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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

Joanne.Lynn@Altarum.org

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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