Quality of Care

1. Quality of Care

2. Plan for Today • Talk about quality of care • What is it? • How do you measure it? • How do you improve it? • How good is the quality of care in HMOs? • Team meeting

3. What is Quality? • Maximizes patient welfare, taking account of expected costs and benefits (Donabedian) • Contributes to improvement or maintenance of quality/duration of life (AMA) • Increases likelihood of desired health outcomes and is consistent with current professional knowledge (Institute of Medicine)

4. Donabedian “Quality is doing the right thing, and doing it right.”

5. Ways of Measuring Quality • Structure • Process • Outcome

6. Structure • Credentials, licenses • Compliance with regulations • Record-keeping • Legal agreements

7. Process • Utilization rates for specific services • Adherence to accepted treatment protocols • Screening and prevention

8. HEDIS process measure forAdolescent Immunization • Percentage of 13-year olds who received immunization for measles, mumps, rubella in previous year • (Booster shot required to ensure continued protection)

9. What can plans do to increase adolescent immunizations? • Birthday card reminders • Educate parents through posters, flyers, member magazines • Remind and educate doctors to immunize when patient is in the office

10. Outcomes • Complication rates • Mortality • Patient functioning • Relief of pain • Patient satisfaction

11. Features of Modern Approach to Quality Improvement • Customer focus • Integrated, “systems” approach • Setting and achieving concrete goals • Measurement • Evaluation

12. Disease Management Programs:Asthma Example • Less than 5% of asthma is “severe” • Nearly half of care costs are for emergency room and hospital • Only 10-20% of asthmatics receive inhaled steroids (Inhaled bronchodilators provide instant relief) • Asthmatics see pharmacists 5 times more often than physicians

13. Rationale for Intervention • High rate of preventable complications • Measurable impact within short time period • Chronic, outpatient-focused condition • High rate of variability in treatment • High rate of patient non-compliance • Consensus on optimal treatment • Desired outcomes are measurable and achievable

14. Case finding and preventive efforts Education and morbidity reduction Management of emergencies Peak flow meter Inhaled steroids Home visits by asthma nurse specialist Phone and mail follow-up Counseling by pharmacist Emergency department triage Protocol for status asthmaticus Identify asthma patients Home environment Smoking cessation Measure baseline functional status

15. Hospitalization Ambulatory follow-up Home visits by asthma nurse specialist Phone and mail follow-up Counseling by pharmacist Critical pathway for asthma exacerbation Conventional case manager role Measurements: Satisfaction surveys, functional status surveys, annual cost of care, readmissions, ER re-visits, medication compliance, missed school/work days

16. How Good is the Care in HMOs?

17. How Good Are HMOs onAdolescent Immunizations ?

18. Are HMOs Better or Worse than Fee-for-Service?

19. Wide variation in quality • Good HMOs and not-so-good HMOs • HMO quality is better in some areas than others

20. Team Meeting • Facilitator, recorder • Recorder’s duties • Give individual contributions to Jen (will be returned on Thursday) • Mail out notes in next few days