© 2012, The Brookings Institution

Current Directions in Quality Measurement

Barbara Gage, PhDFellow, Engelberg Center for Health Care Reform at Brookings

&Sr. VP, Research, Post Acute Care Center for Research

(PACCR)

© 2012, The Brookings Institution

Presentation Overview

• Triple Aim as a Framework for Measuring Quality in HCBS programs

– Person-centered– Coordination of person, caregivers, team approach,

including both medical and social support to improve population health

– Focusing on Value of Services• Defining Value (costs,outcomes, preferences)

– Structured approach for consensus building and prioritizing measures

• Advances in the Scientific Measurement of Quality

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© 2012, The Brookings Institution

National Landscape Post ACA 2010

• Focus on Person-Centered Care and the Triple Aim

• Develop a National Quality Strategy …to guide local, state, and national efforts in achieving 3 aims –– Better Care: improve quality by making care patient-

centered, reliable, and safe– Healthy people/Healthy communities: improve US

population health by addressing behavioral, social, and environmental determinants of health

– Affordable Care: reduce cost of quality care

© 2012, The Brookings Institution

AHRQ-led NQS Development of Six Priorities • Reduce harm in the delivery of care• Engage each person and family as partners in care• Promote effective communication and coordination of

care• Promote the most effective prevention and treatment

practices for leading causes of mortality• Work with communities to promote healthy living• Make quality care more affordable by developing and

spreading new delivery models

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© 2012, The Brookings Institution

The Evolving National Quality Strategy• Establishment of the National Quality Forum• Development of scientific standards for measuring quality• Multistakeholder consideration of quality measures that meet

5 criteria: important to measure, scientifically acceptable (reliable and valid), feasible to collect, usable/actionable, other related metrics

• Stakeholder Prioritization of measure development: NQF workgroups on coordinated care, person-centered care, Alzheimer’s Disease/Dementias, Health Care Quality for the Dual-Eligible, LTPAC populations

© 2012, The Brookings Institution

CMS Framework for Measurementexcerpted from Gage/Mandle presentation to LTC Discussion Group, November 2013,

• Measures should be patient-centered and outcome-oriented whenever possible

• Measure concepts in each of the six domains that are common across providers and settings can form a core set of measures

• Patient experience• Caregiver experience• Preference- and goal-

oriented care

Efficiency andCost Reduction

• Cost• Efficiency• Appropriateness

Care Coordination

• Patient and family activation

• Infrastructure and processes for care coordination

• Impact of care coordination

Clinical Qualityof Care

• Care type (preventive, acute, post-acute, chronic)

• Conditions• Subpopulations

Population/ Community Health

• Health Behaviors• Access• Physical and Social

environment• Health Status

• All-cause harm• HACs• HAIs• Unnecessary care• Medication safety

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Safety

Person- and Caregiver- Centered

Experience and Outcomes

Function

© 2012, The Brookings Institution

Current Uses of Quality Metrics to Achieve Triple Aim• Initiatives underway to incentivize coordination by tying

payments to quality across providers and populations – Accountable Care Organizations– Medical Homes– Bundled Payments– Dual Eligible Coordinated Care

• HIT Initiatives to support data exchangeability– Beacon programs– ONC funded initiatives

• Meaningful use• LTPAC

– TEFT program PHR

© 2012, The Brookings Institution

Medicaid Home and Community-Based Populations• Individual state initiatives• Nationally-funded Grant programs

– Balancing Incentives Programs to support state collection of quality metrics in specified domains for LTSS populations (med,functional,social/env support)

– TEFT programs to test experience of care and functional measures across states

• Foundation-sponsored forums– SCAN funded Meeting on Standardizing Assessments

for LTSS – SCAN funded work in California on standardizing

measurement elements across LTSS programs

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© 2012, The Brookings Institution

Moving LTSS Quality Metrics into the Triple Aim Framework

Selecting what to measure for determining value • Developing consensus on most important areas

– LTSS populations receive medical and social support services

– NQF/CMS advanced science on medical quality metrics

– Medicaid quality measurement programs vary in terms of:» Range of concepts that are prioritized» Range of measures within concepts» Specifications of “measures”» Scientific reliability of measures

© 2012, The Brookings Institution

Measuring Quality in HCBS Populations

• What Domains Can We Reliably Measure Today– Medical status– Functional status

• Physical• Cognitive

– Social Support factors• Availability/Types of Caregivers• Level of Assistance Needed• Availability of Willing and Able

– Experience of Care

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© 2012, The Brookings Institution

Measuring Quality in HCBS Populations

• What Areas Need Greater Attention Today– Caregiver Support Needs: support them in supporting

person with needs and you will improve population health and reduce likelihood of adverse medical events

– Care Coordination: coordination across all caregivers, including medical, social, and others identified by person with needs

– Person/Family Preferences: implementing person-centered care by engaging person, their caregivers in a collaboration to promote health/independence

– Behavioral Health: impacts overall health status

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© 2012, The Brookings Institution

NQF “High Priority Gaps in Measures”(Source: NQF 2014 Input on Quality Measures for Dual-Eligible Beneficiaries)

• Goal-directed, person-centered care planning and implementation

• Shared decisionmaking• Systems to coordinate acute care, long-term services

and supports, and nonmedical community resources• Beneficiary sense of control/autonomy/self-determination• Psychosocial needs• Community integration/inclusion and participation• Optimal functioning (e.g., improving when possible,

maintaining, managing decline)

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© 2012, The Brookings Institution

Redesign Thinking

• Not a question of a medical model or a social model

• Focus instead on holistic person-centered model– Health factors– Social factors– Personal preferences/goals– “System” coordination across all needs

• Medical• Social• Behavioral• Informal• Personal preferencs

– Other domains 13

© 2012, The Brookings Institution

Thank You.

Barbara Gage, PhDFellow

Engelberg Center for Health Reform Brookings Institution

Bgage@Brookings.eduOr

Sr. VP, Scientific Research & EvaluationPost Acute Care Center for Research

Bgage@paccr.org