Last month my colleagues Athena Mandros and Ken Carr ask a “simple” question: How does an organization go about creating innovative, value-based partnerships with health plans (see Using Your Performance Metrics To Build A Value Proposition For Health Plans)? Their article deserves a thorough read but can be summed up as: addressing payer “pain” points and surviving in a value-based reimbursement environment means leveraging performance data to design services that deliver better results at a lower cost.
This month, I reached out to a few executives from the field to see how they are balancing this market demand, and to pose two questions.
- What are the two or three organizational performance measures (either financial or clinical) that you think are most important for health and human service executive teams to monitor and manage?
- Are your organization’s operating systems currently able to provide your executive team with these measures? If no, what are the challenges to regular tracking and if yes, how do you use these measures in planning and management?
What did we find out? There were three primary concerns that are driving the use of performance measures—consumer engagement; readmission rates; and staff turnover. And this makes sense. Engaged consumers have better outcomes and use fewer resources (see Better Outcomes For Less Cost Will Follow Engaged Patients); readmission prevention/hospital diversion programs have become a key feature in both specialty provider organizations and primary care (see The Most Common Program Innovations Among Specialty Provider Organizations); and the cost of recruiting, training, and paying of interim staff can add up to 16-20% of annual compensation for each position that needs replaced (see What Should Your Approach Be To Retaining Great Team Members?).
But that’s just a quick overview. Here is a deep dive into the performance measures these executives are pursing, and the challenges they have had to overcome in that pursuit.
Terence G. Blackwell, Jr., BCBA, President & Chief Executive Officer, Chimes International Limited
Chimes International Limited is a non-profit organization based in Baltimore, Maryland, and people with intellectual and behavioral challenges. President & Chief Executive Officer Terry Blackwell noted that key performance measures included vacancy rate, turn over, attendance, financials, health/safety measures, productivity, visit count, and show rate.
The performance measures are vacancy rate, turn over, attendance, financials, health/safety measures, productivity, visit count, and show rate. We consider all of these both clinical and financial performance measures. They all speak to consumer engagement as well as contribute to the health of the bottom line. When we are meeting our targets, consumers can get the services prescribed or authorized. When consumers get the services authorized, our bottom line is healthier, and consumers/families have a better chance at recovery.
Only recently are we able to measure vacancy and turnover. Not automatically, but we can pull and manually calculate. We have not been very successful in measuring the satisfaction of our program participants and feel it would be helpful in making improvements to our programs. We also need help with staff recruitment and retention.
The challenges to ongoing monitoring of measures are: new technology and hard wiring new processes. We need a report writer who could pull the appropriate data into a report to inform operations. Currently, we can pull information from our electronic health record (EHR), but we then must manipulate the data in order to calculate the rates/measures. We have program goals for all program participants, but do not do a good job of measuring success. The accomplishments of goal are done quickly at Life Span Plan annual meeting. We attempt to do exit interviews, but many employees don’t participate so we would like more accurate information on why they stay and why the leave.
How do you use these measures in planning and management? The collected information allows us to prioritize resources, review processes, make changes on pol/pro. Visit count information, when calculated, is used to project whether we will meet monthly markers. Productivity and show rate can be used to help motivate staff and provide a consistent (bi-weekly) information feed to staff. It helps us identify low and high performers. We reward the high performers and use corrective action for low performers.
Peggy S. Terhune, Ph.D., Chief Executive Officer, Monarch
Monarch, a non-profit based in Albemarle, North Carolina, serves consumers with intellectual/developmental disabilities, mental illness, and substance use issues. Chief Executive Officer Peggy Terhune, Ph.D. noted that Monarch relies on two important key performance measures, consumer clinical improvement on the PHQ-9 and readmission hospitalization rates.
The introduction of Managed Care and shift towards pay-for-performance has increased the need for organizations, like Monarch, to track, report, and analyze key outcome metrics. Improving outcome measures is becoming more necessary to demonstrate treatment effectiveness within behavioral health. Outcomes are not just reporting data but demonstrating that people are benefiting from the care provided. We realize it is equally important to understand how and why we collect the data, but it’s also critical to create meaningful dialogue with staff on why it’s important to improve care. Outcome measures can provide some valuable insight on treatment delivery and the need for continuous quality improvement.
Two important performance measures that gauge effectiveness in behavioral health treatment is the PHQ-9 and readmission hospitalization rates. Both measures tell a vital story in the care provided and offer outcomes to support care delivery. We ask ourselves several key questions:
1. PHQ-9 – Response/ Remission Rates
Is the person getting better while in treatment? Measurement-based tools can provide validated measurable data in determining a person’s progress while in treatment. It can also be used to assist with clinical pathways and as a therapeutic tool during sessions. Depression Remission or Response for Adolescents and Adults and Depression Remission at Six or Twelve Months are a few measures that facilitate this data.
2. Behavioral Health Readmission Rates
Is the person stable while in treatment? Did they have an emergency department (ED) or inpatient (IP) admission? Readmission following a hospitalization is an important behavioral health outcome measure. Hospitalizations are very costly, but many times can be prevented if receiving the right follow-up care. Timely follow-up care after a hospitalization can impact and reduce hospital readmissions.
Finance is also a critical component in performance measures. Productivity continues to be an important part of providing care in the value-based world, just as it has been in the unit cost reimbursement area. As an organization, we will need to provide the best care using providers in the most meaningful and efficient ways possible. We currently measure our physicians’ and therapists’ productivity weekly, monthly and quarterly through set expectations and goals by provider. These productivity reports are created from our electronic health record (EHR) system electronically, reviewed and analyzed by our finance analyst teams, who then send out to our management group and providers. Reporting weekly or daily to our providers to include outcome measures alongside productivity is a goal for us, at Monarch, and will be an opportunity moving forward with a new EHR system we plan to implement in the next few months.
We believe the new value-based world is and will bring more and more challenges for revenue cycle management and EHR billing systems. Flexibility and advanced processes will be needed to accomplish billing our partners through Value Based Reimbursement Contracts where incentives exist for meeting or not meeting outcomes required for a varied number of different reimbursement plans.
Cost of services based on population health will be more and more critical. Utilizing data both from financial systems as well as EHR systems will be required. An ongoing emphasis on improving this data and building a data warehouse is a focus for our organization.
Is our organization’s operating systems currently able to provide our executive team with these measures?
Monarch is currently tracking PHQ-9 scores within our Electronic Health Record (EHR). It is important to track that staff are utilizing the PHQ-9 tool and that those in treatment are reassessed. This is accomplished by breaking down the data collected into sections to determine where improvement is needed. For example:
- First step is to determine if the PHQ-9 tool is administered upon initial assessment.
- If so, is the PHQ-9 tool reassessed in a follow-up session.
- If yes, what is the score variance between the two assessments…is there improvement?
This data can be broken down by program, age, clinician and evidenced-based treatment used. The data also provides insight into any potential QI opportunities needed. This provides meaningful data in determining the most effective intervention for those served. Our next step will be, why is there improvement? This can help to improve clinical workflow per population and care provided.
Monarch is moving towards a true data-driven organization. Data is reviewed in the Performance Improvement Committee and with operational senior leadership. This data is also shared internally within our departmental newsletters and intranet site. This allows the data to be transparent, improves ownership within the programs and assists with improvement efforts.
Readmission rates can sometimes be tricky to track. Outpatient behavioral health clinics often rely on external resources or claims for data procurement. Access to statewide electronic medical health information can assist with this measure but can be limited. In North Carolina, NC HealthConnex is a statewide system that links providers and other health information exchange (HIE) networks together to share patient medical information. This is currently under development and only participating providers can share/access information.
Currently at Monarch, this data is tracked via claims or self-report but access to this information is limited. Monarch created an inpatient tracker to collect an IP/ED admissions and referral module to track follow-up appointments in our EHR. These are under review and on hold until the HIE is available.
The goal is to determine if we are truly keeping people stable, healthy and out of the hospital. This is true meaningful data and will help demonstrate positive treatment outcomes and cost effectiveness for stakeholders.
We want to use the best method to ensure we are increasing quality care and helping people to lead healthier lives. A meaningful strategy has helped us to define, monitor and often, recalibrate, so we can continue to position ourselves as a value-based company.
Marlin Wilkerson, Senior Vice President of Operations, Mosaic
Mosaic is a non-profit organization operating in 11 states, serving people with disabilities, mental and behavioral health needs and autism, as well as aging adults. Senior Vice President of Operations, Marlin Wilkerson, explained that Mosaic sets both strategic and operational performance measures.
From a strategic point of view our organization develops organizational outcomes that are both strategic and operational in nature. Once an organizational outcome is identified it is cascaded throughout the organization and specific targets are developed at all levels of the organization.
Our primary focus is providing residential supports to individuals with intellectual disabilities. Most states are not releasing new funds to serve more people. Most of our populations are getting older. We are seeing increased vacancies as a result and slower turnaround in ability to replace those vacancies. We have been intentional of improving our internal processes to help remediate this issue.
To assure quality outcomes, we must assure we have quality, well trained staff to provide supports. We have experienced increased difficulty in recruiting those quality staff. This is a priority area for us. We are pursuing non-traditional supports to relieve the tensions created by this shortage.
Another focus area for us is to assure meaningful care plans for our individuals and to assure we have tools to document the support we provide. We are evaluating current practices to identify opportunities to be more effective in how we document the services we provide. We believe this will be a critical area of focus as we move towards the VBR environment. We use a lot data to track our current state and progress towards our desired future state. It is difficult to identify which of our goals are most important as all are critical to current and future success.
For provider organizations starting at the beginning of this process, the goal is to find the most relevant way to measure performance, analyze your data to demonstrate where your team adds value, and then find a way to highlight how your performance achievements will impact health plans’ results.