding areas since 1981. We have worked with RCH since the inception of the Kentucky REC in early 2011, advising them on what was then the original EHR Incentive Program, when we used to call it Meaningful Use. We began that original work under a grant from the Office of the National Coordinator. When we transitioned over to a sustainable model, they stuck with us. Over the past 12 plus years, RCH has used nearly every service offering provided by the Kentucky REC, from MU to PI, SRA, PTN, VBPS, MIPS and every acronym in between. We enjoy working with the RCH group – they are a really great team. We appreciate our relationship and hope to work together for another 12 years. To show our appreciation we are awarding them with the KY REC Client Hospital Legacy Award. Congratulations Russell County Hospital!

 

Multi-State Hospital Partnership Award - Rural Hospital Group

Rural Hospital Group is in the business of investing in small-to-medium sized rural hospitals located primarily in less populated and more remote areas of the Central United States. This is where rural hospitals are usually the sole provider of emergency, acute care inpatient and outpatient clinic services to their communities.

While we have advised Crittenden Community Hospital in Marion, KY on the Medicare PI Program for many years, at the beginning of 2022 we added several other RHG facilities: Hillsboro Community Hospital in Hillsboro, Kansas; Lauderdale Community Hospital in Ripley, Tennessee; Drumright Regional Hospital in Drumright, Oklahoma; and Salem Memorial District Hospital in Salem, Missouri. Some were struggling to keep up with the ever-evolving requirements of the Medicare PI Program and were also reaching the program’s limit of allowable hardship exceptions at some locations. We’ve provided education and support, getting them back on track. We host a monthly conference call, bringing together the Promoting Interoperability team from each location.

This Community of Practice, bringing together multiple states, is acting as a collaborative environment to communicate, connect, and share best practices. As a result, all five hospitals have greatly improved their performance and successfully attested to the Medicare PI program. We’ve enjoyed crossing state lines and value this multi-state partnership and are very proud of their accomplishments! Congratulations, Rural Hospital Group!

Kentucky REC 2023 Client Grant Awards

2023 was a very busy year for grant funded quality improvement programs. Kentucky REC is proud to work with so many organizations committed to improving the health of our fellow Kentuckians. Awardees were chosen by the advisor team and presentations were made at our Annual Conference. Below are the organizations chosen in 2023 for their exemplary performance.

Hypertension Learning Collaborative: The Blood Pressure Buster Award

University of Kentucky North Fork Valley Community Health Center participated in the Hypertension Learning Collaborative over the past year. Their focus has been to improve hypertension in their population of focus, by identifying patients to refer to and educate patients through the CARE SMBP program and implement workflows that improve rates in statin therapy.

North Fork Valley has a wonderful physician champion, Dr. Douthitt, along with a great team that helped to facilitate the PDSA cycles that were tested and provide CARE SMBP education to their patients. They met and exceeded all of the goals that were set for each measure of the Collaborative and had great patient success stories throughout the process. This in itself is a huge accomplishment, but they were also able to make these improvements during a very hard time for Eastern Kentucky with the devastating floods that impacted their patients and staff. This clinic’s strong desire for their community of patients and their health outcomes is a driving force in their success. Congratulations to North Fork Valley for their “Blood Pressure Buster Award!”

The Colorectal Cancer Crusader Award

Pennyroyal Healthcare Services is headquartered in Princeton, Kentucky and became a FQHC in 2013. They have 3 locations: Princeton, Oak Grove, and Hopkinsville. They have participated over the past several years in multiple grants around improving Colorectal Cancer screening rates.

They have implemented several PDSA cycles such as provider assessment and feedback reports, provider reminders, and patient reminders such as writing due dates of FIT tests, and wonderful community events have led to CRC screening improvement across all clinic locations. They recognize the need to work in multiple areas to improve this measure. This clinic’s commitment spans across their staff: from their CEO, Quality Improvement Coordinator, providers, and staff, make their work a true team effort.  Congratulations to Pennyroyal for their “Colorectal Crusader Award!”

Asthma Grant Practice Innovation Award

The Kentucky REC Team would like to recognize King’s Daughters Medical Center (KDMC) for their outstanding performance in the first year of their participation in Asthma Improvement grant. KDMC is a not-for-profit, regional referral center covering a 150-mile radius that includes southern Ohio and eastern Kentucky. KDMC’s primary service area encompasses four counties in two states, Boyd, Carter and Greenup counties in Kentucky, and Lawrence County, Ohio.

The organization serves a population of approximately 175,000 lives. As part of the first year of this grant, KDMC has engaged an internal multidisciplinary team comprised of Pulmonology Administration, Pharmacy, AS-ME Certified Educators, Health Informatics, Data Analysts, and Marketing resources to lead this quality improvement opportunity across their organization. KDMC is piloting focused improvement with three adult primary care provider practices and their outpatient pulmonology practice to develop, test, and optimize successful workflows that will be scaled throughout the ambulatory population.

KDMC has developed a system-wide database to identify and monitor patients with asthma for targeted outcome improvement. They have expanded AS-ME services and have launched marketing campaigns to outreach to the community to create awareness of asthma as a disease state and how their services can help.

The improvement team has created Clinical Decision Support tools such as EHR-embedded asthma screening tools, developed built-in alerts to aid providers in identifying patients with asthma to complete ACT screenings, and have developed a more robust AS-ME referral process and tracking mechanism to monitor completion of education so that no patient falls through the cracks who could benefit from services. KDMC has hosted numerous community engagement activities increasing asthma awareness and AS-ME resources since the start of this partnership.

The team has conducted health screening fairs, provided asthma awareness education to middle schoolers across the region and have conducted in-service trainings for school nurses, athletic trainers & coaching staff as well as area fire & rescue personnel as part of this grant.  Additionally, in an effort to promote the implementation of Kentucky’s Stock Albuterol program, KDMC has partnered with Greenup County Public School System school-based clinics to provide clinic staff training & guidance in the implementation of this valuable and potentially life-saving resource for area children.

Prediabetes Learning Collaborative: Diabetes Prevention Pioneer Award

KDMC is a hospital system based in Ashland, Kentucky. They also have locations in Boyd, Carter, Johnson, Floyd, Elliott, Lawrence, Greenup Counties in KY; Lawrence, Scioto Counties in Ohio. They are currently working with patients of 2 providers; Jane Strader, MD and Shayne Bennett, APRN, for their population of focus in the Prediabetes Learning Collaborative.

These two providers currently have 1776 patients between them. Their goal is to improve the health outcomes of their patients with prediabetes by referring them to the National Diabetes Prevention Program. They are also working on identifying patients with prediabetes who are not currently listed as prediabetic in their chart. They have made impressive strides in improvements with all these measures, surpassing all goals in just the first six months of the project. This clinic’s commitment from their provider champions and improved workflow is a driving force in their success. Congratulations to KDMC for their “Diabetes Prevention Pioneer Award!”

Exemplary Coverdell Stroke Grant Partner

Cumberland Family Medical Center has been instrumental in helping to grow our work within the Coverdell grant. Their excitement and dedication for utilizing the CARE Collaborative program to help their patients has led to numerous stories of success within their patient population by improving the self-management of their own blood pressure and encouraging lifestyle modifications.

Beyond the success they’ve had with their patients, they have also provided best practices for implementation and monitoring of the CARE Collaborative program as it has spread to other grant participants. Their stewardship on implementing the CARE Collaborative and cooperation to share their barriers as well as successes has made working with this practice extremely beneficial and enjoyable. We can’t thank them enough for their hard work on the Coverdell Stroke Grant.

Diabetes Learning Collaborative: The Sweet Success Award

Mt. Sterling clinic is a small practice in Montgomery County, Kentucky.  They currently have 3 providers and are utilizing one of those providers in the current Diabetes Learning Collaborative with us and the Kentucky Department for Public Health.  They currently serve nearly 2500 patients in their rural practice.  Their goal is to improve the health outcomes of their diabetic patient population by improving A1C Poor Control, BP Control, Referrals to the DSMES program and Diabetic Eye Exams.

They have made strong strides in improvements with all these measures, nearly surpassing all goals ahead of schedule, and achieved this while learning their newly implemented EHR software earlier in the year.  They’ve also begun electronic DSMES referral usage with eClinical with staff and clinicians; resulting in more workflow efficiencies for their staff. This clinic’s strong desire for their community of patients and their health outcomes is a driving force in their success.  Congratulations to Mt. Sterling Clinic for their “Sweet Success!”