SB1004 Technical Assistance Series:Topic 4: Gauging and Promoting

Sustainability and Success

Anne Kinderman, MDDirector, Supportive & Palliative Care ServiceZuckerberg San Francisco General HospitalAssociate Clinical Professor of Medicine,UCSF

Kathleen Kerr, BAKerr Healthcare Analytics

April 2018

Building blocks for implementingcommunity-based palliative care

Estimatingmember/patient

need

Estimating costsfor delivering

services

Assessing capacityfor palliative care& launching svcs

Gauging andpromoting

sustainabilityand success

Lessons learnedand adjusting

programs

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Objectives

• Review information from DHCS regarding initial programreporting requirements

• Describe resources available to measure palliative carequality

• Outline process steps to select quality metrics based onlocal needs, resources and challenges

• Create processes for routine program review and qualityassessment

• Outline factors that promote sustainability and scaling ofservices

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Outline

• Review SB 1004 reporting requirements

• Measuring quality in palliative care

• Selecting metrics for your program

• Recommendations for promoting programsustainability

• Review

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SB 1004 Reporting Requirements

• Final template released February 2018• Quarterly reporting• Reporting domains

• Patient level: name, diagnosis, approval date,disenrollment date, reason for disenrollment

• Referrals: number made, approved, accepted, declined,denied and if denied why

• Network: provider name, type (mix of disciplines andservices), specialty, telehealth use

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Focus: Who was referred, who was served, why/why notserved, how long served, by whom

6https://cahps.ahrq.gov/consumer-reporting/talkingquality/create/sixdomains.html

Safe

Effective

Efficient

Equitable

Timely

Patient-Centered

QualityCare

Avoiding harm topatients from thecare that isintended to helpthem.

Providing servicesbased on scientificknowledge to allwho could benefitand refraining fromproviding services tothose not likely tobenefit

Avoiding waste, including wasteof equipment, supplies, ideas,and energy.

Providing care that doesnot vary in qualitybecause of personalcharacteristics such asgender, ethnicity,geographic location,and socioeconomicstatus

Providing care that isrespectful of andresponsive toindividual patientpreferences, needs,and values andensuring that patientvalues guide all clinicaldecisions.Reducing waits and sometimes

harmful delays for both those whoreceive and those who give care.

Components of quality

Much more you will want to know

Metrics that describe:• What was done, by whom, how often• Adherence to best practices• How things turned out

Where to find metrics?• Case studies / peers• QI collaboratives• Endorsed by the field

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• 6 teams of payer and provider organizations

• Providers: large academic medical centers, hospices, and a specialtypalliative care practice

• Payers: national insurers, regional insurers, a Medicaid managedcare plan

• 6 month planning process, resulting in operational and financialplans for delivering CBPC

• 24 month implementation phase, where contracts were executedand clinical services were delivered

To learn more about the PPI project: https://www.chcf.org/project/payer-provider-partnerships-to-expand-community-based-palliative-care/

CHCF Payer-Provider Partnerships Initiative

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(Selected) Metrics used by PPI participants

Operational• # Patients referred, % with scheduled visits, % visited• # Visits (average and range) per patient in enrollment period• # Days (average and range) from referral to initial visit• # Days (average and range) between visits• % seen within 14 days of referral• Referral source• Referral reason• Use of tele-visits

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Metrics used by PPI teams

Screening and assessments• % for which spiritual assessment is completed• % for which functional assessment is completed• Symptom Burden by ESAS (repeated)• Patient distress by Distress Thermometer (repeated)• % for which medication reconciliation is done with 72h of

hospital discharge

Planning and preferences• % with advance care planning discussed• % with advance directive or POLST completed

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Metrics used by PPI teams

Hospice and End of Life Care• % remaining on service through end of life• % death within one year of enrollment• % enrolled in hospice at the time of death• Average/median hospice length of service• Location of death• % dying in preferred location

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Metrics used by PPI teams

Utilization and fiscal• PMPM cost of care, enrolled patients vs comparison

population• Health care utilization/costs 6 months prior to enrollment

compared to 6 months during/after:• # Acute care admissions• # (Total) hospital days• # ICU admissions• # ICU days• # ER visits• Cost per member (total)• Cost per member (inpatient)• Cost per member (outpatient)

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National learning collaborative committed to improvingthe care of seriously ill patients and their families

Palliative Care Quality Network

Learn More: https://pcqn.org ● Angela Marks angela.marks@ucsf.edu

Patient- level data registry with real-time, easy to accessreports that allow for benchmarking across member sites.

Quality improvement activities including mentored multi-site QI projects, QI education, and case reviews.

Education & community building opportunitiesincluding monthly educational webinars and in-personconferences.

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Encounter level data collection

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Metrics for assessment and benchmarking

SEE HANDOUT

PC metrics endorsed by NQF

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Use NQF’s QPS to find endorsed metrics

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What‘s inside

• 299 metrics from 19 sources• Information about each metric:

• Required data• Metric type (structure, process, outcome)• National Consensus Project (NCP) guideline it addresses• Who developed it• Settings used/tested in• Important endorsements

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You can use the tool to select for the types of metrics that areappropriate for your setting and service, and to exclude fromconsideration metrics that are unimportant (to you) or not feasible.

Filter view

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This number will changeas filters are applied

Results view

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Learn more about the NCPguideline reference for a metricby going to the NCP Guidelinessection of the Resources tab

Results view

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Use the “Add” buttons to savemetrics to your My Metrics cart

My Metrics

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Export your MyMetrics cartcontents

Click on the “MyMetrics” button topreview and edit thecontents of your cart

Export a Spreadsheet File

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Outline

• Review draft SB 1004 reporting requirements

• Measuring quality in palliative care

• Selecting metrics for your program

• Recommendations for promoting programsustainability

• Review

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Selecting Quality Metrics:Factors to Consider

• Whenever possible, start with metrics recognizedby external entities and/or used by other programs

From that long list, make selections by considering:• What matters to stakeholders• Feasibility of data collection & analysis• Balanced portfolio

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Selecting Quality Metrics:What Matters to Stakeholders

1. Who are your stakeholders?• Whose support is needed for success,

sustainability, scaling?• Whose initiatives/programs might be impacted

(or threatened)?• Who might have expectations about what the

program will deliver?

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Selecting Quality Metrics:What Matters to Stakeholders

1. Who are your stakeholders?• Internal

• Organizational leadership• Clinically-oriented• Financially-oriented• Regulatory

• External• Payer/provider partner• Referring providers• Community partners• DHCS

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2. Initial questions to ask• What would a successful palliative care program

look like?• What are you hoping the program will achieve?• If you only had one measurement of program

quality, what would it be?• How might the palliative care program impact

(or be impacted by) other programs?

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Selecting Quality Metrics:What Matters to Stakeholders

For each metric you’re considering…• Is it already being collected, reported?• Where would you get the data?

• Available in EHR• What would it take to generate routine reports?

• Could be collected specifically for this purpose• How labor-intensive might that collection process be?• Who would need to be involved? How much bandwidth do

those stakeholders have to take on new tasks?

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Selecting Quality Metrics:Assess Availability and Feasibility

For each metric you’re considering…• Would the data be consistently available?• How reliable would the data be?• Where/how would you record the data?• What would the analysis process require?

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Selecting Quality Metrics:Assess Availability and Feasibility

With stakeholders from your organizationand/or partner organization, complete:Metrics Preparation Worksheet

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Preparing for Metrics Selection

Selecting Quality Metrics:Factors to Consider

üRecognition of metric by external entities, use byother programs

üWhat matters to stakeholdersüFeasibility of data collection & analysis• Balanced portfolio

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Selecting Quality Metrics:Aim for a balanced portfolio

• Different types of metrics• Structure• Process• Outcome

• Different focus areas• Effort required

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Aim for a diverse portfolio of palliative care programmetrics, with balance across:

Different types of metrics

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Selecting Quality Metrics:Aim for a Balanced Portfolio

• Describe the program• Ex. Available 24/7Structure

• Describe how care is delivered• Ex. Screenings done at specific points in

timeProcess

• Describe the impact of the program• Ex. Change in pain scoresOutcome

Different focus areas

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Selecting Quality Metrics:Aim for a Balanced Portfolio

Operational Screening &Assessments

Planning &Preferences

Hospice &End-of-Life

Care

Utilization &Fiscal

See Metrics Balance Check Worksheet for examples of metrics in each category

Selecting Quality Metrics:Aim for a Balanced Portfolio

Consider total effort required for collection, analysis

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Easy

Hard

Key point:Make sure that you don’thave all high-effortmetrics… but consideradding a small number ofthese if the informationwould be particularlyvaluable to you or yourpartner organization

Example of metrics selection:Zuckerberg San Francisco General

• Inpatient & Outpatient programs• Patients seen by both, or just one

• Cannot pull data from EHR• Limited administrative support

Context

• Internal• System leaders• Inpatient and outpatient teams

• External• SF Health Plan• Grant funders

Stakeholders

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Preliminarydiscussion of

program goals

• What would a successful program look like?• Any specific outcomes that would be very

important?

FeasibilityAssessment

• Available/obtainable?• Already collecting, in database?

Review shortlist with

stakeholders• Balanced portfolio• Collection & analysis workflows

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Example of metrics selection:Zuckerberg San Francisco General

Structure/Process/Outcome

QualityFocus area

Important toPlan

Important toProvider

Important toother(s)

Easy to collect,analyze

Interdisciplinaryteam, PC certified

Structure Operational ++ ++ ++Joint

Commission

++

% of patientsscreened forpsychosocialdistress

Process Screening &Assessments

0 ++ ++Cancer

Committee

0/+

Number ofpatients seen peryear

Outcome Operational ++ ++ ++System

leadership

+

Average costs ofpatients in last yr.of life

Outcome Utilization &Fiscal

++ ++ ++PC field

-/0

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Example of metrics selection:Zuckerberg San Francisco General

Putting it all together

Structure/Process/Outcome

QualityFocus area

Importantto Plan

Importantto Provider

Importantto other(s)

Easy tocollect,analyze

Metric 1

Metric 2

Metric 3

With others from your organization and yourpartner organization, complete theMetrics Balance Check Worksheet

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You’ve selected your metrics…Now What?

• Discuss with partner, stakeholders• Targets

• Who defines the target?• What happens if target isn’t achieved?

• Interval for reporting• Internal• External

• Format for reporting, communicationpreferences

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Outline

• Review draft SB 1004 reporting requirements

• Measuring quality in palliative care

• Selecting metrics for your program

• Recommendations for promoting programsustainability

• Review

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Promoting Sustainability:Recommendations

Pilot & Re-evaluate

Routine communication

Repeat the needs assessment

Pay attention to relationship with payer/provider

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A wise person once said…

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Promoting Sustainability:

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Predicting the future is impossibleIssue #1:

Promoting Sustainability:Pilot & Re-evaluate

Many things are hard to predict• Where referrals will come from, how much marketing

and outreach will be required• Which patient populations will be largest• Roles/responsibilities of different team members• How workflows will need to change (with changes in

venue, volume, staffing, etc.)• Projected vs. actual costs

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First choice … best choice?

INITIAL PLAN CHALLENGES(Pilot) contractmandated 2 RN homevisits per patient permonth

· Some patients didnot make themselvesavailable for visits atpredictable intervals,which reducedrevenues for provider

· Some patients didnot need both RNvisits, but insteadreally needed weeklySW visits, at least insome months

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Promoting Sustainability:Pilot & Re-evaluate

• Initial efforts should be framed as pilot• Start with expectation that things will need to be

adjusted• Define parameters

• Interval for reassessment• Evaluation metrics

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First choice … best choice?

INITIAL PLAN CHALLENGES POSSIBLE SOLUTIONS(Pilot) contractmandated 2 RN homevisits per patient permonth

· Some patients did notmake themselvesavailable for visits atpredictable intervals,which reducedrevenues for provider

· Some patients did notneed both RN visits,but instead reallyneeded weekly SWvisits, at least in somemonths

· Create process to waiveor adjust requirementfor certain patients /certain circumstances

· Suggest high-frequencyinitial phase followedby maintenance phase

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Promoting Sustainability:Pilot & Re-evaluate

Lesson #1:Many successful payer-provider partnerships includeroutine re-evaluation of program goals, structures,workflows, outcomes

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Predicting the future is impossibleIssue #1:

Promoting Sustainability:

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Different organizations have different cultures anddifferent ways they prefer to communicate

Issue #2:

Promoting Sustainability:Routine Communication

• Develop plan for communicating regularly,particularly at the beginning of the partnership,and after any major changes in the program

• Rationale• Changes in staffing/leadership happen• Your partner’s goals/priorities will change• Identify gaps, unmet needs on both sides• Fix small issues before they grow

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Promoting Sustainability:Routine CommunicationContent to consider

• Clinical• Troubleshooting difficult cases• Foster communication between plan-based providers and

palliative care providers• Operational/Programmatic

• How many patients/members are being enrolled? Howdoes this compare with predictions?

• Which clinics/provider groups are (or aren’t) referring?• Are there barriers or inefficiencies in the referral process?• How long are patients/members remaining enrolled?• What resources are lacking, for patient/caregiver

support?

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Promoting Sustainability:Routine Communication

• What works best for communication?• Email/written• Remote• In-person

• How often are meetings needed?• Who should be involved in different meetings?

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Promoting Sustainability:Routine Communication

Lesson #2:Be explicit in developing routine communicationstrategies with your plan/provider partner(s) thatwill work for both organizations.

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Different organizations have different cultures anddifferent ways they prefer to communicate

Issue #2:

Promoting Sustainability:

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Changes in personnel, leadership, and programscope can dramatically affect payer-providerpartnerships.

Issue #3:

Promoting Sustainability:Repeat the Needs Assessment

• Because things change, there may be key timeswhen you should consider repeating a needsassessment

• Change in partner(s) or key stakeholder(s)• Program expansion• Change in scope of work/responsibility• Changes in support and/or funding

You’ve done a thorough needs assessment at theoutset of the program, now you’re set, right?

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Promoting Sustainability:Repeat the Needs Assessment

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• Leadership• Key clinician• Referring partner• Community partner

Change inpartner or key

stakeholder

• New location• New setting of care• New patient population

Programexpansion

Promoting Sustainability:Repeat the Needs Assessment

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• New task assigned• Partner takes over task• Incentive/penalty proposed

Change inscope or

responsibility

• Grant start/finish• In-kind donation changes• Community program

changes

Change insupport or

funding

Promoting Sustainability:Repeat the Needs Assessment

Resources for needs assessments• SB 1004 Technical Assistance Series (chcf.org/sb1004)

• Topic 1: Estimating Volume• Topic 2: Estimating Costs• Topic 3: Gauging Capacity

• Center to Advance Palliative Care• CSU Institute for Palliative Care

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Promoting Sustainability:Repeat the Needs Assessment

Lesson #3:Repeat a needs assessment after significant changesoccur on either side.

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Changes in personnel, leadership, and programscope can dramatically affect payer-providerpartnerships.

Issue #3:

Promoting Sustainability:

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Relationships are really important, but hard.Issue #4:

Relationship issues

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Even a great service can’t thrive if the payer-provider relationship is bad

• Partners need to be willing to communicate openly andfrequently about all aspects of program planning andimplementation.

• Partners need to build trust, understand why they eachwant to engage in this work, and show an appreciation forthe pressures and priorities that impact the otherorganization.

“Most important” characteristic that you lookfor in a CBPC partner?

Provider:

“That they be collaborative and flexible, able to appreciate theperspective of a small partner”

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Payer:“Ideal partner characteristics would be an ability to take ininformation from many perspectives (vision and mission pluspractical information about service delivery nuts and bolts, andthe environment), including an ability to appreciate theperspective of a payer partner.”

Characteristics that might predict a poor fit?

Provider:“As we brought issues to the forefront (big and small) the planwas always willing to engage in a conversation - to hear fromour perspective how a contract requirement would impact care.Even if the plan didn’t agree, it was important to us that theywere willing to have that collaborative conversation. Not seeingthis kind of openness would be a huge red flag; a payer that justsays, ‘This is the way we do it’ would be a difficult partner.”

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Payer:“I try to get a sense during early meetings whether they are comfortabletaking risks, if they have demonstrated an ability to think differently, andif they have a record of implementing innovations. An absence of suchcharacteristics/history, or a rigid attachment to their own model of caredelivery would indicate a poor fit.”

Promoting Sustainability:Pay Attention to Relationships

Lesson #4:Flexible good. Rigid bad.Listening, transparency, empathy and collaborativeproblem solving are valued highly; inflexibility is not

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Relationships are important, but hard.Issue #4:

Outline

• Review draft SB 1004 reporting requirements

• Measuring quality in palliative care

• Selecting metrics for your program

• Recommendations for promoting programsustainability

• Review

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Objectives Review

• Supplement information reported to DHCS with processand outcome metrics that describe care quality

• When considering metrics look to what peers and QIcollaboratives are using, and those endorsed byprofessional organizations

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Review information from DHCS regarding initialprogram reporting requirements

Describe resources available to measure palliativecare quality

Objectives Review

• Think about how success is defined by key stakeholders,and focus on the subset of metrics that speak to thoseareas

• Assess feasibility of both data collection and analysis• Aim for a balance of metrics – in terms of metric type,

focus area, and effort required to obtain the data

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Outline process steps to select quality metricsbased on local needs, resources and challenges

Objectives Review

• Establish schedule for program reporting,communication

• Repeat needs assessments at key junctures (e.g. changein personnel, leadership, or patient population)

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Create processes for routine program review andquality assessment

Objectives Review

• Just because you started doesn’t mean you are done –ongoing monitoring and modifications will be needed

• Culture and communication differences can have a bigimpact on partnerships – identify issues up-front andwork toward solutions that work for both organizations

• Prioritize creating and sustaining good payer-providerrelationships

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Outline factors that promote sustainability andscaling of services

Acknowledgements and Resources

Thanks to colleagues who shared their knowledge,wisdom and experiences

• Maria Aguila, Health Plan of San Jaoquin• Diane Coluzzi, California Health and Wellness• Ujjwala Dheeriya, Care Connect• Michael Siegel, Molina Health Care

• SB 1004 Questions• http://www.dhcs.ca.gov/provgovpart/Pages/Palliative-Care-and-SB-1004.aspx• SB1004@dhcs.ca.gov

• Technical Assistance Series: kmeyers@chcf.org

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