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CCO Oregon Round Table Health Metrics and Outcomes. Amit Shah, MD. Why measure?. Population Health. "Triple Aim". Experience of Care. Cost per Capita. What We All Want . Patient/ Provider View. Payer/ Purchaser View. Access to Care Be there when I need you. Accountability

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Cco oregon round table health metrics and outcomes

CCO Oregon Round TableHealth Metrics and Outcomes

Amit Shah, MD



What we all want

Population Health

"Triple Aim"

Experience of Care

Cost per Capita

What We All Want

Patient/ Provider View

Payer/ Purchaser View

Access to Care

Be there when I need you.

Accountability

Take responsibility for making sure I receive the best possible health care.

Comprehensive Whole Person Care

Provide or help me get the health care services I need

Continuity

Be my partner over time in caring for my health.

Coordination And Integration

Help me navigate the health care system to get the care I need in a safe and timely way.

Person and Family Centered Care

Recognize that I am the most important member of my care team – and that I am ultimately responsible for my overall health and wellness.


Why measure1
Why Measure?

  • -Health care transformation will require significant amount of infrastructural and

  • clinical system redesign

  • -We know what we should be doing but why are we not achieving?

  • -We know what we should be doing but often do not know how we are doing?

  • -Allocation of funds to move transformation based on performance

  • -Subjective improvement not always =objective improvement


Oha incentive metric
OHA Incentive metric

  • -P4P program part of CMS waiver granted to Oregon for transformation

  • -Outcomes based (important to move towards outcomes with understanding of what is need to build the process)

  • -OHA delegated committee to determine which metrics used and approved by CMS

  • -17 of 33 metrics are incentivized (must reach certain threshold in order to obtain full quality bonus and participate in bonus pool of money)

  • -monies used to fund transformation at clinic system level


List of measures
List of Measures

  • Alcohol or substance (SBIRT)

  • Follow-up after hospitalization for mental illness

  • Screening for clinical depression and follow-up plan

  • Prenatal timeliness of care

  • Elective delivery before 39 weeks

  • Ambulatory Care: Outpatient and ED utilization

  • CRC

  • Patient-Centered Primary Care Home Enrollment

  • Developmental screening in the first 36 months of life

  • Adolescent Well Child Visits

  • HgA1C control

  • CAHPS

  • EHR adoption

  • Mental and physical health assessment within 60 days for children in DHS custody


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