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Quality Measure Development

Tracking quality of care for vulnerable patients in post-acute and long-term care settings

As the main health care purchasers for millions of Americans, Medicare and Medicaid face a two-pronged challenge: providing quality care to patients, while also ensuring value for taxpayers. Meeting this challenge involves monitoring a diverse, wide-ranging, and dynamic landscape of health care providers.

Quality measures are increasingly critical as the Centers for Medicare and Medicaid Services (CMS) implements and tests complex payment models, and moves from paying for amount of services provided to patients to paying for value in health care. Patient outcomes such as fewer rehospitalizations, fewer emergency department visits, fewer complications (e.g., infections), improved mobility and function, and better symptom management (e.g., pain control) are the focus of many quality measures. CMS needs quality measures that can be applied uniformly across settings, allowing them to understand the quality of care patients experience across the continuum of health care providers.

Quality measures enable providers to understand how well they are addressing patients’ symptoms and following clinical practice guidelines for preventive care and patient safety. By considering quality measures along with other indicators, such as the transfer of health information as patients move from one setting to another, providers are able to identify and act on performance gaps and areas for improvement. Finally, quality measures are important to patients and families facing the task of selecting the right hospice care provider or nursing home.

CMS chose RTI to develop quality measures for two growing sectors of health care: post-acute care settings and hospices. Although all of these providers serve vulnerable older adults, many with serious illness, there are some key differences in what is most important to measure and what constitutes high-quality care across these providers. Using our in-depth knowledge of each sector, we are developing, testing, and validating quality measures that are publicly reported and can be used by patients and families to select a provider.  

Post-acute care takes place in a variety of settings—inpatient rehabilitation facilities, long-term care hospitals, skilled nursing facilities, and patients’ homes with the help of home-health agencies—all of which share the goal of helping patients maintain or regain some level of health or independence. Hospice care can take place in a facility or in a patient’s home, and the mission is to provide support and comfort for patients nearing the end of life and their families. CMS, patients, and families need ways of evaluating each type of facility that acknowledge the goals, preferences, and expectations of patients at different stages.

One driver for the development of these quality measures was the IMPACT Act—the Improving Medicare Post-Acute Care Transformation Act of 2014. Under this legislation, providers are to report data that capture interoperable quality measures across the post-acute care continuum. The IMPACT Act requires developing measures in specific domains, including skin conditions, cognitive function, and major falls. To date, we have designed nine new measures to meet the requirements of the IMPACT act, and we continue to design and maintain approximately 50 other measures across three post-acute care settings.

Our experts apply comprehensive knowledge of measure development, implementation, and maintenance to develop meaningful quality measures. To be meaningful, these quality measures must be both scientifically sound and clinically relevant, backed by evidence that improving a process will have a positive effect on patient outcomes.

Building on Health Care Knowledge and Specialized Technology to Ensure Interoperability

A key standard for quality measures is interoperability, which means that they measure characteristics uniformly across different settings. Ensuring interoperability requires a substantive background in health information technology, which we have both the knowledge and the infrastructure to support.

Any project concerning the quality of health care and long-term care services also benefits from an understanding of the human side of health care: patients and their families, their goals and experience of care, as well as the clinicians, staff, and organization of the providers supplying that care. To ensure that the measures we develop meet the needs of all stakeholders, we are leading a participatory process that involves inviting outside experts and patients and families to provide their input on the measures. We are also training providers nationwide across a variety of health care settings who will be implementing and using the measures, providing help desk support accessible by all providers to assist them with measure implementation.

Meeting America’s Need for Quality Measures that Make a Difference

Another important use of our measures, and one that is particularly visible to the public, is displaying them across Medicare’s series of websites so that patients and families can compare the quality of health care providers, and select a provider that best meets their needs. The Compare websites, as they are known, feature the ability to look up side-by-side statistics on measures relevant to different types of facilities or settings. The sites also include detailed information on why the measures are important and how website users should interpret them.

For example, hospice providers are rated on whether they consulted patients about their beliefs and values, and how they treated symptoms such as pain and shortness of breath. These and other factors help create comfort and peace of mind for terminally ill patients and their families.

Nursing homes are rated in different categories based on the distinct needs of short-term and long-term patients. For short-term residents, whom often have left the hospital but are not ready to go home, the ratings look at whether they improved their mobility and were successfully discharged. For long-term patients, examples of measures include the percentage of patients who experience falls, depression, pressure ulcers, and drastic weight loss.

By definition, the choice of a post-acute care or hospice provider comes at a stressful, vulnerable time for patients and families. The multitude of individual outcomes makes the quality of care in these settings difficult to assess. Through our collaborative approach, we have worked to measure quality in the most meaningful way for all concerned. We hope that our measures lead to better decisions for patients seeking care, providers working in post-acute and hospice care settings, and policymakers setting the course for the future of health care.