Essential Attributes of a High-Quality System of Care: How Communities Approach Quality Measurement

Transcription

1 Essential Attributes f a High-Quality System f Care: Hw Cmmunities Apprach Quality Measurement Octber 2016 Supprted by a grant frm The SCAN Fundatin

2 Essential Attributes f a High-Quality System f Care: Hw Cmmunities Apprach Quality Measurement Cntents Executive Summary... 3 Backgrund... 3 Summary f Findings... 4 Cmmunity Exemplars... 4 Geneva Twer Health Cllabrative... 4 The Alliance f Chicag Cmmunity Health Services (Alliance) and The Prtcl fr Respnding t and Assessing Patients Assets, Risks, and Experiences (PRAPARE)... 4 Supprts and Services at Hme (SASH)... 5 Leveraging Data t Infrm, Evaluate, and Advance Essential Attributes... 5 Next Steps... 7 Appendix A: Case Studies... 8 Supprted by a grant frm The SCAN Fundatin advancing a crdinated and easily navigated system f high-quality services fr lder adults that preserve dignity and independence. Fr mre infrmatin, visit

3 Executive Summary In 2016, a wrking grup f natinal experts supprted by The SCAN Fundatin described the fur Essential Attributes f a high-quality healthcare system fr adults with cmplex care needs. T build upn this effrt, the Natinal Quality Frum (NQF) develped case studies that demnstrate hw cmmunities (that is, systems f peple and/r rganizatins in a specific lcal r reginal lcatin) have apprached at least ne f the Essential Attributes. NQF fund that the first Essential Attribute t identify and regularly re-evaluate a persn s medical and nnmedical needs and gals n an nging basis fr care planning is the ne mst cmmnly being accmplished by using data, measurement tls, and instruments in innvative ways. Thrugh the case study lens, NQF presents measure gaps fr further examinatin and utlines lessns learned in rder t help guide the develpment and use f quality measures fr imprving services received by adults with cmplex care needs. Backgrund The SCAN Fundatin recently published a reprt, What Matters Mst: Essential Attributes f a High- Quality System f Care fr Adults with Cmplex Needs, which utlines elements that define a wellfunctining system f care where individuals are able t live their lives with services and supprts reflecting their values and preferences in the least restrictive, mst independent setting pssible. By bringing tgether a wrking grup f diverse experts representing the interests f adults with cmplex care needs, this reprt details what matters mst t individuals and their caregivers and utlines the fur Essential Attributes f a high-quality system f care: 1. Each individual s range f needs and gals, bth medical and nnmedical, as well as fr family/caregivers, are identified and reevaluated n an nging basis t drive care plans. 2. Each individual s needs are addressed in a cmpassinate, meaningful, and persn-fcused way and incrprated int a care plan that is tailred, safe, and timely. 3. Individuals have a chesive, easily navigable delivery system s that they can get the services and infrmatin they want by themselves r with supprt when needed, and avid the services they d nt need r want. 4. Individuals and their family/ caregivers cntinually infrm the way the delivery system is structured t ensure that it is addressing their needs and prviding resurces tailred t them. These Essential Attributes are intended t help guide future effrts t transfrm delivery systems and develp quality measures that capture an individual s gals, preferences, and desired utcmes. While mnitring and measuring activities require systems t cllect and analyze unifrm data in rder t ppulate standardized metrics, NQF sught t determine hw data, quality measurement tls, and measures are used in cmmunities t imprve the health and quality f life fr adults with cmplex care needs. Specifically, NQF sught t determine hw healthcare delivery system and scial services data are cmbined t supprt better quality-f-life utcmes, and what barriers cmmunities face in using this infrmatin t imprve the lives f adults with cmplex care needs. 3

4 NQF mined its previus wrk and interviewed key infrmants representing health plans, prviders, and health centers t identify wh is using data innvatively t supprt lder adults. The case studies summarize three exemplar grups, highlighting bth hw they have used infrmatin in alignment with the Essential Attributes and issues they encuntered. Summary f Findings NQF examined hw cmmunities serving adults with cmplex care needs cllect, analyze, and cmbine health system and scial services system data t supprt ne f the Essential Attributes. In its limited review, n single perfect example was fund wherein data r measures are being used t measure and imprve upn an Essential Attribute in its entirety. While many cmmunities are wrking t imprve quality, mst are nly in the early stages f learning hw t access r integrate varius surces f data and are largely nt yet at the pint f measuring r thinking abut hw t measure the quality f such care. Mst f the cmmunities examined are fcusing n identifying individual needs and gals, bth medical and nnmedical (Essential Attribute 1), and sme cmmunities are beginning t address these identified needs thrugh persn-centered care plans (Essential Attribute 2). In additin t interviewing varius rganizatins, NQF cnsidered lessns learned frm its previus wrk (e.g., Geneva Twer Health Cllabrative). NQF narrwed its fcus n hw Essential Attribute 1 is currently being addressed in three exemplar cmmunities. While NQF fcused n finding cmmunities wh depicted at least ne f the attributes, it was clear that the ability diminished when prgressing frm Essential Attribute 1 thrugh Essential Attribute 4. Cmmunity Exemplars The fllwing examples highlight hw Essential Attribute 1 is addressed in specific cmmunities. Mre extensive case studies and descriptins f previus related NQF prjects are presented in the Appendix. Geneva Twer Health Cllabrative The Geneva Twer Health Cllabrative fcuses n imprving the health f the residents f Geneva Twer, a 183-unit apartment cmplex in Cedar Rapids, Iwa, which huses lw incme lder adults and/r peple with disabilities. Leaders frm several types f rganizatins in the cmmunity recgnized that the residents were a particularly vulnerable subppulatin, and s came tgether t better crdinate services, reduce barriers t care, and identify ways t imprve the quality f life fr the residents. The Alliance f Chicag Cmmunity Health Services (Alliance) and The Prtcl fr Respnding t and Assessing Patients Assets, Risks, and Experiences (PRAPARE) The Alliance, lcated in Chicag, prvides its member health centers detailed reprts which can be drilled dwn t individual prvider-level r patient-level detail. The reprts can als be stratified by race, ethnicity, and primary language t identify disparities in care. The Alliance uses the PRAPARE mdel and has develped an electrnic health recrd (EHR) implementatin mdel that encurages 4

5 standardized data entry, which can be used fr individual patient care r aggregated fr ppulatin-level analyses. The PRAPARE mdel is a prime example f a tl that takes int accunt an individual s entire histry and impacts n their verall health by dcumenting a patient s assets, risks, and experiences. It aims t empwer patients, t imprve pint-f-service care management, t imprve the health f the patient ppulatin, t infrm cmmunity plicies, t encurage and strengthen partnerships, and t infrm state and natinal plicies. Supprts and Services at Hme (SASH) The SASH prgram is a Vermnt statewide initiative t create a netwrk f persn-centered, crdinated healthcare and supprt services that engage participants, family, and friends in rder t prvide the right services and supprts at the right time, tailred t lcal cnditins and participant needs. An annual assessment prvides a baseline well-being status and identifies the needs and supprt gaps f each SASH participant, which builds the fundatin f the participant s Healthy Living Plan. Leveraging Data t Infrm, Evaluate, and Advance Essential Attributes NQF identified the fllwing cmmn themes and lessns learned: 1. Exemplar cmmunities are using data in innvative ways, particularly in effrts t identify high-need patients and assess their scial supprts (Essential Attribute 1). The Geneva Twer Health Cllabrative fcuses n a lw-incme apartment cmplex and uses a cmbinatin f ppulatin health data, clinical data, and data frm residents surveys t identify high-need, lw-resurce residents. The Alliance uses a multilayered analytics platfrm t integrate data frm different surces fr bth patient-level and ppulatin-level analyses. The data are stred in a centralized EHR data warehuse, and users can track bth patient-level and prviderlevel imprvements ver time. The PRAPARE mdel used by the Alliance ffers a standardized patient risk assessment prtcl t identify risk related t scial determinants f health. The SASH assessment gathers cmprehensive well-being infrmatin abut each participant n an annual basis which is used t identify supprt gaps. 2. Prgrams still tend t use medically riented utcmes t determine the impact f their interventins. The Geneva Twer Health Cllabrative fcuses n clinical measures like number f nn-admissin emergency department visits and percentage f residents with hypertensin. They als measure self-assessed availability f scial supprts. The Alliance uses its data platfrms t examine perfrmance n natinal quality measures; these measures are largely medically riented. 5

6 The SASH prgram has been extremely beneficial in reducing Medicare expenditures, reducing the number f falls, cntrlling hypertensin, and increasing immunizatins. While almst all f the benefits are medically fcused, SASH is lking t imprve utcme measures that fcus n mre nnmedical results such as scial islatin. 3. Cmmunity cllabratin is essential t establishing a trusted cntinuum f services. The Geneva Twer Health Cllabrative engages many cmmunity partners including the apartment cmplex; prviders f care fr physical, mental, and substance use issues; aging services; public health representatives, and thers. PRAPARE uses data t identify and supprt the develpment f needed prgrams, cnnect patients with cmmunity resurces and patient navigatrs, target patients fr specific screenings, and identify the necessary level f care management. Fr example: A team in Iwa develped a relatinship with the lcal transprtatin authrity and negtiated bulk discunts fr taxi vuchers and bus tkens. They als gemapped data t highlight areas experiencing the highest transprtatin need, and plan t use this t advcate fr new bus rutes. A team in Hawaii discvered that many diabetic patients felt scially islated. They partnered with lcal churches and the American Diabetes Assciatin t ffer peer supprt grups fr diabetes management in the churches. SASH crdinatrs and wellness nurses are trusted guides fr the participants and their families and help cnnect them t cmmunity partners wh can prvide a cntinuum f supprts and services that meet participants needs. 4. Data sharing capabilities amng prviders are variable, and challenges exist fr integrating healthcare data and ther types f data (e.g., scial determinants). The Geneva Twer Health Cllabrative recgnizes the limitatins f self-administered surveys (e.g., challenge f cllecting data, inherent biases). They als acknwledge difficulty with access t EHRs since residents are cared fr in a variety f places. The Alliance uses standardized dcumentatin practices in their data analytics platfrm, but recgnizes that EHRs were nt designed fr ppulatin-level data analysis r reprting, and therefre internal tls are limited. They als nte that effective data capture als ften requires mdificatin f wrkflws. PRAPARE cllects data n scial determinants f health (e.g., race and ethnicity, husing status, scial integratin) and has been incrprated int fur EHRs which are used by nearly 60 percent f all health centers. SASH uses DcSite, Vermnt s statewide clinical registry, which cllects data n cmprehensive well-being (e.g., basic health infrmatin, use f and need fr scial services), and is used by cmmunity health teams, physicians, and hspitals. 6

7 Next Steps NQF, alng with plicymakers and stakehlders acrss the health and scial services sectrs, plays an imprtant rle in future effrts t ensure high-quality care fr adults with cmplex care needs. Supprt fr cmmunities aspiring t achieve the Essential Attributes is incumbent upn all stakehlders. At the federal level, effrts t imprve interperability and sharing f data need t have heightened fcus n scial services infrmatin in additin t data frm the healthcare delivery system. Natinal philanthrpic initiatives, such as thse by Rbert Wd Jhnsn Fundatin (e.g., Data Acrss Sectrs fr Health, r DASH) and the recently annunced five fundatin cllabratin arund high-need, highcst individuals, can prvide cmbined supprt fr innvative cmmunities t determine hw t cllect, integrate, and use medical and scial service infrmatin effectively t imprve quality f life, and t publicize these effrts t serve as examples t thers. NQF, thrugh its Measure Incubatr, ffers a unique pprtunity t engage and facilitate the wrk f thse fcused n delivering high-quality care fr adults with cmplex care needs. Leveraging the Measure Incubatr prcess, NQF wuld cnvene these experts t facilitate the develpment f measures that align with the Essential Attributes. 7

8 Appendix A: Case Studies Findings frm Current and Prir NQF Wrk NQF reviewed several current and prir prjects related t the care f adults with cmplex care needs. These prjects highlight the need fr the develpment f measures that capture individuals gals, preferences, and desired utcmes. The Measuring HCBS Quality prject invlves the creatin f a cnceptual framewrk fr measurement f Hme and Cmmunity-Based Services (HCBS), an envirnmental scan fr measures and measure cncepts, the identificatin f gaps in quality measurement, and recmmendatins fr priritizatin in measurement. As a part f the cnceptual framewrk, the HCBS Cmmittee develped high-level dmains f measurement fr HCBS: Service delivery and effectiveness; Persn-centered planning and crdinatin; Chice and cntrl; Cmmunity inclusin; and Caregiver supprt. Each f the dmains als had priritized subdmains. Next, using the cnceptual framewrk, NQF staff cmpleted a synthesis f evidence and an envirnmental scan t assess the current state f the HCBS quality measurement landscape. In the Cmmittee s third interim reprt, they presented 261 measures, 394 measure cncepts, and 75 instruments relevant t these dmains. Hwever, verall, the Cmmittee fund a lack f standardized measures fr HCBS and a lack f r limited access t timely data. Ntably, they fund n measures, measure cncepts, r instruments under the initial dmain f cnsumer vice. The Cmmittee determined that high-quality HCBS shuld be delivered in a manner that prvides fr a persn-driven system that ptimizes individual chice and cntrl in the pursuit f self-identified gals and life preferences. Further, sme f the subdmains given pririty are: the level t which the HCBS system incrprates the HCBS cnsumer s gals int services and supprts; the level t which the HCBS system and prviders ascertain the HCBS cnsumer s needs and gals; the level t which the planning prcess is directed by the persn, with supprt as needed, and results in an executable plan fr achieving gals the persn deems imprtant; and the level t which services and plans describe, develp, and supprt individual chices and life gals. These priritized areas fr measure develpment align with the attributes identified by the Natinal Quality Framewrk fr Cmplex Needs Ppulatins prject, and shuld serve as a starting pint fr future wrk in measure develpment. 8

9 In the Ppulatin Health Framewrk prject, NQF is develping a cmmn framewrk fr cmmunities t help them wrk cllabratively with public health and clinical care systems t imprve ppulatin health. T date, the Cmmittee fr that prject has develped an actin guide fr individuals and grups at the lcal, reginal, and natinal levels. The third versin f the actin guide includes prfiles f grups that wrked cllabratively with NQF t field test the actin guide. Many f these field testing grups may serve as case studies fr addressing adults with cmplex healthcare cnditins. Fr example, a shrtened versin f the Geneva Twer Health Cllabrative case study as develped by the Ppulatin Health Framewrk prject is presented belw. Geneva Twer Health Cllabrative (Cllabrative) Overview Geneva Twer is an apartment cmplex in Cedar Rapids, Iwa, which huses lw-incme lder adults and disabled adults. Mercy Medical Center and Abbe Center fr Cmmunity Mental Health, bth f which prvide prgrams and services t many f the individuals living at the residence, cllabrated with the Affrdable Husing Netwrk, Aging Services, Area Substance Abuse Cuncil, and Linn Cunty Public Health t prvide additinal supprt fr the cmmunity and imprve health and well-being. By prviding services and supprt n site, the Cllabrative reduces barriers t care, including a lack f transprtatin and financial resurces. Gals and Apprach Thrugh analysis f ppulatin health data, the Cllabrative identified Geneva Twer s ZIP cde as shwing disparities in access t care and abve average use f emergency department services. In additin, calls t the plice department frm Geneva Twer residents included a high prprtin f medically related issues. Health imprvement activities have included events t help residents understand their Medicaid benefits, an unused prescriptin drp-ff prgram in partnership with lcal plice, and prviding a sixweek chrnic disease self-management prgram n site. Fllwing the assessment f initial healthrelated utreach effrts, the Cllabrative discvered that residents had several cmpeting pririties that impede the residents interest in participating in health imprvement activities and health care. Fr example, sme struggled t meet basic needs like cnsistent access t fd and sufficient clthing. Engaging residents has cntinued t be a challenge, but the Cllabrative is explring different appraches t address this issue, including fstering trust with residents by appinting a resident representative t its bard and launching a health and wellness resident cmmittee. This cmmittee is helping t prepare certain individuals t becme champins within their wn resident cmmunity and garner supprt amng their peers and neighbrs fr health-related initiatives. The Cllabrative is cllecting baseline data thrugh resident surveys. Hwever, there are challenges with this methd; the surveys are self-administered, which makes infrmatin difficult t btain due t issues recruiting participants, and data may carry inherent biases where residents are reluctant t reprt accurate infrmatin n certain tpics. 9

10 Measures Used PATIENT SURVEY Percentage f members wh had a preventive care visit in last 12 mnths Percentage f residents wh can identify their primary care physician Percentage f residents with current tbacc use Percentage f residents wh eat three r mre servings f fruits r vegetables in a day Percentage f residents wh exercise fr at least 20 minutes a day Percentage f residents interested in participating in health activities Percentage f residents wh are satisfied with their health status Percentage f residents with diagnses f diabetes Percentage f residents wh have felt tense, anxius, r depressed in last 30 days Percentage f residents engaging in binge drinking during past seven days Self-assessed availability f scial supprts CLINICAL AND OTHER DATA Number f medically related plice calls t Geneva Twer Number f nn-admissin emergency department visits fr individuals wh are Mercy patients Percentage f residents with hypertensin Percentage residents wh are verweight r bese Lessns Learned and Next Steps Because the Cllabrative is fcusing n a subppulatin defined by a cmmn residence, the value f gegraphically defined data surces is limited. The resident turnver rate at Geneva Twer als makes it difficult t cmpare rates ver time t the baseline data, because the individuals invlved fluctuate frm ne perid t the next. While Geneva Twer has partnered with Medicaid managed care plans t analyze integrated health hme data, this nly captures infrmatin fr abut half f the resident ppulatin. The clinical data prvided by Mercy Medical Center als has limited relevance, since nt all Geneva Twer residents are patients f that particular hspital system. Attempts t aggregate data acrss prviders have nt been successful due t issues with access t electrnic health recrds (EHRs). The Calitin is hpeful, hwever, that reginal data access and measure alignment will imprve. Linn Cunty s recent Cmmunity Health Assessment and Cmmunity Health Imprvement Plan has priritized data sharing and effective use f technlgy within the lcal public health system in rder t identify and address emerging health trends. New Exemplar Case Studies In additin t a review f relevant NQF prjects and cnsideratin f the previusly develped Geneva Twer case study, NQF staff als reached ut t stakehlders fr advice n ptential new case studies. 10

11 These key infrmants referred staff t a variety f peple and prjects, cnfirmed that the cncept f integrating and using multiple data surces acrss bth medical and scial dmains was abslutely needed, and cited many examples f prgrams and cmmunities that have begun this type f wrk. Hwever, virtually all agreed that nt many peple r prgrams are very far alng in the use f data t measure the persn-centeredness f such care. The fllwing exemplars prvide sme insight int tls being used t identify adults with cmplex needs, appraches fr prviding mre persn-centered care that address bth health care and scial service needs, challenges t cllecting and integrating data, and challenges in measuring success. The Prtcl fr Respnding t and Assessing Patients Assets, Risks, and Experiences (PRAPARE) The PRAPARE mdel is a prime example f a tl that dcuments a patient s assets, risks, and experiences t empwer patients, imprve pint-f-service care management, imprve the health f the patient ppulatin, infrm cmmunity plicies, encurage and strengthen partnerships, and infrm state and natinal plicies. Centers using this mdel are prmting cmmunity integratin, scial supprts, and care crdinatin while taking int accunt an individual s entire histry and impacts n their verall health. Overview In September 2013, the Natinal Assciatin f Cmmunity Health Centers (NACHC), the Assciatin f Asian Pacific Cmmunity Health Organizatins (AAPCHO), the Oregn Primary Care Assciatin (OPCA), and the Institute fr Alternative Futures (IAF) launched a prject funded by the Kresge Fundatin, Kaiser Cmmunity Benefit, and Blue Shield f Califrnia Fundatin t create, implement, and prmte a standardized patient risk assessment prtcl that ges beynd medical acuity t identify risks related t scial determinants f health. The gal f this prject is t develp, pilt, and disseminate a cnsensus-driven standardized patient risk assessment prtcl. PRAPARE was develped in partnership with health centers and Health Center Cntrlled Netwrks t imprve bth patient and ppulatin health. The natinal netwrk f Cmmunity, Migrant, Hmeless, and Public Husing Health Centers (ften knwn as Federally Qualified Health Centers) serve ver 25 millin patients acrss the United States. Mre than 70 percent have incmes belw pverty, and nearly all have incmes belw 200 percent f the federal pverty level. Apprximately tw-thirds are members f racial and ethnic minrity grups, and mre than 1 in 5 prefer t be served in languages ther than English. The vast majrity is uninsured r has Medicaid. 1 Mst patients experience multiple and cmpunding scial determinants that impact their health and well-being in adverse and cstly ways. Since their start mre than 50 years ag, health centers have incrprated scial needs int their ppulatin-fcused mdel f care. But until recently, there had been n cncerted effrt t standardize data arund their patients scial determinants f health. What Is It? PRAPARE is a natinal effrt t help health centers and ther prviders cllect the data needed t better understand, manage, and act n their patients scial determinants f health thrugh a 22-questin 11

12 assessment. As prviders are increasingly held accuntable fr reaching ppulatin health gals while reducing csts, it is imprtant that they have tls and strategies t identify the upstream sciecnmic drivers f pr utcmes and higher csts. With data n the scial determinants f health, health centers can define and dcument the increased cmplexity f their patients, transfrm care with integrated services and cmmunity partnerships t meet the needs f their patients, advcate fr change in their cmmunities, and demnstrate the value they bring t patients, cmmunities, and payers. What Des PRAPARE Measure? 2 Race and ethnicity Farmwrker status Veteran status Husing status Insurance status Language preference Educatin Emplyment Transprtatin Neighbrhd Safety Dmestic vilence Material security (e.g., fd, utilities, clthing) Scial integratin and supprt Stress Incarceratin histry Refugee status Cuntry f rigin Hw Des PRAPARE Help? PRAPARE prpels prviders wh serve underserved ppulatins tward transfrmed, integrated care while assisting rganizatins t develp interventins and partnerships t streamline care management prgrams. The data being captured allw health centers t dcument the extent t which each patient and their ttal patient ppulatins are cmplex which in turn can be used t imprve patient health, effect change at the cmmunity r ppulatin level, and sustain resurces and create cmmunity partnerships necessary t imprve health. Hw Are Data Being Cllected? The teams that pilted PRAPARE develped wrkflws based n their lcal care team and staffing mdels. 3 Currently, mst patient data are gathered in the waiting rm r during the exam. Varius staff members engaged patients in administering PRAPARE (e.g., medical assistants, care crdinatrs, 12

13 patient navigatrs). A cncept f n wrng dr was adpted by ne pilt team suggesting any staff member culd cntribute t administratin f the tl based n the wrkflw f the center by asking questins at varius stages f the clinic visit. While the tl was designed t assess scial risk acrss all patients, ne pilt team chse t fcus n medically high-risk patients during the pilt perid. PRAPARE has been incrprated int fur EHRs (NextGen, eclinical Wrks, GW Centricity, and Epic), which are used by nearly 60 percent f all health centers. PRAPARE templates will be made freely available t anyne using these EHRs. Wh Is Invlved? Fur implementatin teams cnsisting f at least ne health center and ne health center netwrk have been invlved t pilt test PRAPARE. 4 These teams include: One primary care assciatin Seven Federally Qualified Health Centers One health plan Three Health Center Cntrlled Netwrks 40 care delivery sites One technical slutins cmpany At the start f the pilt perid (January 2015), all health center rganizatins had been certified r were pending certificatin as patient-centered medical hmes. Teams have prir experience cllecting and recrding data n patient scial histry and use f enabling services which help patients vercme nnclinical barriers t accessing care (e.g., financial cunseling, interpretatin, case management, transprtatin). The data being cllected thrugh these surveys are being used t identify and supprt the develpment f needed prgrams, cnnect patients with cmmunity resurces and patient navigatrs, target patients fr specific screenings, and identify the necessary level f care management fr each patient. What Are the Psitive Impacts Already Being Seen? One team in Iwa started ging t the lcal transprtatin authrity s meetings and develped a relatinship with them. The health center invited the transprtatin authrity staff t visit their health center. As a result, they have been able t negtiate bulk discunts fr taxi vuchers and bus tkens. The team als ge-mapped their data t highlight areas experiencing the highest transprtatin need, and plan t shw this data t the reginal transprtatin authrity t advcate fr new bus rutes t thse areas. One team in Hawaii discvered that many f their diabetic patients felt scially islated. Subsequently, they teamed up with lcal churches and the American Diabetes Assciatin t ffer peer supprt grups fr diabetes management in the lcal churches t prvide health care and health educatin in a supprtive envirnment. 13

14 What Are the Lng-term Gals? 5 1. Imprve health, reduce disparities, and prevent avidable use f cstly health care services. 2. Better identify, manage, and address patients full range f needs. 3. Better understand and manage the patient ppulatin. 4. Prvide data t the cmmunity t supprt plicy change in areas strngly related t health in rder t reduce scial determinants f health-related risks fr individuals and the cmmunity. 5. Prvide data t ther lcal health care prviders t target scial determinants f health-related actins, including transfrming care delivery mdels t create integrated cmmunity partnerships and sustainable interventins. 6. Imprve health center capacity fr serving cmplex patients, including ensuring that that payment fr health care adequately incentivizes addressing thse scial determinants which adversely affect health, and supprts ppulatin-based interventins and partnerships invlved in managing r addressing scial determinants f health. Lessns Learned Next Steps Staff are able t implement PRAPARE under varius wrkflws. Staff reprt that PRAPARE helps build relatinships with patients, aligns with transfrmatin effrts, identifies new needs frm patients, and leads t new cmmunity partnerships. Staff reprt minimum burden. Generally, PRAPARE takes less than nine minutes t administer, althugh sme health centers reprt that the time respnding t a patient s scial circumstances can be lengthy. Patients reprted psitive reactins t the questins, saying that the health centers cared abut them beynd their clinical needs r cmplaints. Health centers frm acrss the natin, ther prviders, natinal partners, researchers, and thers have expressed interest in r eagerness t adpt PRAPARE, and there is a grwing number f health centers that are already using PRAPARE. T help bring PRAPARE t scale, NACHC, AAPCHO, OPCA, and IAF will sn release a PRAPARE Implementatin and Actin Tlkit that will cntain resurces any ptential user wuld need t implement PRAPARE, ranging frm change management materials, technical implementatin resurces like the fur EHR templates, wrkflw diagrams t cllect the data, and examples t use the data t address scial determinants f health. In additin, NACHC, AAPCHO, and OPCA are wrking t launch a Natinal PRAPARE Learning Netwrk that will facilitate spread and augment effrts t use standardized data n patient scial risk t drive transfrmatin at the patient and ppulatin levels. At the same time, the netwrk will lay the grundwrk fr aggregating data acrss prviders and mre effectively putting the data t use. The PRAPARE Learning Netwrk wuld build ff the successes f Phase 1, and serve as an umbrella fr multiple cmplementary effrts, including: 14

15 1. A Live University t prmte the use f PRAPARE and serve as a frum fr all implementatin resurces, shared learning, and tracking innvatins; 2. Data validatin and aggregatin t dcument scial risks and evaluate the impact scial determinants f health have n health, utilizatin, and/r cst; 3. Braden the cllectin f standardized data n nnclinical health risks and interventins prvided; and 4. Leverage existing and create new partnerships that can directly cntribute t building health center capacity t implement and effectively use PRAPARE fr ppulatin health and systemic change. Alliance f Chicag Cmmunity Health Services Alliance f Chicag Cmmunity Health Services (Alliance) is ne f the sites using the PRAPARE mdel. The EHR implementatin mdel develped by the Alliance encurages standardized data entry such that data can be used fr individual patient care, r aggregated fr ppulatin-level analyses. Tw f the critical uses f data by the Alliance are fr research and tracking perfrmance n quality measures (perfrmance imprvement). The Alliance prvides its member health centers detailed dashbard reprts f perfrmance n natinal quality measures n a mnthly basis. These reprts can be drilled dwn t individual prvider-level r patient-level detail by each health center, and can als be stratified by race, ethnicity, and primary language t identify disparities in care. In using this mdel, Alliance is prviding users with the ability t share infrmatin abut the individuals they serve and their gals, preferences, strengths, and values. Overview Alliance ( has ver 15 years f experience in wrking with cmmunity health centers (CHCs) t develp infrastructure t supprt clinical quality imprvement. As a key element f this infrastructure, Alliance hsts an EHR system and has maintained a custmized data warehuse since Alliance nw supprts the fur funding Alliance partner CHCs, as well as an additinal 29 CHCs natinally. These CHCs perate ut fr mre than 250 urban and rural sites in 18 states. The centers serve a diverse, underserved, high-risk set f ppulatins including the uninsured, pr, minrity, nn- English speaking, lder adult, and hmeless. All Alliance CHCs utilize the cmmn EHR system with unifrm data definitins and capture methds. What Data Surces r Tls Are They Using? One f the mst valuable Alliance assets is its data analytics platfrm. Alliance perates a multilayered analytics platfrm designed t integrate data frm different surces and by users f varying degrees f sphisticatin. The flexible platfrm can be accessed by a variety f analytic and reprting tls, and allws reprting at bth the patient and ppulatin level. This flexibility prvides the CHCs with greater insights int the ppulatins they serve, and allws them t crdinate care amng varius settings and disciplines, wrking tward high-quality equitable care. Hw Are the Data Being Captured? Alliance data are stred in a centralized EHR data warehuse and ffers clinical applicatin abilities including a dashbard fr users, a cmmn envirnment fr netwrk-level reprting, ease f merging 15

16 data frm ther systems, clinical decisin supprt, and advanced analytics. CHC staff requires nging training t understand these prcesses and access t resurces and leadership mentrship as needed. What Are the Impacts? Using the data analytics platfrm, Alliance has built and is disseminating a highly dynamic quality reprting tl fr use in Unifrm Data System quality measures. This tl allws CHC staff t stratify reprts t identify and drill dwn t areas f cncern, track imprvements ver time, and benchmark against the larger Alliance cmmunity. It is dynamic and allws fr the selectin f multiple levels f granularity and analysis at real time. Analysis is user friendly s even inexperienced users can carry ut these analyses instantaneusly using familiar terms. What Are the Lng-term Gals? Alliance will extend the data analytics platfrm t all CHCs, train them n its use, and supprt quality imprvement activities. Practice caches will assure that reprts are run mnthly t facilitate imprvement n the measures. Imprvement is further facilitated by the ability t generate views f specific patients and prviders tied t failed measures, ffering an pprtunity fr patient-level utreach and prvider training. What Lessns Have they Learned? T prmte the cllectin f cmplete and reliable data t supprt data integratin, clinical decisin supprt, and analytics, it is essential that users appreciate the imprtance f adhering t standardized dcumentatin practices and the recrding f relevant infrmatin as discrete usable elements. Data capture design must be well-integrated int clinical wrkflws t supprt this adherence and cmpleteness and timeliness f infrmatin. EHRs were nt designed fr ppulatin-level data analysis r reprting, and therefre internal tls are limited. Reprting functinality needs t supprt patients, staff, and quality f care, and address the emerging imprtance f incrprating infrmatin frm utside the CHCs walls. Therefre, CHCs require a data repsitry t aggregate infrmatin, and apprpriate functinality t carry ut advanced analytics and reprting. Quality measures are expected t evlve ver the cming years and will need t be tested t meet measure specificatins, capture and display data effectively, and prmte imprvement initiatives, as well as meet reprting requirements. Effective data capture als ften requires mdificatin f wrkflws. Successfully meeting these needs requires clse cllabratin between CHC staff and data/infrmatics experts. Supprt and Services at Hme (SASH) The SASH prgram is a Vermnt-wide initiative t create a netwrk f persn-centered, crdinated health care and supprt services that engage participants, family, and friends in rder t prvide the right services and supprts at the right time, tailred t lcal cnditins and participant needs. An annual assessment prvides a baseline well-being status and identifies the needs and supprt gaps f each SASH participant, which builds the fundatin f the participant s Healthy Living Plan. Overview In 2008, the nnprfit Cathedral Square Crpratin (CSC) in Suth Burlingtn, Vt., began develping the SASH prgram ut f cncern that frail residents in its prperties were nt able t access r receive adequate supprts t remain safely in their hmes. The SASH mdel is part f the Blueprint fr Health, 16

17 Vermnt s statewide health care refrm initiative and helps lder adults and individuals with special needs access the care and supprt they need t stay healthy while living cmfrtably and safely at hme. SASH is available thrughut Vermnt, serves primarily persns 65 and lder r with disabilities, and uses data and tls t imprve care. This prgram is wrking t imprve/maintain the health, functin, quality f life, and independence f Vermnters; creating a netwrk f persn-centered, crdinated health care and supprt services; engaging participants in the design f their prgram and their individual healthy aging plans; engaging family and friends; and prviding the right services and supprts at the right time, tailred t lcal cnditins and participant needs. Thus, SASH exemplifies a number f sub-attributes including the identificatin f adults with cmplex care needs and the prmtin f cmmunity integratin, scial supprts, and care crdinatin. What Is It? The SASH prgram is a Vermnt-wide initiative crdinated at the state, reginal, and lcal level. CSC versees the prgram at the state level and is respnsible fr defining and implementing the prgrammatic elements alng with crdinating prgram expansin and training. At the reginal level, six Designated Reginal Husing Organizatins are respnsible fr planning the rll-ut f the SASH prgram acrss their gegraphic regins. The prgram is delivered at the cmmunity level thrugh SASH panels, which are perated by the husing hst rganizatins. 6 When individuals chse t participate in the SASH prgram, they cnsent t allwing the SASH staff and cmmunity partners t share infrmatin abut them with each ther and their health care prviders. With this cnsent, SASH staff wrk with the participants healthcare prviders when necessary t ensure prper medicatin usage, successful hspital discharges, and verall crdinatin and cntinuity f care. Imprtantly, the SASH prgram des nt discharge participants. Rather, the SASH prgram prvides a cntinuum f supprt and services that meet participants needs whether they are extremely healthy and lking fr minimal supprts r very frail participants in need f mre rbust supprt frm the full SASH team. Hw Des SASH Help? The SASH prgram strives fr an rganized, persn-centered apprach t wellness in the husing cmmunity. SASH staff wrk t develp persnal relatinships and build trust with participants and the peple wh supprt them. Specific staff members (e.g., SASH crdinatr embedded at the facility, a wellness nurse) are trusted guides and integral t the success f the mdel. They fcus their effrts arund three types f interventins: transitins supprt, self-management educatin, and care crdinatin. These staff members are a resurce nt just fr residents, but als fr family members and cmmunity service prviders. SASH staff has significantly increased participants ability t access their primary care prviders What Data Are Being Cllected? The SASH Assessment gathers cmprehensive well-being infrmatin abut each SASH participant n an annual basis. The assessment is a cmbinatin f self-reprt (by persn, family, r caregiver) with fllw-up questins and bservatin by the assessr. Staff inputs the assessment infrmatin directly 17

18 int the DcSite clinical registry during the assessment interview. DcSite is Vermnt s statewide clinical registry used by Blueprint fr Health cmmunity health teams, physicians, and hspitals. The assessment prvides a baseline well-being status and identifies the needs and supprt gaps f each SASH participant, which builds the fundatin f the participant s Healthy Living Plan. It assists the SASH team in determining what services, if any, the participant may need and in facilitating the crdinatin f care amng health care and scial service prviders. Lastly, the infrmatin guides the SASH team in creating a structure t implement evidence-based and prmising preventin prgrams. The assessment cllects: Basic health infrmatin including diagnsed health cnditins, medicatins, treatments received, and prviders f care; Infrmatin regarding a participant s past health histry including histry f recent falls, nursing hme admissins, emergency department visits, and hspitalizatins; A falls risk assessment; An assessment f a participant s ability t perfrm activities f daily living and instrumental activities f daily living; Supprt services currently being used by the participant, and services r supprts needed; and Infrmatin n mental health, nutritin, and cgnitin status using validated screening tls. Hw Are Data Being Cllected? SASH crdinatrs and wellness nurses are the state s largest users f DcSite fr primary entry. SASH staff created a large dataset within DcSite that is being used by the health department, cmmunity health teams, and prviders fr data analytics n a ppulatin level. As DcSite cntinues t add mre clinical data t its system, SASH staff are sme f the first and mst rbust users f SASH s integrated health recrds functinality. This will enable SASH t better link with cmmunity health teams and mre efficiently utilize available resurces and crdinate care fr participants. 7 What are the benefits t SASH participants? Imprved quality f life Cmprehensive health and wellness assessments Individualized Healthy Living Plan develped by the patient and SASH crdinatr t highlight their health and wellness gals and identify areas where assistance is needed Mney savings thrugh preventive health care Check-ins and health caching Cnvenient access t a wellness cach Planning fr successful transitins A trusted guide t help navigate lng-term care An infrmed team t help in a crisis 18

19 Next Steps Access t preventin and wellness prgrams Medicatin management assistance SASH has prven t be extremely beneficial in reducing Medicare expenditures, reducing the number f falls, cntrlling hypertensin, and increasing immunizatins. While almst all f the benefits are medically fcused, SASH is lking t imprve utcme measures that fcus n mre nnmedical results such as scial islatin. References 1 Health Resurces and Services Administratin Health Center Data; Available at Last accessed August Healthcare Cmmunities. PRAPARE Overview and Tl; Available at Last accessed August Natinal Assciatin f Cmmunity Health Centers. PRAPARE Frequently Asked Questins (FAQ); Available at Last accessed August Healthcare Cmmunities. PRAPARE Abstract and LC Overview; Available at Last accessed August Healthcare Cmmunities. PRAPARE Prject Ratinale and Lng Term Gals; Available at Last accessed August Office f the Assistant Secretary fr Planning and Evaluatin. Supprt and Services at Hme (SASH) Evaluatin: Secnd Annual Reprt; Available at Last accessed August ASTHO. Issue brief: Supprt and Services at Hme: A Care Management Mdel Utilizing Cmmunity Health Wrkers; Available at Last accessed August

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