Transcript Quality Metrics for Housecalls Medicine: the Current State / Linking

Bruce Leff, MD
Professor of Medicine
Johns Hopkins University School of Medicine
AAHCM Annual Meeting, Mary 14, 2014, Orlando, FL
©AAHCM
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Frame the importance of quality measurement
for house calls practices
Current state of house calls practices – readiness
Current state of what practices are doing in the
area of quality measurement
Lead in to Dr. Ritchie’s talk on the future of
quality measurement for house calls
©AAHCM
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We don’t get enough respect for what we do
Shift to value-based care – we MUST be able to
demonstrate this clearly and unequivocally to
stakeholders
Challenge: lack of appropriate quality indicators,
benchmarking data, mechanism to report quality
©AAHCM
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Funded by The Commonwealth Fund and The
Retirement Research Fund
Created a Network of exemplar practices, patient
advocacy groups, professional societies to
develop quality indicators for the field, practicebased registry, tools for practice-based quality
improvement
Survey of house calls practices was performed to
inform our approach
©AAHCM
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58-question survey
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Sent to all AAHCM members – email / mail
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48% response rate, 456 individuals
responded = 296 practices
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Practice Basics
% of
Practices
56
Group (v solo)
Single site v multiple, median # sites, (range)
85, 1,
(1-34)
For-profit (v not)
75
Sponsor
Independent provider / provider group………..
Hospital or health system…………………………
Practice funding source
Insurance reimbursement…………………………
Self-pay……………………………………………….
Subsidy by hospital or health system…………..
Philanthropy………………………………………….
Academic affiliation
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70
19
94
30
14
7
22
Practice
Personnel
%w
Provider
Type
85
Mean
FTEs
Median
FTE
Range
FTE
5.6
1
0-165
NP
73
4.7
2
0-85
PA
33
1.7
1
0-20
RN
37
2.2
1
0-60
Med Assistant
42
6.8
2
0-225
SW
25
1
0
0-10
Case manager/care
coor
23
2.2
0.2
0-30
OT/PT
15
0.5
0
0-20
Administrative
61
13
2
0-1020
MD% w Provider,
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Service Issues
% of
Practices
Average daily census, mean, median, (range)
358,100,
(1-8000)
Practice offers 24/7 coverage
94
Same day or next day visit for urgent / emerg
complaints
68
Frequency of scheduled follow-up for clinically
stable patients – every month or more frequent
45
Practice always or usually assumes 1º care
81
Practice holds regular team meetings to discuss 53 (46)
specific patients (frequency weekly or daily)
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Practice Tech Issues
% of Practices
Practice uses EMR
88
Uses EMR for
Documentation…………………………..
E-prescribing…………………………….
Care coordination w other practices…
Registry functions……………………….
Coordinate with HHA……………………
Sign HH orders……………………………
Communicate pt preferences across
settings, e.g. POLST, MOLST…………..
©AAHCM
97
88
60
48
45
41
30
Patients Served and Quality of Care
Issues
%
Patients served ages 65+
87
% Patients served in home/apt v ALF/dom
61
% Patients primary insurance Medicare
80
% Practices caring for Medicare Ad or SNP pts
63
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Quality of Care-Related Issues
Practice involved in NCQA PCMH
% of
Practice
s
14
Practice is IAH site
9
Practice involved in ACO
13
Practice surveys patient re care experience
Annually or more frequently………………………..
Less often than annually…………………………….
Doesn’t survey…………………………………………
Practice uses defined quality improvement process
37
12
51
33
Practice collects and monitors quality indicators
48
Practice would participate in QI process that would 56
provide feedback on house call QIs
©AAHCM
Factor
Odds 95% CI
Ratio
Practice holds regularly scheduled team
meetings to discuss specific patients
2.25
1.13,
4.47
Practice conducts survey of patients
7.57
3.76,
15.2
Practice involved in NCQA PCMH
2.90
1.12,
7.57
©AAHCM
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Range of practice types – size, biz model,
provider types, approaches to quality of care
issues
1/3 house calls practices use a defined QI
process
Substantial proportion of practices engage in
activities that may feed into QI activities: team
meetings, pt and CG surveys, use of EMR
Majority of practices would be amenable to
participate in QI process
©AAHCM
Christine Ritchie, MD, MSPH
Professor of Medicine
University of California San Francisco
AAHCM Annual Meeting, Mary 14, 2014, Orlando, FL
©AAHCM
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Quality measurement
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Trends in “value-based care”
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Registries as a reporting mechanism for
value-based care.
The past and ongoing work of the Medical
House Calls Network (also known as Homecentered Primary and Palliative Care)
©AAHCM
NEEDS
PROCESSES
OUTCOMES
Functional
Functional
Clinical
Expectation
Costs
Clinical
Assess>>Dx>>Rx>>Follow
Patients with need
Satisfaction
Costs
Patients with need met
©AAHCM
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Expectations for measurement and QI activities in
five “quality domains”
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Clinical care
Safety
Care coordination
Patient & caregiver experience
Population health
Prevention
Reimbursement (positive and negative)
predicated on performance on certain quality
measures and clinical performance improvement
activities
©AAHCM
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Most quality measures are:
◦ disease focused
◦ Not applicable to those with functional limitations
◦ Not applicable to those who are home-limited
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Housecalls (Home-centered Primary and
Palliative Care) is at risk:
◦ Of not all being Patient-centered Medical Homes
◦ Not have professional society/discipline/settingspecific measures/standards
©AAHCM
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Measures that…
◦ Make sense for home-centered primary/palliative
care (HCPPC) practices
◦ Take into account multiple chronic conditions
◦ Are validated in homebound populations
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A Registry for…
◦ HCPPC practices
◦ Meeting quality reporting requirements
◦ Benchmarking
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A Network to…
◦ Develop and test measures
◦ Test and implement a registry
©AAHCM
• House
Call Doctors
• Kaiser Family Foundation
• Amer. Acad. of
Hospice/Palliative Med.
• Senior Advocate
Resources
• Amer. Acad. of Home
Care Med
• National Partner. Women
& Families
• Mount Sinai Visiting
Doctors Program
• Cleveland Clinic Med.
Care at Home
• Call
Doctor Medical Group
• Visiting Physicians Assoc.
• Vir. Commonwealth Univ.
• HomeCare Physicians
• Washington Hosp. Ctr
• Department of Veterans
Affairs
• AARP Public Policy Institute
• American Geriatrics Society
• Johns Hopkins Elder House
Calls
• Housecall Providers
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Measure development
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Comprehensive literature review
Health/Human Services Multiple Chronic Conditions Framework
Qualitative interviews with all network members
Qualitative interviews with patients and caregivers
Development of standards from 10 domains
Iterative refinement of standards
Mapping of measures:
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Over 2000 measures
Culling process over 16 calls and 4 months
Final number: 95 measures
Second culling process: 48 measures
RAND modified Delphi process: 30 measures
Domains and Standards
Domain: Assessment
Perform a comprehensive assessment that includes:
• Symptoms (physical, emotional, social, spiritual)
• Physical, executive and cognitive function
• Health literacy
• Patient goals and sources of meaning and purpose
• Care coordination needs
• Treatment burden experienced by patients and
caregivers
• Patient and caregivers stressors
• Social support and social risk
• Safety concerns
Gaps
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Domains and Standards
Domain: Care Coordination
• Coordinate handoffs between care settings
• Communicate patient treatment goals and preferences across
settings
• Identify and use appropriate community resources
• Insure that all team members have access to key patient
information
• Assure that the team is notified of sentinel events
Domain: Quality of Life
• Optimize comfort and safety of home environment
• Manage symptoms
• Reduce treatment burden
• Employ preventive services to optimize function
Gaps
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Organized system--use observational study
methods to collect uniform data
Provide population-level reports
– Real-time/rapid cycle
– Risk adjusted
– Including standardized measures
– Including benchmarks
– Different reports for different levels of users
Generate dashboards that facilitate action
Facilitate third-party quality reporting
©AAHCM
©AAHCM
©AAHCM
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Work with the Academy and other professional
societies to have standards approved for care in
this setting
Begin registry development process (in partnership
with the Duke Center for Learning Healthcare
Support housecalls practices in their recognition as
a credible setting of care (Home-centered
Primary/Palliative Care)