By Eva DuGoff, Sydney Dy and Cynthia Boyd
This is the second of three posts on issues measuring quality of care in older adults with multiple chronic conditions.
Care coordination has long been considered integral to the efficient and effective delivery of health care, especially for older adults with multiple chronic health conditions. Under the Patient Protection and Affordable Care Act of 2010, Medicare has funded a number of pilot and demonstration programs testing approaches that incentivize and compensate providers for offering these services. Three of the law’s highest-profile initiatives designed to improve care coordination are Accountable Care Organizations (ACOs), the Independence at Home (IAH) demonstration program and the Community-based Care Transitions Program (CCTP).
In our article recently published in the Journal of Healthcare Quality [1], we examine how these three programs measure care coordination quality in five different domains: 1) Communication includes interpersonal communication and information transfer; 2) Continuity of care includes the capacity to monitor and respond to change, support self-management goals, and link to community resources; 3) Patient centered includes creating a proactive plan of care, assessing needs and goals, and aligning needs and resources; 4) Care transitions includes facilitation transitions as coordination needs change and facilitate transitions across settings; and, 5) Cross-Cutting assesses whether the measure applies to multiple conditions. These measurement domains are drawn from the Care Coordination Measurement Framework and NQF Multiple Chronic Condition Measurement Framework [2, 3].
The selection of the quality measures is a critical design element of these care coordination programs because it determines the empirical evidence base for assessing the success of these programs, as well as financial rewards. While quality measure selection raised a great deal of concern inside the Washington DC beltway, these issues have received little attention in the peer-reviewed literature.
In this article, we consider the ideal scenario to be as described in the following: “Ideally, quality measures in these ACA programs would reward and promote care coordination, particularly for people with MCCs (multiple chronic conditions), and have the same core measurement set to allow for comparisons between programs, and utilize measures endorsed by a national standard-setting organization, such as the National Quality Forum (NQF)” [1]. We focus on how care coordination quality is measured in three high-profile programs, ACOs, Independence at Home, and Community-based Care Transitions, and the NQF care coordination measure set. We collected all measures classified as assessing care coordination and those linked to financial incentives in the three ACA programs. Two reviewers categorized these measures independently then reconciled any differences.
What we find is far from the ideal. There is little overlap in the quality measures used to measure care coordination. While this heterogeneity may reflect the characteristics and needs of different target populations, these differences will inhibit comparison between these programs.
And, too, many aspects of care coordination are not captured by existing, selected measures. “Patient-centered care was not captured by the ACO measures, but was assessed in IAH and CCTP. None of the ACA programs measured aligning resources with patient and population needs. Care coordination activities assessing how well the health care team responds to changes in health needs, care transitions, and monitoring and follow-up were infrequently captured” [1]. In a recent article, Kathryn McDonald and colleagues come to a similar conclusion based on their analysis of care coordination quality measures for primary care practices. They find that there are no adult care coordination quality measures assessing care transitions or measuring how providers respond to changes in a patient’s health needs [4].
Further research is needed to identity meaningful care coordination quality measures that will allow policymakers to comprehensively assess these care coordination programs. There are few measures that measure care coordination in ways relevant to people with multiple chronic conditions—even those these are the people are the most in need of care coordination. In the short-term policymakers could consider aligning care coordination quality measures to the extent feasible across these three programs and future initiatives.
References
[1] DuGoff EH, Dy S, Giovannetti ER, Leff B, Boyd CM. Setting standards at the forefront of delivery system reform: aligning care coordination quality measures for multiple chronic conditions. J Healthc Qual. 2013 Sep-Oct;35(5):58-69.
[2] McDonald K, Schultz E, Albin L, Pineda N, Lonhart J, Sundaram V, Smith-Spangler C, Brustrum J, Malcolm E. Care Coordination Atlas Version 3 (Prepared by Stanford University under subcontract to Battelle on Contract No. 290-04-0020) Rockville, MD: Agency for Healthcare Research and Quality; 2010. Available at: http://www.ahrq.gov/professionals/systems/long-term-care/resources/coordination/atlas/index.html.
[3] Multiple Chronic Conditions Measurement Framework. (2012) (pp. 1-74). Washington, DC: National Quality Forum.
[4] McDonald KM, Schultz E, Pineda N, Lonhart J, Chapman T, Davies S. Care Coordination Accountability Measures for Primary Care Practice (Prepared by Stanford University under subcontract to Battelle on Contract No. 290-04-0020) Rockville, MD: Agency for Healthcare Research and Quality; 2012.
