QIOs in Action: How BFCC-QIOs Help Patients Take Action

Help Spread the Word!: 

Sometimes Medicare patients need to make quick decisions or find themselves in circumstances that require pressing action. Whether it is difficulty scheduling an appointment or concerns about not receiving critical medical equipment, patients can feel pressure under the weight of such situations. But just because there isn’t much time doesn’t mean that Medicare patients have to act alone.

Within the Centers for Medicare & Medicaid Services’ Quality Improvement Organization (QIO) Program, two Beneficiary and Family Centered Care-QIOs (BFCC-QIOs) administer a free program for people with Medicare called Immediate Advocacy.

Under this program, BFCC-QIO staff spring to action to try and make sure Medicare patients get the information they need to make important decisions. Immediate Advocacy is an informal dispute resolution process used to quickly resolve a verbal complaint a Medicare patient has regarding the quality of Medicare-covered health care. It is a voluntary program for both the Medicare patient and the provider.

One real-world example of the importance of the Immediate Advocacy program comes from KEPRO, a BFCC-QIO representing more than 30 U.S. states.

A Medicare patient had concerns about her hospital discharge plan regarding wound care. She had undergone a hernia repair and was sent home from the hospital with a non-functioning vacuum-assisted closure pump and no direction for receiving home health care.

Soon after discharge, the staples came out of her wound, leaving it open. The patient called a home health care agency to ask for a home visit to assess the wound, but after an initial evaluation, agency staff told her that she did not qualify for home health care because she was not completely homebound.

Frustrated, the Medicare patient decided to seek further help. She felt that due to her situation, she should qualify for home health. She called KEPRO, her state’s BFCC-QIO, and a representative agreed to contact the home health agency on her behalf.

KEPRO contacted the director of the home health agency and explained that the patient only left her house once a week to get groceries, and even that was difficult for her. The director promised to call the patient about providing home health services. If the patient was able to verify her homebound status, the agency could start home health; if not, the agency would arrange outpatient services.

Results

KEPRO received a message from the director of the home health agency several days later. The director said that the patient did indeed meet the criteria for being homebound and that the home health agency had admitted the beneficiary for wound care services. During a follow-up telephone conversation with KEPRO, the patient expressed sincere appreciation and stated that this would not have happened without the BFCC-QIO’s assistance.