Altarum Invites Communities to Apply for Eldercare Planning Contracts

 Posted by on June 18, 2018  1 Response »  Tagged with: , , , , ,
Jun 182018
 

The Program to Improve Eldercare (PIE) at Altarum Institute is preparing to award several small contracts to healthcare organizations, Public Health Departments, Area Agencies on Aging, and community-based organizations (CBOs) to carry out guided planning efforts to improve care for frail elders though more effective use of existing data concerning persons living in their catchment areas. The overall goal is to help local management define and generate measures of the local system’s performance concerning eldercare.

The contracts will not require collecting any new data. Each site will work with their own data that is already on hand to conduct aggregated analyses for their own community and region. The results of all funded contracts will form the basis for a national White Paper on how communities across the United States can monitor and manage the arrangements for care for elders living with disabilities and chronic conditions through improved use of aggregated data from multiple sources, such as clinical care, surveys, and use of community services.

Our goal is to empower communities and therefore to fund pilot projects that show high promise using several different approaches to community management of eldercare. Throughout, we aim to work with the sites to identify and document business models in use at the partner sites to support existing or improved system performance for providing adequate supportive care services.

This effort is funded by the Gordon and Betty Moore Foundation through Grant GBMF5662 to Altarum Institute (“Aggregating Care Plans to Manage Supportive Care Services for Elders”), Joanne Lynn, M.D., Principal Investigator.

We invite organizations to contact us to discuss this in order to determine their interest in participating. Please contact us via email to [email protected]. We will be happy to help you determine if your community would be a suitable candidate for these projects.

Contracts will be awarded in two phases.

  1. Site Readiness Assessment Contracts (Performed from July 2018 through November 2018)
  2. Site Pilot Implementation Contracts (to be completed by June 2019)

Site Readiness Assessment Contracts (Performed from July 2018 through November 2018)

  • The Readiness Assessment contract phase will select up to ten geographically-focused organizations (“sites”) to receive a contract of $10,000 to participate in a structured strategic planning process to help the sites evaluate their current uses of data related to service provision for elders in their geographic region. We are looking for sites that at least begin to represent a geographic community’s population and that include at least some attention to both social supports and medical care. We are interested in entire catchment areas as a service delivery setting. With assistance from our national program staff, the sites will prepare a Readiness Assessment and strategic plan for improving quality and reducing cost for their eldercare system through better use of data and management information systems.
  • Our national staff will work with each of the sites to prepare a customized project plan that works backward from the seven strategic planning outputs we are studying for each site. The list of outputs in seven study domains is summarized in Appendix A, below. At the end of the planning process, each site will receive a Readiness Assessment report that will form the basis of our selection process for the next round of contracts, which will provide limited funding toward some costs of actual implementations in some sites.

Site Pilot Implementation Contracts (to be completed by June 2019)

  • This phase will award Pilot Implementation contracts at up to six sites to carry out pilot projects based on their Readiness Assessment results. The amount of the Pilot Implementation Contracts will vary depending on the projects proposed by the sites, but we expect that the minimum awards will be approximately $30,000 per site. Some sites may receive larger awards if their plans are complex. As with the Readiness Assessment contracts, our national staff will provide advisory assistance, but actual work will be done by the sites themselves to ensure that an ongoing capability is built locally in a sustainable manner. The Pilot Implementation contracts will probably not cover all implementation costs for every project. Local participation will be needed to ensure the pilot has some chance of being sustainable.
  • If, at the end of the Pilot Implementation, a site has built a working data flow environment and demonstration management information system and has shown that the analytics coming from it are of actionable value to decisionmakers, our national staff will explore with them ways to seek continuation funding to help them transition the pilot system to an ongoing management reporting system. Continuation funding is not guaranteed as part of this effort, so finding ways to create sustainable business models is an important part of the process.

How to apply to partner in this work

To apply, send Email to [email protected] AND [email protected] with the following information:

  • Subject line – “Community Eldercare Metrics, Planning”
  • State the contact email(s) and phone number(s) of the person or team applying.
  • Define the community you aim to serve.
  • Briefly explain your vision, governance, and data available to the project.
  • Send it soon! We will follow up with the more promising teams on a rolling basis and aim to have all teams identified within July 2018 and to have plans and contracts within August and September 2018, depending upon labor availability at the sites and in our staff.

Appendix A: Overview of Site Readiness Assessment Domains

The site Readiness Assessment planning process will provide sites with a $10,000 contract to work with our national staff to explore seven key domains that are essential to creation of an effective management reporting system for community eldercare. We do not expect that all sites will have advanced information technology capabilities in place. Information for this process is expected to be collected primarily by videoconferencing, with little or no travel expenditures for site personnel. The questions listed in this table will be explored during the Readiness Assessment contract period, and need not be answered as part of a contract application.

You may download a PDF file with details on the seven Site Readiness Assessment Domains.

You may download a PowerPoint presentation with further details on the process for Site Readiness Assessments and information on how to apply.

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Interim Reports on Aggregating Care Plans to Manage Supportive Care Services for Elders

 Posted by on March 28, 2018  No Responses »  Tagged with: , , , , , , ,
Mar 282018
 

By Les Morgan

The following reports were produced as deliverables for our project “Aggregating Care Plans to Manage Supportive Care Services for Elders” (Joanne Lynn, M.D., Principal Investigator).This project is funded by the Gordon and Betty Moore Foundation through Grant GBMF5662 to Altarum Institute. Dr. Lynn will provide a more detailed report on the project as a whole in a following blog post.

We are releasing these reports now particularly to help some of the community groups we are working with on data projects. The first three reports cover technical details of how care plans can be structured, stored, and shared in electronic information systems. Those three reports taken together provide useful information that can be used by community groups seeking insight into eldercare through the use of data aggregation methods.

Communities that are seeking to improve eldercare need trustworthy data to use in setting priorities and in monitoring improvements. One appealing approach is to aggregate existing health-related records and analyze the data for key indicators of how their local system is functioning. However, for most of the communities we have worked with, on a practical level the aggregation of this sort of data seems to be very difficult or impossible, given important concerns over privacy and the serious penalties associated with breaches of privacy obligations. Our hope is that these reports will help overcome some of the obstacles that stand in the way of improving care for some of our most vulnerable citizens.

To read the full reports in PDF format, click on the report name you wish to view.

Report 1

Interim Report on the Variety and Merits of Care Plan Templates and Regulations in Use, Including Implications for Information Technology [PDF]

Joanne Lynn and Les Morgan. October 20, 2017

Effective multidisciplinary clinical teams know their patients but document only a skeletal summary of the case. That summary generally includes diagnoses, basics of the living situation, medications, treatments, and supportive services in use or recommended. The various biases, omissions, and lack of long-term perspectives in the clinical documentation are substantial, as summarized in the report.

Our scan of forms and data formats for care plan documentation shows a wide variety of approaches. All made heavy use of free-text narrative elements. The most complete and up-to-date set of care plan records that we have seen was done longhand on a typewritten sheet by a single care coordinator responsible for over one hundred high-need patients seen at one hospital.

The electronic record systems that we reviewed used only to carry the minimal information needed for a C-CDA transmission mostly limited to immediate and near-term needs. None of the electronic records we examined were being used to record the caregivers with their roles, the prognosis, or an advance directive. None used the existing FHIR data format standards for complete care plans.

Report 2

Interim Report Summarizing Data Aggregation Methods in Use To Date and Their Strengths and Weaknesses [PDF]

Les Morgan. October 20, 2017

This is a high-level Information Technology (IT) architectural review discussing major variations in system design approaches for care plan data aggregation, based on a content analysis of interviews with vendors and some key users. A series of architectural diagrams is included to classify approaches. Our interviews with technology vendors are ongoing, and this preliminary summary of methods will evolve as we see more examples of working systems.

Report 3

Aggregating Patient-Level Data: Regulatory, Ethical, and Privacy Issues for Communities [PDF]

Les Morgan and Joanne Lynn. March 2018

This report gives an overview and assessment of regulatory, ethical, and privacy issues specifically related to the use of aggregated care plan and related health data for analytical use across defined geographical catchment areas. The literature covering regulation and privacy of healthcare data is extensive and often contentious. Our review here highlights some major sources for authoritative guidance, then moves on to the specific situation of using aggregated and de-identified data sets for geographic analysis. Regulations that are specific to requirements for maintaining care plans were covered in our prior project report (Interim Report on the Variety and Merits of Care Plan Templates and Regulations in Use, Including Implications for Information Technology) and are not repeated in this report.

A key conclusion of our review is that using aggregated and de-identified data on a broad geographic basis is probably not restricted as much as many of our community stakeholders and leaders think. Some uses of such data are specifically exempted from key privacy laws when appropriate protections are in place. Some regional health care payer systems and Health Information Exchanges (HIEs) have mechanisms to enable such research now, using very large data sets they have already compiled. This means that it is feasible to carry out pilot projects to demonstrate practical methods for data aggregation and analysis for a community or region in many parts of the United States.

Report 4

Benchmarking the Eldercare Workforce: A Community Focus [PDF]

Meghan Hendricksen and Joanne Lynn. February 2018

The overall purpose of this report is to provide an initial, alpha-version, benchmark of the workforce within geographic communities to use for illuminating comparisons with their own workforce estimates.

This baseline benchmark will provide a tool for consideration, and then feedback for improving the tool. In essence, we are creating the start of a learning system for optimizing the workforce in a geographic community. Once the estimates and ranges become substantiated in multiple communities and improvement activities, the maturing benchmarks will provide a trustworthy source of guidance for communities, where evidence is currently lacking, on what the priority needs are for the workforce that is serving older adults living in the community and also will provide a tool for monitoring improvements. Measuring the local workforce capacity also helps engaged community leaders to envision their whole system and its products, even though that “system” is owned and operated by many different entities that are not necessarily coordinated.

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Measuring Performance of a Community’s Elder Care System

 Posted by on March 1, 2017  No Responses »  Tagged with: , , , , ,
Mar 012017
 
Portrait of Dr. Joanne Lynn
Joanne Lynn, MD

By Joanne Lynn

Most of us now reading this will get the extraordinary privilege of being able to live into old age. For nearly all of human history, few people lived to be old, and even fewer lived long with serious disabilities. Now, most of us will have a substantial period of increasing disability at the end of long lives. The experience of people with serious illnesses and disabilities in old age (“frail elders”) and the experience of caregiving for an elderly person are profoundly shaped by the availability of supportive resources and appropriate medical care in the local community.

For example, some communities have ready availability of services such as home-delivered meals and wheelchair-adapted housing, while others have exceedingly long waiting lists for often-inadequate services. Some communities have developed substantial geriatric medical care, including house calls and telemedicine, while others rely on the hospital for every complication. Little is known about the experiences of elders and their caregivers in the usual community, since very little is captured about the community’s experience of this part of life in conventional surveys and reports. Many health systems and communities like to take on the responsibility of monitoring and improving the care system for disabled elders and their caregivers, rather than just offering rescue services for serious and often preventable complications; but they find that the reliable metrics needed to guide improvement are unavailable.

We’ve given some thought to potential ways to meet these needs, and here’s what seems possible and affordable in order to make a measurement dashboard to guide improving a community’s eldercare system. First, one could mine large existing databases, such as Medicare and Medicaid claims, Outcome and Assessment Information Set (OASIS) home health agency assessments, and Minimum Data Set (MDS) nursing home assessments. Then, one could monitor demand for and performance of key service providers, such as wait lists for home-delivered meals or availability of wheelchair-adapted housing. Third, the community could interview family and caregivers for a sample of elderly decedents and describe the experience of the last couple of years. This strategy would sample those who received few services and demanded little, and it would allow exploration of critical issues such as bankrupting elders and families and providing culturally appropriate services.

Our last data source, learning by aggregating care plans, is a bit beyond current implementation, but it could enable the opportunity for substantial monitoring and improvement efforts. We envision having records with the key elements of service needs for nearly all frail and disabled elders in a geographic area. Being able to combine them electronically would yield rich data in order to summarize needs, services provided, gaps, oversupply, and quality problems—both for the whole community and by mapping to clarify the locus of some issues. If, for example, the community has 500 elderly people so disabled that they should have medical care at home, and the community had current capacity only for 100, then one could identify and map the areas of need and examine the current and potential supply options to address the gaps. Furthermore, with data on demand and supply for a dozen important service needs, the community would be able to set priorities for investments in public resources. You can read more about how this kind of community management would work in our book.

Of course this work requires adequate care plans, preferably in a format that allows electronic identification of the plan and its elements. At present, too few elders living with advanced illnesses have reasonably comprehensive care plans created, and even fewer have them written down, even in narrative form. We’ve also realized that shortages of, or quality shortcomings with, important services are addressed explicitly or noted in the record. Thus, a person who really would do better with door-to-door wheelchair transportation and lives in a community lacking this service will instead have the substitute arrangements in his care plan, such as “transportation relies on the availability of his son-in-law Tom, so appointments need to revolve around Tom’s availability.” The shortage of appropriate transportation options might be inferred but is not likely to be explicitly stated. Similarly, the lack of respite for a caregiver will not be noted. Therefore, additional work is needed to develop comprehensive care planning, which includes collaboration with the regulatory and technical bodies that are working on the standards for care planning.

With funding from the Gordon and Betty Moore Foundation, we are working to develop the methodology to do care plan aggregation. We are actively seeking communities that would like to help us develop these methods by letting us try it out with their population. We want to know what information from care plans you think would be most relevant and how you’d want to act on that knowledge, what entity in your community might be able and willing to act, and whether it is worthwhile to push for better and more standardized care plans.

Please email us at [email protected] if you know of or belong to an organization that might be able to work with us.

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Purchasing Value – Not Yet Right for Medicare’s Frail Elders

 Posted by on February 25, 2015  1 Response »  Tagged with: , , , , , , , , ,
Feb 252015
 

By Joanne Lynn

In late January, Department of Health and Human Services Secretary Sylvia Matthews Burwell announced that Medicare would purchase most services on the basis of value rather than volume, aiming for 90% of fee-for-service payments by 2018 [http://www.hhs.gov/blog/2015/01/26/progress-towards-better-care-smarter-spending-healthier-people.html]. Of course, paying on the basis of value is much better than paying on the basis of volume. But a moment’s reflection shows that this strategy requires figuring out what people value. For a child with a broken arm or a middle-aged woman with a gall-bladder attack, desirable outcomes are obvious, widely agreed upon, and readily measured. But this is just not the case for frail elders.

Consider a new heart attack affecting a 94-year-old living with multiple chronic conditions, self-care disability, and a lifetime of experiences and relationships. Different 94-year-olds will value very different things when it comes to treatment characteristics and quality-of-life goals; for example, some will desperately want not to go to the hospital, even if doing so would likely extend their lives, and others will welcome hospitalization with intensive care and every opportunity to get back to the way things were.

Even well-established quality metrics that are important to elder care, including avoiding delirium or the degree to which the person’s symptoms are addressed, are not yet used by Medicare, and the program has done little to develop ways to identify excellent care for frail elders. Rates of certain calamities and medical errors are currently measured, but elderly persons and their families expect that more will be monitored than mere safety. When we are old and frail and facing death, we need the quality of our care to be measured by whether it offers an opportunity to attend to important relationships, live comfortably, and pursue what matters most to each of us. Generic measures that reflect what someone else values won’t suffice.

Consider first what Medicare has set up as measures for this population. A starkly disturbing insight arises in the list of measures under consideration for implementing the Improving Medicare Post‐Acute Care Transformation (IMPACT) Act that are meant to measure outcomes and quality in after-hospital care. [List of Ad Hoc Measures under Consideration for the Improving Medicare Post‐Acute Care Transformation (IMPACT) Act of 2014, http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=78784.] Given the short timeline, the Centers for Medicare and Medicaid Services (CMS) has proposed measures that have already been approved or that are in the process of approval. CMS proposes four measures, each applied in four care settings: the rate of pressure ulcers, the rate of falls with injury, the existence of functional assessment and whether there is a care plan with a goal that involves function, and readmissions.

But in setting out to talk with frail, elderly people leaving the hospital for a short-term stay in a nursing home before they go home, what do we imagine are their highest priorities? The four that Medicare proposes might make the list, except that the way we measure readmissions is seriously deficient, even with risk adjustment [ https://medicaring.org/2014/12/16/protecting-hospitals/; https://medicaring.org/2014/12/08/lynn-evidence/ ]. But most people have other priorities that are equally or more important, such as whether there is a workable plan to get the daily care and support needed (e.g., housing modifications, food, transportation, and personal care). Another question elders often ask is what the effects of their disabilities on the family will be, especially if family members have to provide more care. Elders may also want to be sure that they will have the symptom (pain) control, spiritual support, and reliable supportive care that they will need as their conditions get worse, whether they are in a care system that will maximally preserve their financial assets so that they have a lower risk of running out, and whether they will have to move to a nursing home. Medicare’s metrics don’t yet even try to address these concerns.

Even more troubling is the fact that Medicare does not yet have any methods to judge the match between the services given and the patient’s perspective as to what matters. Current metrics are all grounded in professional standards, and professionals have been slow to build standards that truly take into account the very different things that individuals want in late life. A high-quality service delivery system must try to match the priority needs and preferences of each elder.

As Medicare moves toward paying its providers on the basis of value, it is important to keep in mind what you value is often not what I value, and this difference becomes more pronounced as we have to live with physical and financial limitations and the increasing proximity of death. Here are some steps that we can take:

  • We should demand that Medicare invest in developing measures that matter for the frail phase of life before distorting the delivery system with incentives applying to everyone (e.g., to avoid pressure ulcers, falls, and readmissions) and to have and achieve goals concerning function.
  • CMS should be willing to be the “measures steward” or should fund another entity to do so, since the money available for frail elder care does not spin off strong organizations that can do the developmental work and then maintain updated measures.
  • Our health information systems (e.g., in Meaningful Use Stage 3) should at least start making room in medical records to document each patient’s priorities and the care plan that is supposed to reflect those priorities.

Buying on value is the right idea, but buying value for each elder requires knowing what each one values.

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High and Worsening Symptom Prevalence in the Last Year of Life

 Posted by on February 2, 2015  1 Response »  Tagged with: , , , , , ,
Feb 022015
 

by Adam Singer

Symptoms such as pain and confusion are very distressing for those nearing the end of life and their families. That’s why increasing attention to end-of-life care is spurring greater interest in alleviating such symptoms as a critical component of quality of life. Yet there is still a long way to go: a just-published in the Annals of Internal Medicine (https://www.acpjournals.org/doi/10.7326/M13-1609) finds there has been no improvement in the prevalence of common symptoms among end-of-life patients. In fact, many important symptoms — including pain and depression — have actually become more common.

In 1997, the Institute of Medicine (IOM) released a seminal report on the state of end-of-life care in the US that called for major changes in the organization and delivery of end-of-life care.[1] Many of the IOM’s indictments have ostensibly been addressed since that time through the expansion of palliative care and hospice, along with a greater focus on symptom management in both policy and practice. The Annals study was designed to ask whether end-of-life symptoms have become less prevalent from 1998 to 2010.

The study used data from the Health and Retirement Study (HRS), a nationally representative longitudinal survey of community-dwelling adults aged 51 or older (http://hrsonline.isr.umich.edu/). Using an interview design, HRS collects information after each participant’s death from a proxy informant (usually a family member) about that individual’s end-of-life experience, including whether the person had any of the following eight symptoms for at least a month during the last year of life: pain, depression, periodic confusion, dyspnea, severe fatigue, incontinence, anorexia, and frequent vomiting. Using that information and the date of each participant’s death, the study analyzed the prevalence of each symptom over time for the population as a whole and also for subgroups that died suddenly or had cancer, congestive heart failure (CHF), chronic lung disease, or frailty.

The study found that many alarming symptoms were common in the last year of life and affected more people from 1998 to 2010. For example, in the whole population, pain affected 54% in 1998 and 61% in 2010 (a 12% increase). Depression affected 45% in 1998 and 57% in 2010 (a 27% increase). Periodic confusion affected 41% in 1998 and 54% in 2010 (a 31% increase). Depression and periodic confusion also became more prevalent in subgroups with CHF and/or chronic lung disease and frailty. These results are summarized in Table 1 below.

Prevalence of Key Symptoms in the Last Year of Life in 1998 and 2010

Prevalence of Key Symptoms in the Last Year of Life in 1998 and 2010

In addition to the key results highlighted in Table 1, nearly all other symptoms in the whole population and in each of the subgroups trended toward increases in prevalence from 1998 to 2010, although most of these trends did not reach statistical significance. The one exception is that there were no significant changes in the subgroup with cancer.

High and worsening symptom prevalence near the end of life raises serious concerns about stubbornly ingrained shortcomings in end-of-life care despite the increasing national attention and resources being devoted to it. Indeed, recent studies of health care performance suggest that many providers continue to fall short in symptom management near the end of life.[2],[3],[4] The fact that pain remains common is particularly troubling, as this symptom is highly visible, well-studied, relatively reliably ameliorated, and has a large impact on health-related quality of life.[5] On the other hand, it is encouraging that trends in symptom prevalence in cancer may have stabilized.

While there have been many positive developments in end-of-life care since 1997, the Annals study shows that much more effort is needed to ensure that policy and organizational change translate to improvements in actual patient outcomes. Along these lines, there are many reasons why end-of-life symptom prevalence may not have improved since the IOM report:

  • Intensity of treatment has been increasing near the end of life, and even though hospice use doubled from 2000 to 2009, the median stay is under three weeks.[6],[7] “Tacking on” hospice to otherwise intense late life care may leave patients suffering in the meantime and simply may not provide enough time for hospice to help alleviate symptoms.
  • Palliative care services are more common in hospitals (where palliative care programs have tripled since 2000),[8] but most of the course of a terminal illness takes place outside of the hospital. Many patients may not have consistent access to palliative services known to be effective in promoting symptomatic relief.
  • Effective treatments exist for many end-of-life symptoms, but there are significant gaps in their delivery.[9],[10] Interventions may not be reaching the right patients in the right ways.

In summary, the prevalence of many end-of-life symptoms remains unacceptably and disappointingly high in light of active efforts to improve end-of-life care. Some best practices simply are not being followed. Some choices are not being adequately explained and offered to patients and the family caregivers supporting them. Aligning current care with best practices represents a promising way to harvest low-hanging fruit in order to reverse these negative trends and reduce end-of-life symptom burden for millions of Americans. But beyond that, the trends characterized in the Annals study must be parsed further in order to identify better and more coordinated ways to organize and deliver high-quality end-of-life symptom management.

Footnotes:

References

[1] Approaching death: Improving care at the end of life. Washington, D.C.: Institute of Medicine; 1997.

[2] Walling, A.M., Asch, S.M., Lorenz, K.A., et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.

[3] Dy, S.M., Asch, S.M., Lorenz, K.A., et al. Quality of end-of-life care for patients with advanced cancer in an academic medical center. J Palliat Med. 2011;14(4):451-457.

[4] Malin, J.L., O’Neill, S.M., Asch, S.M., et al. Quality of supportive care for patients with advanced cancer in a VA medical center. J Palliat Med. 2011;14(5):573-577.

[5] Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington, D.C.: Institute of Medicine;2011.

[6] Teno, J.M., Gozalo, P.L., Bynum, J.P., et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009.JAMA. 2013;309(5):470-477.

[7] NHPCO facts and figures: Hospice care in America. Alexandria, VA: National Hospice and Palliative Care Organization;2014.

[8] Growth of palliative care in U.S. hospitals: 2014 snapshot. New York, NY: Center to Advance Palliative Care;2014.

[9] Walling, A.M., Asch, S.M., Lorenz, K.A., et al. The quality of supportive care among inpatients dying with advanced cancer. Support Care Cancer. 2012;20(9):2189-2194.

[10] Walling, A.M., Tisnado, D., Asch, S.M., et al. The quality of supportive cancer care in the veterans affairs health system and targets for improvement. JAMA Intern Med. 2013;173(22):2071-2079.

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Senior Alert: A Swedish National Dashboard for Preventive Care for the Elderly

 Posted by on December 22, 2014  No Responses »  Tagged with: , , , ,
Dec 222014
 

By Elizabeth Rolf

Take a look at the Swedish national dashboard for eldercare. It’s a great model. An analytics approach that works, Senior Alert (http://plus.lj.se/senioralert) takes the preventive care of every individual patient and inputs the data outcomes in a quality dashboard for each municipality, accessible to doctors, patients, and the public. The civic leader or ordinary citizen can see how their municipality is doing in reducing pressure ulcers or antipsychotic use, and how many patients who need a preventive intervention have had it done. An interactive data system like this is an aspiration for many in the United States, but in Sweden, it is a wonderful reality. Earlier this month, Goran Hendriks, Susanne Lundblad, and Dennis Nordvall presented Sweden’s action plan to an audience in a webinar, which is available online. Many were able to see the results that this remarkable, comprehensive dashboard provides to guide improvement in preventive care by tracking data concerning the risks of falls, pressure ulcers, malnutrition, poor oral health, and incontinence. The information gained in a systematic way is often useful to understand how to treat the problem areas for each elderly patient as an individual, but the exciting application is the guidance it provides for shaping the care system for the entire elderly population of a particular municipality or country.

Lilly, age 95, provides the example used to demonstrate Senior Alert. Her story centers on declining health, increasing disability, and need of reliable care process. The registry that monitors her condition and services helps ensure comprehensive care. By registering Lilly for Senior Alert, her doctor, her family and she are assured that she will have a risk assessment by a team of professionals who will recommend and implement preventive interventions, evaluate these interventions and adjust accordingly.

The data system combines Lilly’s data with all from her geo-political area and provides up-to-date and interactive information as to the progress of each municipality and county with regard to excellent preventive service for fragile elderly persons.

Senior Alert was implemented in 2010, and in the last four years, all 21 counties in Sweden use the program and 288 of 290 municipalities are involved as well. In addition to public programs, 129 private health care providers use Senior Alert. In this time, patients are receiving personalized care plans, along with fewer risks to the patients because of the attention to the needs of each patient. As the process is followed, both the patient and the doctor can see improved results, and these results can be viewed publically online. The data collected can be used to track prevention progress daily for individual patients in many different categories, but collectively creating a reliable care process for Sweden’s entire elderly population. All results keep the patient confidential of course, but the public can access results of various actions.

Want to know more?

Link to Senior Alert: http://plus.lj.se/senioralert

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IMPACT’s Impact on Quality Measurement for Frail Elders

 Posted by on October 28, 2014  2 Responses »  Tagged with: , ,
Oct 282014
 

By Joanne Lynn

What matters in the lives of frail elders centers on function — and understanding an elderly person’s course, over time, requires that everyone involved learn to measure functioning in the same way. That’s the core of the new Improved Medicare Post-Acute Care Transformation (IMPACT) Act, passed by Congress in September 2014. Within a few years, we will have a uniform way of measuring what matters, including at least functional ability, across all post-hospital settings. The work that Medicare will have to do to implement IMPACT provides a remarkable opening for advocates to get Medicare measuring the things that matter.

About a decade ago, I started working at the Centers for Medicare & Medicaid Services (CMS) in the Quality Measurement and Health Assessment Group. In straightening up my cubicle on the first day, I was dumbfounded to find a small cache of notepads emblazoned with “HCFA” and even more yellowed ones saying “Social Security Administration.” But the real gem was a set of transcripts from hearings nearly 30 years ago that addressed the wisdom of having a Uniform Assessment Instrument (UNAI) for the elderly. The arguments were cogent, and many of those testifying were well-known in geriatrics and gerontology to this day. But the world did not turn their way.

CMS ended up with some assessment instruments: the Minimum Data Set (MDS) for nursing homes, the Outcome Assessment and Information Set (OASIS) for home care, and the Inpatient Rehab Facility-Patient Assessment Instrument (IRF-PAI) for rehabilitation hospitals. There was little consistency between them. One instrument might ask whether an elder could do a task, another asked if he did do the task, and the last could ask how quickly he did it. If a person were in a sequence of settings that used different instruments, there was no way to see whether the person changed or it was just that the specific questions were different. This inconsistency was crazy! It precluded doing a serious study of outcomes across settings, characterizing populations of frail elders who used multiple settings, or even training practitioners to optimize the quality of data.

CMS has done one remarkable study, the Post-Acute Care Payment Reform Demonstration (PAC-PRD), in which elderly hospitalized persons were measured with a standardized tool, called the CARE Instrument. The findings have slowly surfaced and show that most outcomes are not affected by the setting of treatment, but the costs are dramatically different. This has led the Medicare Payment Advisory Commission (MEDPAC), in its June 2014 Report to Congress, to take notice and call for more site-neutral payments. This would mean that Medicare would not pay differently for treatment in settings that are not shown to make a difference in outcomes.

But for any rationalization of the increasingly expensive period just after hospitalization, one really needs the UNAI, a uniform way of measuring what matters, including at least functional ability, across all settings and time. That is the core of IMPACT. The Act requires that CMS promulgate a standard assessment and that all post-hospital providers use it and report data in that form. This meshes with an entirely separate project by the same name, Impact, an Office of the National Coordinator for Health Information Technology project that has identified and standardized hundreds of elements that might be part of an assessment and care plan and is beginning to pilot-test the interoperability of records across sites in long-term care. The IMPACT Act makes UNAI real, with various deadlines, mostly 2018.

Having uniform data that will allow identification of functional disability and other important clinical categories creates the possibility of developing quality measures that reflect the priorities of frail elders, and the Act and the Executive Action Fact Sheet that accompany it give clear instruction to build measures of this sort.

How do the IMPACT Act and the associated executive actions give us a window of opportunity? IMPACT, in its section on quality measures, requires that care preferences of the individual and the family caregiver be part of the data to be reported at the time of a transition in setting of care. In a section on quality measure use, the Act requires that conditions of participation include procedures to address the patient’s treatment preferences and goals of care. The Act also calls for studies of the effects of socioeconomic factors and beneficiary activation on quality measures. The Act requires stakeholder input, and all of us are stakeholders. We hope to grow old, and we hope our loved ones do also.

What matters most when we are living with disabilities, chronic conditions, and frailty associated with advanced age? Most people still want to live a bit longer if possible. But most of us become more aware with age that we are working with a truncated timeline and long-term outcomes are no longer relevant. For that and other reasons, many additional considerations start crowding the stage. Some want to be sure that a disabled adult son has assets to live on; others have no dependents. Some want to honor their faith traditions; others want to solidify their departure from those beliefs. The endless variations make it impossible to have one care plan that fits all people.

So why do we now measure quality for frail elderly people as if everyone wanted mainly just to live longer with better health? Often, our metrics just comply with professional (mostly physician) guidelines on how to take care of (somewhat younger) bodies. People become more and more individualized with their particular family, finances, dreams, and fears as they age. We really must learn to measure the quality of health care by the degree to which it serves the individual’s priorities. We must learn to ask, “What matters to you, and what matters most to you?” and to judge quality by how well the services actually deliver on what matters most.

Could we do that? Sure! First, we need to document what matters most to the frail elderly person (and family) and what strategies will most likely accomplish the feat — commonly termed an “assessment and care plan.” Then we need to measure whether the elderly person (and family, as appropriate) feels that the services help to achieve what matters most. We could start with a simple scale: “Working against my interests,” “Not clear or not particularly helpful,” and “Completely or mostly aligned with what matters to me.” We would learn how to do it better, but the important thing is to start caring about what matters to the individual person.

Of course, some things are important to so many people that we might learn to measure them across the frail elder population. Metrics of “what really matters to me” could include, for example, “the rate at which the care system spends down my financial assets,” “the likelihood that I can stay in my home as long as I want to,” “my confidence in having adequate preparation for adverse events and adequate backup for challenges,” and “the stress that my family and friends feel as they try to ensure that I have what I need.” Most people care about avoiding falls and injuries and living where they want to live. While we are at it, let’s start measuring important things about family caregivers: availability, skills, stresses, and challenges. These are what most often really matter when you are living your last years with disabilities and limitations. How different this is from the usual “percentage with diabetes under control” or “percentage with colon cancer screenings”!

Let’s do what we can to help CMS commit to building the metrics that we need. Here are some suggestions:

  1. Contact the organizations to which you belong and encourage them to include advocacy on behalf of quality measures appropriate for frail elderly people in their work with Medicare and Medicaid.
  2. Write to CMS and your congressional representatives to push for metrics that really reflect the concerns of frail elderly people and their families.
  3. If you are funding or doing research in this arena, stretch the scope to include what really matters.
  4. When you look at Nursing Home Compare, Home Health Compare, or any of the quality information for the public sites, send a comment to CMS, your congressional representatives, or your Quality Improvement Network that the metrics are not yet what you hope to see. You can offer some of the ones that I listed above as examples of what we should have.
  5. Some responsive and forceful advocacy for frail elderly people is at Consumer Voice, OWL, and Gray Panthers and caregiver groups. Join them and encourage their work in these arenas.
  6. Write to us with suggestions and plans. The time is upon us! We will watch for CMS requests for information, proposed regulations or conditions of participation, and RFPs. You can also let us know if you see something potentially important going by.

This is important, and an opportunity has opened up that might move us along well.

Want to know more?

Post-Acute Care Payment Reform Demonstration: Final Report
http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/Research-Reports-Items/PAC_Payment_Reform_Demo_Final.html

CARE Instrument
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/CARE-Item-Set-and-B-CARE.html

Medicare Payment Advisory Commission (MEDPAC) June 2014 Report to Congress
http://www.medpac.gov/docs/default-source/reports/june-2016-report-to-the-congress-medicare-and-the-health-care-delivery-system.pdf?sfvrsn=0.pdf?sfvrsn=2

Standards & Interoperability (S&I) Framework
https://www.healthit.gov/topic/interoperability/standards-interoperability-si-framework

White House Fact Sheet on Executive Actions to Improve Quality of Care
http://www.whitehouse.gov/the-press-office/2014/10/06/fact-sheet-administration-announces-new-executive-actions-improve-qualit

PDF Download of the full text of HR 4994 (the Act)
http://www.gpo.gov/fdsys/pkg/BILLS-113hr4994enr/pdf/BILLS-113hr4994enr.pdf

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A Dangerous Malfunction in the Measure of Readmission Reduction

 Posted by on August 26, 2014  No Responses »  Tagged with: , , , , , ,
Aug 262014
 

By Joanne Lynn and Steve Jencks

Work to reduce readmissions has started to yield remarkable improvements in integration of care for frail elderly people – by prompting hospital personnel to talk with community-based service providers, by teaching patients and families how to manage conditions and navigate the health care system more easily, and by paying more attention to trying to fill gaps in the community’s services. But the measure being used to track improvement is seriously misfiring in some settings, and if CMS does not mitigate the adverse impacts, they may become destructive to the momentum and the good that has been done. This is much more than an issue of imperfect risk adjustment or inadequate identification of planned readmissions: it is a punitive error that undermines program goals.

Since CMS mostly aims to assign responsibility for readmissions to the discharging hospital, the key metric has been the risk of readmission for the average person discharged, which is the number of readmissions, divided by the number of live discharges. Any time outcomes are monitored with a ratio, one has to watch out for whether interventions that affect the numerator also affect the denominator. Here, that’s happening enough to completely obliterate the usefulness of the metric – at least in some circumstances.

Here’s a quick hypothetical example: At baseline, a hospital has 1,000 Medicare fee-for-service (FFS) discharges per quarter, with 200 of them back within 30 days. Subsequently, the hospital team and various community-based providers work together and drop the readmissions to 160 per quarter. Does the readmission rate go down to 16% under the metric? No. First, they no longer have the 40 readmissions that are also admissions and in the denominator. But more important – the very things that are reducing the readmission rate also affect the likelihood of coming back in 45 days, or 6 months, or ever! Patients are supported in learning to take care of themselves and to advocate for themselves in the care system, they make good care plans (including advance care plans), and they encounter a more supportive care system in the community. These things are still affecting the patient many months after the hospitalization. Indeed, as the care system learns how to support fragile people in the community better, fewer patients will need to come to the hospital in the first place. The result for our hypothetical hospital is that it ends up with 800 discharges per quarter, and it has not budged its readmission rate! Officially, it has not improved, even though the work done by the hospital, by patients and families, and by community-based providers has improved care substantially, and has saved millions of dollars for Medicare. Yet, using the current flawed metric, the hospital is still likely to be penalized for having a high rate of readmissions!

This is not a new observation. The first sizable pilot project that CMS sponsored involved 14 communities, and the readmissions/discharges metric functioned so poorly that the outcome measure was changed during the project to a population-based measure: readmissions per 1,000 Medicare FFS beneficiaries in the geographic community [See: http://jama.jamanetwork.com/article.aspx?articleid=1558278]. That measure works to track changes in the experience of those living in a community, but it does not help in assigning credit or blame to particular providers (unless there is only one provider in the area). It is intrinsically community-anchored. The rub is that while good care of frail, chronically ill persons is at heart a community endeavor, Medicare has few tools to incentivize or penalize communities.

Furthermore, it is not clear what the “right rate” of readmissions should be. Very little work has been published on how well the various metrics perform in various circumstances, though NQF has a score of new ones under consideration [See: http://www.qualityforum.org/ProjectDescription.aspx?projectID=73619]. The hospital penalty measure has a very complicated risk adjustment, but should the population-based measure also be risk-adjusted (perhaps at least for the population age structure and whether the person is in Medicare due to disability or age)?

The problem here is more urgent than other controversies regarding the Medicare readmission measure such as higher readmission rates in disadvantaged populations and whether communities with low total hospital utilization should be expected to have higher readmission rates. In the case of measuring change, the measurement flaw directly punishes hospitals and communities for doing what the Affordable Care Act and the Medicare Readmissions Reduction Program otherwise encourage them to do: reduce preventable hospitalizations.

What should a responsible system manager like Medicare do? Below are some suggestions.

In the short-term:

  1. Quickly sort out how to exclude certain contexts, perhaps as part of risk adjustment – e.g., whether CMS is authorized to limit application of the readmissions/discharges metric through regulation, or whether the issue has to go back to Congress.
    1. For safety net hospitals – don’t penalize hospitals primarily serving poor beneficiaries.
    2. For reducing admissions – see which of these approaches works best (or combine them)
      1. Hospitals with declining admissions (and the same bed size), when the decline is at roughly the same rate (or more) than declining readmissions
      2. Hospitals with >50% of their Medicare FFS utilization in counties with admission rates in the lowest quartile in the nation
  2. Allow hospitals in a particular geographic area to propose accountability for a population – jointly or singly – so long as they together supply more than, for example, 70% of the hospital use for that population. Then measure their success on a population basis (readmissions/1,000 relevant people living in the area/quarter, and admissions/1,000/quarter)

In the longer-term:

  1. Develop useful metrics for continuity and quality of care, especially for:
    1. Reliability, patient/family sense of trustworthiness/preparation; and
    2. Patient/family driven care plans, evaluated for quality with feedback
  2. Develop useful metrics for the global costs of care, including private and Medicaid costs, for longer terms of illness, not depending upon hospitalization as the trigger, and including long-term services and supports.

What Can You Do Now?

If you agree, let’s talk about how to make improvements to the metric with the National Quality Forum, CMS, hospitals, and other interested organizations and colleagues. Feel free to add comments and suggestions here, too. Let’s build a commitment to evolving toward measures that really reflect optimal care, rather than staying with the under-performing and often misleading ones we have.

Want to know more?

Jencks et al.’s New England Journal of Medicine article on readmission statistics:
http://www.nejm.org/doi/full/10.1056/NEJMsa0803563

The Hospital Readmissions Reduction Program:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

The Community-based Care Transitions Program:
http://innovation.cms.gov/initiatives/CCTP/

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JAMA Report Finds Community Collaboration Key to Reducing Hospitalizations and Rehospitalizations

 Posted by on January 23, 2013  1 Response »  Tagged with: , , , , , , , , ,
Jan 232013
 

By Dr. Joanne Lynn

The latest issue of JAMA features our paper describing   an exciting and successful initiative from the Centers for Medicare and Medicaid Services (CMS) and fourteen of its quality improvement organizations (QIOs).  Grounded in quality improvement methodology—plan-do-study-act–this unusual project offers many insights for those aiming to reduce avoidable readmissions.  And its raises a number of important question about how we measure progress in reducing readmissions. (For more on that topic, see our earlier MediCaring blog, https://medicaring.org/2013/01/07/readmissions-count-should-cms-revise-its-calculations/ )

A Medicare patient’s ability to receive successful treatment during care transitions from one setting to another has a crucial effect on the overall cost and efficiency of the Medicare system. Errors in information transfer, care planning or community support can cause hospitalizations, rehospitalizations and unnecessary costs to the Medicare program.

This project involved a three-year, community-based effort to improve the care transition process for fee-for-service Medicare beneficiaries. Participating QIOs facilitated cooperation among providers, health care facilities, and social services programs, such as Area Agencies on Aging. They centered their efforts around each community’s unique needs.   QIOs worked with communities to understand their own particular causes of readmissions, and to implement appropriate, evidence-based models to address them.  Communities analyzed results of the intervention along the way, and changed course to stick with interventions most likely to work.

The results, when compared to 50 comparison communities, showed significant reductions in hospitalizations and rehospitalizations, both by an almost 6% average, saving Medicare $3 million in hospitalization costs per average community per year.

This correlation has already led to new national efforts such as Partnership for Patients and the Community-based Care Transitions Program. In addition, in the 10th Scope of Work, all 53 QIOs are leading community projects nationwide (so far, in more than 400 communities).

This paper may be the first time one of America’s leading medical journals has published a report based on QI methods. Doing so represents a profound change in the openness of American medicine to learn not only what works for a patient, but works for the delivery system, too.

key words: quality improvement, care transitions, CMS, CFMC, Joanne Lynn, readmissions, community coalitions, JAMA

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Learning from Reviewing Readmissions: Tools You Can Use

 Posted by on August 8, 2011  No Responses »  Tagged with: , , , , , , ,
Aug 082011
 

A colleague asked an important question: Which tools are best for reviewing causes of readmissions? Two examples, from Georgia and New Jersey, are attached to this posting. Georgia’s form requires starting from a patient/family interview review, and does not pull much from the record of the hospitalization. New Jersey’s form starts from the other direction – all pulled from charts, with just the contact information that enables an interview if someone undertakes it.  Each has targeted a certain set of issues — clear plan, medications, teach-back, advance directives, social problems, and so on.  Although the two forms overlap on many targets, on others they do not.

NJ_Readmission Chart Review tool

NEW_GA ReadmissionWorksheet

The Institute for Healthcare Improvement (IHI) has developed another useful form, which can be found on page 88 at this URL: http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingTransitionstoReduceAvoidableRehospitalizations.aspx.  It “feels” more succinct, because it is set up to do 5 readmissions at a time and to focus upon themes.  But it also requires a more insightful reviewer, one who has thought about what it is that makes for rapid readmissions and what might work to make transitions bette

One way to get started is to simply review just a few charts of people who were readmitted to the hospital with which you are most familiar, and see what you most wanted to learn. You might start with the IHI form and then try filling out the other two to see what additional elements you might consider. Call a few patients or families, or, if that is not appropriate, call the main attending physician in the community. Try to gain some insight from the perspectives of people involved.
Keep track of the time it takes to do this review.  If you can get someone to pull the charts, the work to this point will take about two or three hours. Of the time involved, what seemed most productive and what was most illuminating?

Then put together your own form, starting with whichever one is most suited and adding or deleting the elements to end up with the ones that you found to be most useful.  Test that form on another two or three records, perhaps asking a colleague to do those (to learn what instructions are needed and whether another perspective identifies other things that are very important to include.
My prediction would be that you’ll find some remarkable stories–people in fragile condition whose community doctors did not really know they were out of the hospital or doctors who were unfamiliar with the patient’s situation and medications; people who could not afford the treatment prescribed; and people who simply greatly misunderstood what they were to do. (I recall the patient who told me about having to eat fresh vegetables for his heart – whereupon he opened a fresh can of peas every day!) Those stories will greatly help you galvanize the will to move ahead.  And you’ll have a process and form that you can persuade the quality improvement team at each hospital to do: Perhaps at large hospitals, five each week for four weeks and at small hospitals, five in the month.  Within a month, you’d have enough data and stories to build the endeavor, and continuing to collect the data provides rapid feedback about progress. Pick a lead intervention or two and get it tested and underway!

You are likely to find a certain sense of chaos– that there is a lot of “catch as catch can” processing with thorough unreliability on all sides. If this is the case, your coalition might well work on standardizing the process simply so that it is reliable.  You may find that the issues affecting the frail elders are different from those affecting younger populations– more complexity and fragility in the elders and more lack of access or barriers arising from mental illness in the younger.  Whatever you find, this is the “root cause analysis” that you’ll need to decide priorities and to apply for CCTP funds.

Key words: root cause analysis, reviewing readmissions, discharge record review, quality improvement tools, CCTP funding

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