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NQF endorses chronic conditions measures
Effort to look at patients across the continuum
As the National Committee for Quality Assurance hopes that all-cause readmission rate reporting by health plans will assist in creating more consideration of patient care across the continuum, the National Quality Forum (NQF) hopes a new measurement framework for multiple chronic conditions will likewise help improve care in and out of the hospital.
"This is a guide that can help inform decision-making," says Karen Adams, PhD, MT, vice president of national priorities for the organization. "This provides a way for us to look at care not by patient, and not by setting, but through something else."
A patient might be in a hospital, in rehab, having home health care, or just at his or her primary care physician, she continues. This is a way to approach care across phases and look at performance measurements that meet the needs of patients. Looking at issues such as care coordination, functional status, hand-offs and shared accountability could change the game. "This puts the patient as the unit, not the place where the care is given."
Among the concepts key to the new framework, the framework document notes, are:
"I think of the value of the framework as how it would be used and what work it would inform," says Tom Valuck, MD, JD, senior vice president for strategic partnership at NQF. It could impact policy makers and researchers, and how payers reward and punish providers for the care they give to these patients. It might even help consumers make better decisions, he adds.
Valuck says the framework will also be instrumental in helping determine measurement gaps for this population.
This all started from the previous framework on patient-focused episodes of care, Adams explains.
"This was when we first started to think across settings," she says. "We looked through various conditions — cancer, diabetes, substance abuse, AMI. But what's important from that learning is that for a large portion of the population, you aren't just someone with one of those, but with multiple conditions. This evolution of looking at multiple diseases is different."
If you instead used the measures for each of a patient's individual conditions, you could end up with some unintended consequences, she notes — harm to the patient, extra work for various providers, and greater cost for payers.
Adams would like to see professionals throughout the healthcare community gain a real understanding that the care doesn't end at the door to their office or facility. "I know they want to provide high-quality care in that setting," she says. "But there have to be hand-offs, and providers know that they can't achieve good outcomes in isolation. We want them to think about how to orient their quality improvement, how they respond to external entities along the continuum of care. When you think of transitions, what measures do you want to pilot or use? Think of that. Be ahead of the game."
Organizing around outcomes
Valuck worries that there is a cacophony of disorganized quality measurement on the front line of healthcare. This kind of framework — applied specifically here, but bootstrapped elsewhere in the future — can help rationalize and organize all the work that patient safety and quality improvement staff do. "If we can make measurement line up in ways that make sense to QI and providers alike — wouldn't that be great?" he asks.
The key is to organize the process around patient outcomes. "If Javier has depression, COPD and diabetes, we could do a lot of process measures around each of these diseases," Adams says. "If we provide guidelines for each of these, are we paying attention to what matters most to this patient? One might want to walk across the room to pick up his grandchild. That means regimented A1C measurement might make him too wobbly to do that. But we can titrate that so that we meet health needs and patient goals."
That's what this is all about, Valuck concludes. "It's about triaging, and prioritizing at the highest level opportunities. It's about helping the provider focus on what's most important."
The entire measurement framework report is available at www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=71227.
For more information on this topic, contact Tom Valuck, MD, JD, Senior Vice President of Strategic Partnerships, and Karen Adams, PhD, MT, Vice President of National Priorities, National Quality Forum. Washington, DC. Telephone: (202) 783-1300.