By Daniel J. Marino, President & CEO, Health Directions
As ACO leaders shift their attention from high-level planning to working out the nuts and bolts of operations. The main challenge is learning how to manage performance under Medicare’s 33 quality measures. Success or failure will be determined by how well an ACO can create effective change in clinical processes.
The first priority is to develop processes for capturing the data needed for reporting. But reporting quality data is just the tip of the iceberg. The underlying aim of the quality measures is to provide more coordinated care. Caregivers will need to adopt new behaviors and practices, and ACOs will have to create tools to support new clinical behaviors and actively manage care coordination. This in turn will call for a broader approach to healthcare information. ACOs will need to capture clinical data not only to report measures but also to drive care improvement initiatives.
How Can ACOs Create Targeted Change at the Clinic Level?
Leading organizations are taking a systematic approach—translating each of the 33 quality measures into clinical processes, programs and information systems that drive reporting and improve clinical outcomes.
Case in Point
Operationalizing Measure 12. One of the core strategies of accountable care is to reduce errors and improve patient outcomes through better medication management. ACO Measure 12 supports this goal by requiring organizations to report the percentage of patients who receive timely medication reconciliation after discharge from an inpatient facility. While the measure is straightforward, the underlying problem is complex. Patient hospitalizations usually involve several medication changes, and hospitals do not consistently communicate discharge medications to primary care physicians and other treating providers. Physicians are often unable to determine the rationale of discharge medications and may have a hard time incorporating new drugs and doses into revised care plans. Disjointed medication management—especially for patients with multiple comorbidities—results in post-discharge complications and hospital readmissions.
Considering the full scope of the problem, what does an ACO need to do to operationalize Measure 12? Start with the patient’s needs at discharge and work backwards. The following example illustrates one possible approach:
In most organizations, providers will need to put more emphasis on consistently providing medication reconciliation for recently discharged patients. Nurses may need to adopt new processes for documenting and verifying current medications, and physicians will need to incorporate medication reconciliation into standard practice patterns. All providers will need to document medication reconciliation correctly, which may require additional training.
To perform medication reconciliation in the post-acute clinic, physicians and nurses will need consistent access to discharge medication lists. Create interfaces for pulling discharge medications by drug name, dose, frequency and route from the hospital information system. Building a discharge medication list may involve establishing electronic feeds from hospitalist, specialty consultant and discharge planner notes.
In addition to processes and information systems that are directly involved in operationalizing Measure 12, an ACO will need to create programs that support new behaviors and drive performance improvement. Organizations might implement one or more of the following:
- Proactive collaboration: Hospitalists could spearhead an effort to proactively coordinate discharge planning with post-acute physicians.
- Direct physician contact can simplify medication reconciliation for primary care providers and help prevent drug-related complications.
- Nurse navigators: New processes are not enough to ensure all patients receive timely medication reconciliation. Someone needs to quarterback the overall system. An ACO could assign nurses to identify patients in post-discharge and schedule appointments with primary care physicians. Create a trigger within the hospital information system to alert a nurse navigator when a patient has been discharged. Use claims data to identify beneficiaries who leak out of the system (e.g., a patient who is hospitalized while vacationing out of state).
- Patient outreach: Nurse navigators could use contact management software to communicate key information to patients during the post-discharge period. Healthcare-specific contact software exists, but many organizations have simply adapted business contact tools to the healthcare environment. Home health nurses could facilitate medication reconciliation for the most complex patients and work with patients to ensure medication compliance.
The system described above is only one way to operationalize Measure 12. Several effective approaches are possible. The important point is to develop a strategy that aligns clinical operations with the goals of the measure, with a comprehensive system of interventions built on care plans, clinical roles, efficient communication and electronic exchange of information. Implemented appropriately, a comprehensive strategy will help caregivers achieve advanced performance outcomes and higher quality patient care following hospitalization.
Tools and Techniques
Clinical process translation is a huge task. ACOs need to establish new work processes, create new data feeds to populate the clinical disease registry, and develop new support programs for each of the 33 quality measures. Ideally, all new processes will be rolled up into a comprehensive care management program for ACO beneficiaries.
One approach is to develop an Acute-to-Ambulatory Transition Program that coordinates medication reconciliation efforts with other care initiatives. The program could identify patients who have been admitted to an inpatient facility and take steps to address the risks that lead to preventable readmissions. Specific program elements could include better efforts to create and communicate discharge care plans. Contact management tools could be used to communicate with primary care physicians and send education materials and appointment reminders to patients.
How can an ACO manage a patient population across multiple care programs? The most useful tool is the care gap report. Populated from the ACO’s clinical disease registry, care gap reports identify discrepancies between care protocols and the actual care delivered to specific patients. ACOs can use care gap reports to track their performance on both quality measures and the clinical processes that support them. For instance, ACOs need to improve the health of diabetic patients through better hemoglobin A1c control (Measures 22 and 27). Providers could use a care gap report to flag patients who have not had an HbA1c reading in the last three months. Nurse navigators or other program staff could then contact patients to schedule lab work and guide appropriate follow-through.
Care gap reports can tie together several measures to enable more efficient interventions. For example, if a patient has been identified to come in for an HbA1c blood test, the report could also prompt a flu shot (Measure 14), pneumococcal vaccine (Measure 15) and other preventive health services. The system could also be configured so that care gap reports trigger alerts within the ambulatory EMR, prompting physicians and nurses to deliver protocol interventions. As the Shared Savings Program transitions from pure reporting to performance measurement, care gap reports will become a critical tool not only for meeting quality measures but for driving clinical process change and managing costs. Process improvement dovetails with current efforts to operationalize the ACO measures. Both follow an evolution:
- First, capture the clinical information elements needed to drive the measures.
- Second, aggregate the data elements to enable analysis.
- Third, interpret the data to drive improvements in clinical workflow and care coordination.
Clinical process improvement will ultimately be the main driver of ACO performance and profitability. To the extent that ACOs can do a better job of managing care for high-risk and transitional-risk patients, they will dramatically improve clinical and financial outcomes.
Ongoing Performance Gains. A systematic approach to operationalizing the 33 quality measures will help organizations ensure that clinical process workflows support care management goals. Process translation teams should include strong representation from clinical providers and administrative staff, including physicians, nurses and IT technicians. Multidisciplinary collaboration is the key to creating clinical processes that not only enable reporting, but allow an ACO to achieve ongoing performance gains by controlling costs and improving patient outcomes.