Quality Assessment and Performance Improvement Report - January 2019
There are four areas all InnovAge PACE centers focus 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
The medication delivery project is intended to improve timely delivery of medications to PACE participants. To do this, InnovAge will implement standardized procedures for re-ordering medications and improve training on re-ordering and distribution processes, including direct delivery from the pharmacy, as well as cycle refill for eligible participants. The pharmacy group will develop proactive measures to ensure participants re-order medications on time, transportation will ensure all medications are delivered on time, and a detailed process will be created for any missed deliveries.
Colorado: Wound Risk and Assessment
Pressure wounds are a complex clinical issue that reduce quality of life for our participants. The wound care team was created with representation from all InnovAge PACE centers to standardize the process for identifying particiapants who are at-risk for pressure wounds using the Braden score method. The wound care team also works to standardize the process for ordering wound treatments through electronic medical records in order to reduce the number of reportable Level II pressure wounds. A wound care specialist joined InnovAge's primary care team to provide additional expertise at the centers with the goal of shortening the time it takes to heal and increasing participant satisfaction.
New Mexico: Infections
Infection tracking and trending for InnovAge New Mexico PACE includes monitoring trends with participants and employees. When a participant or employee is ill, an infection/infestation report is filled via InnovAge's incident reporting system. Reports are tracked by the quality department and monitored for trends. If a trend is identified, proactive measures may be taken to mitigate its spread, depending on the organism and location. Identified organisms will be reported to the New Mexico Department for Public Health and Environment, per state guidelines. Examples of items that are reported and tracked include pneumonia, influenza, norovirus, bed bugs, scabies, and others. Annual competency training also educates InnovAge staff about the infection control policy and disease reporting guidelines. During flu season (November through March), weekly communications are sent to the clinical nurse manager to keep them informed about vaccination rates, including a list of participants who still need appropriate vaccinations. This process improves performance awareness and helps nursing staff focus their outreach efforts.
Pennsylvania: Day Center Safety
The InnovAge Pennsylvania LIFE (IPAL) Emergency Preparedness Manual was developed and approved by the state. As part of InnovAge's ongoing emergency preparedness development, IPAL attends the monthly North Zone Healthcare Coalition meeting in Philadelphia. Further, as part of the CMS regulatory requirement, these meetings provide additional emergency planning information and resources, as well as develop a connection with other entities that may assist in emergency situations. Annual emergency drills and education are provided to staff with re-evaluation of current emergency practices following trainings. Emergency risk assessments for each center are reviewed and updated at least annually to identify specific vulnerabilities at each center and determine any necessary modifications to the emergency plan.
Virginia: Medication Delivery & Education
InnovAge Virginia PACE (IVAP) will continue to educate PACE participants and caregivers regarding medications in InnovAge's current fiscal year. This education will consist of information about providers, the medication delivery process, medication packaging, and home medication destruction. Partnership meetings will also be held to improve communication, processes, and efficiencies for the medication delivery process. IVAP has a pharmacist that reviews medications and partners with the primary care team to improve safety and compliance. The goal is to ensure that participants do not experience an increase in medication errors, medication related incidents, or hospitalizations.
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.
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