1. © 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)

2. © 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 2

3. © 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 patient- centered, 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

4. © 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 4

5. © 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

6. © 2012, The Brookings Institution CMS Framework for Measurement excerpted from Gage/Mandle presentation to LTC Discussion Group, November 2013, Measures should be patient- centered 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 Patient experience Caregiver experience Preference- and goal- oriented care Efficiency and Cost Reduction Cost Efficiency Appropriateness Care Coordination Patient and family activation Infrastructure and processes for care coordination Impact of care coordination Clinical Quality of Care Care type (preventive, acute, post-acute, chronic) Conditions Subpopulations Population/ Community Health Health Behaviors Access Physical and Social environment Health Status All-cause harm HACs HAIs Unnecessary care Medication safety 6 Safety Person- and Caregiver- Centered Experience and Outcomes Function

7. © 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

8. © 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 8

9. © 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

10. © 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 10

11. © 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 person- centered care by engaging person, their caregivers in a collaboration to promote health/independence –Behavioral Health: impacts overall health status 11

12. © 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) 12

13. © 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 13

14. © 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