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Using Outcomes to Assess Performance
NC Council Conference
December 7, 2016
Jennifer Ternay, MBA, CPA, PCMH-CCEJLS Advisory Group, LLC
Outcomes
CCHBC
P4P
Integrated Care
PCMH
Political Environment2
CMSState
Population Health
u Health outcomes of a group of individuals, including the distribution of such outcomes within the group
u Health outcomes are more than the absence of disease
u Product of complex interactions – multiple determinants
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Kindig, DA, Stoddart G. (2003). What is population health? American Journal of Public Health, 93, 366-369. http://www.improvingpopulationhealth.org/blog/2010/05/the-state-of-the-field-of-population-health.html
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Objectives
u Determine how to create meaningful outcomes
u Identify available outcomes tools u Identify how to implement outcomes measuresu Examine how utilize data in routine operationsu Describe how to connect outcomes measures to pay for
performanceu Learn about provider activities associated with outcome
measurements
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What Are Outcome Measures?
Determination and evaluation of the results of an activity, plan, process, or program and their comparison with the intended or projected results
www.businessdictionary.com/definition/outcome-measure.html
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Creating Meaningful OutcomesPlanning
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The Starting PointSelf -Assessment
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Self Assessment
u What is the status of your organization today?
u How does this compare to where you need to be?u What are the steps you need to take to get to the end
goal?
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Planning Considerations
u Organizational mission
u Population servedu Infrastructure and technologyu Accreditation/recognition
u Available resourcesu Stakeholder and employee feedback
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Mission
Goals
Outcomes
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Population Served
u Characteristics
u Gaps in careu Risk stratification
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Who is in Your Population?
u Established patients
u Family member or caregiveru Former patientsu Non-utilizers
u Combined data for MCO
u Capitation or assigned models
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Understanding Your Clients
u Patterns in utilization and length of stay
u Mystery shoppersu Feedback – letter, grievances, etc.u Focus groupsu Patient satisfaction survey
u Ask about music, decorations, logo etc.
u Nothing is static
Expectations change all the time
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NC Health Outcomes Map
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http://www.countyhealthrankings.org/app/north-carolina/2016/overview
Based on how long people live and how healthy people feel while alive.
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NC Health Factors Map
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Based on health behaviors, clinical care, social and economic, and physical environment factors.
http://www.countyhealthrankings.org/app/north-carolina/2016/overview
Ability to Collect and Analyze Data
u What does/can your EHR collect?
u Certified vendoruMU and PQRSu Integrated care
u NC-TOPPS data
u Data warehousingu Reporting
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Accreditation and Recognition
u CARF
u COAu The Joint Commissionu NCQA
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Benchmarks and Available Resources
u SAMHSAu Integrated care
u Behavioral health
u AHRQu Accreditationu State
u Pilots
u Payersu Funding
u HEDIS
u Regional factors
u NC TOPPS
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Standard of Performance
Performance – Expectation = Satisfaction
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Golden Rule Platinum Rule Double Platinum Rule
Involve Stakeholders and Employees
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Planning Outcomes
Business always needs to find new and creative ways to mobilize
brainpower, passion and creative energies of the workforce
~ Be Our Guest
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Creating Meaningful OutcomesSelecting
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Priority Scale
u Determine which outcomes to select
u Meaningful u Feasibleu Actionableu Purposeu Impact
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SafetyCourtesy
ShowEfficiency
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Types of Outcomes
u Symptoms
u Functioningu Quality of lifeu Satisfaction
u Cost effectiveness
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Domains
u Acute care
u Behavioral healthu Care coordinationu Chronic care
u Cost-relatedu Immunization
u Preventive care
u Social determinants of health
u Educationu Employment
u Justice involvement
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National Behavioral Health Quality Framework (SAMHSA )Quality measures included in the NBHQF will:
u Be endorsed by NQF or other relevant national quality entities
u Be relevant to NQS and NBHQF priorities
u Address “high-impact” health conditions
u Promote alignment with attributes across programs including health and social programs
u Reflect a mix of measurement types: outcome, process, cost/appropriateness and structure
u Apply across patient-centered episodes of care
u Account for population disparities.
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Measures in NBHQF
u Evidence-based practices
u Person-centered careu Coordinated careu Healthy living for communitiesu Reduction in adverse eventsu Affordable and accessible care
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Sample Outcomesu Adherence to oral psychotics for individuals with
schizophrenia u Follow-up after hospitalization for mental illness
u Rate of readmission to psychiatric hospital within 30 days u Percentage of individual diagnosed with a new episode of
major depression, treated with antidepressant medication and remained on the medication for at least 180 days
u Patients who initiate treatment for alcohol and other drug treatment through an inpatient admission, outpatient visit, intensive outpatient or partial hospitalization within 14 days of diagnosis
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CCBHC Data Collection Requirements
u Consumer characteristics
u Staffingu Access to servicesu Use of servicesu Costs
u Care coordination
u Other processes of careu Screening, prevention and
treatmentu Consumer outcomes
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Brainstorming Outcome Measures
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Outcomes Tools
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Sample of Available Outcomes Tools
u RAND-36u SCOFF – eating disorderu CAGE-AID – alcohol and
drugsu Duke Health Profile and
Duke Population HealthProfile
u California Quality of Life Survey
u BASIS-24u ACORNu Brief Psychiatric Rating
Scaleu DLA-20u NC-TOPPS
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RAND-36 (SF-36) Domains
u Vitality
u Physical functioningu General health
perceptionsu Physical role
functioning
u Bodily pain
u Emotional role functioning
u Social role functioningu Mental health
Source: https://www.rand.org/health/surveys_tools/mos/36-item-short-form.html34
SCOFF
u Do you make yourself Sick because you feel uncomfortably full?
u Do you worry that you have lost Control over how much you eat?
u Have you recently lost more than One stone (14 lb) in a 3-month period?
u Do you believe yourself to be Fat when others say you are too thin?
u Would you say that Food dominates your life?
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070794
CAGE-AID
u Have you ever felt that you ought to cut down on your drinking or drug use?
u Have people annoyed you by criticizing your drinking or drug use?
u Have you ever felt bad or guilty about your drinking or drug use?
u Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
u 2 or more yes – evaluate further 36
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Duke Health Measures
Duke Population Healthu Quality of life
u Determinantsu Outcomesu Population health
Duke 8u Physical
u Mentalu Socialu Perceived healthu Disabilityu Overall health
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Duke Health Profile
u Physical health
u Mental healthu Social healthu General healthu Perceived healthu Self-esteem
u Anxiety
u Depressionu Anxiety-depressionu Painu Disability
u 17 question
https://cfm.duke.edu/research/duke-health-measures 38
Quality of Life
u CMS project
u Money Follows the Personu Mathematica Policy
Research
u Sample from California http://www.dhcs.ca.gov/services/ltc/Documents/QualityofLifeSurvey.pdf
u Living situation
u Choice and controlu Access to personal careu Respect and dignityu Community integration
and inclusionu Satisfactionu Health status
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BASIS-24
u McLean Hospital – Harvard Medical School Affiliateu Overall scoreu Subscales
uDepression and functioningu Interpersonal relationshipsuPsychosisu Substance abuseuEmotional liabilityu Self-harm
http://ebasis.org/basis24.php
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ACORNa collaborative outcomes resource network
u Multiple surveys availableu Adult, adolescent and childu SPMIu Recoveryu Gamblingu Eating disordersu Trauma
https://www.psychoutcomes.org/COMMONS/WebHome
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Brief Psychiatric Rating Scale (BPRS)
u Major psychiatric disorders, including schizophrenia
u Assesses positive, negative and affective symptoms
http://www.oqmeasures.com/measures/adult-measures/bprs/
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Daily Living Activities (DLA-20)
u Includes versions for u Adult
u Child
u Developmental disabilities
u Alcohol/drug abuse
u 20 indicatorsu Sample and information
u https://www.thenationalcouncil.org/wp-content/uploads/2012/11/DLA-Sample.pdf
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NC TOPPS
u Required in North Carolina
u Adult and adolescent
u Mental health and substance use
u Initial, update and episode completion interviews
u Superuser access
u Ability to compare to peers and Statewide
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NC TOPPS 2.0 Dashboard
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Statewide Report
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MCO Comparison Report
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Report Options: MCO/Provider
u Statewide, MCO or provider
u Consumer group
u Outcome measureu Chart type (bar or
column)u Update type (3 or 6
month)
u Update range (6 or 12 month)OR
u Year (calendar or fiscal)
u Optional selectionu Service (procedure code)
OR
u County of residence
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Consumer Groups
u Adult mental health
u Adult substance use disorderu Adolescent mental healthu Adolescent substance abuse disorderu Child mental health
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Simple Query
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Simple Query
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SimpleQuery
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Implementing Outcomes
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Change Management
u Urgency
u Team with championu Shared visionu Communicate
u Eliminate obstacles
u Celebrate accomplishment
u Build on momentumu Embed in culture
Based on John Kotter’s Eight Step Model for Leading Change
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Managing ChangeVision Skills Incentives Resources Action
Plan
Skills Incentives Resources Action Plan
Vision Incentives Resources Action Plan
Vision Skills Resources Action Plan
Vision Skills Incentives Action Plan
Vision Skills Incentives Resources
Change
Confusion
False Start
Frustration
Slow Change
Anxiety
Ambrose, D. (1987). Managing complex change. Pittsburgh, PA: The Enterprise Ltd.
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Key Points of Communication
u Broad context of healthcare environment
u Vision and mission of organizationu Overview of outcomes and quality improvementu Timelinesu Why it matters “what’s in it for me”u Progress updatesu Success stories
56Vision
Fostering Change
u Change resistant u “I’m already overworked and now you want to me to do what?”
u Team effortu Consistencyu Not an overnight event – it’s a journey
57Vision
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Culture Shift
u Behavior at work
u Attitudesu Not always easy to defineu “The way we do things”
u Culture can vary by department and location
u Hard to shift
u Must be managed
58Vision
Modes of Communication
u Bulletin board
u Meetings u Emailu Newsletteru Retreatu Consider your audience
59Vision
Communication
u Communicate
u Communicateu Communicate
And when you think you’ve communicated enoughSay it again
60Vision
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Training
u Key aspects of communication plan
u New skillsu Data intimidationu Analysisu Process
61Skills
Establishing a Team
62Resources
Implementation Team
u Personal aspectsu Motivation
u Learning style
u Influence
u Effect on current responsibilitiesu Balance of skills
63Resources
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Roles
Championu Authority
u Resources
u Communication
u Prioritization
u Buy-in
Team Leadu Coaching
u Consensus building
u Team building
u Facilitation
u Change management
u Project management
64Resources
Project Management
u Tasks
u Project planu Milestones
u Deadlines
u Resources
u Transform processesu Incorporates all components
65Action Plan
Considerations for Incentives
u Rewards should be more frequent (not annual)
u Achievableu Not a single high threshold
u Target the correct peopleu Who are you trying to get to
change behavior
u Framing
u Financial u Socialu Connecting outside of
the visitu Regret lotteries
66Incentives
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Framing
Minister to superior:
u May I smoke while praying?u May I pray while smoking?
67Incentives
Financial Incentives Provider and Patient
u Controlled trial involving 1503 patients and 238 PCP
u Incentivesu Physician only - $1024
u Patient only - $1024
u Shared incentive – 50/50; $512 each
u Control group
u Primary outcome – reduction of LDL at 12 months
68Incentives
Outcome and Incentive
••Shared••PhysicianRx
••Shared••PatientAdherence
LDL Reduction(Shared)
69Incentives
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Effect of Financial Incentives
Effect of Financial Incentives to Physicians, Patients, or Both on Lipid LevelsA Randomized Clinical Trial
JAMA. 2015; 314(18):1926-1935. doi:10.1001/jama.2015.14850
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Financial Penalty – A Disincentive
Gneezy and Rustichini; The Journal of Legal Studies 2000 29:1, 1-17 http://rady.ucsd.edu/faculty/directory/gneezy/pub/docs/fine.pdf
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Social Incentives
u Based on relationships
u Can be self-sustainingu Pro-social
u Diet
u Stressu Exerciseu Medication adherence
72Incentives
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Connect Outside of the Visit
u How many hours actually connected directly to the patient?
u How to develop support when outside of the program/office?
u Peer mentors
u Trial with goal to reduce A1c
u Control group
u Peer mentor - min weekly talks
u Financial Incentive $100 or $200
-0.01
-1.08
-0.4
Change in A1c
Care as Usual Peer Mentor Financial
http://annals.org/aim/article/1090722/peer-mentoring-financial-incentives-improve-glucose-control-african-american-veterans
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Regret Lotteries
u Confirm taking daily medication
u Receive a number i.e. 39u If the number appears in the lottery, win $125u Get a message that your number (39) appeared
u You would have won if you took your medication
u Try again tomorrow
74Incentives
Open Table – Regret Lottery
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Pilot Program
u Start smallu Role specific
u Who u What
u Whenu How
u Group effortu Why
u Where
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Continuous Assessment
Train
Test
Tweak
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Selecting outcomes measures is not just about what you are
getting paid to do…
but it’s not a bad place to start
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Data in Routine Operations
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Technology Hype Cycle
http://www.gartner.com/technology/research/methodologies/hype-cycle.jsp
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Tracking Measurement
u Historical –where have we been
u Current – where are we today
u Future – where are we going
History
Today
Future81
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Data Driven Requirementsu Quality – verifiable
and repeatableu Effective analysis
and interpretationu Prioritize
u Understandableu Not overwhelmingu Accessible
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Dashboards - Design
u Planning content and designu Who, what, why and how
u Design workflowu Data source
u Maintenance
u Distribution
u KISSu Readable data
u Colors, fonts and graphics
u White space83
Dashboards - Structure
u Excel
u Raw datau Analysisu Dashboardu Table of contentsu Notes
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Sample Dashboard
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Monitoring Outcomes
Plan
Do
Study
Act
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Tracking QI Activities for Outcomes
u Measure – specific by domain, consider disparities
u Opportunity identified
u Date of initial performance/measurement period
u Performance at Initial performance/measurement period (average)
u Performance goal
u Action taken and date of implementation
u Second measurement period (date)
u Performance at second measurement period (average)
u Demonstrated improvement
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Drivers of Outcomes
u Map what affects the measured outcome
u Apply to identified outcomes
People
Process
Action
Outcome
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Connecting Outcomes to P4P
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Claims Data
u Treasure trove of information
u Lacks qualitative factors
u Your goal and challenge is to tie financial and quality together
u Improve the patient experience of care (including quality and satisfaction)
u Improve the health of populations
u Reduce the per capita cost of health care
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Types of Data
Descriptive Diagnostic Predictive Prescriptive
What Why What will
How to make it happen
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Predictive Analytics
u Guest IDu Credit card
u Email
u Coupon
u Survey
u Mail refund
u Visit website
u Demographics
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http://www.nytimes.com/2012/02/19/magazine/shopping-habits.html
“Just wait. We’ll be sending you coupons for things you want before you even
know you want them.”
Progression of Value Based Payment
FFS No Link to Quality and Value
FFS Linked to Quality and Value
Alternative Payment
Built on FFS
Population-Based
Payment
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Reimbursement Spectrum
Fee for Service
Performance-based
Bundled payment
Shared savings
Shared risk
Capitation + performance-
based
Increasing Level of Financial Risk
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Making Your Offer Enticing
u How do you contribute to MCO’s performance evaluation?
u How do you offer better value?u What risk are you willing to accept?u Demonstrate cost neutrality or savingsu Communicationu Completeness of analysisu Actuarial rate setting for MCO
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HEDIS Measures
u Antidepressant Medication Management
u Follow-up Care for Children Prescribed ADHD Medication
u Follow-up After Hospitalization for Mental Illness
u Identification of Alcohol and Other Drug Services
u Use of Multiple Concurrent Antipsychotics in Children and Adolescents
u Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics
u Mental Health Utilization
u Inpatient and ED Utilization
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Strategic Investment
u Technology
u Analytical capabilities u Trainingu Quality improvementu Financial management
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Provider PanelLearning from Peer Experiences
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Panel Representatives
u Alvin Grindstaff, Jr., MAQPTraining CoordinatorA Caring Alternative
u Megan JohnsonChief Operating Officer Carter’s Circle of Care, Inc.
u Ben Millsap, LCSW, LCAS, CCSChief Clinical OfficerMonarch
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