Standardizing Community Care Coordination (CCC) Measures Linked to Improvements

in Quality of Life and Health Outcomes among Vulnerable Populations

 

Research sponsored by the National Institute on Minority Health and Health

Disparities, National Institutes of Health, US Department of Health and Human Services

 

 

NIH-SPONSORED RESEARCH

 

PROJECT OVERVIEW

Standardizing Community Care Coordination (CCC) Measures Linked to Improvements in Quality of Life and Health Outcomes among Vulnerable Populations, is a cross-cutting effort of broad relevance to a range of populations, diseases, and health outcomes. It will address the need for:

 

• A Quality Measurement Framework for Community-Based Care Coordination—The project will address the lack of standardized health care quality and access measures for these care coordination programs. It will create a measurement framework that focuses on key processes and outcomes, thereby providing a basis for quality improvement.  It will also build a mechanism for providing performance feedback to the participating programs, thereby providing the informational foundation needed to improve processes and clinical health outcomes for the patients served by these programs.

 

• Measures Specific to Unserved and Underserved High-Risk Populations—The participating care coordination networks focus on connecting unserved and/or underserved high-risk individuals to appropriate services.  There are few existing health care quality measures developed to assess services aimed at these populations. The proposed project supports current health reform and U.S. Department of Health and Human Services (DHHS) efforts to reduce health disparities through improved health outcomes for at risk populations.

 

• An Evidence-Base for Effective Care Coordination—The results of this project will advance the field by creating new and newly validated measures for assessing the unique impact of community-based care coordination on health and well-being, as well as beginning to build evidence base.

 

The outcomes of the project will be a set of tested measure specifications that can be used by care coordination organizations to assess and improve their operations, thereby advancing their mission to improve health.  This project will directly address the lack of appropriate measures to assess care coordination outcomes – the tools that come out of the study will make it possible to evaluate the quality of care, in this area over time.  This work will be of value to the health system when it is in the public domain. The CCCLN members and others will continue to use the measures that come out of this project over time as these measures will help them improve the quality of care as well as demonstrate the value and impact of care coordination.

 

The specific goals of the project are:

  1. Develop a logic framework for community-based care coordination, and identify related

      measurement domains for a comprehensive assessment of community-based care coordination

      quality and outcomes.

  2. Draft detailed specifications for specific care coordination quality and outcomes measures.  The

      measures will be cross-cutting across health conditions, processes of care, and outcomes.  They

      will also be designed for use across a range of populations and care coordination organizational

      designs.

  3. Assess the relevance, feasibility, validity and reliability of the measures through a pilot test at 5 sites.

  4. Finalize the measure specifications and develop documentation, data collection and reporting

      templates, benchmarking reports, and other tools to facilitate their use.

  5. Educate community care coordination providers on the use of data to inform decision-making.

 

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OPPORTUNITY AND POTENTIAL IMPACT 

This project addresses the lack of validated measures of care coordination quality and performance, and the lack of comparative performance data, particularly for community-based care coordination organizations.  This gap limits the ability of these organizations to assess and improve their performance.  The participating sites all structure their services around the Pathways Model of care coordination.  This will facilitate the development of a conceptual framework for measurement and increase the usefulness of the results for other organizations using similar types of care coordination interventions.  The measures will be sensitive to the needs of vulnerable high-risk populations including racial and ethnic minorities, underserved populations, and populations with complex medical needs as these groups are well represented among the populations served by these organizations.  One of the outputs from the project will be a functioning information technology platform that produces comparative reports and other data displays useful to program managers for identifying and addressing service delivery problems. This research will meet the needs of the community organizations to achieve their primary focus and simultaneously create the tools and systems to enable them to monitor and report on their service quality.

 

Areas of potential impact include:

 

• Develop Community-based Collaborations—This project will use qualitative and quantitative research methods to help community-based organizations work together and pool resources to develop a set of measures that will assist them in assessing the effectiveness of their care coordination programs.  This collaborative effort can be a valuable model for other community-based activities, promoting efficiency and coalition building to tackle other health care issues. 

 

• Bridge the Gap between Research and Practice—This project will provide a venue for community-based organizations to work with researchers to develop useful tools for use in real world settings.  Bridging the gap between researchers and practitioners is a constructive strategy for addressing issues that require first-hand practical knowledge integrated with theoretically- and research-based solutions. What is learned as a result of this project will be useful to other communities and other health-related problems as strategies are developed to improve other health outcomes.

 

• Apply Fiscal Resources Where Funding is Limited—This project makes funds available for important work that would be out of reach for any individual organization.  The web-based data management system will include components for data entry, analysis, and reporting.  The data will include clinical measures, process measures relating to the models of care, and measures of patient experiences. The data may be aggregated at multiple levels to serve individual program needs as well as needs at the community, county, state, region, or national levels.  These data are currently unavailable to the participating community which limits their abilities to assess their programs.

 

• Provide Input into the Health Care Reform Debate—The data generated from this project will inform the health care reform debate.  These objective data will provide information on both the model of health care delivery—care coordination—and on patients’ health outcomes.  The model is intended to improve the quality of care provided to patients (particularly those at high risk for poor outcomes), reduce the duplication of services provided, improve efficiency of service delivery, improve patients’ experiences with the health care system, and increase effective utilization of the health care system.

 

• Provide Input into Health Care Financing—The model employed in this project is intended ultimately, to impact payor systems—both public and private insurance—by reducing duplication of services, avoiding inefficiencies in the delivery system, and reducing the number of claims from costly emergency room visits.  The data collected by project participants will address these concerns.