Bringing medicine, 

patients and 

community-based services 

together.
How Community-Based Organizations 

(CBOs) Can Impact Quality Measures 

for Health Plans and Medical Provider 

Groups 

Evidence-based programs, assessments & 

risk screening to address quality measures 

Presentation to ACL Business Acumen 

Learning Collaborative 

April 2, 2014 

By Sandy Atkins, VP, Strategic Initiatives 

Partners in Care Foundation 
The Triple Aim & Other Motivators 

• Healthcare is motivated in these 3 areas: 

– Better population health 

– Better patient experience of care 

– Lower per-capita costs 

• Patient experience and population health are in 

the quality domain 

• Member retention is a primary metric for health 

plans – also related to quality 

• Healthier & well-managed patients means better 

satisfied physicians 
Better Population Health 

• Better care coordination 

– Care Transitions 

– Service coordination, navigation 

– Improved access – transportation, assist with 

scheduling, companion, etc. 

• Improved functioning & behavioral health 

– EnhanceFitness, Fit & Strong, Healthy Moves, Tai Chi 

– PEARLS, Healthy IDEAS 

– Stanford programs 
Better Patient Experience 

• Represent the plan or provider group (not 

your agency/network) 

– Hospital visits 

– Home visits 

– Relationship with care coordinator 

– Transportation & assistance w/appointments 

– Benefits Checkup 

– Find free/discounted services 
Lower Per-Capita Costs 

• Quality enhancements must be at least cost neutral 

– Better to have a positive ROI 

• Reduce falls 

– Matter of Balance, Healthy Moves, HomeMeds 

• Reduce ED visits 

– Fall prevention, symptom management, self-management, 

call center – 911 alternatives 

• Reduce admissions/readmissions 

– CTI, Bridge 

– EnhanceFitness, Stanford Self-Management Programs 

(SMPs) 
Healthcare Effectiveness Data and Information Set (HEDIS) 

Older Adult Measures 

• During year received: 

– Advance care planning 

– Medication review 

– Functional status assessment 

– Pain assessment 

• All typical Waiver or Case Management (CM) services or 

included in assessment 

• One home visit would meet all measures 
Star Ratings – Medicare Advantage

• Yearly review of all medications/supplements being taken 

• Yearly pain screening or pain management plan 

• Controlling blood pressure 

• Reducing risk of falling 

• Readmission to a hospital within 30 days of being 

discharged 

• Plan members 65+ on high-risk drugs, when there may be 

safer drug choices 

• Medication adherence for hypertension: Taking meds as 

directed 

Bonuses for 4 & 5 Star Plans – growing!! 
HEDIS for Physicians

• Percentage of Medicare members 66+ who 

received at least one high-risk medication 

– Goal is low %. High-risk typically means Beers 

Criteria related to risk of falls, confusion, gastric 

bleeding, etc. 

• Fall Risk Management: Discussion & 

Management 

• Potentially Harmful Drug-Disease Interactions 
HEDIS Physician Standards – deeper dive

• Percentage of Medicare members 66 + who received at least 

one high-risk medication 

– Associated with higher hospitalization in communitydwelling elders1 

– Associated with adverse drug reactions and cost across 

settings1 

• Potentially Harmful Drug-Disease Interactions in the Elderly: 

– Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS 

– Dementia and Tricyclic Antidepressants or Anticholinergic Agents 

– Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents 

– Potentially Harmful Drug-Disease Interactions: Overall Rate 

1

Jano E, Aparasu RR, Healthcare outcomes associated with Beers' criteria: a 

systematic review. Ann Pharmacother. 2007 Mar;41(3):438-47. Accessed at: 

http://www.ncbi.nlm.nih.gov/pubmed/17311835?dopt=Abstract
Door Openers: Fall Prevention 

Fall risk management: % of Medicare members 65+ who 

had a fall or had problems with balance or walking in the 

past 12 months who received fall risk intervention in past 

12 months. 

• Tarrant County, TX (Ft. Worth) 

– Local fall prevention collaborative w/hospitals, pub health 

– Fire Dept. mapping 911 calls for falls 

– Target Matter of Balance & HomeMeds for frequent fallers 

http://www.qualitymeasures.ahrq.gov/content.aspx?id=43758 
Door Openers: Meds Management 

• HomeMedsSM addresses multiple quality domains 

– Fall risk management 

– High-risk medications 

– Hypertension control 

– Pain control/assessment (and dangerous side effects 

of pain meds) 

• In Care Transitions serves as medication reconciliation –

required by the National Committee for Quality 

Assurance (NCQA) for health plans 
What else can we do? 

• % Screened – glaucoma, mammogram, etc. 

– Transportation 

– Assistance with scheduling 

– Reminders/encouragement 

• Clinical outcomes 

– BP/HTN control – assistance with med adherence 

– Cholesterol – meals, dietary counseling, med 

adherence 

– Diabetes – purchase of monitoring supplies, meals, 

dietary counseling, med adherence, DSMP, family 

counseling 
Healthy People 2020 – Older Adults 

• Confidence in managing their chronic conditions 

– Chronic Disease Self-Management Program (CDSMP) and 

variants 

• Receipt of Diabetes Self-Management Benefits 

– Diabetes Self-Management Program (DSMP) 

• Leisure-time physical activities among older adults 

– EnhanceFitness, Fit & Strong, etc. 

• Caregiver support services 

– Savvy Caregiver; Powerful Tools 

• ED visits due to falls among older adults 

– HomeMeds, MOB, Healthy Moves 

http://healthypeople.gov/2020/topicsobjectives2020/pdfs/OlderAdults.pdf 
NCQA CM Accreditation 

• Health Plans Must Assess/Evaluate Members’

– Clinical hx & medications 

– ADLs 

– Cognitive function 

– Psychosocial issues 

– Health behaviors 

– Life-planning activities 

– Cultural/linguistic needs, preferences, limitations 

– Visual/hearing needs, preferences, limitations 

– Caregiver resources/involvement 

– Available benefits 

– Community resources 

• For high-risk members a phone call won’t do
Can we hurt quality measures? 

• Health plan delegation rules – accreditation or 

license for care management 

– Must follow all NCQA standards 

– Documentation/systems 

– Quality assurance 

– Metrics 

• Customer service 

– Timeliness – not on waiver timeline, but hospital 

– Who was that stranger who called? 

• We will represent the plan 
Usual work, new standards 

• What we do now can help quality measures 

for health plans, hospitals, Accountable Care 

Organizations (ACOs), and provider groups 

• We have to do it better & faster 

– New Culture: How high?!! 

• We have to measure & improve constantly 

– Data – We MUST require contracting partners to 

share data and information so we can improve 
Contact 

• Partners in Care Foundation 

– Sandy Atkins, VP, Strategic Initiatives 

– 818.632.3544 

– satkins@picf.org

– www.picf.org; www.HomeMeds.org