member to review and comment on the sustainability plan’s feasibility. Such input should be identified in the submission to CMS of the sustainability plan. If the QIN-QIO is coordinating this plan with the care transitions sustainability plan, or other sustainability plans in its area, this information shall be included in the submission. Section E. Schedule of Deliverables The contractor shall provide all deliverables for Task B.2 – Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts (EDC) in accordance with Attachment A, Task Order 001, Schedule of Deliverables. Section F. Measurement and Evaluation of Performance See Attachment B, Task Order 001, Evaluation Measures Table for Task B.2. Everyone with Diabetes Counts measures. Also, see Section C.6, Contractor Performance Measurement in the base contract. Section G. Quarterly Minimum Recruitment for Participating Physician Practices and Beneficiary DSME Completion Targets Each of the following minimum quarterly performance targets contained in Table 1 must be met for each state/territory in the area. Table 1. Minimum Recruitment for Participating Physician Practices/Offices/Clinics and Beneficiary DSME Targets Monitoring Period (by Quarter) % of New PPs Recruited (% of QIN-QIO Target) % of New Beneficiaries Completing DSME (% of Target) Year 1 Year 1 Year 1 1 – Aug 1, 2014 – Oct 31, 2014 0% 0% 2 – Nov 1, 2014 – Jan 31, 2015 4% 0% 3 – Feb 1, 2015 – Apr 30, 2015 6% 3% 4 – May 1, 2015 – Jul 31, 2015 10% 4% Year 2 Year 2 Year 2 5 – Aug 1, 2015 – Oct 31, 2015 10% 7% 6 – Nov 1, 2015 – Jan 31, 2016 10% 7% 7 – Feb 1, 2016 – Apr 30, 2016 10% 7% 8 – May 1, 2016 – Jul 31, 2016 10% 7% Year 3 Year 3 Year 3 9 – Aug 1, 2016 – Oct 31, 2016 10% 7% 10 – Nov 1, 2016 – Jan 31, 2017 10% 7% 11 – Feb 1, 2017 – Apr 30, 2017 10% 7% 12 – May 1, 2017 – Jul 31, 2017 10% 7% Year 4 Year 4 Maintain % of PP Target Year 4
GOAL 3: Promote Effective Communication and Coordination of Care Task C.3: Coordination of Care Section A. Overview and Background Improving communication and the coordination of clinical decisions is a cornerstone of both the National and CMS Quality Strategies, and the IOM provides concrete recommendations for fostering organizational and leadership cultures that strengthen community-clinical partnerships. QIN-QIOs are uniquely situated to engage cross-cutting communities of practitioners, long-term services and support providers, and other community stakeholders to improve the quality of care for a population of Medicare beneficiaries. Employing a framework for quality improvement that centers on community organizing tactics, QIN-QIOs shall support the development of community coalitions that: Define a shared, measureable, population goal for improving care coordination in a defined geographic community. Perform community specific root cause analyses to identify the drivers of ineffective care transitions such as a lack of timely and complete communication, poor patient activation, and other system level process deficiencies that can lead to poor health outcomes including ADEs that can lead to increased utilization of acute care services Identify and implement appropriate community-level interventions that improve the coordination of care for beneficiaries and their family members across provider settings. Increase medication safety in the community to prevent adverse drug events, reduce readmissions, and improve care coordination for beneficiaries across provider settings. Collect data and determine measures to monitor community-level interventions that demonstrate improved outcomes across various populations of Medicare beneficiaries. CMS and its federal partners have employed many strategies focused on improving the care coordination and transition of Medicare beneficiaries across settings. Programs and interventions that improve care transitions from hospital to post-acute care settings such as the Care Transitions Program and Partnership for Patients Initiatives under Center for Medicare and Medicaid Innovation (CMMI), the Administration for Community Living’s Aging and Disability Resource Center Grant Programs, AHRQ’s Project RED and the Integrated Care for Populations and Communities Aim under the QIO 10th SOW have contributed to national declines in readmission and admission rates in hospitals across the country. But while there have been significant gains in reducing readmissions and admissions in hospitals, care coordination does not begin or end with an in-patient hospital stay. Beneficiaries and family