QUALITY MEASUREMENT AND THE … ASA slides_Quality...QUALITY MEASUREMENT AND THE COMMUNITY’S ROLE...
Transcript of QUALITY MEASUREMENT AND THE … ASA slides_Quality...QUALITY MEASUREMENT AND THE COMMUNITY’S ROLE...
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QUALITY MEASUREMENT
AND THE COMMUNITY’S ROLE
IN MEETING QUALITY GOALS
Aging in America Conference
March 23, 2016
12:30 – 2:00pm
Today’s Agenda
Welcome
Speaker presentations
Bob Applebaum, MSW, PhD
Erin Giovannetti, PhD
Sandy Atkins, MPA
Joanne Lynn, MD, MA, MS
Panel discussion
Moderated by Robyn Golden, LCSW
Opportunity for audience questions
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Bob Applebaum
Scripps Gerontology Center
ASA Conference
March 2016
The changes now being experienced in the aging network are dramatic (but we are not alone– law, health care, education, manufacturing, journalism, technology– you name it)
Good News– More individuals making it to old age, should mean busy times for aging services
Bad news– More competition than ever before. Growth of numbers and funding means a shift in system structure
From pretty much all not-for-profit coordinators and providers, to a mix of providers, to now a mix of providers and coordinators .
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Organizations can fail because of bad products:
White Star Lines (Titanic)-- Sharper Image, when their lead product the Ionic Breeze Air Purifier added ozone to the home air supply
Or bad ideas- The Harley Davidson perfume line, Cosmo , Yogurt, Thirsty Dog’s flavored bottled water for pets
But organizations also fail with quality products, because the world changes and they do not (Kodak, Blockbuster, Motorola cell phone, Blackberry)
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Quality approaches dominated by health and safety values
Underlying assumption that service recipients are unable to assess or communicate about quality
In our search for measureable outcomes we have relied heavily on structural elements
The media, society in general and politics all reinforces these beliefs
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Quality assurance- Donabedian concepts of structure, process, outcomes to assess quality
Quality improvement, total quality management Six Sigma– all based on the concept of continuous improvement–Deming, Crosby
Quality Lessons From TQM
1) Who Are Our Customers?
2) How Do We Hear Their Voices?
3) Information is Critical for
Good Decisions
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Quality Lessons From TQM
4) The Group is Smarter
Than the Individual
5) Sub-Optimization is a Key
Challenge for Service
Organizations
Whether it be the state, federal government, or managed care plans – it is all about achieving outcomes
But whose outcomes? Back to who is the customer? Consumer, family, funder, regulator, advocate, legislator, manager
NQF Home Care Quality Advisory Group–charge is to identify potential measures
Experience thus far has very much been very much about whose outcomes
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Erin Giovannetti
March 23, 2016
Improving Outcomes for
Individuals with Complex
Needs
Model for Evaluating Quality
Individual and Caregiver Engagement and Rights
Population Management and Health Information Technology
Quality Improvement Systems
Screening and
Assessment
IndividualizedShared Goal-
OrientedCare Plan
CoordinatedService
Delivery
Healthy PeopleHealthy
Communities
Better Care
Affordable Care
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“Integrated Care” is a misnomer
• Care continues to be delivered in silos
• Medical
• Behavioral
• Supportive services
• Information sharing impeded and
idiosyncratic
• Language and culture of different disciplines
• Technology
• Communication depends on case manager
Most care plans are guided by goals… but it could be better
• Where documented, goals are
substantially aligned with what people
say is important
• Rarely identical or discordant
• Care manager’s words or summary
• Short term, service-focused, related to
outcomes important to individual, but
logical connection is not documented
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Current quality measures aren’t meeting needs
• Quality measures don’t reflect what is
most import to individuals
• Systems are not organized to elicit and
document what is most important to
individuals
• Cacophony of measures leads to lack of
trust in quality measurement
Short-term and long-term steps to better quality measurement
Short Term:
Developing
Standards for LTSS
and Integrated
Care
Long Term:
Developing Person
Driven Outcome
Measures
• Standards for best practices in goal setting and outcome
measurement
• Person-driven outcome measures for accreditation
• Lay the foundation for implementation of person-driven
outcome measures
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Piloting Standards to Support Coordination of LTSS and General Medical Care
• Target organizations
• Managed care plans responsible for LTSS
• Community Based Organizations that provide case
management for LTSS
• Learning Collaborative including 10 organizations is underway
• Updates to NCQA Accreditation programs
• Implementation guide: Tools, resources and examples
to help organizations improve their ability to meet the
standards
Piloting Standards to Support Coordination of LTSS and General Medical Care
• Initial assessment captures more social needs
• Care plans include individuals’ goals, back-up plans
• Care transitions requirements include LTSS
• New requirement to vet and support LTSS providers
• New requirement for a critical incident management
system
• Allow more sources to support case management
program including standards of practice and state
requirements.
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Person-Driven Outcome Measurement: Two Approaches
Goal Attainment Measurement
• Short-term individual goals
are set
• Expected outcomes are
defined and assigned
numerical value
• Outcomes on goal are
assessed as worse than
expected, as expected,
better than expected
Patient Prioritized Outcomes
• Draw from existing validated
PROMs to develop “bank” of
PROMs representing many
potential outcomes
• Individual selects the outcome
of most importance to them
and complete the
corresponding PROM
• Combine individually selected
PROM score into population
level measure of change
Goal Setting and
Negotiation
Identify Measureable
Outcome
Action Step
Appraisal and
Feedback
Individual outcome
measurement
Population Performance
Measures
Goal Setting and Outcome Measurement Framework
• % patients with PROM measurement at two points in time
• % patients with goal/target documented
• % patients who met goal/target
• % patients who show improvement in PROM
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Developing Person-Driven Outcome Measures
• Recruited Organizations
• 2 case management programs in Medicare Advantage and Integrated Special Needs
Plan
• 1 Geriatric practice
• 2 Home-based primary care practice
• Activities
• Focus groups
• Pilot with 100-150 patients to begin June 2016
Thank you
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Identifying, Quantifying, and
Proving CBO Value to
Healthcare Payers
Sandy Atkins, MPAVP, Strategic Initiatives
Partners in Care Foundation
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Paths to Partnerships w/ Payers• Establish opportunities by:
– Joining professional organizations on the payer side and participating in committees
– Recruiting board members from the healthcare world
• Open discussion with HomeMeds/med rec• Highlight self-management support through Evidence-
Based programs• Pilot and require data exchange
– CCTP was a boon– Academic medical centers attract data wonks
• Use data from original EB studies if no actual data• Calculate ROI
Metrics Step 1: Define Success• Speed – Meet needs when they occur
– Time from ID/referral to contact to service
• Access – Acceptance rates– Reaching people with bad contact info
• Info that home health/OASIS would miss– Psychosocial, PHQ, med errors, caregivers, falls, etc.
• Clinical improvement • Self-management improvement• Satisfaction – Member Retention• HEDIS/Star Ratings
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Value Proposition: CBOs & Triple Aim
• ED
• IPCOST
• Pain
• FallsHEALTH
• Needs Met
• Member Retention
QUALITY
Care Transitions Coaching
HomeMedsPlus
Stanford Self-Management Workshops
HomeMedsA Matter of BalanceHealthy Moves
Complex Community Care Management
MealsHome visitTransportation
Results for Our Programs• LTSS waiver program for duals
– Keeps Medicaid nursing-home-eligible seniors at home for an average of 5 years!
• Medicaid Cost? $357/month vs. $3,000+ for SNF
• Coleman CTI, HomeMeds & Bridge Hybrid– 25,000 CCTP interventions @ avg. 34% reduction in 30-day
readmissions vs. baseline per CMS
• HomeMedsPlus– Home visit, med rec, pharmacist, psychosocial/ functional
assessment, home safety evaluation• In physician group post hospital – 13% lower rate of ED use &
22% lower rate of readmission w/in 30 days• Discovered medication-related problems in 63% per
pharmacist…AFTER hospital medication reconciliation
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Results Example: CDSMP• Intervention: Stanford CDSMP plus monthly meetings &
incentive to attend
• Population: 571 union members w/chronic conditions in MCO
• Outcomes:
– Compared to baseline, after 12 months• Self-rated health good or excellent: 60% vs. 32% at baseline
• BMI 1 point
• A1C 1 point
• Systolic BP 11 points
• Depression score from 5.8 at baseline to 3.2
• Pain from 3.2/10 to 2.0/10
– Compared to baseline over 12 months• aerobic exercise from 51 to 75 minutes per week
• stretching/strength exercise from 21 to 35 minutes per week
Where to get cost & utilization data• From the targeted healthcare entity
– ASK! What’s your average cost/reimbursement per ED visit, /readmit?
• From your Quality Improvement Organization– Geographic average – e.g., SoCal is 99th percentile
• For CCTP, from CMS QMRs & KPMAs• Patient self-report
– Call within 30 days – Ask if they’ve been to ER or stayed overnight in hospital or SNF
• CMS & state healthcare planning agency– CA Office of Statewide Health Planning & Development
• Dartmouth Atlas, Kaiser, Commonwealth, Google, CHCF• State & National Health Interview Survey
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ROI Calculator
CCTP Site
n= %
readmit rate
% decr. readmit
rate
# 30-day
readmit
# Readmit Averted
$ saved @ $15,500
Total Cost @ $600/
pt.
ROINet
Savings
West 10,139 13.0% 38.4% 1,318 821 $12.7mil $6.1 mil 110%$6.6 mil
East 6,130 13.4% 35.3% 821 448 $6.9 mil $3.7 mil 88%$3.3 mil
Nor. 7,176 13.4% 35.3% 962 524 $8.1 mil $4.3 mil 88%$3.8 mil
NCQA Accreditation
• Why?– So health plan could delegate under CA state Dept of
Managed Health care v – So payers can bill appropriately
• Complex case management• For average CBO – pretty expensive
– $33,000 to NCQA– $35,000 to consultant
• Heck of a lot of work! • Transformational commitment to a new way of
operating based on evidence, data, standardization, and CQI
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NCQA CM Accreditation –Not that foreign for CBOs
• Health Plans Must Assess/Evaluate Members’:– Clinical history & medications– ADLs– Cognitive function– Psychosocial issues– Health behaviors– Life-planning activities– Cultural/linguistic needs, preferences, limitations– Visual/hearing needs, preferences, limitations– Caregiver resources/involvement– Available benefits– Community resources
You don’t have to be perfect• Typical range that is accreditable: 60-80%• Some current standards just plain ol’ didn’t fit
– Incoming LTSS standards MUCH better!!!
• Quality improvement efforts imply quality isn’t perfect– Systems to encourage active/proactive disclosure
• Incident reports, committees, f-u systems
– Top management support– Immediate response– Documented resolution/improvement
• Generally no-fault approach except deliberate acts or repeated after correction
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Where we lost points• HR systems
– Systematic & frequent licensure checks from primary sources (i.e., not just a copy of current/active license)
• IT systems (and human follow-through)– Automated clinical guidelines – Automated prompts/reminders– Analyze rates of ED use, hospital use, SNF use to improve
practices
• Formal QI systems• Relying ONLY on state requirements
– Patient/client rights – all services available vs. those for which one is qualified – in client’s language
– PHI/HIPAA rights statements– Systems for addressing complaints
Measures where CBOs can DO it
C08 SNP Health Risk AssessmentSeek out members (drive-by, home visit, etc.) who do not respond – complete HRA
C09 Care for Older Adults –Medication Review
Requires Clinical pharmacist or prescriber, part of HomeMeds. CPTII: 1159F Meds documented; 1160F: Meds reviewed – both on same day. Billable CPT: 90862, 99605, 99606
C10 Care for Older Adults –Functional Status Assessment
Any providerCPT II: 1170F
C11 Care for Older Adults – Pain Assessment
Any providerCPT II 0521F – Pain plan of care documentedCPT II 1125F – Assessed: Pain CPT II 1126F – Assessed: No Pain
C18 Reducing the Risk of Falling Doctor or other health provider. Policy change might be in order – CBOs do well!
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Measures where CBOs can contributeStandard/measure CBO activities
C01
C02
Preventive screenings –
mammogram,
colonoscopy
Track due date, encourage, schedule
appointment, arrange transport, reminders, help
follow instructions for preparation, accompany to
office, help get results,
C03 Annual Flu Vaccine Nurse ride along w/ MOW; reminder, transport,
clinic in senior center, etc.
C04 % Who Improve or
Maintain Physical Health CDSMP, DSMP, EnhanceFitness, etc.
C05 Improving or Maintaining
Mental Health
Screen – PHQ-9, etc. – and connect to
behavioral health program. PEARLS, Healthy
IDEAS.
C06 Monitoring Physical
Activity Discuss w/doctor with activity plan recommended
C07 Adult BMI Assessment Computed and recoded in health record
C19 Plan All-Cause
Readmissions
Coleman CTI, Bridge, HomeMeds.
LARGE numbers of highest risk required to
impact all-cause
Altarum Institute integrates independent research and client-centered consulting to deliver comprehensive, systems-based solutions that improve health and health care. A nonprofit, Altarum serves clients in both the public and private sectors. For more information, visit www.altarum.org
Measuring Quality for Frail EldersJoanne Lynn, MD
Director, Center for Elder Care and Advanced IllnessAging in America, March 2016
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Single Classic “Terminal” Disease: “Dying”
Onset incurable disease Often a few years, but decline usually over a few months
Fu
ncti
on
Time
Death
Mostly cancer
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Prolonged dwindling
Mostly frailty and dementia
Now, most Americans have this course.
The numbers will triple in 30 years.
Onset could be deficits in
ADL, speech, ambulation
Fu
ncti
on
Time
Death
Quite variable, often 6-8 years
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What matters to elders living with illness and disability?
Relationships – family, friends, spirituality
Control, finances, dignity, respect
Familiarity, meaningfulness, significance
Comfort
Confidence
Survival time
What do we measure?
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What do we measure in nursing homes?
Moderate to severe pain
New or worsened pressure ulcers; any pressure ulcers
Flu and pneumococcal vaccine
New anti-psychotic medication; any antipsychotic medication
Increasing need for ADL help
Weight loss
Losing control of bowel or bladder
Urinary catheters
UTIs
Depression
Restraints
Falls with injury
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What more do we measure in home care?
Improved mobility
Improved bathing
Improved breathing
Improved wounds
Improved understanding of medications
How often the home care team checked on various things
How often – hospitalization, ER use, readmissions
Patient rating of overall care, professionalism, communication
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What’s missing?
Most of what matters most!
Customization to patient/family priorities
Meaningfulness
Comfort beyond serious pain
Independence and control
Finances
AND a public health perspective – the well-being of frail
elders living in a particular community
Why?
What should be done?
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Meals on Wheels (June 2013)
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Improvement possibilities
Measure care planning processes, develop standards
Measure alignment of services with priorities
Measure confidence in the care system
Measure community elders’ well-being
Sample
Topics
• Housing, food, transportation, isolation, caregiver support
• Confidence
• Efficiency, waste
Methods
• Build from aggregating care plans
• Build from follow-back on death certificates
• Tally productive interventions – e.g., universal design, elimination of waiting lists
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BÄTTRE LIV FÖR DE MEST SJUKA ÄLDRE
I JÖNKÖPINGS LÄN
– KOMMUNER OCH LANDSTING TILLSAMMANS
[better life for the elderly people in Jonkoping}
MÄTTAVLA [dashboard]
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Äldres läkemedelsanvändning i Jönköpings län
Jonkoping hospitalsand municipalities
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Why is improving quality measurement for frail elders
especially important NOW?
Demographics – increased proportion of the population
Value-based purchasing
MACRA
Other savings and performance incentives
Business relationships between aging services and health care
IF we measure quality in misleading ways, good practices will be penalized and unsustainable.
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How can YOU help?
Push for better quality measures in policy agendas of
membership organizations
Talk with managers – managed care, hospitals, educational
centers, etc.
Press your political representatives - e.g., the Care Planning
Act proposed
Comment on NPRMs and other CMS actions
Comment to the newspapers, radio stations, etc.
Try out some novel metrics and report those that seem to
work.
Put meaningful metrics into contracts, wherever possible
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How to Get Started: Channel Outrage
Get angry!
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“Unless someone like you
cares a whole awful lot,
Nothing is going to get better. It's not.”
- Dr. Seuss, The Lorax
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PANEL
DISCUSSION FACILITATED BY
ROBYN GOLDEN, LCSW
Bob Applebaum, MSW, PhD
Erin Giovannetti, PhD
Sandy Atkins, MPA
Joanne Lynn, MD, MA, MS
INTERESTED IN
CONNECTING WITH US?
Come to our N3C meeting today from 2:10 – 3:00 in the
Congressional Board Room (Marriott hotel, lobby level)
or
Contact us! www.rush.edu/national-coalition-care-coordination