Quality Metrics Tracking

An accountable care organization (ACO) is a health care organization that follows a model where reimbursements are directly tied to quality metrics and reduced costs. Or, according to the Centers for Medicare and Medicaid Services, “Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.”

Not all health care organizations are ACOs. In order to become an ACO, health organizations may need to make quality improvements—and in order to make these improvements, they may need to track their quality metrics better in order to document the kinds of changes they need to make. This can be a challenge at small rural hospitals where quality metrics have not been tracked well in the past. Because care coordinators work closely with patients are aware of barriers to care and other community issues, they may be asked to assist in the process of helping to devise a better metrics tracking system so that the hospital might qualify to become an ACO.

After completing the activity, you will be prepared to:

• Investigate strategies for expanding the health information technology (HIT) at a small rural hospital to better track quality metrics.
• Recommend strategies for improving the tracking of quality metrics at a small rural hospital so that this hospital can qualify to become an ACO.

Challenge Details

You continue your work as a newly hired case manager at Sacred Heart Hospital, located in Valley City, North Dakota. As you know, SHH was recently acquired by Vila Health, a large health care system that operates hospitals and clinics in several Midwestern states.

Vila Health wants all of its hospitals to be Accountable Care Organizations. However, as a small rural hospital, SHH will have to make many improvements in order to qualify for ACO status. In order to develop a strategy for making these improvements, the first step will be to track quality metrics better so that the hospital will have data to work with to measure problems and to track improvements. You, the new case manager, will be asked to develop a strategy for tracking quality metrics to help facilitate the hospital’s qualification for ACO status.

Quality Metrics Tracking

From: Karen Dellington, Admissions and Discharge Director

To: Student Intern

Hello! Thank you so much for all your hard work in helping SHH to develop a strategy for achieving Triple Aim Outcomes. The hospital has another, similar project, and we need your help to complete it.

As you know, SHH was recently acquired by Vila Health. Vila Health wants all of its hospitals to become Accountable Care Organizations (ACOs). However, in order to qualify to become an ACO, SHH will have to make a number of quality improvements.The Center for Medicaid and Medicare Services says that an organization has to show quality improvements in the following areas in order to become an ACO:

1. Patient experience.
2. Care coordination/patient safety.
3. Preventative health.
4. At-risk population health.

For more information on ACOs, please read the Accountable Care Organizations: What Providers Need to Know document, which I will be sending to you.

After reading through the Barnes County Community Health profile, and after interviewing various stakeholders at the hospital and in the community, I know you’re already aware of some of these needed improvements. For example, preventative care is an issue in this region. Patients are not seeing their primary physicians often enough—or they don’t have primary physicians—and they aren’t getting diagnostic tests like mammograms or colonoscopies at a satisfactory rate.

Here’s where we need your help. In order to make the improvements we need to qualify as an ACO, we need to improve our Health Information Technology (HIT) system so that we are tracking quality metrics data better. We are not doing a good job with this. Our EHR is out of date, and we’re not gathering nearly enough data from patients. We need you to give us recommendations for how to improve our HIT so that we track the information we need to understand fully how to make the improvements we need to become an ACO.

So, here’s what I’d like for you to do:

1. First, I’d like for you to meet with a patient named Caroline McGlade, who has recently been diagnosed with breast cancer. Mrs. McGlade is a typical example of one of our patients who hasn’t gotten enough preventative care. I’d also like for you to look at her EHR—which, as you’ll see, isn’t very thorough. As you think about this case, ask yourself this: how could we be tracking data in cases like this one better to help us to make the improvements we need to qualify for ACO status?
2. Second, I’d like for you to interview a series of stakeholders who can provide you with information about changes that need to be made in our HIT.
3. After completing these tasks, I need you to write recommendations for how we can expand our HIT to better include quality metrics—with the ultimate goal of qualifying for ACO status.

This is a challenging assignment, but I know that you’re up to it! Best of luck.

Thanks,
Karen

Caroline McGlade-EHR

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Patient Information – 04/24/19

Patient Name: Caroline McGlade
Patient ID:
DOB:
Gender:
Phone:
Address:
Insurance: 
Primary Care Provider: Dr. Brown
Contact Permissions: Mike McGlade, husband

History – 04/24/19

H&P: Mrs. McGlade is a 61-year-old woman with a PMH of breast cancer. 
Family Hx Mother: 
Father: Alive.
Sister:
Meds on Adm:
Neuro:
Cardio: EKG Normal.
Respiratory:
GU: Menses have ceased.
GI:
POC:

Allergies & Medication – 04/24/19

Allergies: NA.
Medication: Estrogen

Lab – 04/23/19

CBC:
RBC: 5.1
HCT: 38.8
HGB: 14.7
WBC: 11.1
MCV: 81
MCH: 31
PLT: 301

BMP:
Glucose: 399
BUN: 15
CR: 1.1
Sodium: 138
Potassium: 4.2Chloride: 106
Chloride: 106
Co2: 23
Calcium: 11
Protein: 7.9
CA-125-1700 U

Primary Care Notes – 04/24/19

04/21/19: Mrs. McGlade is a 61-year-old woman with a lump that may be breast cancer. DX: Dr. McCall, suspected breast cancer
Called Dr. Brown-GYN ONC. Consult expected for tomorrow. Suggested CA-124, HCG, AFP prior to consult.

04/23/19:

04/24/19: MRI negative for spinal cord or brain lesions. 
Plan of care: Breast oncology consult. 
CBC, BMP, CA-125, HCG, AFP, Paracentesis, in am. PT, SW, CM consult.

GYN/ONC Note – 04/24/19

61-year-old woman with a possible PMH of breast cancer.

Her initial exam revealed an enlarged mass in right breast. GYN/ONC physical exam. Based on physical presentation, blood work and radiology studies, breast cancer is confirmed. Discuss with pt. treatment options such as surgery and/or chemotherapy and radiation.

VALLEY CITY, NORTH DAKOTA

Sacred Heart Hospital

It’s time to meet Caroline McGlade, a 60-year-old patient who has breast cancer. Remember, you’ve been asked to talk with this patient because she’s a typical example of someone who hasn’t been getting preventative care—a factor that makes it difficult for the hospital to qualify for ACO status. Be sure to refer back to her EHR, and think about ways the EHR could be modified to better collect qualify metrics for patients like this one.

Mrs. McGlade, how are you feeling?

Caroline: I feel just fine. A little scared, I guess. But it’s hard to believe I have cancer. I mean, I don’t feel sick at all. I guess I’ll start feeling sick once they start giving me that chemo. I’m not looking forward to that, believe me!

Can you tell me a little bit about yourself?

Caroline: I guess you could say I’m a pretty typical lady from Valley City—not very exciting! I’ve lived in this county all my life. I grew up on a farm near Tower City. Then I got married to my high school sweetheart and we live on a big plot of land about 45 minutes from here. I wouldn’t want to live anywhere else. Sometimes I wish we had more neighbors, but Mike and I like living in the middle of nowhere! I guess you could say we’re independent spirits? That’s how we were raised—we don’t like to be dependent on other people. We have four kids—our son lives in Valley City and our three girls live in the Fargo-Moorhead area. Nine grandkids so far.

How did you discover the cancer?

Caroline: I felt a lump. It wasn’t big and at first I didn’t think it was anything to worry about. I don’t like running to the doctor every time something feels weird in my body—I mean, that’s just part of getting old, right? But my daughter finally convinced me to get checked. And I guess I’m glad I did. Stage 3 breast cancer—that’s pretty serious.

Have you ever gotten a mammogram?

Caroline: Yeah. I think twice? Maybe three times? It’s been a long time though. I don’t know…I guess they could’ve caught the cancer earlier if I went more often. But I’ve heard that mammograms aren’t all that important. You can find a lump pretty easy by checking your breasts, right? And I do that once a month or so.

Do you regularly see a gynecologist?

Caroline: Well, I did when I was pregnant—but that was a long time ago. My youngest daughter is 30 years old. And when I needed birth control pills—then I used to go. But there’s no reason for me to go at my age, right? It’s not like I need birth control pills anymore—I mean, I finished with menopause when I was 47! I don’t know—I guess maybe I should have gone more often. But I really hate … you know, putting my legs in those icky metal things? I just don’t like having doctors poking around my private parts. Maybe if there were a woman doctor around here I might have gone more often, but around here there’s not a lot of choice who you see. All the gynecologists I’ve ever been to, they’re old guys who are kind of creepy.

Do you regularly see a primary care physician?

Caroline: No, not anymore. When Dr. Tucker was alive my husband and I used to go… but he died about seven, eight years ago? And we’ve never bothered finding a new doctor. Like I said, there aren’t a lot of doctors around here, and we’d have to drive 45 minutes to get to one. Gas is expensive, so we don’t like to go on trips that aren’t necessary. And I don’t want to go to someone I don’t know. Dr. Tucker, he was my doctor since I was a teenager. I guess we ought to find a new doctor, but we just don’t get sick very often. A few times we’ve gone to Urgent Care, but we don’t like to go running to the doctor every time we have some aches and pains. We can’t stand people who do that.

Have you ever gotten a colonoscopy?

Caroline: NO! No no no. Nobody’s sticking a camera up in there, or whatever it is they do. My husband’s never gotten one either–I’m pretty sure he’d rather die! Besides, those tests costs a fortune.

How do you feel about preventative care?

shots and such? We got all the immunizations for our kids. Oh, do you mean, like preventative care for adults? Like getting your cholesterol checked and all that? I don’t know. I guess I kind of feel like that’s a waste of time. And it’s expensive too. We just try to eat healthy and get some exercise. Neither one of us is overweight, so it’s not like we’re going to get diabetes or anything like that.

Why haven’t you gotten more preventative care?

Caroline: Well, why would we? Like I said, we’re pretty healthy and we don’t like to run to the doctor for every little thing. If there were a doctor around who I trusted, I guess I would go more often. Plus going to the doctor is expensive. It didn’t used to be so bad when we were younger, but now going to the doctor costs a fortune. My husband and I are doing okay, but we definitely don’ t have money for extras.

Have you always had health insurance?

Caroline: No, we’ve almost never had health insurance. Just during this one period when my husband was working in town for a factory that closed down. But we have health insurance now, thanks to that Obama! We don’t have a choice anymore, do we? Although much as I hate to admit it, maybe it’s a good thing we have insurance. Otherwise I don’t know how we’d pay for cancer treatments.

Do you think your views about health care and preventative care are typical for people in this area?

Caroline: Yeah. I don’t know anyone who goes to the doctor a lot. Most of the people I know, they have even less money than we do. And like I said, people are independent around here. People don’t like to ask for help unless we really need it. So going to the doctor a lot… I guess that’s not something people like to do around here.

Email response:

RE: Quality Metrics Tracking

From: Karen Dellington, Admissions and Discharge Director

To: Employee

I see you’ve spoken with Caroline McGlade! I wanted you to meet with her because her case is typical of so many that we see around here. We need to address the types of issues you encountered with this patient—especially regarding preventative care—if we’re going to become an ACO. And before we can do that, we need to gather data on these issues.

I’ve arranged for you to meet with a panel of four people at SHH so you can ask them some questions about the strategies we need to develop in order to better track quality metrics. The panel will consist of:

1. Todd Chester, Director of Quality Assurance
2. Mary Loudsinger, a social worker
3. Pete Wade, Director of Information Technology
4. Trish Walstrom, the Care Coordination Manager

Thanks again for your hard work!

–Karen