Closing Care Gaps: It Takes a Village

April 11, 2018
Shelley Riser, RN, BSN, MSHA, Vice President, Consulting Services and Clinical Innovation


Doctor and nurse discuss patient diagnosis.

Albeit a much smaller village now than in recent years. After all, it was not that long ago when ‘chart chasing’ was one of the most effective ways to close care gaps.

To improve population health, care gaps – a disparity between recommended best practices and the care that is actually delivered to individuals – must be identified and closed. To succeed in population health and value-based care, care gaps must be addressed efficiently and in a timely manner. HEDIS® measures, for example HbA1c testing and eye exams for diabetics, typically are based on the calendar year, and in the case of measures such as osteoporosis management in women ages 67-85 who had a fracture, there is a deadline of six months post-fracture to ensure a woman has either had a bone mineral density test or received a prescription for a drug to treat osteoporosis. 

Anyone who’s worked on the health plan side of HEDIS® measures and Medicare Star ratings is all too familiar with the late summer and fall scramble to close as many care gaps as possible. Health plans send teams of nurses to provider offices to review thousands of charts, otherwise known as ‘chart chasing.’ Many plans use expensive, labor-intensive, one-off tactics like mobile mammograms, bone density scans. And then have to do it all over again the next year. It’s quite costly to health plans, frustrating for participating providers and not necessarily the best way to achieve the Triple Aim.

There is a better way than chart chasing.

Earlier this year, Geneia’s CEO Mark Caron wrote about our vision of how healthcare providers, payers and employers work together to improve the health and quality of life for people with metabolic syndrome or prediabetes. At the heart of their collaboration and coordination is a shared analytics, insights and care management platform.

Given the specificity and complexity of HEDIS® measures, it’s difficult for me to imagine how to systematically identify and close care gaps without a shared platform. Currently, HEDIS® consists of 94 measures across seven domains of care. Measures are tied to a person’s age, gender and health status, and each has specific documentation requirements. For example, HEDIS® measures for children include well-child visits, and evidence of all of the following must be captured:

  • Health and development history (physical and mental)
  • Physical exam
  • Health education/anticipatory guidance

Let’s look more closely at Lucy.

Lucy* is a 42-year old mother of two teenagers and a part-time caregiver for her elderly father. For a woman of her age, there are a number of recommended best practice HEDIS® measures she should receive, such as:

  • Adult Body Mass Index (BMI) Assessment
  • Cervical Cancer Screening
  • Depression Screening and Follow up
Lucy a Hispanic forty something woman sitting. 

There are roles for Lucy’s health plan, her physician and his care team, and even Lucy to ensure she receives these preventive tests in a timely and efficient way.

In many ways, this work begins with the health plan. For the past three years, Lucy’s insurer has been the Allegiant Health Plan.

Improving HEDIS® Performance at Allegiant Health Plan

Allegiant Health Plan is a regional insurer that operates in a very competitive market. To distinguish itself among competitors, the plan sought National Committee for Quality Assurance (NCQA) accreditation five years ago, and has maintained this hallmark of quality since then.

Jaime Hedis Director and Dr. Todd Becker Lucys doctor. 

Jaime is the HEDIS® director at Allegiant Health Plan. At a population level, Jaime works to cost-effectively improve her plan’s HEDIS® performance by simplifying quality measure tracking for network providers including Lucy’s physician, Dr. Todd Becker and his colleagues at Granite Physicians.

Three years ago, Allegiant licensed Geneia’s Theon® platform to, in part, support Jaime’s work. (Allegiant’s value-based care providers, including Lucy’s physician, also use the platform.) As a result of Jaime’s use of the platform, she has been able to undertake three primary activities to improve her plan’s HEDIS® performance:

 

  1. Select priority areas for improvement in consultation with the plan’s clinical leaders.The rates of diabetes in Allegiant’s service area are quite high, and the three-year trend suggests the number will continue to grow. That’s why Allegiant has focused on closing HEDIS® measures related to diabetes, including measuring BMI, testing blood glucose levels and blood pressure screening, and has increasingly sought to identify prediabetics.
  2. Identify subpopulations of members with gaps in care, many of whom also are the plan’s rising-risk patients.For example, Jaime reviewed BMI trends to generate lists of members at risk for or with a metabolic syndrome diagnosis, which were then shared with Allegiant’s value-based care practices through the Theon® platform. Granite Physicians’ list from 15 months ago included Lucy.
  3. Create a timely, accurate and concise scorecard showing where Allegiant stands in relation to its annual HEDIS® goals and ultimately its NCQA accreditation.The scorecard helps Allegiant effectively target resources by pinpointing the best measures to focus on, which becomes increasingly important as the end of the calendar year approaches.

 

Each of Jaime’s initiatives have improved care for members like Lucy and simplified care gap closure for Lucy’s physician, Dr. Becker, and the plan’s value-based care providers. As a part of his practice’s pre-visit planning, Dr. Becker viewed Lucy’s information in the Theon® platform as well as Jaime’s list of members at risk for metabolic syndrome. Because Lucy was on Allegiant Health’s list of potential prediabetics, he ordered the fasting blood glucose test a year ago that showed Lucy, in fact, has metabolic syndrome or prediabetes.

Research shows about 70% of people with prediabetes will develop type 2 diabetes, and according to the Joslin Diabetes Center, prediabetics “are at increased risk of developing type 2 diabetes within a decade unless they adopt a healthier lifestyle that includes weight loss and more physical activity.” To prevent Lucy from progressing to diabetes, she needs to be supported to adopt a healthier lifestyle and engage in her health.

Research shows 70 percent of prediabetics will get type two diabetes. 

The use of the Theon® platform by her health plan, physician and care team simplifies and coordinates these efforts. In the year since Lucy’s diagnosis, Dr. Becker and his team have used the platform to monitor her progress on her care plan, including annual measurement of her BMI and nutritional counseling. Lucy’s referral to Allegiant’s health education program was done within the analytics platform.

And now the good news – 

In contrast to 90 percent of people with metabolic syndrome, Lucy knows she is prediabetic as does her health plan and physician. All of her care gaps have been closed. She’s received targeted, personalized and coordinated support to prevent her from becoming diabetic, all of which has been made easier through the collective use of the Theon® platform. 


* Lucy is fictional and not intended to represent any specific person. This information is provided for illustrative purposes only.


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