Designing Healthcare Systems That Work for People With Chronic Illnesses and Disabilities

Quality in Chronic Care Programs

Presenters: Maureen Booth, M.R.P., Director, Managed Care Initiatives, Muskie School of Public Service, University of Southern Maine, Portland, and National Academy for State Health Policy Fellow. Judith Pinner Baskins, R.N., M.S.N., President, National PACE Association and Vice President of Geriatric Services, Palmetto Richland Memorial Hospital, Columbia, SC.

State and Federal initiatives have largely focused on quality management systems for overseeing care to a general population. Many of these traditional tools and practices must be adapted or new ones developed to address the special challenges of monitoring and improving care to persons with complex needs.

Key questions in designing quality management systems for populations needing chronic care include:

• Can we identify this population? Do we know their needs and any barriers to meeting these needs?
• Do we know what we want from the contractor? "We" includes more than just the Medicaid agency; agreements must be reached when multiple State agencies, consumer constituencies, or Federal agencies are involved in serving the population.

Once agreement has been reached, program designers must determine how realistic the expectations are given the contractors' capacity/authority/credibility, how to measure the expected standard, and whether the expected standard would actually make a difference in consumer outcomes. After making these determinations, expectations should be clearly documented in contract language.

Contract language can be performance-based (in which the purchaser determines the standard but leaves the "how to" up to the Managed Care Organizations [MCO]); prescriptive (which sets forth the "how to"; this can lead to comparability among MCOs, but can also halt innovation); or a blend of both.

Ms. Booth noted that contract language is necessary but not sufficient to ensure quality care; it establishes the infrastructure so that quality care can take place.

• Do we have qualified providers? Including specifications on "qualified" versus "experienced" provider has implications for quality but can get into subjective judgments.
• Can we measure performance? Such measurement is not easy. The diversity of the population, the small numbers of the target population within an MCO making statistical validity difficult, the lag time for obtaining data, the lag time for seeing improvements, and the importance of "soft" variables that influence the consumer's healthcare experience (e.g., relationships with providers) all present challenges.
• Are we improving quality? How do we know if we are meeting the needs of the members? Ms. Booth noted that, overall, research findings are mixed.

Approaches to performance measurement include satisfaction surveys, focus groups, complaints and grievances, and focus studies. Each of these approaches has strengths and weaknesses. Therefore, utilizing multiple methods creates a fuller picture of the quality of care.

Most important is to maintain a dialogue, with multiple forums for communication, meaningful consumer participation, and followup. Most problems expressed by individuals have system implications. To make this work requires a large number of people being "on board."

PACE (Program of All-inclusive Care for the Elderly) sites across the country have integrated community-based, capitated managed care systems of acute and long-term care that are designed for older adults certified as nursing facility eligible. All Medicare and Medicaid services are included, plus home and community-based services (HCBS) services at some PACE sites. There are no benefit limitations, copayments, or deductibles.

Ms. Baskins explained that the PACE program has developed a number of performance indicators in order to ensure that sites meet PACE accreditation standards. These include:

• Organizational structure.
• Enrollment, disenrollment and marketing.
• Administration, program management, and human resources.
• Finance.
• Quality improvement.
• Physical environment.
• Service delivery.
• Medical records.

New regulations from the Health Care Financing Administration (HCFA), based on the Quality Improvement Systems for Managed Care Initiatives (QISMC) guidelines, will have an impact on these performance indicators. The indicators include:

• Timeliness of enrollment: How long does enrollment take? (Ms. Baskins noted that enrollment in PACE takes longer than mainstream MCOs because of the assessments done during the process.)
• Enrollment rate: What percentage of eligible adults actually enroll?
• Disenrollments due to death: How does this compare with nursing facility rates?
• Disenrollments due to reasons other than death: Ms. Baskins noted that most disenrollments are due to the member moving out of the service area.
• Enrollee/caregiver complaints (defined as issues resolved within 24 hours) and grievances (that are not resolved within that timeframe).
• Satisfaction with service providers: Includes nonclinical services, such as transportation. Annual satisfaction surveys are required. A survey tool is being developed to be used across all the PACE sites.
• Access to primary care and other needed services: Ms. Baskins noted that this gets a great deal of attention in the annual member satisfaction survey.
• Member involvement in care decisions. (This has been discussed in previous workshop sessions.)
• Quality of care: Includes social services.
• Acute care utilization: Includes hospital discharges, length of stay, re-admissions within 2 weeks, and inpatient days per 1,000 per year.
• Nursing home utilization: Includes length of stay for short-term stays, long-term discharges, and length of stay for long-term stays.
• Inpatient psychiatric services.
• Inpatient rehabilitative services.
• Use of prescription drugs, including psychotropic drugs: Ms. Baskins noted that polypharmacy is a huge issue for this population, so PACE sites need to closely supervise. Some sites use Pharm.D.'s to track this information.
• Use of in-home personal care/chore services: Examines the number of hours of either community-based or specialized housing services members receive.
• PACE Center attendance: While members are not required to participate in adult day healthcare, it is a substitute for many higher cost services, including skilled home care.
• Tuberculosis screening and immunizations for influenza and pneumonia: These are parts of the admission criteria.
• Use of physical restraints: Ms. Baskins noted that in its proposed PACE regulations, HCFA is looking at standards for hospitalized patients, but in her opinion it would be more appropriate to look at standards for skilled nursing facility residents.
• Weight loss.

With this data in hand, quality improvements can be made. Ms. Baskins recommended the following steps:

• Analyze your system.
• Acknowledge your limitations but do not accept them without thought.
• Determine where you can make changes.
• Determine if access or services should be restructured, and if so, how.
• Develop a plan.
• Implement the plan.
• Re-evaluate.

References

Booth M. Quality management for people with chronic illnesses and disability: resource sheet and additional suggested reading; Nov 1999.

Eng C, Pedulla J, Eleazer P, et al. Program of All-inclusive Care for Elderly (PACE): an innovative model of integrated geriatric care and financing. J Am Geriat Soc 1997;45:223-32.

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