1. Bruce Leff, MD Professor of Medicine Johns Hopkins University School of Medicine AAHCM Annual Meeting, Mary 14, 2014, Orlando, FL ©AAHCM

2.  Frame the importance of quality measurement for house calls practices  Current state of house calls practices – readiness  Current state of what practices are doing in the area of quality measurement  Lead in to Dr. Ritchie’s talk on the future of quality measurement for house calls ©AAHCM

3.  We don’t get enough respect for what we do  Shift to value-based care – we MUST be able to demonstrate this clearly and unequivocally to stakeholders  Challenge: lack of appropriate quality indicators, benchmarking data, mechanism to report quality ©AAHCM

4.  Funded by The Commonwealth Fund and The Retirement Research Fund  Created a Network of exemplar practices, patient advocacy groups, professional societies to develop quality indicators for the field, practice- based registry, tools for practice-based quality improvement  Survey of house calls practices was performed to inform our approach ©AAHCM

5.  58-question survey  Sent to all AAHCM members – email / mail  48% response rate, 456 individuals responded = 296 practices ©AAHCM

6. Practice Basics % of Practices Group (v solo)56 Single site v multiple, median # sites, (range)85, 1, (1-34) For-profit (v not)75 Sponsor Independent provider / provider group……….. Hospital or health system………………………… 70 19 Practice funding source Insurance reimbursement………………………… Self-pay………………………………………………. Subsidy by hospital or health system………….. Philanthropy…………………………………………. 94 30 14 7 Academic affiliation22 ©AAHCM

7. Practice Personnel % w Provider Type Mean FTEs Median FTE Range FTE MD% w Provider,855.610-165 NP734.720-85 PA331.710-20 RN372.210-60 Med Assistant426.820-225 SW25100-10 Case manager/care coor 232.20.20-30 OT/PT150.500-20 Administrative611320-1020 ©AAHCM

8. Service Issues % of Practices Average daily census, mean, median, (range)358,100, (1-8000) Practice offers 24/7 coverage94 Same day or next day visit for urgent / emerg complaints 68 Frequency of scheduled follow-up for clinically stable patients – every month or more frequent 45 Practice always or usually assumes 1º care81 Practice holds regular team meetings to discuss specific patients (frequency weekly or daily) 53 (46) ©AAHCM

9. Practice Tech Issues % of Practices Practice uses EMR88 Uses EMR for Documentation………………………….. E-prescribing……………………………. Care coordination w other practices… Registry functions………………………. Coordinate with HHA…………………… Sign HH orders…………………………… Communicate pt preferences across settings, e.g. POLST, MOLST………….. 97 88 60 48 45 41 30 ©AAHCM

10. Patients Served and Quality of Care Issues % Patients served ages 65+87 % Patients served in home/apt v ALF/dom61 % Patients primary insurance Medicare80 % Practices caring for Medicare Ad or SNP pts63 ©AAHCM

11. Quality of Care-Related Issues % of Practice s Practice involved in NCQA PCMH14 Practice is IAH site9 Practice involved in ACO13 Practice surveys patient re care experience Annually or more frequently……………………….. Less often than annually……………………………. Doesn’t survey………………………………………… 37 12 51 Practice uses defined quality improvement process33 Practice collects and monitors quality indicators48 Practice would participate in QI process that would provide feedback on house call QIs 56 ©AAHCM

12. FactorOdds Ratio 95% CI Practice holds regularly scheduled team meetings to discuss specific patients 2.251.13, 4.47 Practice conducts survey of patients7.573.76, 15.2 Practice involved in NCQA PCMH2.901.12, 7.57 ©AAHCM

13.  Range of practice types – size, biz model, provider types, approaches to quality of care issues  1/3 house calls practices use a defined QI process  Substantial proportion of practices engage in activities that may feed into QI activities: team meetings, pt and CG surveys, use of EMR  Majority of practices would be amenable to participate in QI process ©AAHCM

14. Christine Ritchie, MD, MSPH Professor of Medicine University of California San Francisco AAHCM Annual Meeting, Mary 14, 2014, Orlando, FL ©AAHCM

15.  Quality measurement  Trends in “value-based care”  Registries as a reporting mechanism for value-based care.  The past and ongoing work of the Medical House Calls Network (also known as Home- centered Primary and Palliative Care) ©AAHCM

16. NEEDS PROCESSES OUTCOMES Functional ClinicalExpectation Costs Functional Clinical Costs Satisfaction Assess>>Dx>>Rx>>Follow Patients with needPatients with need met

17.  Expectations for measurement and QI activities in five “quality domains” ◦ Clinical care ◦ Safety ◦ Care coordination ◦ Patient & caregiver experience ◦ Population health ◦ Prevention  Reimbursement (positive and negative) predicated on performance on certain quality measures and clinical performance improvement activities ©AAHCM

18.  Most quality measures are: ◦ disease focused ◦ Not applicable to those with functional limitations ◦ Not applicable to those who are home-limited  Housecalls (Home-centered Primary and Palliative Care) is at risk: ◦ Of not all being Patient-centered Medical Homes ◦ Not have professional society/discipline/setting- specific measures/standards ©AAHCM

19.  Measures that… ◦ Make sense for home-centered primary/palliative care (HCPPC) practices ◦ Take into account multiple chronic conditions ◦ Are validated in homebound populations  A Registry for… ◦ HCPPC practices ◦ Meeting quality reporting requirements ◦ Benchmarking  A Network to… ◦ Develop and test measures ◦ Test and implement a registry ©AAHCM

20. House Call Doctors Kaiser Family Foundation Amer. Acad. of Hospice/Palliative Med. Senior Advocate Resources Amer. Acad. of Home Care Med National Partner. Women & Families Mount Sinai Visiting Doctors Program Cleveland Clinic Med. Care at Home Call Doctor Medical Group Visiting Physicians Assoc. Vir. Commonwealth Univ. HomeCare Physicians Washington Hosp. Ctr Department of Veterans Affairs AARP Public Policy Institute American Geriatrics Society Johns Hopkins Elder House Calls Housecall Providers

21. Measure development Comprehensive literature review Health/Human Services Multiple Chronic Conditions Framework Qualitative interviews with all network members Qualitative interviews with patients and caregivers Development of standards from 10 domains Iterative refinement of standards Mapping of measures: Over 2000 measures Culling process over 16 calls and 4 months Final number: 95 measures Second culling process: 48 measures RAND modified Delphi process: 30 measures

22. Domains and StandardsGaps Domain: Assessment Perform a comprehensive assessment that includes: Symptoms (physical, emotional, social, spiritual) Physical, executive and cognitive function Health literacy Patient goals and sources of meaning and purpose Care coordination needs Treatment burden experienced by patients and caregivers Patient and caregivers stressors Social support and social risk Safety concerns

23. Domains and StandardsGaps Domain: Care Coordination Coordinate handoffs between care settings Communicate patient treatment goals and preferences across settings Identify and use appropriate community resources Insure that all team members have access to key patient information Assure that the team is notified of sentinel events Domain: Quality of Life Optimize comfort and safety of home environment Manage symptoms Reduce treatment burden Employ preventive services to optimize function

24.  Organized system--use observational study methods to collect uniform data  Provide population-level reports – Real-time/rapid cycle – Risk adjusted – Including standardized measures – Including benchmarks – Different reports for different levels of users  Generate dashboards that facilitate action  Facilitate third-party quality reporting ©AAHCM

27.  Work with the Academy and other professional societies to have standards approved for care in this setting  Begin registry development process (in partnership with the Duke Center for Learning Healthcare  Support housecalls practices in their recognition as a credible setting of care (Home-centered Primary/Palliative Care)