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Advisory Council April 2019 Meeting Presentation: Care Planning Accountability

Monday, April 29, 2019

Printer Friendly Version in PDF Format (  PDF pages)


Accountability for Person-Centered Care Planning: Performance Measurement and Accreditation

Jessica Briefer French, Assistant Vice President, Research
National Committee for Quality Assurance

This work is supported by a grant from The SCAN Foundation and The John A. Hartford Foundation

Quality Measurement: One Size Does Not Fit All

What Matters Most?

  • Sample of goals from focus groups with disabled older adults and their caregivers
    • Stay out of the hospital
    • Manage physical symptoms (e.g., Control pain)
    • Practice religion and spirituality
    • Have legal and financial affairs in order
    • Have more free time for caregiver
    • Not be a burden on family
    • Maintain or regain independence
    • Return to home setting
  • Some goals were unexpected
    • Practice religion and spirituality
    • Have more free time for caregiver
    • Not be a burden on family
    • Maintain or regain independence

Our Vision: Person-Driven Outcomes

  • Person-Driven Outcomes
    • Outcomes identified by the individual (or caregiver) as important that can be used for care planning and quality measurement

Person-Driven Outcome Approach and Quality Measures

Person-Driven Outcome Measures Demonstration
Elicit what is important; Identify and measure a person-driven outcome (person-reported outcome measure; goal attainment scaling); Action Step; Re-assess person-driven outcome; Improve or maintain person driven outcome.

Pilot and Demonstration Project

Why do we think this will work?

  • Agencies
    • iCare
    • Care Source
    • University of California San Francisco
    • UCLA Health
    • U.S. Medical Management
    • Kaiser Permanente
    • Priority Health
    • Community HEalth Plan of Washington
    • MedStar Good Samaritan Hospital
  • Pilot Findings
    • Approach was feasible and added value to care planning
    • Adds on average 20 min to an encounter
    • Potentially increased patient activation
    • Providers felt it fit well within their current practice
    • Feasible metric for showing improvement in outcomes
  • Research outcomes
    • Patient activation
    • Well-being
    • Shared-decision making
    • Experience of care
    • Caregiver strain
    • Hospitalization
    • Emergency department
    • Skilled nursing facility

Demonstration Objectives

  • Future of Quality Measurement
    • % of individuals with a goal and plan of care
    • % of individuals with follow-up on goal
    • % of individuals who achieve goal

HEDIS® 2019: Technical Specifications for Long-Term Services and Supports Measures

LTSS Comprehensive Care Plan and Update

  • Numerator Rate 1
  • Members who had a comprehensive LTSS care plan completed during calendar year 2018 (within 120 days of enrollment for new members), with 9 core elements documented.
  • Rate 1: Core Elements
    1. Member goal
    2. Plan for medical needs
    3. Plan for functional needs
    4. Plan for cognitive needs
    5. List of all LTSS services
    6. Follow-up & communication plan
    7. Emergency need plan
    8. Caregiver involvement
    9. Member agreement to plan

NCQA's LTSS Accreditation Programs

Organization Chart: Top--LTSS Programs; Second--(1)Accreditation of Case Management for LTSS, (2)HP Accreditation w/ LTSS Distinction, (3)MBHO Accreditation w/ LTSS Distinction, (4)CM Accreditation w/ LTSS Distinction. #1,2,3 were launched July 2016; #4 was launched January 2017.
HP = Health Plan
MBHO = Managed Behavioral Healthcare Organization

Program Requirements at a Glance

  • CM-LTSS Accreditation Standards
    • LTSS 1: Program Description
    • LTSS 2: Assessment Process
    • LTSS 3: Person-Centered Care Planning and Monitoring
    • LTSS 4: Care Transitions
    • LTSS 5: Measurement & Quality Improvement
    • LTSS 6: Staffing, Training and Verification
    • LTSS 7: Rights and Responsibilities
    • LTSS 8: Delegation
  • LTSS 3: Person-Centered Care Planning
    • Coordinate person-centered services for individuals by developing of individualized case management plans and monitoring progress against the plans.
  • Element A - Person-Centered Assessments
    • The organization has a process to:
      • Assess individuals' prioritized goals. *
      • Assess individuals' preferences. *
      • Assess individuals' life planning activities.
      • Identify individuals' preferred method of communication.

What is the path forward?

  • Focus on what matters
  • Build knowledge and confidence
  • Build shared accountability
  • Make it easy


Measuring quality. Improving health care.