December 2020 Town HallWith End-Stage Renal Disease (ESRD) Outreach,

Communication, and Training (EOCT) Team

December 17, 2020–2 PM to 3 PM ET

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Submitting Questions

Type questions in the “Q&A” section, located to the right of your screen.

Send all Q&A questions to “All Panelists”

Note: Some questions may require additional research. Unanswered questions may be submitted

to CRAFT@MyCROWNWeb.org.

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Today’s Host and Presenters

Oniel Delva, MS, CTT+Communications Director EOCT

Alissa Kapke, MS ESRD QIP Support Program ManagerArbor Research Collaborative for Health

Acronyms

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BSI Bloodstream Infection

CMS Centers for Medicare & Medicaid Services

CY Calendar Year

ECE Extraordinary Circumstance Exception

EQRS End-Stage Renal Disease Quality Reporting System

ESRD End-Stage Renal Disease

ESRD QIP End-Stage Renal Disease Quality Incentive Program

HARP Healthcare Quality Information System Access Roles and Profile

HCQIS Healthcare Quality Information System

ICH CAHPS

In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems

Kt/VDialysis adequacy measure (K–dialyzer clearance of urea; t–dialysis time; and, V–volume of distribution of urea)

N/A Not Applicable

NHSN National Healthcare Safety Network

PLR Patient List Report

POC Point of Contact

PSC Performance Score Certificate

PSR Performance Score Report

PSSR Preview Performance Score Summary Report

PY Payment Year

SFR Standardized Fistula Rate

SHR Standardized Hospitalization Ratio

SRR Standardized Readmission Ratio

STrR Standardized Transfusion Ratio

TPS Total Performance Score

UFR Ultrafiltration Rate

UI User Interface

Latest News and Reminders

Facility Dashboard: Upcoming Reminders

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• Use the ESRD Quality Reporting System (EQRS)Facility Dashboard for clinical closure reminders.

EQRS System Deadline Extended

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• The September 2020 and October 2020 Clinical Monthswere extended to February 1, 2021 at 11:59 PM PacificTime.

• Please note that this date adjustment is for the September2020 and October 2020 Clinical Months only and willhave no effect on previous or future due dates.

Reporting Month Clinical Closure Date

September 2020 Clinical Month February 1, 2021 at 11:59 PM PT

October 2020 Clinical Month

November 2020 Clinical Month February 1, 2021 at 11:59 PM PT

February 1, 2021 at 11:59 PM PT

2020 EQRS Recap

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January 2020

Medication Reconciliation Added to Clinical Screen

February 2020

HCQIS Access Roles and Profile (HARP) Released

July 2020

ESRD Quality Incentive Program (QIP) User Interface Released in EQRS

November 2020

CROWNWeb Sunset EQRS Rollout

Save the Date: CMS-2744 Training

9*Date subject to change.

• CMS-2744 Annual Facility Survey training coming February 2021.

ESRD QIP Final PSRs and PSCs for PY 2021 Now Available Online

ESRD QIP PSRs and PSCs Now Available

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• CMS has released the Payment Year (PY) 2021 ESRD QIP Final Performance Score Reports (PSRs) and Performance Score Certificates (PSCs).

• Authorized facility staff may log in to the EQRS to download and save these documents as soon as possible.

ESRD QIP PY 2021 Final PSR and PSC

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PY 2021 Final PSR• The PY 2021 Final PSR documents your facility’s performance during

2019 and any payment reduction that CMS will impose on 2021 claims.

• The Final PSR reflects any applicable revisions to your facility’s performance scores from those displayed during the Preview Period.

PY 2021 PSC• Each facility is required to download, print, and post both the English

and Spanish versions of the PSC in a prominent patient area within fifteen (15) business days of their availability; facilities also must ensure that these documents remain posted throughout 2021.

Accessing Your PY 2021 PSRs and PSCs

ESRD QIP UI Roles

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ESRD QIP Role Reports

Facility Point of Contact (POC) View and download reports (PLR, PSR, PSC)

Corporate POC View and download all reports (PLR, PSR, PSSR, PSC)

Facility Viewer View and download reports (PSR, PSC only)

Corporate Viewer(Future role)

View and download reports (PSR, PSSR, PSC only)

NOTE: Additional roles are available for Network, CMS, and CMS Support users.

NOTE: Corporate-level roles can view and access materials for all facilities owned by an organization.

Click View/Download Reports

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1. Log in to EQRS with HARP account via https://eqrs.cms.gov/globalapp/.

2. Click “QIP Scores.”3. Click “View/Download Reports.”

https://eqrs.cms.gov/globalapp/

Select Facility and Payment Year

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• Users can set filters to assist with search efforts, if they have access to multiple facilities.

• Enter Facility Name, Facility CCN or Dialysis Organization.• Click “Apply Filter.”

Select Available Reports

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4. Click on the hyperlink of the report you would like to view or click “Select” and “Download Selected Files.”

Corporate Users

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• Check the “This is an Organizational level search” checkbox and Apply Filter.

Poll Questions

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Have you downloaded your PY 2021 ESRD QIP Final Performance Score Report?• Yes• No

Have you downloaded your PY 2021 ESRD QIP Performance Score Certificate?• Yes• No

Understanding the PY 2021 ESRD QIP Final Performance Score Report

PY 2021 Preview Period Inquiries

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• PY 2021 Preview Period: July 29, 2020 to August 31, 2020• A total of 423 inquiries were received • Inquiries by theme:

– Missing data disputes• Comprehensive Kt/V• UFR reporting measure• NHSN measures (BSI, Dialysis Event reporting)

– Clarification of data used for scores• UFR reporting measure• Data reported during ECE months• Use of attestations for ICH CAHPS

– Scoring methodology• An error was identified where a COVID-19 exception was

incorrectly applied to other measures.

PY 2021 Preview Period Inquiries (cont.)

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Number of Inquiries by Measure:

UFR: 60 ICH CAHPS: 60

Kt/V: 77 SHR: 12

Hypercalcemia: 26 NHSN Dialysis Event: 52

SFR: 6 Long-Term Catheter: 7

SRR: 18 Clinical Depression: 6

STrR: 12 NHSN BSI: 75

PY 2021 Payment Adjustments

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Distribution of Payment Reductions

Payment Reduction # Facilities % Facilities

0.0% 4,679 61.4

0.5% 1,609 21.1

1.0% 929 12.2

1.5% 297 3.9

2.0% 111 1.5

Reviewing the Final PSR

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Reviewing the Final PSR (cont.)

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Reviewing the Final PSR (cont.)

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Reviewing the Final PSR (cont.)

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Reviewing the Final PSR (cont.)

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Other Final Reports

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Final Performance Score Summary Report (PSSR)

Final Patient List Report (PLR)

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PY 2021 ESRD QIP Resources

• Guide to PY 2021 ESRD QIP Performance Score Report (PSR)

• ESRD QIP User Interface (UI) QuickStart Guide

https://qualitynet.org/esrd/esrdqip/reportshttps://qualitynet.org/esrd/esrdqip/reportshttps://www.qualitynet.org/esrd/esrdqip/reportshttps://www.qualitynet.org/esrd/esrdqip/reports

Public Reporting & Certificates

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• PSSR and Public Use data files are accessible via https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/08_ReportandCert

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/08_ReportandCert

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Questions

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Thanks for Attending!

Our next Town Hall Event will be held on January 28, 2021.

Time: 2:00 PM – 3:00 PM ET

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For Further Information…

Help Me Form: http://help.MyCROWNWeb.org

Website: http://www.MyCROWNWeb.org

QualityNet Service Desk: 1-866-288-8912

QualityNet Service Desk Email: qnetsupport-esrd@hcqis.org

ESRD QIP Questions: ESRD QIP ServiceNow Q&A Tool

EQRS User Research: EQRSUserResearch@cms.hhs.gov

ESRD Network Map: https://esrdncc.org/en/ESRD-network-map/

An evaluation will pop up in your browser when the session ends.

Please follow the link and let us know what you think and what you would like to be covered in future Town Hall events, thank you!

http://help.mycrownweb.org/http://www.mycrownweb.org/mailto:qnetsupport-esrd@hcqis.orghttps://cmsqualitysupport.servicenowservices.com/qnet_qamailto:EQRSUserResearch@cms.hhs.govhttps://esrdncc.org/en/ESRD-network-map/

Disclaimer

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This presentation was current at the time of publication and/or upload. If Medicare policy, requirements, or guidance changes following the date of posting, this presentation will not necessarily reflect those changes; given that it will remain as an archived copy, it will not be updated. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. Any references or links to statutes, regulations, and/or other policy materials are provided as summary information. No material contained herein is intended to replace either written laws or regulations. In the event of any discrepancy between the information provided by the presentation and any information included in any Medicare rules and/or regulations, the rules or regulations shall govern. The specific statutes, regulations, and other interpretive materials should be reviewed independently for a full and accurate statement of their contents.

Submitting QuestionsToday’s Host and PresentersAcronymsLatest News and RemindersFacility Dashboard: Upcoming RemindersEQRS System Deadline Extended2020 EQRS RecapSave the Date: CMS-2744 TrainingESRD QIP Final PSRs and PSCs for PY 2021 Now Available OnlineESRD QIP PSRs and PSCs Now AvailableESRD QIP PY 2021 Final PSR and PSCAccessing Your PY 2021 PSRs and PSCsESRD QIP UI RolesClick View/Download ReportsSelect Facility and Payment YearSelect Available ReportsCorporate UsersPoll QuestionsUnderstanding the PY 2021 ESRD QIP Final Performance Score ReportPY 2021 Preview Period InquiriesPY 2021 Preview Period Inquiries (cont.)PY 2021 Payment AdjustmentsReviewing the Final PSRReviewing the Final PSR (cont.)Reviewing the Final PSR (cont.)Reviewing the Final PSR (cont.)Reviewing the Final PSR (cont.)Other Final ReportsPY 2021 ESRD QIP ResourcesPublic Reporting & CertificatesQuestionsThanks for Attending!For Further Information…Disclaimer