A Strong Signal from NCQA: New Standards for Population Health Management
The National Committee for Quality Assurance (NCQA) has introduced a new category that helps health plans set and achieve population health goals.
We’re pleased to see the 2018 Health Plan Accreditation (HPA) standards and guidelines: a new category — Population Health Management (PHM) — is a shift from evaluation of single-disease state toward a whole-person focus.
Within the PHM category, health plans must describe their strategy for addressing the needs of members, then demonstrate effective execution of that strategy.
Turn-Key is looking at these new NCQA standards to identify opportunities to help payers set and achieve population health goals, with a focused lens on targeted senior populations.
Population Health Management Strategy
Plans describe their comprehensive PHM strategy—targeted populations, programs, services and activities offered to members, in addition to demonstrating that they provide basic program information to members and instructions for using program services.
This new strategy will encourage health plans, ACOs and provider organizations to identify targeted populations and develop new programs that address specific needs. This will be especially helpful for identifying large groups of patients with more complex health care needs — especially the frail elderly, many of whom struggle with a serious or advanced When compared to other plan enrollees, these member clearly require a specialized approach that utilizes palliative care principles to population health.
Without services to ensure improved care coordination, enhanced home support services and opportunities to identify and document goals of care, these patients are more likely to go to hospitals, emergency rooms and ICUs, and experience fragmented, crisis-driven care. During their final months of life, they are risk to receive over-medicalized, non-beneficial treatment that is costly, unwanted and negatively impacts quality of life.
Fortunately, new models of specialized population health that integrate the appropriate set of tools and resources, such as structured and systemized palliative care extended into the home and community setting, are now available.
In the past, palliative care was relegated solely to the in-patient setting. While the provision of palliative care is beneficial for hospitalized patients and their families, this approach has demonstrated improved cost and quality of life outcomes when introduced earlier in the disease process and delivered in the home to potentially avoid hospitalization and over-medicalization.
Plans integrate data to identify and assess the needs of members and connect them with appropriate programs or services.
This category recognizes the important role of data analytics for identifying population needs, targeting resources to the right individuals and evaluating the impact of their strategy. This approach allows removal of a number of outdated standards, such as siloed disease management and practice guidelines.
This new standard clearly calls for more focused PHM.
While a generalized population health approach is valuable for tracking compliance with screenings, such as annual mammograms or diabetes retinal exams, it lacks the focus required to successfully address the impact and effectiveness of interventions for members with a serious illness.
Specialized predictive analytics and greater specificity are needed to predict future, likely outcomes and optimize initiatives within the broader PHM framework. This new data-driven approach allows opportunities to identify individuals who would benefit from palliative care who might otherwise go undetected by traditional means.
Predictive data analytics should be combined with clinically driven approaches that result in improved coordination of care and patient outcomes. This includes the appropriate care management infrastructure, staffing and resources to connect these very sick patients and their caregivers with programs and services, such as palliative care.
Delivery System Supports
Plans demonstrate how they support providers or practitioners in their delivery system – providing data directly to ACOs or providing practice transformation support to budding PCMHs– and demonstrate that they engage providers and practitioners in value-based payment arrangements.
This is an opportunity for ACOs and their “budding PCMHs” to integrate a formalized approach to palliative care into their population health initiatives. In select models, there are structured processes for conducting patient assessments – in-home or telephonic — to document point-of-care findings, as well as systematically report patient progress and outcomes.
Newer, innovative models guide the delivery of expert level palliative care in a uniform and standardized manner, to both predict behavior, as well as to inform areas in need of improvement. This includes clinical indicators (symptom management, satisfaction, et. al.), patient engagement (completion of goals of care, advanced care planning, communication), and patient alignment (psychosocial, family dynamics, and physician communication).
Armed with this information and data, organizations are better prepared to document and demonstrate value, supporting their efforts take on risk under value-based arrangements.
Population Health Management Impact
Plans conduct a comprehensive analysis of their PHM efforts, to determine the effectiveness of their strategy. Analysis includes measures related to clinical processes or outcome, member experience and cost/utilization.
This new standard requires plans to demonstrate how they are achieving the Triple Aim: better care, lower costs and improved health.
This is where Turn-Key Health’s Palliative Illness Management™ (PIM™) program has significant value: it enables plans to achieve the Triple Aim for the targeted population of seniors facing a serious illness.
The following is an analysis of the effectiveness of the PIM™ strategy:
By improving knowledge and understanding, and by establishing goals of care for shared decision-making, this approach reduces over-medicalization and unplanned care, and a decreased expense for members and health plans.
• Increase in appropriate election of hospice benefit
• Improvement in mean and median hospice length of stay
• Decrease in acute care utilization through polypharmacy review/medication therapy management (MTM)
• Diminished symptom burden and condition exacerbation through improved medication adherence
Palliative Illness Management™ Aligns with New Standards
This unique model of population health integrates the appropriate set of tools and resources such as palliative care extended into the home and community setting. The PIM™ platform ensures a structured, scalable approach to clinical engagement, enabling payer organizations to increase the scope and frequency of interaction with patients and caregivers.
Community-based palliative care is provided by our proprietary national network of trained nurses and clinical social workers who help to guide care for this vulnerable population. Recognized under the model as Palliative Extensivists™ (PEs), they utilize comprehensive and standardized, baseline and follow-up telephonic and home visit motivation interviewing techniques to improve patient and caregiver quality of life.
PEs aim to keep patients healthier outside the hospital with regular, routine home visits and telephonic outreach, helping to avoid emergency room visits, hospitalizations, readmissions, and ICU stays.
As shown above, the PIM™ model ensures better care, lower costs and improved health.