Initiatives & Organizational Efforts to Improve Quality in Post-Acute Care & Long-Term Care

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Slide 1

Initiatives & Organizational Efforts to Improve Quality in Post-Acute Care & Long-Term Care

AHRQ Annual Conference

Carol Raphael
Chair—LTQA
Chair, National Quality Forum (NQF) Measure Applications Partnership (MAP) Workgroup on Post-Acute and Long-Term Care
September 10, 2012

Image: The logo of the Long-Term Quality Alliance (LTQA) is shown.

Slide 2

Measure Applications Partnership

Statutory Authority

Health reform legislation, the Affordable Care Act (ACA), requires HHS to contract with the consensus-based entity (i.e., NQF) to "convene multi-stakeholder groups to provide input on the selection of quality measures" for public reporting, payment, and other programs.

Slide 3

MAP Goal and Objectives

GOAL: Achieve improvement, transparency, and value, in pursuit of the aims, priorities and goals of the National Quality Strategy.

Objectives:

• Improve outcomes in high-leverage areas for patients and their families (i.e., progress towards realization of the NQS).
• Align performance measurement across programs and sectors to provide consistent and meaningful information that supports provider/clinician improvement, informs consumer choice, and enables purchasers and payers to buy on value.
• Coordinate measurement efforts to accelerate improvement, enhance system efficiency, and reduce provider data collection burden.

Slide 4

MAP 2012 Structure

Image: An organizational chart shows the MAP structure. The MAP Coordinating Committee is at the top; four workgroups are beneath it, comprising the Strategy Task Force: the Hospital Workgroup, the Clinician Workgroup, the PAC/LTC Workgroup, the Dual Eligible Beneficiaries Workgroup. Beneath these workgroups, a triangle indicates further Task Forces: the Cardiovascular and Diabetes Task Force, the Safety and Care Coordination Task Force, and Future Task Forces.

Slide 5

Measure Applications Partnership Finalized Reports

Slide 6

MAP Measure Selection Criteria

1. Measures are NQF-endorsed or meet the requirements for expedited review.
2. Adequately addresses each of the National Quality Strategy (NQS) priorities.
3. Adequately addresses high-impact conditions relevant to the program's intended population(s).
4. Promotes alignment with specific program attributes, as well as alignment across programs.
5. Includes an appropriate mix of measure types.
6. Enables measurement across the person-centered episode of care.
7. Includes considerations for healthcare disparities.
8. Promotes parsimony.

Slide 7

PAC/LTC Measure Alignment Considerations

Need to balance customizing measures for each setting with alignment across settings:

• Distinct types of care and levels of care across post-acute care and long-term care settings.
• Multiple provider types with varying payment structures (particularly differing requirements between Medicare and Medicaid).
• Similar measure concepts should be standardized across settings; however, additional measures should address the unique qualities of each setting.
• Use of multiple assessment tools to capture similar information.

Slide 8

PAC/LTC High-Leverage Opportunities and Core Measure Concepts

Slide 9

PAC/LTC Priority Measure Gaps

• Functional status.
• Patient-reported measures:
  • Patient experience.
  • Shared-decisionmaking.
  • Establishment of patient/family/caregiver goals.
• Care coordination:
  • Communication across settings.
  • Transition planning.
• Cost, overuse.
• Mental health.

Slide 10

MAP Data Platform Principles

• A standardized measurement data collection and transmission infrastructure is needed across all payers and settings to support data flow and reduce data collection burden.
  • New tools or data collection systems must build on or replace current processes to avoid additional burden.
• A library of all data elements needed for all PAC/LTC measures should be created and maintained.
  • CARE tool could potentially be used across all PAC and LTC settings, replacing current tools.
  • CARE tool should align with the Quality Data Model and requires additional field testing.
• Data collection should occur during the course of care, when possible, to minimize burden and maximize the use of data in clinical decisionmaking.
  • Enable capture of patient goals and preferences, monitor progress on care plan.
• Systematic review of data and feedback loops should be implemented to ensure data integrity and to inform continuous improvement of data validity and measure specifications.
• Timely feedback of measurement results is imperative to support improvement, inform purchaser and consumer decision making, and monitor cost shifting.

Slide 11

Measure Applications Partnership
Upcoming Work

Slide 12

MAP Contact Information

• MAP Web page:
  http://www.qualityforum.org/Setting_Priorities/Partnership/Measure_Applications_Partnership.aspx .
• MAP Email:
  measureapplications@qualityforum.org.

Slide 13

LTQA

• Launched January 30, 2010—Brookings Institution.
• Mathematica Policy Research developed Strategic Plan.
• 30 member Board appointed—
  • Inaugural Executive Committee:
    • Mary Naylor—Chair.
    • Carol Raphael—Vice-Chair.
    • Gail Hunt—Secretary.
    • Larry Minnix—Treasurer.
    • Mark McClellan—At large.
• Developed Statement of Principles.

Slide 14

Mission Statement

To improve the effectiveness and efficiency of care and the quality of life of people receiving long-term services and supports by fostering person- and family-centered quality measurement and advancing innovative best practices.

Slide 15

Image: At the center of the figure is a circle captioned "Effective Care Transitions for Adults Receiving Long-Term Services and Supports." Around this circle and slightly overlapping it are three smaller circles captioned "Quality Measurement/Key Indicators Workgroup," "Outreach/Public Awareness Workgroup," and "Quality Improvement/Best Practices Workgroup." Double-headed arrows point between each of these three smaller circles, forming a triangle. At the rim of the figure is a circle of text repeating "Person-and-Family-Centered-Care" four times; arrows pointing in a clockwise direction appear between each iteration of this text.

Slide 16

LTQA Members

Images: The logos of LTQA Members are shown:

• AARP.
• American College of Health Care Administrators.
• Alliance for Quality Nursing Home Care.
• American Seniors Housing Association (ASHA).
• The ARC of the United States.
• Assisted Living Federation of America (ALFA).
• American Health Care Association (AHCA).
• Engelberg Center for Health Care Reform at Brookings.
• Columbia University School of Social Work.
• Commission on Accreditation of Rehabilitation Facilities (CARF) International.
• CCAL—Advancing Person-Centered Living
• National Alliance for Caregiving.
• The Commonwealth Fund.
• Direct Care Alliance.
• Institute for Healthcare Improvement (IHI).
• The Green House Project.
• LeadingAge.
• Long Term Care Pharmacy Alliance (LTCPA).

Slide 17

LTQA Members

Images: The logos of more LTQA Members are shown:

• Medicaid Health Plans of America.
• National Association of Area Agencies on Aging (n4a).
• National Association of Long Term Care Administrator Boards (NAB).
• National Association of State Units on Aging and Disability (NASUAD).
• National PAC Association.
• National Center for Assisted Living (NCAL).
• National Committee for Quality Assurance (NCQA).
• National Investment Center for the Seniors Housing & Care Industry (NIC).
• National Quality Forum (NQF).
• NewCourtland.
• Optum Health.
• PHI.
• University of Pennsylvania School of Nursing.
• Rush University Medical Center.
• The SCAN Foundation.
• Total Longterm Care.
• Visiting Nurse Service of NY.
• United Hospital Fund.

Slide 18

Grants

• The SCAN Foundation.
• The Commonwealth Fund.
• AHRQ—The Agency for Healthcare Research and Quality.

Images: The logos of The SCAN Foundation and The Commonwealth Fund are shown.

Slide 19

Accomplishments To Date

Slide 20

Quality Measurement Workgroup Report

• Achieved consensus on domains for measurement of transitional care in LTSS:
  • Person/Family Centered Care.
  • Transitional Care Processes.
  • Performance Outcomes.
• Identified and recommended set of 12 transitional care measures.
• Identified gaps in measurement relevant to transitional care which represent areas for measure development and/or research.

Image: The cover of the LTQA Quality Measurement Workgroup Report is shown.

Slide 21

Gaps in Transitional Care Measurement

• Person and family-centeredness (beyond clinical outcomes).
• Process and outcome measures for older adults with cognitive impairment and those receiving palliative care.
• Transitional care management across episodes of care.
• Discharge readiness and social support.
• Preventive care.
• Access to, cost and cost-effectiveness of transitional care.
• Disparities and measures reflective of unique subpopulations.
• Performance of measure "bundle."

Slide 22

White Paper on Preventable Hospitalizations

• Although the decision to go to the hospital is often made in LTSS settings, there are no available validated measures to help long-term care organizations determine what is a preventable hospitalization. 
• The paper includes seven recommendations for the LTQA to pursue. These include:
  • Defining preventable hospitalizations in general instead of by setting.
  • Defining as precisely as possible the population receiving LTSS.
  • Beginning a process to develop appropriate measures or measure-based procedures to identify potentially preventable hospitalizations in the LTQA population.
  • Advocating for studies of measures.
  • Advocating with the Centers for Medicare & Medicaid Services (CMS) for rigorous monitoring of programs designed to reduce preventable hospitalizations.
  • Expanding education for clinicians who trigger hospitalizations.
  • Advocating for expanded implementation of existing tools for reducing preventable hospitalizations.

Image: The cover of the LTQA White Paper on potentially preventable hospitalizations is shown.

Slide 23

Health Affairs—The Care Span
July 2012

• Unintended Consequences Of Steps To Cut Readmissions And Reform Payment May Threaten Care of Vulnerable Older Adults
  by Mary Naylor, Ellen Kurtzman, David Grabowski, Charlene Harrington, Mark McClellan, Susan Reinhard.
  • Selected ACA Provisions—Impact on Transitions Among Older Adults Receiving LTSS:
    • Readmissions—Section 3025.
    • Bundled payments—Section 3023.
    • CCTP—Section 3026.
• Two webinars in August.

This work is funded by The Commonwealth Fund.

Slide 24

Policy Recommendations Going Beyond the Affordable Care Act

• Anticipate unintended consequences:
  • Identify negative effects through warning signs.
  • Longitudinally monitor consequences.
  • Enhance existing performance measures and available data.
• Advance payment policies that integrate care:
  • Reform needs to incorporate LTSS.
  • Shorter-term, immediate pathways that build on existing programs (e.g., extend readmissions penalties to LTSS).
• Promote needed delivery system reforms:
  • Support for providers in their implementation of these provisions.

Slide 25

In Development

• White Paper—Achieving Higher Value Person-Centered LTSS Through Statewide Payment and Delivery System Reform. 
  • Why do states need to 'fix' LTSS?
  • A vision for higher value, person-centered LTSS.
  • Challenges in achieving higher value, person-centered LTSS.
  • Description of statewide approaches and analysis of each in addressing core values and features of higher value, person-centered LTSS.
  • Policy recommendations.
• Two webinars this Fall.

This work is funded by The Commonwealth Fund.

Slide 26

How do communities navigate this transition?

Image: Cartoon drawings of an elderly woman in a wheelchair and an elderly man with a walker are shown outside a hospital building. A map of lines connecting images of other buildings shows how they go from the hospital to "Home" though Rehabilitation, Nursing Homes, a Retirement Community, the Community Resource Connection, Home Health Care, Assisted Living, and local and State health services.

Slide 27

Innovative Communities—Why?

• Community-Based Approach:
  • Communities across the US are beginning to consider transitions of care as a community –based challenge that requires shared ownership and close collaboration across settings. (Institute for Healthcare Improvement)

LTQA is convinced that the most important health reform victories will take place at the local level, in cities and towns... A broad range of community stakeholders...is needed to help older people and people with disabilities remain healthy and independent..."

—"Innovative Communities: Breaking Down Barriers for the Good of Consumers and their Family Caregivers." p.3

Slide 28

December 2010 Innovative Communities Summit

• Participants in the inaugural meeting worked together to create a common vision for a more collaborative future for those who provide and those who receive care and services.
• That vision, as outlined in our first report, called for:
  • Empowerment of consumers through a customized, coordinated life-care plan that is person-centered and developed with the involvement of family.
  • Development of community teams made up of equal partners and led by an independent and invested leadership.
• To help make this vision a reality, participants in the 1st Innovative Communities Summit encouraged LTQA to:
  • Serve as a repository for information that could help local stakeholders create and support Innovative Communities at the local level.
  • Serve as a cheerleader for Innovative Communities by coaching fledgling communities and convening regular meetings to encourage sharing of ideas and best practices.
  • Help Innovative Communities identify federal and state sources of funding and offer them advice on ways to access that funding.

Image: The cover of the proceedings for the LTQA December 2010 Innovative Communities Summit is shown.

Slide 29

June 2011 Innovative Communities Summit

• Summit participants represented:
  • 20 Innovative Communities.
  • 20 federal agencies.
  • 15 state and local governments.
  • 5 foundations.
  • 7 consumers.
  • 32 providers.
  • 14 health-care purchasers and payers.
  • 16 academicians.
• Leaders explored how LTQA can support Innovative Communities and how these communities can work together to improve care transitions and reduce unnecessary rehospitalizations.
• 11 presenters facilitated panels and small-group discussions. Presenters represented three major categories of stakeholders:
  • Innovative Communities.
  • National & State Support Programs.
  • Private Foundations.

Image: The cover of the proceedings for the LTQA June 2011 Innovative Communities Summit is shown.

Slide 30

3rd Innovative Communities Summit

Proceedings Report due in October

Image: The announcement for the upcoming LTQA Innovative Communities Summit is shown.

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What's Next?

Slide 32

Importance of LTSS

"Without the involvement of long-term services and supports, ACO's or other new collaborative models of service delivery will not be able to achieve sustained quality improvements and reduced costs."

—Mark McClellan, MD, PhD
Director, Engelberg Center for Health Care Reform
Leonard D. Schaeffer Chair in Health Policy Studies
Brookings Institution, Washington DC

Slide 33

Health Care Table

Image: The text "Health Care Table" appears at the center of the figure. Around it are a number of blue squares in a circle; these squares are captioned "Hospitals," "Government," "Insurance," [Blank square], "Pharma," "Business," "Physicians," "Nurses," "Labor," and "Special Interests." Another blue square captioned "LTSS" sits outside the circle in the upper right corner of the slide.

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Image: The figure on Slide 15 is repeated.

Slide 35

• New Taskforces launching in Fall 2012:
  • Advancing Measurement Task Force.
  • Advancing Best Practices Task Force.
  • Advancing LTSS Task Force.

Slide 36

For more information contact—

Doug Pace
Executive Director
dpace@leadingage.org
202-508-9454
http://www.ltqa.org