Domain 3 - Quality, Outcomes Evaluation and Measurements Flashcards
Key steps in the Evidence Based Practice (EBP) process:
Identify the Problem
Design the question
Search, Appraise and Synthesize the Evidence
Implement the change
Evaluate the change
Integrate the Change into practice
Evidence Based Practice
A problem-solving approach to practice that integrates:
* Best evidence available from well-designed research studies
* Client values and preferences for care
* Expertise of clinicians in making decisions about the provision of
care for clients/support systems
A cost-benefit report is done to:
Formally document savings related to Case Management involvement.
In a cost benefit report, what is the difference between hard savings and soft savings?
Hard savings: actual savings based on real numbers (discounts, negotiated reductions,
etc.)
Soft savings: possible or potential savings based on avoidance of services, use experience with like clients, and past experience of the client
How to calculate the cost savings:
Cost savings = Potential costs – (Actual cost + cost of Case Management)
Acuity
Goes to the need for level and frequency of comprehensive and
integrated case management intervention
Represents the level of complexity of the case management intervention, the severity of the client’s needs, and the response of the healthcare delivery system
Determined through a process of stratification that encompasses many factors and can be a complex process using not only current clinical information, but also historical claims information
Factors impacting acuity:
-Current illness or injury, client understanding of the illness or injury, and the complexity of the condition
-How complex are the medical/behavioral needs
-What care is needed immediately and what care might be needed moving forward
-Medication concerns – number, type, and potential for adverse reactions
-What is the extent and engagement of their support system?
-What is their health literacy and understanding of the condition and the care that is and will be required?
-What is the intensity and complexity of needs, and what is the intensity of the resources and services that will be necessary?
Why do case managers stratify risk?
To define a specific population, provide the most attention necessary to clients with the greatest needs, consider the desired outcomes for and with those clients, and determine interventions to achieve these outcomes.
Risk Stratification
-occurs early in the Case Management Process (Domain 1)
-applies various tools to assess for risk
-determines a client’s risk category, also known as risk class:
* Low, Medium, or High
-Informs the care plan to determine:
* Appropriate level of intervention
* Targeted interventions to enhance outcomes
What is included in the 3 levels of risk stratification?
High: intensive case and disease management
Medium: health coaching and lifestyle management
Low: health education and promotion
Predictive modeling
Individuals at risk for complications or declining health condition – or whose environment is likely to render them either ineffective at self-care management or unable to follow a medical regimen – are appropriate candidates for case
management services.
HRA
Health Risk Assessment
What is a Health Risk Assessment (HRA)?
Questionnaire about health and lifestyle used to develop personalized care plan that focuses on clinical conditions, health risk factors, and disease state. Can be delivered telephonically, or written via mail in person. Assesses real-time physical, behavioral, mental, emotional and psychosocial status.
With this type of assessment, clients receive aggressive outreach services and
targeted case management interventions to reduce the likelihood of:
* poor health outcomes such as morbidity, mortality, and avoidable costs.
* HRAs can predict clients’ future healthcare service utilization and costs and the
likelihood of progression toward illness or worsening of an existing condition
(Gurley,2007)
CARS
Community Assessment Risk Screen
Community Assessment Risk Screen (CARS)
- used to determine the risk for rehospitalization or ED use for seniors
- focuses on current health status and lifestyle behaviors
- similar to the health risk assessment (HRA) tool
Hierarchical Condition Category (HCC)
Medicare uses the CMS-HCC model to calculate risk scores that quantify and project the
financial risk of each Medicare beneficiary. CMS uses risk scores created by the CMS-HCC
model to adjust Medicare capitation payments to Medicare Advantage (MA) plans. With
risk-adjusted payments, Medicare pays MA plans more money for patients with greater risk
and less money for patients with less risk. Key points:
* payment methodology for Medicare Advantage members based on “risk”
* payment rate for members in same community based on the amount of risk it
takes to maintain health
LACE Tool
- L=Length of Stay
- A=Acuity of Admission
- C=Comorbidities
- E=ED Visits
The higher the score, the higher the risk of hospital readmission.
Johns Hopkins Adjusted Clinical Group® Scoring System (ACG)
allows for more accurate and fairer:
* Evaluation of a healthcare provider’s performance
* Identification of clients at high risk
* Forecasting of healthcare utilization by clients
* Payment structures and rates for the providers of care
* Allocation of appropriate resources
Two ways to evaluate the effectiveness of the case management program are:
- conduct surveys to evaluate the client’s perspective and perceived value
of case management interventions - measure outcomes
Root Cause Analysis
Process used by healthcare providers or administrators to identify the basic or causal factors that contribute to variation in performance and outcomes or underlie the occurrence of a sentinel event
Continuous Quality Improvement (CQI)
- Key component of total quality management
- Uses rigorous, systematic, organization-wide processes to achieve ongoing improvement in quality of healthcare services and operations
- Focuses on both outcomes and processes
Performance Improvement
- Continuous study and adaptation of the functions and processes of a healthcare organization
- To increase probability of achieving desired outcomes and better meet client needs
Quality Assurance
- Use of activities and programs to ensure the quality of client care
- These activities and programs are designed to monitor, prevent, and correct quality deficiencies and noncompliance with the standards of care and practice
Quality Improvement
An array of techniques and methods used for collection and analysis of data gathered in the course of current healthcare practices in a defined care setting
Quality Management
- The monitoring, analysis, and improvement of organizational performance
- It is a formal and planned, systematic approach organization or network wide
- Standards, the quality of client care and services provided, and the likelihood of achieving desired client outcomes
Outcome Indicators
- Measures of quality and cost of care
- Metric used to examine and evaluate results of the care delivered
