Person Centeredness in Quality Measurement SNP Alliance 12th Annual Leadership Forum October 13, 2016

Quality Measurement: An Overview

What Is a Healthcare Performance Measure? 4/18/2018 What Is a Healthcare Performance Measure? Healthcare performance measures are tools used to quantify the quality or cost of care provided to patients and their families. They allow us to gauge the quality of care that is provided and help us understand whether and how much improvement activities improve care and outcomes.

How is Performance Calculated? Numerator (What, How, When) # of individuals enrolled in a program Denominator (Who, Where, When) – Exclusions (NOT) # of individuals with a person-centered plan of care

What Are The Types of Healthcare Performance Measures? Quality Structures of care Processes of care Outcomes Intermediate clinical outcomes Health outcomes (mortality, complications, etc.) Patient-reported outcomes (experience, functional status, engagement, quality of life, etc.) Resource use/cost Efficiency (combination of quality and resource use) 5

Who Uses Measures and Why? 4/18/2018 Who Uses Measures and Why? Many people are interested in the quality, outcomes, and cost of care including: Patients, Consumers, Families, & Caregivers Primary Care, Specialists, & Other Health Professionals Health Systems & Care Facilities Employers & Payers (private & public) Measure Developers and Programs Health and Measurement Researchers

Why Measure? Measurement is a quality improvement tool, For many reasons, including: Measures drive improvement. Measures inform consumers and other stakeholders. Measures influence payment. Measurement is a quality improvement tool, not an end in and of itself A performance measure is a way to calculate whether and how often the system does what it should.

Major Uses of Quality Measures Internal quality improvement Benchmarking Accountability applications Certification Accreditation Defining provider networks Public reporting Payment

What is NQF? An independent, nonprofit, membership organization that brings together all stakeholders working to improve health and healthcare through quality measurement.

How Does NQF Improve Healthcare Quality? Reviews, prioritizes, and endorses measures Seeks opportunities to reduce the number of measures Recommends measures for federal programs Accelerates measure development Identifies measure gaps Serves as a trusted advisor to the U.S. government on federal policy development Identifies what works and what does not in measurement

NQF and Measurement Goal: improved outcomes Measure Gaps Projects Consensus Development Projects Measure Applications Partnership; National Quality Partners

Person Centeredness in Quality Measurement

Person & Family Centered Care Person- and family-centered care (PFCC) is an approach to the planning and delivery of care across settings and time that is centered on collaborative partnerships among individuals, their defined family, and providers of care. It supports health and well-being by being consistent with, respectful of, and responsive to an individual’s priorities, goals, needs, and values.

Person and Family Centered Care Portfolio of Measures Phase One: Experience with Care Measures Phase Two: Health-related quality of life, including functional status and clinician-assessed function Off-Cycle (Phase 2.5): Patient Activation and Annual Update Review Phase Three (2015-2017): Health-related quality of life, functional status, shared-decision making, symptom/symptom-burden, experience of care NQF currently has more than sixty endorsed measures in the Person and Family Centered Care portfolio.

PFCC Measure Portfolio (October 2016)

PFCC Measure Gaps The next level of functional measures measures not tied to traditional inpatient settings, and that focus on functional restoration, becoming independent and non-medical outcomes (e.g. return to employment) Setting-specific measures that ensure issues and outcomes specific to that site are measure Measures for partnerships between large health systems and community- based agencies More measures of informed and shared decision making Measures across the continuum of care, starting in primary care or Emergency Departments, through the completion of all services Measures that specifically address eliciting and aligning patient goals with their plan of care

HCBS Quality Measurement Project Provide multi-stakeholder guidance on the highest priorities for measurement of home and community-based services that support high-quality community living An opportunity to address the gaps in HCBS measurement and provide direction for future performance measurement Supported the aims of the Affordable Care Act, the National Quality Strategy, and HHS’ Community Living Council Maintained a broad and inclusive orientation to community living and maximize opportunities for public input Inclusive of all payers, settings and services

Make recommendations for HCBS measure development Project Objectives Create a conceptual framework for measurement, including an HCBS definition Perform a synthesis of evidence and environmental scan for measures and measure concepts Identify gaps in HCBS measures based on the framework and environmental scan Make recommendations for HCBS measure development

Domains of HCBS Quality Measurement Service Delivery and Effectiveness Person-centered Planning and Coordination Consumer Leadership in System Development Choice and Control Community Inclusion Caregiver Support Workforce Human and Legal Rights Equity Holistic Health and Functioning System Performance and Accountability

Global Recommendations Support quality measurement across all domains and subdomains. Build upon existing quality measurement efforts. Develop and implement a standardized approach to data collection, storage, analysis, and reporting. Ensure that emerging technology standards, development, and implementation are structured to facilitate quality measurement. Triangulate assessment of HCBS quality using an appropriate balance of measure types and units of analysis. Develop a core set of standard measures for use across the HCBS system, along with a menu of supplemental measures that are tailorable to the population, setting, and program. Convene a standing panel of HCBS experts to evaluate and approve candidate measures.

MAP Dual Eligible Beneficiary Workgroup Identifies performance measures for use in dual beneficiary and sub-populations (family of measures) Prioritizes measurement gap areas Provides strategic input for maximizing quality of life for Medicare-Medicaid enrollees Focus on measurement topics for individuals with multiple chronic conditions Explore topics of community integration and connection to resources

Key Characteristics of the Family of Measures

Challenges to Measuring Person Centered Care in the Dual Beneficiary Population Complexity and heterogeneity of the needs of the dual eligible population Tracking of beneficiaries and the services received across various programs, providers, and settings Variation across states in the programs offered and the structure of those programs Measures often developed for the program, not the person Data, Data, Data Difficult to access and often not timely Resources needed to support data collection, analysis, and storage

Another option for Person Centered Measurement…. NQF does not endorse surveys, tools, or instruments. Example: a satisfaction survey is not endorsed by NQF; however, NQF would endorse the measures (% satisfaction with coordination of care) based on the survey items/domains. The PROM or tool is considered a data source for the performance measure. As such, testing of the tool and reporting on reliability and validity of the tool can assist in establishing scientific acceptability. This requirement should be true for both PRO-PMs and ANY tool based measure (e.g., Functional Status, Depression Remission, Quality of Life)

The Pathway from PROs to PRO-PMs Identify the quality performance issue (include broad input) Identify outcomes meaningful to target population and amenable to change Determine whether (PRO) is the best way to assess the outcome of interest PROM Identify existing PROMs for measuring the outcome in the target population Select PROM suitable for use in performance measurement (e.g., reliable, valid, feasible) Use the PROM in real world with the intended target population and setting PRO-PM Specify the outcome performance measure (e.g., average change, percentage improved or meeting a benchmark) Test PRO-PM for reliability, validity, and threats to validity (e.g., measure exclusions; missing data; poor response rate; risk adjustment; discrimination of performance; equivalence of results across PROMs)

PROMs and PRO-PMs Target Population Patients with clinical depression (concept) Symptom: depression PROM (instrument, tool, single-item measure) PHQ-9 ©, a standardized tool to assess depression PRO-PM (PRO-based performance measure)   Percentage of patients with diagnosis of major depression or dysthymia and initial PHQ-9 score >9 with a follow-up PHQ-9 score <5 at 6 months (NQF #0711) and at 12 months (NQF #0710)

Vision: Quality Equations

4/18/2018