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Outcome Metrics: Is Our Service as Good as We Think It Is?

Outcome Metrics: Is Our Service as Good as We Think It Is?. Thursday, October 17, 2013 Audio Conference 1:30 – 2:30 PM EASTERN. Laura C. Hanson, MD, MPH Professor, Geriatric Medicine Co-Director, UNC Palliative Care Program University of North Carolina-Chapel Hill Chapel Hill, NC

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Outcome Metrics: Is Our Service as Good as We Think It Is?

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  1. Outcome Metrics: Is Our Service as Good as We Think It Is? Thursday, October 17, 2013 Audio Conference 1:30 – 2:30 PM EASTERN Laura C. Hanson, MD, MPHProfessor, Geriatric MedicineCo-Director, UNC Palliative Care ProgramUniversity of North Carolina-Chapel Hill Chapel Hill, NC laura_hanson@med.unc.edu

  2. DISCLOSURE No financial conflicts related to the content of this presentation.

  3. PEACE PROJECT Acknowledgements Funded by a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. • Carolinas Center for Medical Excellence (Anna Schenck, PI) • University of North Carolina • Technical Expert Panel • 14 pilot hospice sites • National Hospice and Palliative Care Organization • National Association for Home Care & Hospice • CMS Rural Hospice Demonstration Project • CMS Project and Medical Officers

  4. Objectives • Discuss the case for outcome metrics as central to palliative care • Describe outcome metrics for hospice and palliative care endorsed by the National Quality Forum • Illustrate how to choose and use measures that are relevant for your palliative care team

  5. for Quality Making the Case… Slide 5 of 35

  6. What is high quality care? Care that “increases the likelihood of the desired health outcomes and is consistent with current professional knowledge.” • Empirical / evidence based (when possible) • Normative / expert consensus Measuring the Quality of Health Care (IOM 1999) Medicare: A Strategy for Quality Assurance (IOM 1990) Slide 6 of 35

  7. Satisfaction is high We know we give good care, yet . . . Separate wheat from chaff – provider comparison Ensure quality and protect vulnerable population Justify expansion to administrators Internal quality improvement – lead in new best practices Why measure quality in HPC? Slide 7 of 35

  8. Donald Berwick, MD, MPP President of the Institute for Healthcare Improvement Past Administrator, Centers for Medicare & Medicaid Services Slide 8 of 35

  9. Why measure quality in HPC?Value is the new healthcare imperative Patient Protection and Affordable Care Act (2010) Value-based purchasing begins in 2012 • Hospitals • Cancer hospitals • ESRD • Outpatient clinics • Long-term care hospitals • Acute inpatient rehabilitation • Hospices – NQF measures drive payment by 2016 Slide 9 of 35

  10. Frailty andmulti-morbidity 76 year old woman admitted from a nursing home with nutritional decline, decubitus ulcer, osteomyelitis with uncontrolled pain; depression and early dementia CPR / vent / tube feeding treatment choices Pain and depression Site and goals of care Slide 10 of 35

  11. Advanced stagedisease A 53 year old man with COPD is admitted for leg weakness, hypoxia. X-rays suggest lung CA metastatic to brain. CPR / vent / Cancer treatment choices Dyspnea and anxiety Site and goals of care Slide 11 of 35

  12. Palliative care is expert care in serious illness SEVERITY OF ILLNESS Family / General Medicine Geriatrics Palliative care WHO DO YOU CALL??? Slide 12 of 35

  13. National Quality Metrics Slide 13 of 35

  14. HPC National Consensus Project Domains • Structure and process of care • Care for physical symptoms • Care for psychological or emotional symptoms • Care for spiritual needs • Social / family needs • Cultural needs • Care during active dying • Ethical / legal (communication, advance care planning) www.nationalconsensusproject.org; 2013 Slide 14 of 35

  15. From guidelines to quality measures National Consensus Project (2004, 2009, 2013) • Guidelines and preferred practices Next step – quality measures • Feedback on current care • Improve quality CMS funded the PEACE Project 34 quality measures for hospice & palliative care Slide 15 of 35

  16. How do we measure quality of care? Instrument – structured, specified tool to collect data about an individual patient Quality measure– a numeric summary of how often some care process or outcome (numerator) happens for a defined population (denominator). Slide 16 of 35

  17. What can we measure? Structure – actionable, indirect impact resources, personnel, policies and procedures Processes – actionable, probable impact timing, frequency, quality of assessments and treatments Outcomes – what we really care about (but can providers control?) patient’s health status, comfort, quality of life, quality of the dying experience; family’s satisfaction Slide 17 of 35

  18. How can we measure? • Administrative data • Hospital days, ICU days, cost, re-admission • Record reviews • Decision-making, symptom care processes, symptom scores • Surveys • Satisfaction, continuity of care, quality of life Slide 18 of 35

  19. Quality Measure Sources National Quality Forum (endorsed) www.qualityforum.org • National Quality Measures Clearinghouse (reviewed) qualitymeasures.ahrq.gov/ • FEHC and National Data Set (NHPCO) • PEACE Project • ACOVE • FATE; Nelson ICU measures (VA System) • Cancer Quality ASSIST • QOPI measures (ASCO) Campion FX J Onc Pract Slide 19 of 35

  20. National Quality Forum Endorses • % HPC patients who were screened for pain during the initial encounter. (UNC/PEACE) • % HPC patients who screen positive for pain who are assessed within 24 hours(UNC/PEACE) • Patients treated with opioids who receive a bowel regimen (RAND) • Patients with advanced cancer assessed for pain at an outpatient visit (RAND) • % HPC patients who were screened for dyspnea during the hospice admission evaluation / palliative care initial encounter. (UNC/PEACE) • % patients who screened positive for dyspnea who received treatment within 24 hours of screening. (UNC/PEACE) Slide 20 of 35

  21. National Quality Forum Endorses(cont’d.) • % HPC patients with chart documentation of preferences for life sustaining treatments (UNC/PEACE) • Patients admitted to ICU who have care preferences documented (RAND) • Hospitalized patients who die an expected death with an ICD that has been deactivated (RAND) • Comfortable Dying:  Pain brought to a comfortable level with 48 hours of initial assessment (NHPCO) • Family Evaluation of Hospice Care (NHPCO) • CARE-Consumer Assessments and Reports of End of Life (Center for Gerontology and Healthcare Research, Brown University) • Bereaved Family Survey (VA PROMISE Center) Slide 21 of 35

  22. How TO CHOOSE and use quality measures Slide 22 of 35

  23. Getting Started • Form a team (with a leader) • Define purpose and audience for data • Match scope to resources • Focus on 1-2 domains of quality • Choose quality measures • Research evidence • NQF endorsed • Define the target population Slide 23 of 35

  24. Challenges to quality measurement • Respondent burden (surveys) • Rapidly changing health status • timing • proxy respondents • Crossing health care settings and populations (children, nursing homes, inpatient, home) • Defining population – who is “dying”? Siu and Morrison, Arch Int Med, 2000 Kutner JS, et al. JPSM, 2006 Slide 24 of 35

  25. Challenges to quality measurement (cont’d.) Many patients cannot self-report Our “instruments” are not uniform across providers, and are still being refined Our “best practice” is matching care to preferences Evidence base – which care processes are most effective to improve comfort, QOL? Slide 25 of 35

  26. UNC Palliative Care Program: Investments in Quality Charlotte Rowe, MS, RN, NP, AOCN, ACHPN Kathryn Wessell Anthony J. Caprio, MD Gary Winzelberg, MD Annette Beyea, MD Stephen A. Bernard, MD Division of Geriatric Medicine & Center for Aging and Health Division of Hematology and Oncology Cecil G. Sheps Center for Health Services Research Slide 26 of 35

  27. Does PC improve quality of care for patients with serious illness? (Study) SITE: UNC Hospitals – 799-bed public academic medical center • NCI comprehensive cancer center • Integrated electronic medical record • Interdisciplinary palliative care consultation WITH A COMMITMENT TO USE OF QUALITY METRICS DATA SAMPLE: N=460 patients without palliative care consultation and N=102 patients with palliative care consultation • MICU, SICU • Acute Care for the Elderly unit (aged 65+) • Medical Oncology unit (metastatic solid tumor) Slide 27 of 35

  28. Results: study sample Slide 28 of 35

  29. Results: study sample Slide 29 of 35

  30. Results: study sample Slide 30 of 35

  31. PC Improves Quality

  32. PC Improves Quality

  33. Conclusions Palliative care quality measures • INTERNAL • Quality improvement for PC services • EXTERNAL • Demonstrating added value to leadership • Meeting quality of care standards for all patients Select endorsed quality measures • PEACE – hospice, palliative care charts • ACOVE – vulnerable elders charts • ASSIST – cancer patients charts • FEHC – after-death survey for hospice caregivers • FATE – after-death survey for VA caregivers Slide 33 of 35

  34. Question & Answer Period Thank you for joining us today! ABOUT CAPC The Center to Advance Palliative Care (CAPC) provides health care professionals with the tools, training and technical assistance necessary to start and sustain successful palliative care programs in hospitals and other health care settings. CAPC is a national organization dedicated to increasing the availability of quality palliative care services for people facing serious illness. Slide 34 of 35

  35. Continue the Discussion on CAPCconnectTM Forum! At the conclusion of this audio conference, we welcome you to continue the discussion with your peers and faculty on CAPCconnectTM Forum! Go to: http://www.capc.org/forums to post your message and comments within the “Data Collection and Measurement” discussion topic! Slide 35 of 35

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