© 2012, The Brookings Institution
Current Directions in Quality
Measurement
Barbara Gage, PhD
Fellow, 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 patientcentered, 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 Measurement
excerpted from Gage/Mandle presentation to LTC Discussion Group, November 2013,
Clinical Quality
of Care
• Care type
(preventive, acute,
post-acute, chronic)
• Conditions
• Subpopulations
Person- and
Caregiver- Centered
Experience and
Outcomes
• Patient experience
• Caregiver experience
• Preference- and goaloriented care
Care Coordination
• Patient and family
activation
• Infrastructure and
processes for care
coordination
• Impact of care
coordination
Population/
Community Health
• Health Behaviors
• Access
• Physical and Social
environment
• Health Status
Function
Efficiency and
Cost Reduction
Safety
•
•
•
•
•
All-cause harm
HACs
HAIs
Unnecessary care
Medication safety
• Cost
• Efficiency
• Appropriateness
• Measures should
be patientcentered 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
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© 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 personcentered 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
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© 2012, The Brookings Institution
Thank You.
Barbara Gage, PhD
Fellow
Engelberg Center for Health Reform
Brookings Institution
Bgage@Brookings.edu
Or
Sr. VP, Scientific Research & Evaluation
Post Acute Care Center for Research
Bgage@paccr.org