Form CMS-10356 Discussion Guide

HHSM-500-2010-00058C

Discussion Guide for Key HRR Informants

Note: The interviewee will have received a written project description and verbal explanation of the project during the recruiting call, followed by a written invitation to participate in the study and a confirmation of the date and time of the scheduled site visit and interview(s). Team members will have a site visit package in hand, including the confirmation letter, the HRR fact sheet and map, a description of the organization(s)/individuals to be interviewed, and the tailored discussion guides for each individual interviewee. The interviewer will vary the focus and level of detail of questioning to reflect the interviewees’ background, knowledge, and expertise.

Introduction

Thank you for participating in the study and having us here today. As you know, the Centers for Medicare & Medicaid Services (CMS) Office of Policy has engaged L&M Policy Research, LLC (L&M), to explore patterns of care and care management provided to those dually eligible for Medicare and Medicaid coverage, other Medicare beneficiaries with complex health needs and serious chronic illness, and persons enrolled in the Program of All-Inclusive Care for the Elderly (PACE). [NOTE: PACE would only be mentioned with regard to the two PACE HRRs.]

We appreciate your taking the time to meet with us and help us better understand the landscape of the health care delivery systems in your hospital referral region (HRR). Before we begin, please be advised that according to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to average one hour and fifteen minutes for each interview, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this discussion guide, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Do you have any questions about this disclosure statement? If not, let’s proceed.

We’d like to hear how organizations, programs, and initiatives serving these special populations have been developed and currently operate in your HRR, and the challenges, as well as success factors, associated with delivering quality and cost-effective care to those dually eligible for Medicaid and Medicare as well as those on Medicare with serious chronic illness. We are also exploring health community awareness of published quality and cost-of-care data in individual HRRs and would like to learn about the impact this data may have on activities within institutions and practices as well as on relations among health care providers/ practitioners within a given region.

We are soliciting expertise from a range of different types of individuals and appreciate your perspective on these issues. These interviews typically take an hour to an hour-and-a-half. We encourage you (and your staff) to be candid: your honest opinions and comments will be extremely helpful for the purpose of this research. And, please be assured that the information you share today will not be linked to you or your organization in any identifiable way.

General Background

I’d like to start by asking you a few questions about yourself and your role in your organization and/or program/initiative.

1. Please tell us about your background and your current role within your organization and/or program/initiative.

PROBES:

• Title, years in program/organization

• Past experience

• Responsibilities

• Organizational/program context

Program/Organization Background

2. Please tell us about your organization(s)/program(s)/initiative(s) to serve Medicare and Medicaid beneficiaries and your role within context of HRR as a whole.

PROBES:

• Mission/history/impetus

• Persons and providers involved (doctors, advocates, care givers, health system)

• Operations, major sources of funding, budget, and population reached (for each relevant initiative, past or current)

• Providers, networks, provider contracting arrangements, and provider incentives

• Specific program design(s) and evaluation

Population/Patients Served and Care Delivery

3. What are the population(s) and geographic areas you serve?

PROBES:

• Demographics

• Service area(s)

• Recruitment and retention of participants (successes, challenges, lessons learned)

  • How, if at all, does this vary for the dual-eligible population?

• Cultural differences, language, and other potential barriers to care

4. How does this population compare to the HRR as a whole? [Offer to show the interviewee a map of the HRR should it help in answering this question.]

PROBES:

• What is the estimated reach of your service area(s) within the HRR?

• Approximate area of the HRR you cover

• Do your recruitment and retention processes extend to the entire HRR?

5. Please describe your particular patient/population’s health care delivery system within the context of the HRR as a whole [If interviewee (or organization) is part of a larger network of providers, ask the following question.]

PROBES:

• Provider network (number, types or providers and contractual and financial inter-relationships)

• Extent and nature of information-sharing across system/settings (medical and administrative)

PROMPT:

• How, if at all, does this vary for the dual-eligible population?

6. Please tell us about your patient and clinical care processes and coordination across provider networks within the HRR.

PROBES:

• Medical and utilization management, to include decision-making processes and cost controls

• Use of evidenced-based medicine, national guidelines, clinical protocol

• Use of medical technology and referrals for diagnostic work-ups

• Extent to which notes, communications, appointments, and referrals across settings are available to relevant staff as well as timeliness/ease of use

• Transitions management/how identify, handle follow-up activities

• Integration of services with social workers, community agencies

• Availability of home- and community-based service providers

• Availability and quality of palliative care and hospice services

• Acceptance and use of hospice care

• Efforts to ensure that patient preferences are followed

• Involvement of family and community caregivers within network and HRR

• Other work with and referrals to other providers/across settings

PROMPT:

• How, if at all, does this vary for the dual-eligible population?

7. Please tell us about your organization’s use of HIT and community wide efforts.

PROBES:

• Use of health information technology (HIT) to include

• Decision support, data systems reporting and modeling capacity

• Use of electronic health records (EHRs)

• Use of personal health records (PHRs)

• Use of HIT to share information across settings throughout the HRR

PROMPT

• How, if at all, does this vary for the dual-eligible population?

[If the interviewee has knowledge about PHR use, ask the following question and probe based on the extent of his/her knowledge.]

8. If you can, tell us more about the use of PHRs in your organization and region.

PROBES:

• Use in care delivery or interventions for management of chronic diseases

• Barriers facing individuals with multiple chronic conditions in PHR use

• Sources of data used to populate PHRs (claims, patient response, electronic medical devices, EHRs, caregivers, providers)

• Use of chronic condition management messaging and types used (data-generated alerts, data-generated messaging)

• Receptivity of users (physicians, beneficiaries, caregivers)

• Technology used to manage Health Insurance Portability and Accountability Act (HIPAA) and other privacy issues

• Challenges to implementation, successes, lessons learned, emerging best-practice models

• Impact of public investment in EHRs with PHR use and adoption

• Evidence of improved outcomes or decreased costs

PROMPT

• How, if at all, does this vary for the dual-eligible population?

9. Describe your experience in your organization and across your HRR in working with those dually eligible for Medicare and Medicaid services (duals).

PROBES:

• Population of duals (as proportion of total) served

• Extent to which services offered differs for duals

• Efforts to integrate/coordinate care and its barriers

• Coordination with community organizations, including behavioral health organizations and community service agencies

• Communications and transitions across settings and among providers

• Specifically, integration with geriatricians, social workers, and other home- and community-based service providers – and site-specific policies, protocols, and programs associated with patients receiving care from such providers

• Availability and quality of palliative care and hospice services

• Acceptance and use of hospice care

• Efforts to ensure that patient preferences are followed

• Extent to which patient care processes & self-management/education differs for duals

• Recruitment methods, challenges in both recruitment and program participation/retention for duals

• Barriers faced by duals in receiving interventions for improving care

• Opportunities for duals to better utilize services

• Efforts to reduce inappropriate inpatient admissions or readmissions, emergency room visits

• Use of HIT, including PHRs/EHRs, telecare, remote monitoring, etc.

• Successes, challenges, and lessons learned in improving quality/reducing costs, best practices

• Do you know of any other initiatives within your HRR to better coordinate care for duals?

10. Describe your processes and/or programs in your organization and across your HRR in focusing on patients with serious chronic illness (SCI).

PROBES:

• Population of those with SCI (as proportion of total) served

• Efforts to integrate/coordinate care and barriers with the SCI

• Coordination with community organizations, including behavioral health organizations and community service agencies

• Extent to which services offered differs for this population

• Communications and transitions across settings and among providers

• Specifically, integration with geriatricians, social workers, and other home- and community-based service providers – and site-specific policies, protocols, and programs associated with patients receiving care from such providers

• Availability and quality of palliative care and hospice services

• Acceptance and use of hospice care

• Efforts to ensure that patient preferences are followed

• Extent to which patient care processes & self-management/education differs for those with SCI

• Criteria used to determine eligibility for interventions (e.g. functional status)

• Patterns of care resulting in patients receiving palliative care and number of patients referred to that type of care

• Recruitment methods, barriers in both recruitment and program participation/retention

• Staff managing SCI and management approach, goals and characteristics of interventions

• Barriers faced by duals with serious chronic illness in receiving interventions for improving care

• Extent to which patient care processes & self-management and education differs for those with SCI

• Efforts to ensure that patient preferences are followed with regard to care

• Evaluation of interventions/programs

• Local factors that relate to type of intervention chosen or approach

• Use of HIT, including PHRs/EHRs, telecare, remote monitoring, etc.

• Successes, challenges, and lessons learned in improving quality/reducing costs, best practices

• Do you know of any other initiatives within in your HRR to better coordinate care for beneficiaries with serious chronic illness?

PROMPT

• How, if at all, does this vary for the dual-eligible population?

11. To what extent are you aware of data published related to quality and costs of services in your geographic area or across the country? What, if any, impact does this knowledge have on activities within your organization or on your day-to-day practice? Does this knowledge have any impact on your relations with the other health care providers/ practitioners in your HRR?

12. Could you comment on the patterns of care in your own organization or practice that might have either a positive or negative impact on costs and quality? How about patterns of care in your HRR as a whole?

PROBES:

• Avoidable hospitalizations

• Readmissions

• Emergency department visits

• Use of post-acute services

• Inpatient versus ambulatory surgery performed at free-standing centers

• Settings for post acute care services

• Availability and quality of palliative care and hospice services

• Extent to which home and community based services are available

PROMPT

• How, if at all, does this vary for the dual-eligible population?

13. Can you speak to the history of collaboration among the key stakeholders in your region (e.g., Department of Health, Health Plans, Providers, CBOs, etc.) and the quality of their relationships?

PROBE:

• What about the prioritization of care for duals in your HRR

14. Do you have any other thoughts about the potential causes for variations in the cost and quality of care in your HRR?

PROBE:

• Community or HRR-wide efforts to address to improve quality as a whole or for particular sub-populations

Operations

15. Please describe your program(s) or organization(s) business operations to help us better understand your organizational, financial and management structure and process.

PROBES:

• Finance (payment mechanisms, provider incentives, cost structure, pricing, profit margins)

• Ownership/affiliation

• Specific cost-saving mechanisms/initiatives

• Billing processes

• Capacity management

• Labor (staffing, training, recruitment, union involvement, and retention/turnover)

16. Tell us about your management and executive information systems and technology and how they affect your ability to deliver health and/or community care to the populations you serve.

PROBES:

• Systems available and how they are used, and proliferation/use by site/setting/provider/beneficiary

• Information systems policy for relevant uses/users

• Decision support systems and reporting capacity offered to providers/clinicians

• EHR/PHR use and reception by users

• Timeliness of claims/encounter/administrative data available to clinical and administrative staff

• Status of meaningful use provider incentives and impact on executive/provider decision making

[The following question and probes will only be asked of PACE program staff if not previously answered in response to earlier questions.]

17. Please tell us more specifics about your PACE program and its operations.

PROBES:

• Current and projected enrollment and any barriers to achieving desired enrollment

• Membership demographics (gender, race, native language, geographic area)

• Member recruitment and retention rates

• Facilities/capacity

• Funding/finances/break even point/rate or return

• Interdisciplinary team training and integration

• Integration with behavioral and social services (nature and extent)

• Special initiatives/programs/models/best practices

• Program replicability and sustainability

• Market competition (other programs offering services to this population such as home- and community-based services waivers or integrated program not based on adult day center)

18. Finally, do you have any questions for us?

Thank you for taking the time to meet with us and share your insights for this important study. Your input is much appreciated.

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