Appendix B: Summaries
of PFQ Grantee Activities (continued)
PFQ Grant Summary: A National Center for Value Purchasing Models
Lead Organization: HealthFront
Partner Team: Park Nicollet Institute; National Institute of Health Policy; Colorado
Business Group on Health; Buyers Health Care Action Group
Title: A National Center for Value Purchasing Models
Topic Area: Performance Incentives
Principal Investigators: Michael Callahan, former Executive Director at HealthFront
AHRQ Project Officer: Michael Hagan
Total Cumulative Award: $1,281,576
Funding Period: 9/2002–9/2006
Project Status: Completed 9/29/2006
1. Project
Description
Goals.
The grant had two initial aims: (1) to develop a nationally recognized provider
performance measurement, analysis, and award program, supported by purchasers;
and (2) to develop the analytical capacity needed to support purchaser
decisions on health care value purchasing. The grantee, HealthFront is a
non-profit spin-off of the Minnesota-based Buyers Healthcare Action Group, with
a board consisting of employer purchasers, health care consumers, and
providers. When another organization that was supposed to work on the first
aim withdrew from the project, the grantee focused solely on the second aim.
Specifically, its goal was to evaluate methods for accelerating the adoption of
"best practice" payment incentive systems by all major purchasers in selected communities
by: (a) informing purchasers about the current use of incentives in
pay-for-performance (P4P), public reporting, and tiered network strategies; (b)
educating them about how to use incentive strategies; and (c) helping health
plans align their respective incentives for P4P and public reporting.
Activities
and Progress. Early in the first year after the project decided to focus on
demonstrating how value purchasing could be supported and improved, the
research team, comprised of researchers and staff from HealthFront, the
National Institute of Health Policy, and Park Nicollet Institute, chose the Minnesota market for its initial test. The project partnered with the National Institute of
Health Policy, led by former Senator David Durenberger and based at the
University of St. Thomas (MN), and the Buyers Health Care Action Group (BHCAG),
a group of major employers in the Minneapolis-St. Paul region that gave the
project access to local purchasers and health plans. In the first year, the project
conducted interviews with about 65 health plans and provider organization
representatives regarding their current use of incentives and measures for P4P
and public reporting. Results from these interviews indicated that there were
vast differences among plans in their P4P activities and in the measures they
used. The project team reported this information to purchasers to prompt
discussions between them and the health plans about creating greater
consistency in P4P and public reporting.
Due to other
priorities, BHCAG did not follow up, but they have remained active with the
Smart Buy Purchasing Alliance (a group of state and private health care
purchasers). The core membership of the Alliance consists of a group of
purchasers originally brought together by the grantee to discuss alignment of
incentives. Both BHCAG and HealthFront representatives serve on the Smart Buy
Alliance. The Alliance recently made its first Bridges to Excellence physician
bonus awards. Also, because of the state's involvement with the Alliance, the Minnesota Department of Human Services is pursuing incentive payment reforms
for Medicaid hospital services based on advice from the project team.
In
the second year, the project work expanded into the Colorado market. The
project partnered with the Colorado Business Group on Health (CBGH), which
served as the conduit to employer purchasers in that community, and again
conducted an assessment on the current status of P4P and public reporting in the
market through interviews with local health plans and providers. The grantee
presented the results of the assessment to purchasers, health plans, and other
stakeholders. Although interesting to stakeholders, the findings did not spark
extensive dialogue between purchasers and health plans, nor did it lead to
quantifiable action to align performance incentives. However, the CBGH credits
the project with setting the groundwork for the community's entrance into
Bridges to Excellence, a non-profit organization that recognizes and rewards
health care providers for delivering quality health care.
In
the third year, after the community assessments in Minnesota and Colorado were
completed, the grantee brought together an expert panel via the Internet to
discuss the role of incentives in improving preventive and chronic illness
care, and the clinical capacity to manage care for better outcomes (e.g.,
registries, IT). Providers and purchasers from the two communities also
participated in the discussion. In October 2004, the project conducted a
one-day in-person, retreat at the request of several of the panel members.
The
panel, which included such experts in the area of quality effects of incentives
as Robert Berenson, Lawrence Casalino, and Judith Hibbard, participated in the
discussions, as well as small group exercises that identified the best ways for
purchasers to provide incentives to providers. These results were presented to
purchasers in Minnesota and Colorado.
One
of the findings from the expert panel discussions was that communication was
poor between medical practice leadership and rank and file physicians regarding
P4P practices and public reporting. Since physician response to incentives
determines the effectiveness of P4P, the grantee and partners, at the request
of the purchasers, decided to obtain more information about what physicians
know or think about P4P, public reporting, the use of incentives, and how they
would respond to incentives. Thus, in the third year, the project developed a
survey for medical group managers in Minnesota to assess their perceptions of
P4P, public reporting, and quality incentives in general. Analysis of the
survey results focused on responses from the managers of 78 unique medical
groups representing 6,964 physicians in primary care practice in Minnesota.
In
the fourth year, results from the survey were presented to purchasers and plans
in the state, which generated substantial interest. One of the findings was
that a large number of physicians were uncertain about P4P and public
reporting, either because they had a wait-and-see attitude or because they did
not know much about it. This suggested the need to educate physicians. The
research team wishes to contact the physicians in Minnesota again to see if
there have been any changes in plan activities (e.g., education activities for
physicians) as a result of the findings.
At
the time this summary was prepared, the research team was fielding the
physician survey in Colorado. Because practices in Colorado are smaller than
those in Minnesota, the survey was revised to focus on the individual physician
level rather than the group level. Once the survey and the data analysis are
complete, the project will present findings to the Colorado Medical Society at
its annual meeting. The survey was supported by the local leaders of Colorado
Medical Society, the Colorado Academy of Family Medicine, the American Academy of Pediatrics, and the American College of Physicians.
2. Partnership
Structure/Function
Project
staff at HealthFront formed a core research team with two other groups: (1)
health services researchers from Park Nicollet Institute, which is associated
with a large multi-specialty medical group; and (2) the National Institute for
Health Policy (NIHP), which is affiliated with the University of Minnesota and the University of St. Thomas. (The former Executive Director of NIHP is now at
the University of St. Thomas Center for Business Excellence but remains a key
research partner in the project.) Researchers from the three organizations
held weekly meetings to develop and implement the surveys, conduct community
assessments, analyze survey results, and plan for the dissemination of findings
to community stakeholders.
The
core partners also formed partnerships with CBGH and BHCAG to gain access to
purchasers in the community. The two purchaser coalitions hosted in-person
meetings for the project team to present findings from the assessment of
community activities in P4P, public reporting, and tiered network strategies.
The team formed a close relationship with CBGH in Colorado, and the director of
the purchaser coalition was actively involved in interviewing community
stakeholders and analyzing the data. Relations with BHCAG in Minnesota were not
as close because the organization was more focused on national issues.
Table 1. Major Partner Organizations and Roles in the Project
|
Organization |
Role in Project |
Lead Organization (grant recipient) |
HealthFront
|
Responsible for project administration, coordination,
research support, and employer liaison
Assessed current state of P4P, public reporting, and
tiered networks in Minnesota and Colorado through
interviews with health plans and purchasers
Reported on information from physician survey in
Minnesota to purchasers and health plans to solicit
stakeholder reactions and feedback
|
Key
Collaborators |
Park Nicollet Institute (PNI),
Director, Health Systems
Studies David Knutson
National Institute of Health
Policy (NIHP), Exec. Dir.
Daniel McLaughlin
Colorado Business Group
on Health (CBGH)
Buyers Health Care Action
Group (BHCAG)
|
Health care services research center conducted research
and survey design, financial analysis, and economic
research, and was liaison with CMS and national
research community
Developed physician surveys, fielded surveys, and
analyzed findings
Participated in meetings to present findings from survey
to stakeholders in MN
University-based health policy research center (affiliated
with University of St. Thomas, MN) provided liaison
with CMS, health plans, Medicaid programs, policy, and
educational institutions
Helped gain access to health plans and other
stakeholders for interviews to assess the status of P4P,
public reporting, and tiering in Minnesota
Hosted expert panel meetings to discuss findings and
future steps for research; helped to analyze findings
Helped access stakeholders in the market, including
health plans, purchasers, and physicians
Participated in interviews with stakeholders and helped
to analyze findings
Hosted the meetings to present information from
assessment to CO community
Hosted the meetings to present information from
assessment to MN purchaser community
|
Target Organizations |
Purchasers, health plans,
physicians in the Minnesota
health care market (in 2
areas: Minneapolis/St. Paul
and rural western
Minnesota)
Purchasers, health plans, and
physicians in the Colorado
health care market (Denver)
|
Purchasers, plans, and physicians were interviewed by
project staff to assess the community incentive
environment in these markets
Received information from the project's assessment of
incentive environments
Physician groups were surveyed for their perceptions on
the use of incentives
|
3. Project Evaluation Outcomes/Results
Information from the community assessments was
presented to purchasers and plans in each market. However, the information did
not prompt discussions about value-based purchasing between purchasers and
plans. Although health plans in both communities are now working to achieve
more consistency in measures used for P4P, public reporting, and tiered
strategies, the work is not the direct result of the project findings. In both
Colorado and Minnesota, purchaser groups decided to work through the Bridges
to Excellence program, rather than directly with health plans. In Colorado, however, project partners believe that grant activities contributed to the community
dialogue that led to its decision to participate in the Bridges to Excellence
program.
Researchers believe that information from the
physician surveys on how they respond to payment incentives has the potential
to affect purchaser behavior regarding value-based purchasing. Particularly in
Colorado, where the implementation of incentive programs was less advanced,
the fact that employers are now engaged in an active dialogue with the medical
community regarding value-based purchasing is directly attributable to the
project. This dialogue, in turn, creates employer demand for such programs to
be introduced by insurers and the discussion facilitates and informs
implementation of these programs by educating the providers. The plan is to
follow up to determine to what extent purchaser or health plan activities can
be attributed to survey information. The Colorado physician survey was
completed by August 2006 and the results were presented in September 2006 at a
meeting of the Colorado Business Group on Health, and at the Annual Meeting of
the Colorado Medical Society. Both the employer members of the CBGH and, the
leadership of the Colorado Medical Society in particular found the results of
the survey enlightening. Researchers are drafting papers for submission to a
peer-reviewed journal to include discussion of (1) the purchaser response to
information on value purchasing, (2) results of the medical group manager and
physician surveys, and (3) an exploration of the relationships between market
penetration, alignment of incentive programs, and provider perceptions of them.
4. Major Products
- Medical group
manager survey tool.
- Physician survey
tool.
- Research findings
regarding the responses of large and small medical groups to quality incentives,
and recommendations from the provider community about desirable and actionable
design features of quality incentives.
- Summary of an
expert panel discussion that identified the best ways for purchasers to provide
incentives to providers, and potential unintended consequences that plans and
purchasers policymakers need to guard against.
- Presentation of
physician survey results to Colorado Medical Society, September 16, 2006.
5. Potential for Sustainability/Expansion after PFQ
Grant Ends
Purchasers in Minnesota, including the Buyers Health
Care Action Group, have expressed interest in having the researchers conduct a
second round of the physician survey. The National Business Coalition on
Health, a national non-profit membership organization of employer-based health
coalitions, has expressed interest in working with the project's researchers to
disseminate information to support its member coalitions in trying to improve
quality through P4P, public reporting, and tiered network strategies. The
Colorado Medical Society has asked the team to write articles for its member
publications and is interested in working with the researchers and the CBGH to
continue the dialogue with physicians. The project team plans to conduct
mini-case studies of local markets, how purchasers are using incentives, and
how providers respond to them. The team is developing an online course on
pay-forperformance directed toward an audience of physicians and medical group
managers to be offered by the University of St. Thomas. This online course
builds on the team's experience with the online expert discussion panel
sponsored by the University in 2004.
Return to Appendix B Contents
PFQ Grant Summary: Real-time Optimal Care Plans for Nursing Home Quality Improvement
Lead Organization: International Severity Information Systems, Inc. (ISIS)
Partner Team: IFAS/AAHSA, AHQA, Catholic Health Partners, Good Samaritan
Society, National Church Residences, Christian Home and
Rehabilitation, Sugar Creek Rest, Marywood Nursing Center, Ozanam
Hall, Memorial Hermann Spring Shadow Pines
Title: Real-time Optimal Care Plans for Nursing Home QI
Topic Area: Improve prevention of pressure ulcers in nursing homes
Principal Investigators: Susan Horn, VP for Research at ISIS and Senior Scientist, Institute for
Clinical Outcomes Research (ICOR is a division of ISIS). Co-Investigator is Robyn Stone, Exec. Director of the Institute for the Future
of Aging Services/AAHSA in Washington DC.
AHRQ Project Officer: William Spector (originally Thomas Shaffer)
Total Cumulative Award: $1,297,577
Funding Period: 10/2002–10/2006
Project Status: Received a no-cost extension to March 2007
1. Project Description
Goals. This
project incorporated research findings from the National Pressure Ulcer
Long-term Care Study (NPULS) (1996) into routine, evidence-based best practice
in long-term care (LTC) facilities. The project standardized front-line
documentation and used this information to produce weekly reports to support
clinical decision-making and care planning. Through a staged approach, the
project facilitated clinical process and workflow redesign, introduced
technology tools that assisted providers in identifying high-risk residents,
and empowered front-line staff to take appropriate and timely prevention or
treatment actions. Ultimately, the project aimed to redesign clinical
workflow—instead of concentrating on improving existing processes only—to
reduce the incidence of pressure ulcers among LTC residents in nursing homes.
Activities and
Progress. The project leadership team was led by ISIS; the co-PI at
IFAS/AAHSA was involved in overall project assessment and promotion of project
activities. The American Health Quality Association (AHQA) provided assistance
with dissemination of information regarding project activities, including
presentations at AHQA national meetings and contact with the editor of the
Provider publication.
In the first year, the project
selected a pilot site, Memorial Hermann Spring Shadow Pines in Houston, TX, which formerly had worked with ISIS on the NPULS project. Project staff designed scannable,
comprehensive documentation forms for Certified Nursing Assistants (CNAs) and
tested them at one nursing unit in the pilot site. AAHSA's Institute for the
Future of Aging Services took the lead in recruiting and screening additional
nursing homes for participation in the project, and ISIS used various networks
to recruit study participants, including some affiliated with a PFQ grant
recipient in Ohio. By April 2003, five additional nursing homes in four states
had been selected and had agreed to participate. By May 2004 (the second year
of the project), 20 units in 12 nursing homes from 10 states had been selected
to participate. The project began instituting systems to streamline
documentation for CNAs and nurses. For CNAs, multiple logbooks, clipboards, and
notebooks were consolidated into a single documentation instrument that
included meal and fluid intake, weight, bowel and bladder incontinence, and
behavior observations. Nurses consolidated information into a CareGiver Guide
that included pressure ulcer risk factors, medications, nutritional supplements, and
fluid intake. ISIS assisted with facility-requested customization of the
standardized forms. Clinicians used optical character recognition (OCR) forms,
which allowed facility staff to use the familiar method of documenting on
paper, and faxed them to ISIS where software exported the data to a database. ISIS generated weekly facility-specific reports and provided help with report
interpretation to follow clinical best-practice guidelines at each facility. It
also collected baseline data for evaluation, and began developing plans to
sustain the process at the facility and unit levels.
In the third year, the project held its second and
third project meetings (November 2004 and April 2005); most participating
facilities sent one or more representatives to share progress, challenges, and
outcomes. Many facilities expanded the use of CNA documentation forms to
additional units, and some used the forms facility-wide. Completeness rates
varied; some facilities were very high (rates of more than 95%) and others were
lower (50 to 60 percent). Facilities shared experiences with comprehensive
documentation and gradually decided to use the same documentation forms, so that
standardization was achieved. The standardized CNA form replaced other forms
and became part of the resident's medical record at each facility. Most
facilities began to incorporate data from the six ISIS-generated reports on
resident status into daily or weekly resident care planning, which allowed
staff to identify triggers for specific protocol steps to reduce the risk of
pressure ulcers.
During the last year of the project, the focus shifted
to sustaining project activities in participating facilities. ISIS helped
facilities to explore ways of managing/sustaining process improvements without ISIS support, as for example through electronic medical records or digital pen technology.
(See below, under Potential for Sustainability/Expansion.)
2. Partnership Structure/Function
The project formed an Advisory Committee to provide
input and guidance on standardized documentation, implementation approaches,
and analysis of results. Members included representatives from AMDA (medical
directors of LTC facilities), academic researchers, a foundation
representative, and the executive of a health care IT company. In addition,
the project organized a Working Group, comprised of representatives of
participating nursing home sites, and including some combination of the
facility's medical director, Director of Nursing, administrator, and MDS
coordinator. According to a grantee report: "Another layer of partnerships
exists within each facility. Each facility convened a QI team that is
multi-disciplinary and includes all members of the care team, i.e.,
administrators, nurses, nursing assistants, social workers, MDS coordinators,
dieticians, etc. This representation of all, especially front-line workers, is
an atypical approach to QI efforts." The first project meeting included
Advisory Committee members and facility representatives.
Table 1. Major Partner Organizations and Roles in the Project
|
Organization |
Role in Project |
Lead Organization (grant recipient) |
International Severity Information Systems, Inc. (ISIS)
|
Project management; convening Advisory Board and Working
Groups of participating facilities
Support to each participating facility to develop and process
forms for each resident, generate reports, work with staff at all
levels on implementation of facility-specific work plans
Lead effort to sustain project activities
|
Key
Collaborators |
Institute for the Future of
Aging Services/ AAHSA
American Health Quality
Association
|
Project guidance and support for establishing partnerships with
project sites; recruit and screen project sites
Provided assistance with dissemination and outreach for
project activities, including presentations at AHQA national
meetings and contact with editor of the Provider publication;
also was a conduit to key leaders of nursing home trade
associations
|
Target Organizations |
8-12 nursing homes and,
in some cases, their
corporate organizations
|
11 nursing homes in 7 states implemented the intervention:
developed/ used OCR forms on resident functioning/risk
factors for pressure ulcers, incorporated timely report
information, and began to use or explore technology options to
sustain project activities
Catholic Health Partners had 4 Ohio nursing homes
participating in the project—provided a 'learning-lab' to
examine how experiences of 4 facilities could serve as a model
to standardize processes across an organization and to
disseminate tools to other facilities
|
3. Project Evaluation and Outcomes/Results
The project's evaluation design involved the collection
of baseline and follow-up data on (1) clinical measures (pressure ulcer
incidence acquired in or out of the facility); (2) utilization measures
(hospital admissions and ER visits); (3) operational measures, e.g., number of
forms used prior to intervention; and (4) annual turnover rates and staff satisfaction
measures.
The combined average for 7 facilities that implemented
project processes starting in April 2004 shows an overall reduction of 33% in
the [CMS] quality measure (QM) of high-risk residents with pressure ulcer from
pre-implementation to initial post-implementation time periods (through Quarter
3, 2005). Individual patterns for each facility show reduction in the pressure
ulcer QM and percentage of high-risk residents with pressure ulcers. Pressure
ulcer prevalence in participating facility units dropped to about 8.7% on
average, compared to the national average of 14%, which remained flat over the
life of this project. However, this may not be statistically significant
because it is a small sample. Facilities that implemented the intervention more
fully (e.g., regularly submitting forms, using the reports in regular care
planning meetings) had better results—PU prevalence in the 5 to 6% range—than
those that partially implemented the intervention.
These early findings were updated with Quarter 4, 2005
data to summarize overall impact to date (by facility) on CMS QMs related to
pressure ulcers. It is important to note that the CMS QM for high-risk
pressure ulcer includes in-house and externally acquired, as well as existing
pressure ulcers, and is a measure for the entire facility. While this differs
from the project's primary clinical outcome measure (inhouse acquired pressure
ulcers on participating units), the project team hypothesized that
participating facilities focused improvement efforts on the unit(s) with
highest risk residents; therefore, the interventions would impact the CMS QM
for high-risk residents. Individual patterns for most facilities show reduction
in the pressure ulcer QM percentage of high-risk residents. During Quarter 3,
2003, only two facilities were below the national average. For Quarter 4, 2005,
six facilities were below the national average. All project facilities that
have prevalence rates equal to or greater than the national average have
decreased their prevalence from Quarter 3, 2003 by an average of 38%.
In addition to decreased pressure ulcer development,
the project reduced the number of documentation forms that CNAs fill out at
each facility, which reduces paperwork burden and provides more time for
hands-on care to residents. Information about residents is now available in
"real-time"; quality improvement has shifted from reviewing data quarterly on a
retrospective basis to using weekly clinical reports for timely resident care
planning by all members of the care team. Communication among the care team
reportedly has improved and collaboration across team members has increased.
Data needed for CMS and state survey reports are captured more easily and are
readily available.
4. Major Products
The workflow change process of using standardized
documentation and timely feedback reports for improved care planning has been
presented at many national conferences, including the 2004 and 2005 Annual
Research Meetings of AcademyHealth, the Spring 2004 and 2005 AAHSA Future of
Aging conferences, the 2005 AAHSA Annual Meeting, AHRQ's Translating Research
into Practice meetings in July 2005 and 2006, and the Gerontological Society of
America annual conferences in November 2005 and 2006.
5. Potential for Sustainability/Expansion after PFQ
Grant Ends
Among the 11 facilities that participated in the
project, four will not be involved in future spin-off projects, primarily
because of turnover in the Directors of Nursing, who are key decision makers in
nursing homes. The remaining facilities are joining ISIS in a new Health
Information Technology (HIT) project to continue the standardized documentation
and reporting processes begun in this project; HIT is funded by AHRQ.
Half of the participating facilities were part of
larger systems or corporate chains. This allowed corporate leaders to watch
'the experiment' and decide if it was worth adopting corporate wide. The Good
Samaritan Society (GSS) was impressed enough to adopt the tools; according to
the PI, 240 GSS facilities in 25 states are now using the same approach to
documentation. Mercy Health Partners, which had four facilities participating
in the project, is rolling it out to more of their long-term care facilities.
In addition, standardized comprehensive documentation by front-line staff,
followed by timely reporting, has changed facility workflow. While designed
around pressure ulcer prevention, it is applicable and helpful across clinical
areas. It is being used to facilitate improved resident care and better
responsiveness to federal reporting requirements.
Towards the end of the project's third year, ISIS had
discussions with the Arizona QIO and initiated calls with QIOs in California,
MD-VA-DC (Delmarva), Ohio, Texas, North Carolina, Idaho, Washington, and Rhode
Island to explore their interest in replicating the model through the QIOs'
nursing home quality improvement activities. These discussions led ISIS to submit a separate contract proposal to launch this new approach to replication.
AHRQ funded the contract, which began in September 2005. ISIS is working with California (Lumetra), Idaho (Qualis), Texas, Maryland (Delmarva), North Carolina, and
Arizona QIOs. The QIOs identified about 30 long-term care facilities; ISIS trains facility and QIO staff to help them implement the 'Real-Time' process using
Digital Pen Systems or internal facility IT systems.
In the final grant year, the project intensified its
efforts to disseminate project activities to other long-term care facilities.
It will evaluate results and develop a plan for ongoing initiatives to continue
expanding the number of participating sites, evidence-based medicine content,
and data collection and reporting improvements. To accomplish this, the ISIS project team is working in partnership with the AHRQ-funded contract to Delmarva
Foundation for Medical Care, contract #290-04-0009, 'Real-Time Prevention of
Pressure Ulcers,' which was funded in May 2006.
Return to Appendix B Contents
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