Measurement Matters: Creating an Effective and Sustainable ... 2nd Edition/Module 4...• Outline key elements of a care coordination measurement framework ... making changes to the
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Pediatric Care Coordination CurriculumMODULE 4
Richard Antonelli, MD, MS, FAAPSonja Ziniel, PhDHannah Rosenberg, MSc
Module 1
Module 2
Module 3
Module 4
Module 5
Antonelli R, Huth K, Rosenberg H, Bach A. Pediatric Care Coordination Curriculum: An Interprofessional Resource to Effectively Engage Patients and Families in Achieving Optimal Child Health Outcomes, 2nd Edition. Boston Children’s Hospital, 2019.
Module Citation: Rosenberg H, Ziniel S, Antonelli R. Module 4, Measurement Matters: Creating an Effective and Sustainable Integrated Care Model. In Antonelli R, et al, Pediatric Care Coordination Curriculum, An Interprofessional Resource to Effectively Engage Patients and Families in Achieving Optimal Child Health Outcomes, 2nd Edition. Boston Children’s Hospital, 2019.
The development of the Pediatric Care Coordination Curriculum: An Interprofessional Resource to Effectively Engage Patients and Families in Achieving Optimal Child Health Outcomes, 2nd Edition, is supported through a sub-contract with the National Center for Medical Home Implementation (NCMHI), a cooperative agreement with the Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS). The information or content are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by MCHB, HRSA, HHS or the U.S. Government.
Measurement Matters: Creating an Effective and Sustainable Integrated Care Model
Therearetwotablesincludedbelow.Thefirstisahigh-levelagendaofthemodule. The second is the facilitator guide that includes a breakdown of slide content and talking points. The facilitator should use the guide as a resource to tailor the training.
Measurement Matters: Creating an Effective and Sustainable Integrated Care Model
Module 4Pediatric Care Coordination Curriculum 2nd Edition 2
Make sure to discuss and/or workshop how the tools,measures,andprocessescanbeincorporatedintothelearners’environment.
Ideally,casestudieswillbereadanddiscussedinsmallgroups,withoneleaderpergroupwhocanguidethegroupbyjumpstartingtheconversationor redirecting the group back onto the topic, if necessary.
The Pediatric Care Coordination Curriculum is offered for educational purposes only and is not meant as a substitute for independent medical judgment or the advice of a qualified physician or health care professional. Users who choose to use information or recommendations made available by the Pediatric Care Coordination Curriculum do so at their own risk and should not rely on that information as professional medical advice or use it to replace any relationship with their physicians or other qualified health care professionals.
VazLE,FarnstromCL,FelderKK,Guzman-CottrillJ,RosenbergH,AntonelliRC.Utilizingamodifiedcarecoordinationmeasurement tool to capture value for a pediatric outpatient parenteral and prolonged oral antibiotic therapyprogram. J Pediatric Infect Dis Soc. 2018;7(2):136-142.
Available at: https://doi.org/10.1093/jpids/pix023
Slide deck/handout Slides
Tools presented in the slide deck can be used as handouts
This part of the workshop is intended to give participantstheopportunitytothinkthroughhowtoapplytheirlearningtotheirday-to-daywork.Encouragethemtothinksmall:Arethereelementsoftheoverallmeasurementframeworkthatwouldbeparticularlyvaluabletotheirworkandrelativelyeasytoadopt?
Tocloseoutthemodule,askparticipantstoreportbacktothelargergroupaftersmallgroupdiscussions. A facilitator or volunteer participant canrecordkeypointssharedbythesmallgroupson a whiteboard or flip chart.
Thistimeisintendedtosummarizeandclosethelooponthelearning.Itshouldbefacilitatedbyafacilitatorbutdrivenbyparticipants.Thefacilitatorcaneitherinviteanyonefromthelargegrouptojumpinwiththoughtsonwhatwaslearnedduringthe session or go table to table and ask people to share.Sometimeshavingtheopportunitytospeakideasaloudhelpspeopletoformulatenextsteps.
One option is to write down action steps and includetheminasummaryemailsenttoparticipants after the session.
After the workshop, evaluation questions should beemailedtotheparticipants.Feedbackfromevaluationscanbehelpfultoimprovingtheworkshopovertime.
Agenda Item Time Materials Required Instruction/Notes
Module 4Pediatric Care Coordination Curriculum 2nd Edition 4
Thistimeshouldbeusedtointroducethesessionobjectivesandframethe session. Think through the following:
Why are we here today? Todiscussmeasurementanditsimportanceinthechanginghealthcaredeliveryenvironmentwithitscriticalemphasisonhigh-valueoutcomesandaccountability.Carecoordinationandcareintegrationareessentialtoensuringourabilitytoprovidehigh-valuecare,whichwilllikelybevitalinadvocatingfornecessaryresources in supporting care coordination.
What are we going to do today? Engage in case-based learning aroundtools,processes,andmeasurestosupportmeasurement.Conductthoughtexercisesonhowtoapplytheselearningsandresources to our individual settings.
SLIDE 2 » Educational Purpose Only–No Medical Advice
• Oftentimes,measurementandclinicalimprovementactivitiescanqualifyforMaintenanceofCertification(MOC)forphysiciancontinuing education credit. More about MOC with the AmericanBoardofPediatricsisavailableat: https://www.abp.org/content/maintenance-certification-moc.
• Asklearnerstoshareiftheyhavebeeninvolvedinrapidcycle QI work in their current or previous roles.
SLIDE 5 » Rapid Cycle QI
Facilitator Guide–Slide Deckcontinued
Module 4Pediatric Care Coordination Curriculum 2nd Edition 5
SLIDE 4 » Key Definitions
Accountable Care Organizations(ACOs)aregroupsofphysicians,hospitals,andnonphysicianclinicianswhocometogethervoluntarily togivecoordinatedhigh-qualitycaretotheirMedicarepatients. Thegoalofcoordinatedcareistoensurethatpatients,especially thechronicallyill,gettherightcareattherighttime,whileavoidingunnecessaryduplicationofservicesandpreventingmedicalerrors.WhenanACOsucceedsbothindeliveringhigh-qualitycareandspendinghealthcaredollarsmorewisely,itwillshareinthesavings itachievesfortheMedicareprogram. Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html
Fee-for-serviceisasystemofhealthcarepaymentinwhichaphysicianornonphysicianclinicianispaidseparatelyforeachparticular service rendered. Source: https://www.medicareresources.org/glossary
In global budgeting,agovernmentagencydeterminesthetotal amountofmoneythatithasavailabletoreimburseallhospitals,physicians,nonphysicianclinicians,andclinicsinthenation.The globalbudgetcanbefurthersubdividedinorderforagovernmentagencytoestablishamaximumamountofspendingfortreatingaspecificdiseaseoramaximumbudgetforeachhospitalinastate. Source: https://bizfluent.com
SLIDE 6 » Quality Measures That Can Drive Implementation of Care Coordination
TheMedicaidChildCoreSetofqualitymeasuresprovidesanexampleofthetypesofoutcomesthatstateMedicaidprogramswillbetrackinggoingforward.Often,ifstakeholdershaveagoal,suchasaqualitymeasure,thattheywillbeexpectedtoperformagainst,itmaycatalyzedevelopmentofasharedvisionandcommitmenttoimplementing care coordination activities.
The Medicaid Child Core Set is available at: https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/2018-child-core-set.pdf
SLIDE 8 » Tools for Measurements
Somemeasuresandmeasurementtoolsthatwillbeveryhelpful are listed on the slide.
Module 4Pediatric Care Coordination Curriculum 2nd Edition 7
SLIDE 10 » How to Measure Care Coordination
Itisimportanttomeasureandquantifycarecoordinationandintegration. A valuable tool to achieving this is the Care Coordination MeasurementTool,whichfocusesonprocessratherthanfamilyexperience.
TheCareCoordinationMeasurementTooltemplateandtheaccompanyingAdaptationandImplementationGuidecanbedownloaded at the following site: http://www.childrenshospital.org/integrated-care-program/care-coordination-measurement.
• PediatricIntegratedCareSurvey Available at: http://www.childrenshospital.org/integrated-care-program/patient-and-family-experience-outcome
• FamilyExperienceswithCareCoordination Available at: https://www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra_15-p002-ef.pdf
• Family-CenteredCareAssessmentforFamilies Available at: http://familyvoices.org/wp-content/uploads/2018/06/FCCA-fact-sheet-11-17.pdf
Encourage learners to think through what is helpful about the data.Forinstance,ifdatacollectedfromtheregisterednurseandlicensedclinicalsocialworkerindicatethat30%ofthetaskstheyareperformingdonotrequiretheirlicensure,whatconclusionsmightbedrawn–perhapssomeoneelsewithadifferentskillsetcouldtakeresponsibilityforthoseitemswhilethenurseandsocialworkerperformtasksthatrequireclinicalcompetence?Thetermforthisissometimescalled“workingatthetopofyourlicense.”
One of the case studies can be selected to present or this one can bepresentedinadditiontocasestudy#1todemonstratehowmeasurementcanbeappliedindifferentsettings.
Theseareexamplesofprocess,outcome,andbalancingmeasures.Differentexamplesmaybegiven,basedonhowthecasestudymayhave been adapted for the learners.
Beforeofferingexamplestothelearners,givethemanopportunitytobrainstormaboutexamplesofprocess,outcome,andbalancingmeasures.Askthemtoconsiderhowthemeasuresmightbecollectedin the context of the case.
Usethisfinaltimetoreflectonthesessionandallowthelearnerstimeto think through their next steps. A worksheet could be provided so that the learners can record their thoughts and next steps and have somethingtotakewiththem.
SLIDE 25 » Closing
Facilitator Guide–Slide Deckcontinued
Module 4Pediatric Care Coordination Curriculum 2nd Edition 12
Thistimecouldalsobeanopportunityforthelearnerstoapplyconcepts to their individual settings: After the data are collected, howaretheresultsmessaged?Whoarethekeyplayersthatneedtobeinvolvedinmessaging?Withwhomarethedatashared?WHOtoinvolveandWHENandHOWtheyareinvolvedarecrucialcomponents.
Followingare2distinctcasestudies.Thefirsttakesplaceinageneralpediatriccarepractice,andthesecondissetinapracticefundedbytheTitleVMaternalandChildHealthServicesBlockGrantProgram.Theauthorsintentionallychose2diversesettingstoshowthatcarecoordinationandcareintegrationmeasurementcanbeappliedacrosssettings in the pediatric space. These case studies use tools that the Integrated Care ProgramatBostonChildren’sHospitalincludesinitsqualityimprovementtoolkit;however,thereareothermeasurementtoolsinthisspace.Someadditionaltoolsarelistedthroughoutthismodule.
CASE STUDY #1 Gordon Pediatrics A SMALL, COMMUNITY-BASED, GENERAL PEDIATRIC CARE PRACTICE
Examplemethodology:ThenurseandsocialworkeradapttheCareCoordinationMeasurementTooltocollectcarecoordinationactivityandoutcomesdata.For2weeks,theyeachcollectdataontheirfirst10carecoordinationencounterseveryday.Theydecidethatanimportantgoalistocollectdataindomainsrelatedtoactivities,outcomesprevented,outcomesoccurred,andclinicalcompetence.Includedbelowisasample of their data.
40% of the time: reconciled medicationdiscrepancies
35% of the time: advisedfamilies ontheinforma-tion needed for a school individu-alized education plan and pro-cessed additional schoolforms
30% of the time: discussed insurance options with families
20% of the time: secured prior authorizations
30% of the time: connected familiestocommunityagencies
45% of the time: advised patients onhomemanagement
30% of the time: helped patients obtain additional services in school
20% of the time: prevented gaps inmedication
45% of the time: prevented unnecessary officevisits
30% of the time: prevented additional missedschooldays
30% of the time: recorded tasks did not require clinicalcompe-tence(neithersocial worker nornurse)
Module 4Pediatric Care Coordination Curriculum 2nd Edition 15
TheGordonPediatricsteamdiscussesthedataanddeterminesthatthereisasignificantvolumeofcarecoordinationneedsfromthepatientsandfamiliesit serves.Inaddition,manyoftherequestsdonotrequirenursingorsocialwork clinicalcompetencetobeabletofulfilltheneed.Rather,theynecessitateknowledgeaboutavailablecommunity,local,andstateresourcesandinformationabouthowtoaccesstheseresources,connecttomedicalcareandeducation,andlinktoresourcesthathelppayformedicalandhealth-relatedexpenses.Thenurseandsocialworkeralsobelievethatiftheywereabletogiveawaysomeoftheirnonclinicalresponsibilities,someoftheirtimewouldbefreetofocusonproactiveintervention,suchasreachingouttofamiliesthatpotentiallyneedmorefrequentsupport.Theyconcludethat withvalue-basedcare,inwhichtheyaretakingfullfinancialriskfortheirpatientpopulation,theyneedtooperateasanintegratedsystemandaddressneedsoutside ofthestrictlymedicaldomain.Thirtypercentofthe200carecoordinationencountersweretasksthatdidnotrequireclinicalcompetence,andtheyconcludethatifthesetasks are reallocated to a nonclinical person, the nurse and social worker could focus on expanding their clinical scopes of work.
GordonPediatricsusesthedata,inconjunctionwithadescriptionofthevolume ofrequestsanddifferenttypesofrolesthatthecareteammembersplay,tomake a request for additional resources to support a nonclinical care coordinator.
PART 2: Why measure? To inform gaps and measure change
GordonPediatricsisnowfullyonboardwiththeAccountableCareOrganization (ACO)contract.Clinicleadershiphasbeenabletoprovethatthereisvalueinhaving carecoordinationsupportontheteam,andtheresourcesneededforthisrolehave been budgeted into the ACO contract.
With Anne on board as the care coordinator, Gordon Pediatrics wants to ensure that itisoptimizingitsteam’sresources.SinceGordonPediatricsisnowaccountablefor theoverallcareandwell-beingofthechildrenitserves,itwantstobeginidentifyingareasforimprovement.Fromtalkingwithfamiliesthatfrequentlyvisitthepractice,GordonPediatricsknowstheyoftenhavedifficultyaccessingcommunityresources andevenknowingwhatresourcesareavailable.Familiesalsoindicatedifficultywithunderstandinghowtopayfortheirchildren’sservices.EventhoughGordonPediatricsknowsthisqualitatively,itisstillstrugglingwithdeterminingwheretostartandwhat to prioritize.
Additionally,GordonPediatricswantstoensurethatitisfocusingonthefamiliesthatwouldbenefitthemostfromadditionalsupport.Inordertoselectthepatientsforcarecoordination support, Gordon Pediatrics decides to choose a cohort of patients who havevisitedtheemergencyroom3ormoretimesinthepastyear.
In the past 12 months, how often has someone on your child’s care team explained to you who was responsible for different parts of your child’s care? (Check ONE box)
In the past 12 months, how often did you feel that someone on child’s care team gave you enough information about state or community organizations, such as Early Intervention, Head Start, Family to Family Support, Social Security Disability Insurance (SSD)
GordonPediatricsdecidesthatitwillbegindeployingasocialdeterminantsofhealthscreener,andiffamiliesexpressaneedforsupport,theywillbereferredtothesocialworker.Theteamhopesthatbyusingasystematicscreener,itwillbeabletocapturemorefamilieswhoneedtheseservices.Thesocialworkerhastheabilitytospendmoretimeonclinicalsocialworkissuesandsharessomeoftheadministrativetaskswiththenew care coordinator. Both the care coordinator and social worker continue to use the CareCoordinationMeasurementTool.
Note for the facilitator: In module 3 of the Pediatric Care Coordination Curriculum, there are examples of screeners on social determinants of health.
Ithelpsparentsofchildrenwithchronicorcomplexconditionslocateappropriateservicesinlocal,regional,andstatecommunities,butitdoesnottargetdiagnoses-specificchildren.Connectactsasareferralprogram,whichisadvertisedtopediatricandsubspecialtyprograms.Usingacoordinatormodel,Connectcoordinatorsareeachassignedacaseloadoffamilies,withwhomtheyinitiatepartnerships.Thecoordinatorsalsoworktogetherasateam,reviewingtheircasesinweeklyandmonthlyhuddlestodraw on the expertise of the group.