TS_92190171_Quality300As somebody who actually enjoyed studying statistics and quality improvement, the focus of the new funding portfolio I oversee—Tools and Measures for Quality Care—sets my pulse racing.

But I've been around enough to know my enthusiasm for constructing statistical measures of performance isn't universal and that the greater good would be served if I explained our goals and why this initiative means a lot to all of us, whether we’re patients, caregivers, providers, payers, policy wonks, or other stakeholders.

In recent blog posts, my colleagues Rachael Watman , Nora O’Brien Suric, and Amy Berman introduced the John A. Hartford Foundation's objectives in developing three of our other new grant portfoliosLeadership in Action, Linking Education to Practice, and Models of Care—and gave examples of how we plan to execute our “downstream” strategy. Next Thursday, Marcus Escobedo will explain the fifth and final new funding area: Policy and Communications.

Today, I want to explain what we mean by Tools and Measures for Quality Care. The fundamental questions are not just about our current capacity and performance to deliver appropriate care for older adults. Equally important, we need to ask if our definition of success is the right one in the first place. Getting closer to the right answers requires focus, tenacity, and a multi-dimensional perspective on how our health care system operates.

As the name suggests, the strategic objective of our new portfolio is to improve the tools and measures that make up the infrastructure supporting the delivery of quality care for older adults.

Quality measurement and information technology tools can directly drive improvements in clinical practice and patient outcomes by enabling clinicians to benchmark themselves against peers, to identify poor-performing areas, to prioritize interventions, and to track the progress of quality improvement initiatives.

Given our national focus, the portfolio’s overarching goal is to test, develop, and disseminate new quality measures and information technology tools that provide improved feedback on quality and clinical indicators to providers and health care organizations. We hope to drive changes in the delivery of care for older adults in several ways. Among these, we hope to leverage federal efforts already underway and to shape the design of emerging regulatory frameworks to encourage health systems to make the necessary investments in their organizations to deliver appropriate and effective care.

We also hope to engage the health information technology vendor community in order to influence the spread and design of electronic health records (EHRs) that support clinically relevant processes and related quality measures. Along with this global reorientation, we hope to see health care delivered with a truly team-based approach in which doctors, nurses, and social workers collaborate equally in support of the older adult.

We’ve seen over the past several years a growing use of standard quality measures to help providers improve their work and to assure payers that they are getting value for money spent. As in other domains, we can’t improve what we don’t measure. That said, we need to remain vigilant that the measures and “rules” we’ve adopted are not only right but also work as intended.

As people in the field know, the potential for perverse behavior exists. Strict adherence to clinical practice guidelines may be ineffective or even dangerous for older patients. For example, under standard practice guidelines, a patient with hypertension, myocardial infarction, depression, diabetes mellitus, and osteoporosis can be harmed by the multiple medications prescribed for each condition.

This example also shows the hidden dangers lurking in the way that EHRs and quality improvement campaigns interact in the real world. To date, the increased adoption of EHRs and quality measures tied to Meaningful Use has been driven largely by billing and reimbursement. While that might be an obvious first step—after all, we start by doing what’s feasible—we’ve got to move beyond that paradigm toward a person-centered population health approach that supports relevant clinical processes and appropriate quality measures. To do otherwise is to risk lives.

As I mentioned earlier, we rely on quality measurement to drive improvements in clinical performance by enabling clinicians to benchmark themselves against peers, to identify poor-performing areas, to prioritize interventions and to track the progress of improvement efforts. However, most measures in use today are not designed for—or even tested among—older patients; and most are overwhelmingly disease-specific.

For example, was a patient prescribed aspirin upon discharge after recovery from a heart attack? Conventional measures don't account for multiple chronic conditions that older adults generally have to deal with.

There’s a clear need to specify new measures and goals that reflect the welfare of older adults. It is painfully obvious that our health care system adheres too closely to a limiting set of benchmarks and goals that are out of step with older adults' goals, sometimes doing more harm than good.

Historically, our nation has rewarded the effort of delivering care more than actual quality health outcomes. Unless we invert the prevailing paradigm, our health care system will continue to produce the effort of care without generating quality outcomes.

To attain ideal standards of practice, the portfolio will advance the spread of tools and measures appropriate for older adults; support the development of quality measures that reflect the outcomes that are important to older patients and their families; and promote the adoption of standards of care appropriate for older, vulnerable adults with multiple chronic conditions.

By addressing these issues, the portfolio has the potential to engineer a pathway to foster significant practice and cultural change. It will enable providers and organizations to learn how current practices need to be modified to conform to the “big picture” of an older adult’s life. Moreover, it will reinforce other Hartford Foundation efforts to build health care teams that draw on the geriatric expertise and leadership of multiple disciplines, and it will help lay the foundation for a more integrated delivery system.

As an example of our work in this portfolio, and thanks to a partnership with The SCAN Foundation, the National Committee for Quality Assurance is working to develop outcome-based performance measures to evaluate how well integrated care plans are helping dually eligible beneficiaries attain person-centered goals.

This grant envisions a system of performance assessment in which the personal goals of the patient or the beneficiary set the context for all other goals, including performance on mechanical indicators of clinical and long-term care. In addition, this work will enable long-term care providers to get fair credit for the contributions they make, instead of quality being measured only in ways that health care providers can satisfy.

With new measures and information technology tools in place, we hope to change the structure of incentives and constraints, and ultimately evolve a new system structure that pursues what people—older adults, as well as their caregivers—actually want. And need.

This is the fourth in a series of Health AGEnda posts on the Hartford Foundation’s new funding strategies. Read the previous posts:

What the Heck Are Hartford's New Funding Areas? Part Three: Models of Care

What the Heck Are Hartford’s New Funding Areas? Part Two: Education to Practice

What the Heck Are Hartford’s New Funding Areas? Part One: Leadership in Action