MODULE 10: Designing and Developing Care Improvement Strategies
In this module, we will explain the critical role the network clinical director plays in creating new quality improvement initiatives. We will also review the questions that must be answered before any initiative is implemented. Finally, we’ll discuss the importance of local input and central support and share some of the essential lessons we’ve learned about developing care improvement strategies.
The role of the clinical director
Community Care relies on health networks organized and operated to support PCPs and the medical home. At the heart of these networks are quality improvement and care management initiatives: targeted, patient-focused, physician-created programs that help health professionals provide excellent care at a reasonable cost. Using patient data, these professionals analyze population needs, choose the best care opportunities to pursue and then help define the performance standards they will be expected to meet. This physician-driven approach to improvement is key to obtaining provider support for the medical home model.
Each network has at least one clinical director who leads quality improvement initiatives locally. Clinical directors from Community Care’s original nine pilot networks launched the first initiative, an asthma disease management program, in August 2008. Since then, the clinical directors have met regularly to review and analyze population data, share best practices, design initiatives, set goals and measure performance.
In addition to participating in inter-network meetings, each director chairs a medical management committee with clinical representation from participating practices. In networks that cover large geographic areas, the clinical directors may adapt or choose alternate strategies to better engage their community providers; in some instances, this may require face-to-face meetings at all participating practices.
Figure 1. Managing Clinical Care
The chart above depicts the way clinical directors work with medical management committees and local practices. Clinical directors are responsible for selecting initiatives, determining program components and defining performance measures. They are also responsible for engaging network physicians and ensuring that quality improvements are made, using practice profiles, gaps-in-care analysis and chart audit results to gauge progress.
Creating a quality improvement initiative
Community Care’s clinical directors consider the following when deciding whether to implement a particular quality improvement (QI) initiative.
- Are there are enough Medicaid enrollees with the disease/condition addressed by the proposed QI to obtain a return on investment?
- Will best practices lead to predictable and improved outcomes?
- Are appropriate evidence-based practice guidelines available?
- Will physicians support the process?
- Will patient education and support improve outcomes?
- Are best practices and outcomes measurable, reliable and relevant?
- Does evidence suggest that the proposed quality measures will improve care?
- Is there is room for improvement? Does a gap exist between best practices and everyday practice?
- Can baselines for need, performance and improvement be measured longitudinally?
When considering and implementing a QI initiative, each network designates clinical champions and QI team leaders who employ the model of rapid-cycle quality improvement developed by the Institute of Healthcare Improvement. This model stresses the importance of setting aims, establishing measures and making system changes to remove barriers and support excellent care. The networks join together to:
- Review initial data obtained from claims and chart audits.
- Choose disease management initiatives.
- Develop program expectations.
- Define goals, objectives and performance measures.
- Identify methods of information collection.
- Create plans for implementation, assessment and monitoring.
- Share best practices.
- Develop and implement an evaluation strategy for each initiative.
In Community Care, QI initiatives are carried out by local systems that comprise:
- Enrollees who are linked to medical homes/primary care providers.
- Medical and administrative committees that provide direction on care management activities.
- Dedicated case managers who carry out population management activities in care and disease management in coordination and collaboration with community resources.
In every network, Community Care has implemented disease and care management initiatives for asthma, diabetes and congestive heart failure; high-cost and high-risk care management; pharmacy management and prescribing initiatives; emergency room utilization; and transitional support and chronic care (managing the co-morbid aged, blind and disabled population). In addition, several networks are piloting new models of care that, if successful, will be replicated in other networks. These initiatives address chronic obstructive pulmonary disease (COPD), mental health integration/co-location, childhood obesity, stroke prevention and diabetes disparities, and depression.
The value of network-led pilots cannot be overstated. Local networks understand the nuanced needs of their patient population and community. Whenever possible, we seek grant funding for local pilot initiatives. One such initiative, the Assuring Better Childhood Development (ABCD) program, was launched by one clinical champion and has since spread to nearly every Community Care network, winning recognition as a national child development model. Kate B. Reynolds and the Duke Endowment have supported the development of a number of Community Care pilots.
Central support for QI initiatives
When launching a QI initiative, Community Care provides centralized support to networks and medical homes through the following.
- Offering expertise and leadership, clinical staff is available to meet onsite with practices, physicians and their staffs to provide targeted education and technical assistance.
- Provider toolkits that summarize best practice guidelines and provide office-based tools for adoption and customization.
- Practice profiles on utilization, cost and quality metrics that are provided to all participating practices on a quarterly basis.
- A Web-based case management information system that supports case managers and provides uniform screening and assessment tools, among other aids.
- Provider and patient education materials that can be printed and customized for individual practices.
- Population stratification and gaps-in-care reports.
Community Care evaluates provider and network performance using measures developed by clinical directors. Outcome indicators are typically gathered by claims data; process indicators are gathered by external chart reviews. Community Care has partnered and contracted with Area Health Education Centers (AHECs) to perform randomized chart audits that provide practice-specific feedback and monitoring on process measures (such as performing annual foot exams, lipid management and HbA1c glycemic control for patients with diabetes). A standardized chart audit tool is developed and a random representative sample of charts is identified for review at every medical home. These reviews are now being entered directly into Community Care’s Web-based Case Management Information System (CMIS), allowing care managers to effectively identify patients who need follow-up attention (for example, patients with diabetes who have not received an annual eye exam). The care managers can proactively identify gaps in care and initiate efforts to promote best practices in concert with the medical home.
Making changes at the local level
One key to Community Care’s success is its ability, through its networks, to locally implement system changes as needed at individual practices. Instrumental in engaging community providers, clinical directors also provide credible and provider-friendly reports — powerful tools, particularly when accompanied by benchmarks and comparisons to peers.
Currently, Community Care uses information obtained from claims, electronic records and chart reviews to establish baselines and measure performance. In addition to reporting results for Community Care as a whole, we also report on individual networks and practices. Practices are compared with like-practices (meaning that pediatricians are compared with other pediatricians, etc.). Data is also broken down based on patient age, utilization of services and cost of services (the per-member, per-month cost). Community Care provides each network with reports that help identify segments of its enrolled Medicaid population (identification and stratification) that might benefit from targeted disease and care management interventions.
A partial list of reports Community Care provides:
- Case identification reports, using Medicaid claims data, identify enrollees with:
- Asthma and emerging asthma.
- Diabetes and emerging diabetes.
- Frequent emergency department use.
- Especially high cost of care.
- History of hospitalizations.
- Poly-pharmacy and poly-prescriber issues.
- Co-morbid conditions, including mental health conditions.
- Gaps-in-care analysis, such as:
- Patients with congestive heart failure without a beta-blocker medication fill.
- Patients with diabetes who haven’t had an eye exam in the most recent 12 months.
- Patients with hypertension without an antihypertensive medication fill.
- Patients with a chronic condition who have not visited a PCP.
- Patients with medication adherence issues.
- Summary information on quality audit results on the evidence-based clinical practice guidelines at the network and practice level.
Community Care has earned national recognition for improving quality, utilization and access while reducing cost, prompting leaders from other states and organizations to inquire about our methodology and our ability to engage PCPs. When asked about our program, these are some of the lessons we share.
- Community collaboration combined with local physician leadership is paramount in our model.
- Building a program that centers on the medical home and the patient’s primary care provider is very important. Strong connection to the medical home is key to our program’s success.
- When primary care physicians are invited to help identify, develop and implement initiatives, they take that responsibility seriously and are willing to be held accountable for targeted outcomes.
- It is important to invite PCPs to participate early in the process – ideally during the development phase. Clinical directors can then work with their community physicians, even the late adopters, to implement best practices.
- Solutions to health access and quality issues are local. If solutions are led by local clinical champions, they will resonate with other community providers who then feel more compelled to participate.
- Choose to implement initiatives that can demonstrate quality improvement and impact costs.
- Take the time to build confidence at the provider level in the data and reporting processes. Issue meaningful and provider-friendly reports.
- Primary care physician leaders will be your program’s best ambassadors.
- Align with other provider and quality initiatives in the state.
- Recognize that there are barriers to caring for the Medicaid population (connecting to local resources, working with the patient and family on social issues, providing pharmacy support, etc.) and that PCPs need help to remove those barriers.
- Coming together to share strategies and tools encourages and energizes clinical directors.
- Provide care and wrap around support to help PCPs manage their patients with chronic illness(es).
Community Care’s approach to quality care addresses two emerging trends – the growing shortage of primary care providers and the increasing prevalence of chronic diseases. The community-based infrastructure, led by physicians in concert with other key community agencies, enables us to implement and disseminate patient-centered care that is culturally appropriate and sensitive. We also hope that the principles of Community Care will take root and influence all patient care in the state through practitioners, most of whom care for people with other means to pay or who are uninsured.
Points to remember
- Targeted quality improvement and care management initiatives are at the heart of any medical home approach.
- When considering potential initiatives, evaluate the population need, whether physicians will support the process and if evidence suggests that proposed measures will improve care.
- Within networks, appoint clinical directors to select, champion and manage initiatives.
- Centralized support is fundamental for any QI program.
- Allow clinical directors to make the local system changes that are required by physician practices.
- Network-led pilots are immensely valuable. Use pilot programs to develop and refine initiatives; proven, successful programs can then be launched to a wider population.