DHCS will be making recommendations to CMS regarding quality metrics that should be included in the demonstration evaluation and ongoing quality monitoring, as well as the few metrics linked to the 1%, 2%, and 3% quality withhold.
Linked here is a list of potential performance measures that includes many measures that CMS routinely monitors for Medicare Part C and Part D. Please pay special attention to the measures listed on the past page under the heading “Other Measures to Consider.” Although many of the Part C measures are associated with long-term services and supports and behavioral health, these “other” measures more specifically address those two areas. Suggestions or feedback in these areas is especially appreciated and needed.
Measures will be needed for a national evaluation and also for a California-specific evaluation and quality monitoring strategy. For more information about the evaluation, quality monitoring, and withhold, please see pages 30 – 33 of the demonstration proposal and materials on the Quality Work Group web page.
Please keep in mind that the metrics for the demonstration and the subset associated with the quality withhold may change over the three years of the demonstration. For example, they may be more process-oriented in year 1 and move toward outcome metrics in years 2 and 3.
Additionally, any measure must be highly 1) valid, 2) reliable, 3) feasible/reasonable to obtain and 4) important.
DHCS would like your input on these measures by Thursday June 28th. Please submit comments to info@calduals.org with the subject “Comments on quality measures” or write them in the comment box below.
In your comments, please address:
- What metrics would be good for year 1?
- Which metrics would be useful for years 2 and 3?
- Which metrics would you recommend removing from the list?
- What additional valid measure would you recommend?
Thank you for the opportunity to provide input on quality and evaluation metrics for the Dual Eligibles Integration Demonstration. First, we want to alert you to work that the National Committee for Quality Assurance (NCQA) has underway to develop structure and process measures for integrated care expressly for the dually eligible population. NCQA has a set of proposed measures still under review that will then need to undergo testing but they could be available in time for the second and/or third year of the Demonstration. Several of these measures are foundational to supporting access to long-term services and supports (LTSS). Second, we want to alert you to a comprehensive scan of home- and community-based services (HCBS) measures performed for the Agency for Healthcare Research and Quality (AHRQ) and released in 2010. Among the appendices of this report are measures that have been tested and reflect beneficiary experience and performance measures. This report can be found at: http://www.ahrq.gov/research/ltc/hcbsreport/. There are numerous measures that have been tested from which to select that would be relevant for those who are receiving LTSS. Especially relevant are the measures that reflect consumer opportunity to make choices about providers and services.
One set of evaluation metrics that might be considered would include the identification of those who were deemed “at risk” for LTSS (as defined by the State) and then to evaluate the proportion of those at risk who received a comprehensive assessment that included physical and cognitive function assessment (and those who refuse the assessment should be appropriately documented). While there are existing SNP measures around complex case management that address assessment, they define “complex” in clinical terms and do not expressly consider functional status and LTSS risk. Those who have previously been deemed “at risk” for needing LTSS should continue to be re-assessed at some regular interval and the evaluation should monitor that this is occurring. Furthermore, among those who have been deemed “at risk” and have participated in a comprehensive assessment, the health record should document a care plan or document that services have been offered (whether they are put in place or not).
Given there are few validated measures of structure and process for LTSS and care transitions that are needed for the Demonstration, it is important to ensure that the quality monitoring include periodic surveys of consumers to understand their experience in the Demonstration. Questions should include whether they understand their rights and benefits under the Demonstration, do they know who to contact if they have questions/concerns, and if they need to appeal a care decision. The existing SNP measures require health plans to demonstrate they have developed materials to inform consumers of their rights and benefits, but do not reflect how effective the materials are in communicating these issues and the consumer’s experience in comprehending the information.
The Experience of Care and Health Outcomes (ECHO) measure set focuses on behavioral health but many of the measures in this set would also apply to populations using LTSS. Examples of measures that would be relevant include whether the individual is involved as much as he/she wanted in treatment/service plan decisions. We recommend close examination of this measure set to determine whether there are measures that can appropriately be adapted to the LTSS population.