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Quality Metrics for House Calls Medicine: the Current

StateBruce Leff, MD

Professor of MedicineJohns Hopkins University School of Medicine

AAHCM Annual Meeting, Mary 14, 2014, Orlando, FL

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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

Agenda

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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

Importance of Measuring Quality of Care Provided by House Calls Practices

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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, practice-based registry, tools for practice-based quality improvement

Survey of house calls practices was performed to inform our approach

The Medical House Calls Network

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58-question survey

Sent to all AAHCM members – email / mail

48% response rate, 456 individuals responded = 296 practices

The Current State of House Calls Practices – National Survey

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Practice Basics % of Practice

s

Group (v solo) 56

Single site v multiple, median # sites, (range) 85, 1, (1-34)

For-profit (v not) 75

SponsorIndependent provider / provider group………..Hospital or health system…………………………

7019

Practice funding sourceInsurance reimbursement…………………………Self-pay……………………………………………….Subsidy by hospital or health system…………..Philanthropy………………………………………….

9430147

Academic affiliation 22

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Practice Personnel

% w Provider Type

Mean FTEs

Median FTE

Range FTE

MD% w Provider, 85 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

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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 specific patients (frequency weekly or daily)

53 (46)

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Practice Tech Issues % of Practices

Practice uses EMR 88

Uses EMR forDocumentation…………………………..E-prescribing…………………………….Care coordination w other practices…Registry functions……………………….Coordinate with HHA……………………Sign HH orders……………………………Communicate pt preferences across settings, e.g. POLST, MOLST…………..

978860484541

30

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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

% of Practi

ces

Practice involved in NCQA PCMH 14

Practice is IAH site 9

Practice involved in ACO 13

Practice surveys patient re care experienceAnnually or more frequently………………………..Less often than annually…………………………….Doesn’t survey…………………………………………

371251

Practice uses defined quality improvement process

33

Practice collects and monitors quality indicators 48

Practice would participate in QI process that would provide feedback on house call QIs

56

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Factor Odds

Ratio

95% CI

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

Factors Associated with Practices that Use Defined QI Process

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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

Summary

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Linking Policy to Outcomes in Payment:

the future of House Calls Metrics       Christine Ritchie, MD, MSPH

Professor of MedicineUniversity of California San Francisco

AAHCM Annual Meeting, Mary 14, 2014, Orlando, FL

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Quality measurement

Trends in “value-based care”

Registries as a reporting mechanism for value-based care.

The past and ongoing work of the Medical House Calls Network (also known as Home-centered Primary and Palliative Care)

Agenda

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Quality Measurement

NEEDS PROCESSES OUTCOMES

Functional

Clinical Expectation

Costs

Functional

Clinical

Costs

Satisfaction

Assess>>Dx>>Rx>>Follow

Patients with need Patients with need met

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Expectations for measurement and QI activities in five “quality domains” ◦ 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

Trends in “Value-based Care”

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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

Housecalls (Home-centered Primary and Palliative Care) is at risk:◦ Of not all being Patient-centered Medical Homes ◦ Not have professional society/discipline/setting-

specific measures/standards

Value-based Care for House Calls?

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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

A Registry for…◦ HCPPC practices◦ Meeting quality reporting requirements◦ Benchmarking

A Network to…◦ Develop and test measures◦ Test and implement a registry

Solutions?

Network Members•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

Standards and measures• Measure development• 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: • 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 GapsDomain: 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

Standards and Gaps

Domains and Standards GapsDomain: 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

Standards and 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

Registries

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Data Collection

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Benchmarks

Next steps 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)