Patient Experience of Care

Minnesota Department of Health: Protecting, maintaining and improving the health of all Minnesotans Minnesota Statewide Quality Reporting and Measurement System (SQRMS): Patient Experience of Care March 26, 2014 Vidya Venkataraman Monica S. Hemming

State health reform Objectives and goals Annual measures update Overview Patient Experience of Care Survey Adult, 2014 PCMH supplement for Health Care Homes Adult and Pediatric, 2014 Patient Experience of Care, 2012 Results Resources 2

Context for state health reform High quality in Minnesota relative to other states Wide variation in costs and quality across different health care providers, with no evidence that higher cost or higher use of services is associated with better quality or better health outcomes for patients Health care costs are rising, placing greater share of health care costs on consumers What tools do consumers have to choose how to spend their health care dollars? 3

Health care growth exceeds growth in income and wages 120% Cumulative Percent Change in Key Minnesota Health Care Costs and Economic Indicators 100% 80% 60% 40% 20% 0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Health Care Cost MN Economy Per Capita Income Consumer Price Index Avg. Weekly Wage Note: Health care costs is MN privately insured spending on health care services per person, and does not include enrollee out of pocket spending for deductibles, copayments/coinsurance, and services not covered by insurance Sources: MDH/Health Economics Program; U.S. Department of Commerce, Bureau of Economic Analysis; U.S. Bureau of Labor Statistics; MN Department of Employment and Economic Development. 4

Statutory requirements: Minnesota s 2008 Health Reform Law Minnesota Statutes, 62U.02, Subd. 1 and 3 Establish standards for measuring quality of health care services offered by health care providers Establish a system for risk adjusting quality measures Physician clinics and hospitals are required to report Issue annual public reports on provider quality 5

Objectives and goals Enhance market transparency by creating a uniform approach to quality measurement Improve health / reduce acute care spending Quality measures must be based on medical evidence and be developed through a participatory process Public reporting quality goals: Make more quality information broadly available Use measures related to either high volume or high impact procedures and health issues Report outcome measures or process measures that are linked to improved health outcomes Not increase administrative burden on health care providers where possible 6

Partnership among MDH and community organizations MDH conducted a competitive procurement process in the fall of 2008 and subsequently entered into a contract with MN Community Measurement (MNCM) to carry out key activities: Develop recommendations for quality measures and the quality incentive payment system; Conduct outreach to providers; and Manage data collection activities 7

MDH & MN Community Measurement roles and responsibilities MDH Selects areas and for measure development Obtains input from the public at multiple steps of rulemaking Annually promulgates rules that define the uniform set of measures Publicly reports measures Develops vision for further evolution of SQRMS MNCM Researches new areas of measurement Works with groups of stakeholders to review existing measures and develop new ones and their specifications Develops recommendations of the uniform set of quality measures for the State s consideration Facilitates data collection from physician clinics and hospitals, and data management Submits data collected to MDH 8

Historical Timeline December 2009 First set of administrative rules established SQRMS January 2010 Data collection for publicly reported quality measures began Health plans no longer permitted to require data submission on measures outside the standardized set November 2010 MDH issued its first public report with data on the standardized measures to be publicly reported First update to administrative rules November 2011, 2012, 2013 Annual updates to administrative rules 9

Rulemaking and opportunities for stakeholder input Jan Feb Mar Apr ❶ ❷ May Jun ❸ ❹ 1. MDH invites interested stakeholders to submit recommendations for the addition, removal, or modification of measures to MDH by June 1 2. MNCM submits preliminary measure recommendations to MDH mid-april; MDH opens public comment period 3. MNCM submits final measure recommendations to MDH by June 1; MDH opens public comment period 4. MNCM measure recommendations are presented at a public forum toward the end of June 5. MDH publishes a new proposed rule by mid-august with a 30-day public comment period 6. Final rule adopted by the end of the year Jul Aug ❺ Sep Oct Nov Dec ❻ 10

Requirements 11

Patient Experience of Care What is it? Why are we doing it? What data do we collect? What are the results? 12

What? CAHPS The CAHPS program is a multi-year Agency for Healthcare Research and Quality (AHRQ) initiative which was launched in October 1995. Its goals are to: Develop standardized patient surveys that can be used to compare results across sponsors and over time Generate tools and resources that sponsors can use to produce understandable and usable comparative information for both consumers and health care providers 13

Why? System transformation The use of patient experience information can be an important strategy for transforming practices as well as to drive overall system transformation Transformation emanates from: (1) consumers use of the information to choose their providers; (2) employers and purchasers use of it for payment and benefit design; and (3) physicians and practice administrators use of the data to improve office systems and care Source: Katherine Browne, Deborah Roseman, Dale Shaller and Susan Edgman-Levitan. Analysis and Commentary: Measuring Patient Experience as a Strategy for Improving Primary Care. Health Affairs, 29 no. 5 (2010): 921:925. 14

Why? Improvements in care delivery and health outcomes Research shows that good patient experience has a positive relationship to other aspects of health care quality, including patients engagement with and adherence to providers instructions, clinical processes of care for prevention and disease management, and outcomes Patient experience is also positively correlated with key financial indicators, including patient loyalty and retention, reduced medical malpractice risk, and increased employee satisfaction 15

Triple Aim Why? National activities First aim: Improving the patient experience of care (including quality and satisfaction); Institute of Medicine (IOM) Patient centeredness is one of IOM s six health care quality aims Patient Centered Medical Homes (PCMH) and Multi-Payer Advanced Primary Care Practice (MAPCP) Care coordination and consumer experience are two crucial elements of the medical home; Use of the PCMH-CAHPS survey is recommended Consumer Reports, July 2012 Five health plans participated in a Massachusetts statewide survey of adult, family, and pediatric physician groups using an Ambulatory Care Experiences Survey and CG-CAHPS survey 16

Why? Statutory requirements, Minnesota s 2008 Health Reform Law SQRMS Establish standards for measuring quality of health care services offered by health care providers In addition to measures of care processes and outcomes, the report may include other measures designated by the commissioner, including, but not limited to, care infrastructure and patient satisfaction Health Care Homes Incorporate measures of quality, resource use, cost of care, and patient experience 17

How? Survey versions CG-CAHPS Surveys (State requirements) Description Number of questions in adult survey Domains Additional domains Visit (SQRMS 2012) Some items ask about experiences in the last 12 months; others ask about the most recent visit 12-month core (SQRMS 2014) Asks about experiences with ambulatory care in the last 12 months 37 items 34 items 52 items Access, provider communication, office staff, provider rating Access, provider communication, office staff, provider rating 12-month core + PCMH supplemental questions (HCH 2014) Same as the 12-month version, plus additional items to measure medical home concepts not covered by the core items Access, provider communication, office staff, provider rating Recommend provider Included Can be added Included Attention to mental health Can be added Can be added Included Self-management support Can be added Can be added Included Shared decision-making Can be added Can be added Included 18

What? Domains Patient Experience of Care 12 Month Survey Domain Access to care Provider communication Office staff Provider rating Description The survey asked patients how often they got appointments for care as soon as needed and timely answers to questions when they called the office. The survey asked patients if their doctors explained things clearly, listened carefully, showed respect, provided easy to understand instructions, knew their medical history, and spent enough time with the patient. The survey asked patients if office staff were helpful and treated them with courtesy and respect. The survey asked patients to rate their doctors on a scale of 0 to 10, with 0 being the worst and 10 being the best. 19

Health Care Homes PCMH Supplement Survey Adult and pediatric population 20

HCH Patient Experience Recertification Requirements Health Care Home Rule 4764.0040, subpart 11, is met, when the applicant's outcomes in its primary care services patient population achieve the benchmarks for: patient health patient experience cost-effectiveness Established by the Commissioner of Health. 21

HCH Patient Experience Survey Recommendations Process Workgroup coordinated with HCH clinic participation by MNCM to recommend guidelines. Guidelines endorsed by HCH Performance Measurement Workgroup. Public Comment Period by HCHs Final Recommendations, www.health.state.mn.us/healthreform/homes/outco mes/patient_experience.html 22

HCH PCMH Patient Experience Recommendations Implement the PCMH supplemental questions for adults and children at recertification using the same data collection cycle as SQRMS. Children: Age 0 12 years old Adults: The same processes will be used to assess eligibility as under SQRMS 23

CG-CAHPS PCMH Survey CAHPS Clinician & Group Core Questionnaire* CAHPS PCMH Item Set CAHPS C&G PCMH Survey * NQF endorsed 24 24

PCMH Survey Domains Adult Survey Core Composites PCMH Composites Access Communication Office Staff Provider Rating Comprehensiveness Self-Management Shared Decision Making Child Survey Core Composites PCMH Composites Access Communication Office Staff Provider Rating Child Development Prevention Advice Health Goals 25

Adult PCMH Additional Composites Comprehensiveness: Providers Pay Attention to Your Mental or Emotional Health Talked about personal or family problem/alcohol or drug use Talked about worry or stress in your life Talked about feeling sad or depressed Self-Management Support: Providers support you in taking care of your own health Provider worked with you to set specific goals for your health Provider asked you if there were things that make it hard for you to take care of your health Shared Decision Making: Providers Discuss Medication Decisions Provider talked about reasons to take a medicine Provider talked about reasons not to take a medicine Provider asked what you though was best for you regarding medicine 26 26

Adult PCMH Additional Topic Items Access to Care - Got needed care on evenings, weekends, or holidays - Days you had to wait for an appointment for urgent care Information about Care and Appointments - Got information about what to do if you needed care on evenings, weekends, or holidays - Received reminders between visits Coordination of Care: Attention to care from other providers - Provider s office followed up to give you results of blood test, x-ray, or other test - Provider seemed informed and up-todate about care you got from specialists - Talked with you about prescriptions 27 27

Response Rates Longer surveys do not depress response rates Medicaid respondents are as likely to complete a long survey (95 items) as a short survey (23 items)* Vendors report that adding CAHPS items to proprietary surveys (HCAHPS and CG-CAHPS) actually increases response rates Recent experience with PCMH survey shows response rates averaging between 40-44% *Gallagher P. and Fowler F. Size doesn t matter: response rates of Medicaid enrollees to questionnaires of varying lengths. Center for Survey Research, University of Massachusetts at Boston. 28

For Additional CG-CAHPS PCMH Information PCHM information was presented by Dale Shaller at the HCH Webinar held on July 30 th, 2013, MN Health Care Homes Patient Experience Survey: Implications of Moving from CG-CAHPS Visit to PCMH www.health.state.mn.us/healthreform/homes/outco mes/patient_experience.html 29

Results: Patient Experience of Care, 2012 Domain Top box average Minimum top box average Maximum top box average Clinics below average Clinics above average Access to care 60.2% 32.5% 94.1% 23.4% (165) Provider communication 89.8% 66.1% 99.3% 30.7% (216) Office staff 91.5% 67.0% 100.7% 22.9% (161) Provider rating 78.1% 46.6% 92.8% 26.1% (184) 18.3% (129) 17.0% (120) 14.2% (100) 14.8% (104) N=704 Source: MDH Health Economics Program analysis of SQRMS data. 30

Relationship between Patient Experience of Care and Clinical Care Patient experience domain Optimal Diabetes Care (ODC) Optimal Vascular Care (OVC) Optimal Asthma Care (OAC) Access to care.098*.054.0105* Provider communication.069.037.171** *Correlation is significant at the 0.05 level (2-tailed) **Correlation is significant at the 0.01 level (2-tailed) Optimal care quality measures steward: MNCM. Source: MDH Health Economics Program analysis of SQRMS data. 31

Relationship between Patient Experience of Care and Clinical Care Patient experience of care Appointment urgent Appointment routine Doctors appointment Within 15 minutes Phone during Phone after Provider explain Provide questions/ concerns Provider listen Provider respect Knows medical history Time spent ODC -.016.130**.125*.108*.086.108*.086.021.077.138**.030 OVC -.014.099*.112* -.004.014.050.016.043.054.057.070 OAC.045.160**.227**.060 -.050.182**.148**.113*.129**.162**.122* *Correlation is significant at the 0.05 level (2-tailed) **Correlation is significant at the 0.01 level (2-tailed) Optimal care quality measures steward: MNCM. Source: MDH Health Economics Program analysis of SQRMS data. 32

SQRMS Chartbook 33

SQRMS Website 34

Resources CAHPS website and Improvement Guide cahps.ahrq.gov www.facs.org/ahp/cahps/improvement-guide.pdf SQRMS website www.health.state.mn.us/healthreform/measurement/index.html Subscribe to MDH s Health Reform list-serv to receive weekly email updates www.health.state.mn.us/healthreform/govdelivery.html SQRMS chartbook (coming soon!) www.health.state.mn.us/divs/hpsc/hep/chartbook/index.html 35

Contact Information For questions about SQRMS, contact: Denise McCabe, Denise.McCabe@state.mn.us, 651.201.3569 Vidya Venkataraman, Vidya.Venkataraman@state.mn.us, 651. 201.5933 For questions about HCH, contact Marie Maes-Voreis, Marie.Maes-Voreis@state.mn.us, 651.201.3626 Monica Hemming, Monica.Hemming@state.mn.us, 651. 201.5189 36

Patient Experience of Care 2014 Statewide Patient Experience Survey Dina Wellbrock Project Manager

Agenda Review the survey tool for 2014 measure Review Patient Experience eligibility requirements Implementation Stages Timelines for Major Milestones Tie validation steps to MNCM s data portal Reporting MN Community Measurement 38

Background SQRMS required that Patient Experience of Care be a measure for MN clinics starting in 2012 (every other year). The only clinic specialty excluded is psychiatry clinics. Clinics that saw more than a threshold count of unique patients in the three-month eligibility period of September 1-November 30, 2013 are required to take part in the measure. Pediatric clinics will have to assess the count of unique adult patients towards the eligibility threshold. Health Care Home program incorporated the Patient Experience of Care requirement into their re-certification process in 2012.

Measure Specifications MN Community Measurement http://www.health.state.mn.us/healthreform/measurement/a doptedrule/msr13fnl08exp.pdf 40

Survey Tool The measure will be implemented using the CAHPS Clinician and Group 12-Month Survey. In 2012, the CG CAHPS Visit Survey was used. Why change the tool? Alignment of requirements locally & nationally (HCH, P4P, CMS, etc.) Core set of questions are the same Less ceiling affect using the 4-point scale = greater discrimination The HCH clinics are required to field the CG CAHPS 12- Month + PCMH Supplemental Items Adult PCMH version fulfills the SQRMS requirement CG CAHPS 12-Month Child Survey + PCMH Items (same core) Also incorporates the health status question MN Community Measurement 41

Survey Vendors Like 2012, must be a CMS-certified CAHPS vendor 9 survey vendors involved in the 2012 project Unlike 2012, there is no Central Survey Vendor role Most clinics now have a relationship with a vendor If a CAHPS survey vendor is needed: http://www.hcahpsonline.org/app_vendor.aspx http://www.ma-pdpcahps.org/content/approvedsurvey.aspx MN Community Measurement 42

Mode of Data Collection The survey may be distributed using any of the data collection modes currently approved by the CAHPS Consortium: Mail only Telephone only A mixed mode of mail with telephone follow-up A mixed mode of e-mail with mail follow-up* A mixed mode of e-mail with telephone follow-up* Clinics can choose to have vendor send surveys continuously during measurement period or one-time at end (determines clinic s file frequency to vendor and distribution mode). Clinics and vendors should download a copy of Fielding the CAHPS Clinician and Group Surveys guide from the CAHPS website. https://www.cahps.ahrq.gov/surveys-guidance/cg/instructions/index.html

Eligibility Clinic eligibility is based on a scaling table utilizing number of providers in the clinic as a proxy for size to determine the patient count threshold during September 1, 2013- November 30, 2013. Total # Providers at Clinic: Clinic-level eligibility based on number of providers Threshold for unique patient count # HCH Providers at Clinic: HCH threshold for unique primary care patient count (adult and child) 1-3 450 1-3 450 4-9 500 4-9 500 10-13 575 10-13 575 14+ 715 14+ 715 MN Community Measurement 44

Eligibility Example (for a multi-specialty HCH clinic) Clinic ABC has 10 total providers registered in 2014 and is also a Health Care Home clinic where 3 of their primary care providers are certified under the HCH program. 1 st assessment under the SQRMS requirements: Clinic ABC would had to have seen at least 575 unique adult patients during September 1 November 30, 2013. 2 nd assessment under the HCH requirements: Clinic ABC would had to have seen 450 unique adult patients for primary care visits during September 1 November 30, 2013. 3rd assessment under HCH requirements: Clinic ABC would had to have seen 450 unique pediatric patients for primary care visits during same period. 45 MN Community Measurement

Eligibility Example (for a pediatric HCH clinic) Clinic DEF has 5 total providers registered in 2014 who all are certified under the HCH program. 1 st assessment under the SQRMS requirements: Clinic DEF would had to have seen at least 500 unique adult patients during September 1 November 30, 2013. 2 nd assessment under the HCH requirements: Clinic DEF would had to have seen 500 unique adult patients for primary care visits during September 1 November 30, 2013. 3rd assessment under HCH requirements: Clinic DEF would had to have seen 500 unique pediatric patients for primary care visits during same period. MN Community Measurement 46

Implementation Three Stages Pre-Survey April 1 to July 14, 2014 (reference pages 8-13 in Guide) Surveying September 1, 2014 to February 20, 2015 (reference pages 13-16 in Guide) Post-Survey February 25, 2015 to April 3, 2015 (reference pages 16-17 in Guide)

Pre-Survey Timeline - Clinics Open April 2 nd, 2014 through July 14, 2014 Physician Clinics Answer the eligibility questions in Data Portal based on patient count assessment Contract with survey vendor and designate vendor and clinic contact in MNCM s Data Portal Submit Pre-Survey Validation Documentation (PSVD) to describe the process of selecting all eligible visits Submit test file(s) to survey vendor

Clinic s Home Page MN Community Measurement 49

Eligibility Screen, part 1 MN Community Measurement 50

Eligibility Screen, part 2 MN Community Measurement 51

Eligibility Screen, part 3 MN Community Measurement 52

Clinic s Home Page MN Community Measurement 53

Pre-Survey Validation Screen MN Community Measurement 54

Pre-Survey Validation Document Document how to identify all eligible visits One document required per medical group Upload completed document to Step 4 Include screen shots of EHR parameters MN Community Measurement 55

Pre-Survey Timeline - Vendors Open April 2 nd, 2014 through July 14, 2014 Survey Vendors Survey vendors orient clinics to measure and provide specific procedural information Access MNCM s data portal to request logon Submit 1) survey/cover letter drafts, 2) enter mode and frequency of data files, 3) random sample from test file(s) MN Community Measurement 56

Surveying Timeline September 1, 2014 through February 20, 2015 Physician Clinics Provide the live data file(s) of all eligible patient visits to their vendor. Survey Vendors Responsible for the entire administration of the CG- CAHPS 12-Month and 12-Month + PCMH surveys on behalf of their clinic clients.

Post-Survey Timeline February 25, 2015 through April 3, 2015 Survey Vendors Responsible for generating all final survey data for each clinic for each survey type for their medical group clients. Data file(s) will be uploaded by the vendor to the MNCM data portal along with additional post-survey documentation. Final data files will also be uploaded to the National CAHPS Benchmarking Database (NCBD).

Post-Survey Timeline April - July 2015 MNCM Aggregation and QC of data Risk adjustment procedures applied MACRO program run to generate domain results Two-week Medical Group review of results MN Community Measurement 59

Public Reporting of Survey Results (Adult 12-Month and Adult 12-Month + PCMH) The unit of measurement is the clinic site. Data rolled up into 4 domain scores. Only valid clinic level results will be publicly reported. Results reflected on www.mnhealthscores.org Display will be reviewed for enhancements. Data is expected to be publicly reported in Summer 2015.

Health Care Home Reporting (Adult 12-Month + PCMH and Child 12-Month + PCMH) Unit of measurement is the clinic site. All data is used no reliability threshold. Displayed in the HCH data portal (Non-public). Results are used in re-certification for quality improvement. Four domains plus self-reported health status (excellent) Benchmarking to be applied to the 2012 results with 2014 refresh. 61 MN Community Measurement

Website Resources Minnesota HealthScores: http://www.mnhealthscores.org View results from the 2012 patient experience survey MNCM Data Portal: https://data.mncm.org/login Resources tab Summary Start-Up Guide Download Data Collection Guide Patient Experience measure on Home Page CAHPS website: http://www.cahps.ahrq.gov/surveys- Guidance/CG/Get-Surveys-and-Instructions.aspx

Questions & Support Email: surveysupport@mncm.org Tel: 612-746-4522