1 The Measure Applications Partnership & Quality Measurement in the Dual Eligible Beneficiary Population SNP Leadership Forum Washington Marriott Wardman Park November 1, 2012
2 Dual Eligible Beneficiaries Workgroup MembershipWorkgroup Chair: Alice Lind, RN, MPH Organizational Members American Association on Intellectual and Developmental Disabilities Margaret Nygren, EdD American Federation of State, County and Municipal Employees Sally Tyler, MPA American Geriatrics Society Jennie Chin Hansen, RN, MS, FAAN American Medical Directors Association David Polakoff, MD, MsC Center for Medicare Advocacy Alfred Chiplin, JD, M.Div. Consortium for Citizens with Disabilities E. Clarke Ross, DPA Humana, Inc. George Andrews, MD, MBA, CPE, FACP, FACC, FCCP L.A. Care Health Plan Laura Linebach, RN, BSN, MBA National Association of Public Hospitals and Health Systems Steven Counsell, MD National Association of Social Workers Joan Levy Zlotnik, PhD, ACSW National Health Law Program Leonardo Cuello, JD National PACE Association Adam Burrows, MD SNP Alliance Richard Bringewatt
3 Dual Eligible Beneficiaries Workgroup MembershipSubject Matter Experts Substance Abuse Mady Chalk, MSW, PhD Disability Anne Cohen, MPH Emergency Medical Services James Dunford, MD Measure Methodologist Juliana Preston, MPA Home & Community Based Services Susan Reinhard, RN, PhD, FAAN Mental Health Rhonda Robinson-Beale, MD Nursing Gail Stuart, PhD, RN Federal Government Members Agency for Healthcare Research and Quality D.E.B. Potter, MS CMS Federal Coordinated Healthcare Office Cheryl Powell Health Resources and Services Administration Samantha Meklir, MPP Administration for Community Living Henry Claypool Substance Abuse and Mental Health Services Administration Frances Cotter, MA, MPH Veterans Health Administration Daniel Kivlahan, PhD
4 MAP Dual Eligible Beneficiaries WorkgroupDual Eligible Beneficiaries Workgroup provides: Balanced expertise for CMS and other Federal partners Strategy for performance measurement High-impact quality improvement opportunities Identification of best available measures for the population Prioritization of measure gaps Ideas for new measures to fill gaps Guidance on applying measures to vulnerable populations Pre-rulemaking input to HHS on measures for defined programs and settings of care
5 Guiding Principles for Application of MeasuresPromoting Integrated Care Ensuring Cultural Competence Health Equity Cascading Levels of Analysis Assessing Outcomes Relative to Goals Parsimony Cross-Cutting Measures Inclusivity Avoiding Undesirable Consequences Data Sharing Using Data Dynamically Making the Best Use of Available Data DESIRED EFFECTS MEASUREMENT DESIGN DATA
6 High-Leverage Opportunities for Improvement Through Measurement
7 Gaps in Measurement
8 Major Measure Development Gap ConceptsGoal-directed person-centered care planning and implementation of care plan System structures to connect health system and long-term supports and services Appropriate prescribing and comprehensive medication management Screening for cognitive impairment, poor psychosocial health, poor health literacy Appropriateness of hospitalization (e.g., avoidable admission/readmission) Optimal functioning (e.g., improving when possible, maintaining, managing decline) Sense of control/autonomy/self-determination Independent living skills Appropriateness of care and care setting Level of beneficiary assistance navigating Medicare/Medicaid Utilization benchmarking (e.g., outpatient/ED/nursing facility)
9 Workgroup’s Consideration of High-Need SubgroupsDetermining best available measures and measure gaps for high- need subgroups to include: Older adults with functional limitations and chronic conditions Adults younger than 65 with physical disabilities Individuals with serious mental illness Individuals with cognitive impairment Measures exist along a continuum of readiness for application to the dual eligible beneficiary population. High-need subgroups of beneficiaries have unique needs and circumstances but the current state of measurement has limited ability to reflect these nuances. Basic tenets of high-quality care are shared.
10 Feedback Loop of Stakeholder ExperiencesMAP’s Duals Core Set presents a menu of measure options from which users can choose when designing a measurement program Ongoing dialogue between MAP and users of measures, especially those involved in demonstration programs, to inform and refine recommendations Progress is being made but full realization of MAP’s quality measurement strategy will take time and collaboration of many stakeholders
11 Behavioral Health Consensus Development ProjectPhase 1 began in November 2011 Alcohol Use Tobacco Use Medication Adherence Diabetes and Cardiovascular Health Screening and Assessment Post Care/Hospitalization Follow-up 11 measures were recommended for NQF endorsement Phase 2 began in September 2012 Depression Hospital Based Inpatient Psychiatric Services Patient Experience of Care ADHD 30+ maintenance measures to start A third phase is expected
12 Behavioral Health Project, Phase 1 Recommendations for Future Measure DevelopmentThe Steering Committee recognized gaps in measurement in the areas of: Screening for alcohol and drugs, specifically using tools such as the Screening Brief Intervention and Referral to Treatment (SBIRT) Screening for post-traumatic stress disorder (PTSD) and bipolar disorder in all patients diagnosed with depression, with an eye toward differentiating between the disorders NQF seeks outcome and composite measures in addition to process measures. NQF encourages developers to specify measures with the broadest applicability (target populations, settings, levels of analysis) as supported by the evidence, with stratification to compute and report performance results by different subsets of patients.
13 Current Landscape of Multiple Chronic Conditions (MCCs) MeasurementClinical practice guidelines are developed for and emphasize a single disease perspective; accordingly people with MCCs are not addressed by available quality measures. Uses of condition-specific performance measures for pay-for-performance programs, public reporting, or quality improvement may result in poor quality care and even harm to patients with MCCs, as well as provide misleading feedback for their physicians.
14 Framework for MCCs MeasurementClinical practice guidelines are developed for and emphasize a single disease perspective; accordingly people with MCCs are not well-addressed by available quality measures. An NQF Steering Committee, funded by HHS, developed a framework for assessing the efficiency of care provided to individuals with MCCs. Provides definitions, domains, and guiding principles for measuring quality and cost of care Builds upon the National Quality Strategy, HHS’s Multiple Chronic Conditions Framework and other private sector initiatives Supports the development and application of measures
15 Conceptual Model for Measuring Care Provided to Individuals with MCCs
16 Senior Program Director, NQFThank You June 2012 Final Report: Measuring Healthcare Quality for the Dual Eligible Beneficiary Population MAP Project Website: NQF Quality Positioning System: Sarah Lash Senior Program Director, NQF (202)