Critical Pathways to Improved Care for Serious Illness - Conclusion

Critical Pathways to Improving Care
for Serious Illness
Petrie-Flom/C-TAC Project on Advanced Care and Health Policy
Funded by the Gordon and Betty Moore Foundation
Convening Session
June 23, 2017

Agenda
10:30am – 10:45am Introducing the Project
10:45am – 11:45am Panel Perspectives on Serious Illness
11:45am – 12:30pm Core Framework Concepts
12:30 – 12:45pm Lunch Break
12:45 – 1:30 pm Lunch Table Discussion on Program Innovations
1:30 – 1:45pm Afternoon Break
1:45 – 3:00pm Panel Discussion on Design and Implementation Decisions
3:00 – 3:30pm Ideas for Collective Action and Concluding Remarks
3:30 – 4:00pm Networking Reception
Developing a Serious Illness Care Framework:
DRAFT for Discussion, © 2017 C-TAC
2

June 23 Panelists
Invited Panelists
• Anna Gosline, SM, Senior Director of Health Policy and
Strategic Initiatives, Blue Cross Blue Shield of Massachusetts
• Robert Sowislo, MBA, Government Affairs Officer, U.S. Medical
Management
• David Posch, MS, Executive Vice President, Population Health,
Vanderbilt University Medical Center
• Diana Franchitto, MBA, President & CEO, HopeHealth/Hope
Hospice & Palliative Care
• Gwynn B. Sullivan, MSN, Project Director, National Consensus
Project, National Coalition for Hospice and Palliative Care
• Jay Rajda, MD, MBA, FACP, Chief Clinical Transformation
Officer, Aetna
• Jennifer Valenzuela, MSW, MPH, Principal of Program
Department, HealthLeads
• John E. Barkley, MD, FCCP, Chief Medical Officer, Continuing
Care Services, Carolinas HealthCare System
• Muriel Gillick, MD, Director, Program in Aging, Harvard Pilgrim
Health Care Institute and Professor of Population Medicine,
Harvard Medical School
• Namita Ahuja, MD, Sr. Medical Director, Medicare, UPMC
Health Plan; Clinical Assistant Professor of Medicine, University
of Pittsburgh
• Torrie Fields, MPH, Senior Program Manager, Palliative Care,
Healthcare Quality & Affordability, Blue Shield of California
• Victoria Walker, MD, CMD, Chief Medical & Quality Officer, The
Evangelical Lutheran Good Samaritan Society
Project Partners
• Tom Koutsoumpas, Co-Founder and Co-Chair, Coalition to
Transform Advanced Care (C-TAC)
• Khue Nguyen, PharmD, Chief Operating Officer, C-TAC
Innovations
• Gary Bacher, JD, MPA, Founding Member of Healthsperien, Co-
Director, Smarter Healthcare Coalition, Adjunct Assistant
Professor, Georgetown University
• Janice Bell, PhD, MPH, MN, Associate Professor at the Betty
Irene Moore School of Nursing, University of California, Davis
• Mark Sterling, JD, MPP, Senior Fellow, Project on Advanced
Care and Health Policy, Petrie-Flom Center at Harvard Law
School; Chief Strategy Officer, C-TAC
• Brad Stuart, MD, Chief Medical Officer, C-TAC
• David Longnecker, MD, Chief Clinical Innovations Officer, C-TAC
• Theresa Schmidt, MA, PMP, Vice President of Strategy,
Healthsperien; Director of Data and Quality, National
Partnership for Hospice Innovation
3

Petrie-Flom / C-TAC
Project on Advanced Care and Health Policy
• Collaboration between C-TAC and the Petrie-Flom Center for Health Law
Policy, Biotechnology, and Bioethics at Harvard Law School
• Launched in 2016 to “foster development of improved models of care for
individuals with serious advanced illness nearing end-of-life, and to
apply interdisciplinary analysis to important health law and policy issues
raised by adoption of new person-centered approaches to care for this
growing population”
• C-TAC thanks Petrie-Flom and project partners for their contributions to
the development of the Framework:
• Healthsperien
• Gordon & Betty Moore Foundation
• The Betty Irene Moore School of Nursing at UC Davis
• The Center to Advance Palliative Care (CAPC)
• Kathleen Kerr
Critical Pathways to Improving Care for Serious Illness,
© 2017 C-TAC
4

The Serious Illness Landscape
5
Care
Transitions
PCMH
Home-based
Primary Care
Complex
Care
Management
Palliative
Care
Advanced Illness
Care
Hospice
US has most
expensive health
system among
peers and lowest
population health
quality1
Serious illness hospital
use rates is more than
twice rates for multiple
chronic conditions only2
1. Commonwealth: US Health Care, 2015 Issue Brief
2. Commonwealth: High-Need, High-Cost Patients, 2016 Issue Brief
In 10 years, 1 in 5 Americans will
be 65 or older2

Opportunity:
Shifting from Innovation to Implementation
• What are the organizational opportunities and
challenges in serious illness care to help fill the gap
between usual care and hospice?
• What are the available capabilities and where are the
gaps?
• What are your serious illness population health goals in
the next one to five years?
6
Usual Care Hospice

Project Objectives
Develop a flexible serious
illness care model
implementation framework
within a 6-month timeframe
Identify and assess evidence
related to the design and
implementation of a serious
illness program
Framework should identify
common program elements
and also recognize the need
for local variation in program
design and implementation
related to factors like payment
model, internal capabilities,
care setting, etc.
Framework purpose:
 Inform serious illness program
development, replication, and
scaling
 Integrate with care model
payment design
 Inform care model Proforma
simulator development
 Inform other aspects of design
and development such as
policy, standardized
measurements, and regulatory
analysis
7

Project Methodology to Date
Combine evidence and expertise, build consensus
8
Review of White Papers and Literature; incorporate program
reviews from Kathleen Kerr and Allison Silvers (CAPC)
Develop draft Framework
Host 1st Convening Session with 23 panelists and 46
registrants
Conduct 9 follow-up interviews with stakeholders; host
webinar with 89 Attendees
Refine and enhance Framework; add details and definitions

Framework Objectives
Recognize relevant organizational characteristics and environmental
factors
Understand the range of population needs
Identify promising solutions: program structure and services
Elevate core care outcomes
Analyze implementation considerations
Synthesize findings into a useful Framework for serious illness
program design and implementation
9
Evaluate
evidence to:

1. Reflecting on the goals of the Framework, why are you
interested in this topic?
2. Can you talk about your own experiences implementing or
participating in a serious illness program?
3. Can you share how any experiences you’ve had as a
patient or caregiver have informed your perspective?
10
Panel Perspectives
Discussion Questions

Summary of the
Evidence
11

Summary of the Evidence
• Overarching Objective
• To review current evidence on the effectiveness of
serious illness care models
• Goals
• Provide evidence to support development of the
framework
• Create a resource to support organizations that are
developing serious illness programs
12

Guiding Questions
13
What serious illness care populations are included?
What is the strength and quality of existing evidence?
What program structures and services are associated with
success?
What outcomes are improved by serious illness care
programs?
What implementation considerations are described?

Results
743: Total Papers/ Programs
426 :Randomized or Controlled Clinical Trials
14
Papers identified
through review of
white papers
(n=26)
Papers identified
through expert
panelists
(n=12)
Abstract screened for eligibility after
duplicates removed
(n=36)
Excluded:
Not a review (n=6)
Pediatric only (n=1)
Single Intervention (n=1)
Review papers
included for final
abstraction
(n=28)

Results
Level 1 (13)
RCT=331
Level 2 (9)
RCT=76
Level 3 (6)
RCT=19
15

Serious Illness Care Populations
Category Label Examples Number of
Reviews
Condition Chronic illness, (two or more) chronic
conditions, disability, DM, cancer, HF,
CAD, COPD, CAD, dementia
20
Insurance (FFS) Medicare 8
High/Need High Cost High cost, higher than average costs,
at risk for hospital admission
7
Service Palliative care, hospice, long stay
nursing facility residents, community-
based primary care
7
Age Older adults (>65 years) 4
17

Program Services and Structure
Associated with Success
Patient Targeting
Face-to-Face
Contact
Transition
Management
Care
Coordination
Multidisciplinary
Teams
18

Outcomes
Health Service Use and Costs
Outcome Direction Total Reviews
(Level 1)
Hospital Admissions, Bed Days ↓ 13 (6)
Overall Costs ↓ 10 (6)
ED Use ↓ 5 (1)
19
Other notable findings: ICU days ↓
Specialty Visits ↓
LTC Admissions, Bed days ↓
Hospice Use, LOS ↑

Outcomes
Patient Reported and Other
(Level 1)
Experiences/Satisfaction ↑ 15 (11)
Patient Symptom Burden ↓ 6 (6)
Physical Health Status ↑ 5 (1)
Psychosocial Health Status ↑ 5 (3)
Mortality ↓ 2 (2)
Death at home ↑ 2 (2)
20

Outcomes
Care Process
(Level 1)
Quality of Care ↑ 3 (1)
Care Planning ↑ 2 (2)
Advance Directive Completion ↑ 2 (2)
21
Other notable findings: Communication ↑
Provider adherence to guidelines ↑

Outcomes
Health Service Use and Costs
(Level 1)
Hospital Admissions, Bed
Days
↓ 13 (6)
Overall Costs ↓ 10 (6)
ED Use ↓ 5 (1)
22
Other notable findings: ICU days ↓
Specialty Visits ↓
LTC Admissions, Bed days ↓
Hospice Use, LOS ↑

Considerations Affecting
Implementation
Relationships
Continuous
Improvement
Local Context
Culture Staff
23

Business Models
24
Payment structures should encourage value, scalability, and
sustainability
Program leaders should be financially invested in success
Payment must align incentives to support the care model,
such as moving to a population health model
Examine what reimbursement options exist in current FFS for
key roles (e.g., case managers)

Summary
• Ample evidence to support serious illness care
program development
AND
• Ample opportunities to contribute to this literature
• Health service outcomes beyond admissions
• Cost effectiveness
• Designs that test specific program components
• Tests of Business Models
• Care processes
• Dissemination and implementation
25

Serious Illness
Implementation
Framework
June 23 DRAFT
26

Developing a
Serious Illness Program
1. Assess and plan
Set the vision for the program,
perform an organizational and
environmental assessment, and
develop the appropriate business
model to address context and meet
program goals.
2. Design program
•Refine population parameters for
people you will serve and
understand the needs.
•Develop program structure that will
allow you to provide the services
needed to achieve optimal care
outcomes.
3. Implement program
Create an implementation plan and
guide your organization through
program roll-out and evaluation.
27

Context Matters
28
Payment
Options
Existing
Internal
Capabilities
Regulatory
Framework
Local
Context
Implementation Path
Business Model
Population
Structure
and
Services
Outcomes
Program
Vision
Serious Illness Program

Business Model
Conduct an Assessment to Identify Organizational and
Environmental Considerations
Organization
Operational Structure:
independent program , Part of larger
program, Partnership between
multiple providers / programs /
network
Legal Structure :“common
ownership” vs. convener /
contractual
Internal capabilities, existing
services and infrastructure to
provide and support services
Local context
Leadership
•Governance
•Senior Leadership
•Program / service leadership
Payment Sources
Medicare FFS
Medicaid
Private payer / private insurance
Medicare Advantage / Managed
Medicaid
Patient out of pocket
Charitable contributions
Contracted payment
Alternative payment models
Regulatory
Considerations
Federal requirements: e.g.
Medicare / Medicaid conditions of
participation
State licensure requirements
Restrictions related to referrals
and inducements
Antitrust
29 : Evidence-based characteristic





Organizational Structure
Considerations
30
Organizational Structure
•What are the vision and goals of the program?
•How far upstream and downstream do you want to impact?
•Where do the program’s goals align with organizational goals and
strategies?
•In what kind of organization are you operating? Physician practice,
home health, hospital, health plan
•How is the program structured? This will impact the resources and
program governance:
•Independent
•Part of a larger program
•Partnership between multiple providers / programs / network
Leadership
•Governance: How is program accountability structured? Who is
involved in strategic decisions?
•Senior leadership: how is senior leadership deployed?
•Stakeholder interest and influence: How does the program engage
stakeholders – consumers, providers, community organizations?
Local Context
•What are the needs of the community? How will you incorporate the
“community voice” to learn this?
•What are the availability and relationships among providers in your
area?
•What is the size of the potential population? Is there much variation in
the types of conditions? What are the unique population needs?
•What is the extent of population health programs and risks in the
market?
•What is the extent of your footprint?
• Will you serve a large/small geographic area?
• Urban/rural area?
Internal Capabilities
•What care delivery services already exist and how will they be
leveraged?
•What assets are already in place, and what will you need to buy,
develop, or outsource?
•Staff
•Expertise / Prior Experience
•Technology
•Equipment / Facilities
•What potential partners might fill any gaps?
Legal Structure
Is the organization commonly owned by provider participants, or is it a
convener/contractual model?

Provider Network
Reach of Program
31
P
P
P
PP
P
P
P
P
PP
P
P
P
P
PP
P
Intra-Impact
Provider reach within
program
Inter-Impact A
Provider impacts
connections to other
programs
Inter-Impact B Provider
reaches connected
programs within network
Extra-Impact system-
based program
reaches entire network
P
P
P
PP
P

Financial Considerations
32
Current Risk & Value-based
Payment Participation
Organizational Strategic Plan for
Future Risks/VBP
Federal & State Policies
Population
Health
Investments
Infrastructure
e.g. provider network,
analytics, new organizational
structure
Existing service improvement
(e.g. primary care
improvement) and overall
population health strategy
Serious Illness Programs
• Population Targeting
• Services
• Infrastructure

Payment Models
Payment Model Examples
Health
System
Hospital
Physicians
Home
Health
SNF
Hospice
Risk Contracts with Private Health Plans (e.g. MA, Managed
Medicaid, Commercial)
X X X * * *
ACOs (MSSP & Private Insurer Program) X X X * * *
Hospital Value-based Purchasing X X X * * *
Bunded Payment for Care Improvement X X X * * *
CMMI Primary Care & Specialty Models
(e.g. CPC+, IAH, Oncology, DM, ESRD)
X X
Home Health Valued-based Purchasing * X
SNF Value-based Purchasing * X
Medicare Care Choices Model * X
33
Provider Sector
X: common participant; *: potential participant

Regulatory Considerations
• Design Questions:
• What are the licensure and compliance requirements to deliver
new serious illness program services?
• Under current regulations, what services can your organization
deliver and who can you partner with to fill gaps?
• Common Regulatory Topics:
34
• Home Health Medicare Conditions of Participation: requirements for services delivered by HHA
• Hospice Medicare Conditions of Participation: requirements for services delivered by a Hospice
Federal regulations
• Home-based services
• State by state licensure requirements limit services across state lines
State licensure
• Anti-kickback, Stark
Restrictions related to referrals and inducements
Antitrust

The Serious Illness Population
35
Psychosocial Status
Barriers, Facilitators, and Supports for Coping
and Adaptation
Functional Status
Key conditions
Health Status
Perceived Health, Current
Status, and Trajectory
Care
Management
Needs
Low
Medium
High
Disease
Severity
Moderate
High
Disease
Progression
Stable
Intermittent
Decline
Gradual
Decline
Active
Decline
Physical
Status:
Activities of
Daily Living
Occasional
Assistance
Needed
Frequent
Assistance
Full
Dependence
Cognitive
and
Behavioral
Status
No
assistance
needed
Minimal
Moderate
High
Environment
/ Access
Good
Fair
Poor
Coping /
Resiliency
High
Moderate
Low
Social
Determinants
Positive
Impact
Negative
Impact
And/
0r
And/
0r

Population Characteristics
Prioritize to Program Intervention Design
Health Status
Disease Severity
•Hospitalization risk
•Number/type of chronic conditions and
comorbidities (advanced cancer, dementia)
•Severity of illness
•Condition requires disease management
•Prior utilization patterns, “high-cost / high-
need”
•Risk Score
Disease Progression
•Chronic illness/disability
•Terminal or life-limiting illness
•Expected rapidity of decline
Functional Status
Physical Status / ADLs
•The level of assistance needed for activities and
instrument activities of daily living and/or
caregiver burden
Cognitive and Behavioral Status
•Cognitive impairment
•Dementia/Alzheimer’s
•Mental illness
•Addiction
•Trauma/other psychological needs

Population Characteristics, contd.
Psychosocial status: Barriers, facilitators, and supports for
coping and adaptation
Environment / Access
•Provider availability and linguistic and cultural competency
•Transportation
•Access to food that meets dietary needs
•Insurance coverage or payment ability
•Physical features of residence
•Caregiver status and support at home
Coping / Resiliency
•Cognitive ability and mental illness as it relates to patient’s ability to care for self
•Motivation and self-management skills
•Social networks or isolation
•Existential or spiritual concerns
Other Social Determinants
•Socioeconomic status and economic stability
•Demographics
•Education and health literacy
Reference: http://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-
promoting-health-and-health-equity/

Patient Identification
Examples of Population Targeting Criteria
• Number/type of chronic conditions and comorbidities (advanced
cancer, dementia), life-limiting illnessDiagnoses
• Hospitalization / rehospitalization, other prior utilization patterns,
“high-cost / high-need”Utilization
• Serious mental illness, cognitive impairmentBehavioral Health
• Assistance with ADLs, caregiver burden
Functional
Impairments
• Poverty, access patterns, health insurance statusSocial Vulnerability
• Terminal diagnosis, less than 6 months to livePrognosis
• Risk Screening: “Would you be surprised?”, Risk Score Assessment,
Health Risk Assessment (Self/Qualitative)Risk
38

Population Targeting
by Value-based Payment Models
Alternative Payment Model Example Population Targeting
Medicare Shared Savings Program (ACOs) To be defined by ACO organization
Comprehensive Primary Care Plus Lower or higher risk
Independence at Home High risk w/ functional limitations
Bundled Payment Care Improvement Initiative High risk
Hospital Value-based Purchasing High risk
Home Health Value-based Purchasing High risk
SNF Value-based Purchasing High risk
Medicare-Medicaid ACO Social determinant/high risk
Medicare Care Choices Terminal illness
39

Population Targeting
by Provider Sector
Provider Sector Care Duration Population
Primary Care Low-High Risk
Specialty Care Mod-High Risk
Acute Care High Risk
Home Health High Risk
SNF/LTACH High Risk
Hospice High Risk
40

Multidisciplinary
team-based :
Patient, care mgmnt.
clinicians ,
providers, lay
navigators,
family/caregivers,
community health
workers ,
volunteers
Patient targeting 
Robust communication

Relationship building &
staff consistency 
24/7 Availability 
Site of Care:
Home  (in-person
or virtual services)
physician office/ clinic,
PAC/LTC facility,
hospital
Duration: Episodic vs.
Continuing
Care communication
platform 
Decision support tools

Continuous quality
improvement (CQI) 
Program Services and Structure
Design to Meet Population Characteristics and Needs
Care Coordination and
Transitional Care 
Multidimensional
assessment 
Goal setting and
comprehensive advance
care planning 
Proactive clinical/
symptom management/
medication
management 
Spiritual services
Health coaching / care
training 
Caregiver support 
Transportation
Home safety and access
adaptations 
Homemaker services
“Upstream” community
programming
DRAFT for Discussion, © 2017 C-TAC 41
Additive
Care Management
Services
Program Structure
 : Evidence-based characteristic

Care Management Services
Intervention Description Range of Designs
Care Coordination
& Transitional Care
Identify, coordinate, and facilitate follow-
up services
• Clinical and social services
• Patient coaching vs. coordination with providers vs. direct set-
up of services
• Transitional care focuses on coordination between care
settings/services (e.g. hospital to home)
Multidimensional
Assessment
Person-centered assessment: physical,
emotional, psychological, spiritual, and
social status; future risks
• Disease-focused vs. person-centered
• Hands-on assessment e.g. physical exam vs. question-based
assessment
Goal-setting &
Advance Care
Planning
Facilitate identification of values, beliefs,
and preferences over time. Elevate the
patient’s voice. Promote shared decision-
making
• Frequencies of planning: once vs. occasional vs. ongoing
during advanced illness to end-of-life
• Aspects of planning: advanced directive, link personal
values/preferences with end-of-life treatment modalities
Proactive
Clinical/Symptom
Management
Facilitate proactive management of
clinical issues (includes ADL support,
cognitive support, psychological support,
behavioral health, medication
management, etc.)
• Monitor and anticipate clinical status and coordinate with
treating providers
• Provide clinical expertise and manage clinical issues along with
treating providers
Spiritual Services Operational processes to identify and
enroll eligible patients
• Strict vs. informal eligibility determination, linked to exclusion
and discharge process
• Organized vs. informal identification process
• Access to EHR for clinical information or automated reports
42

Care Management Services, contd.
Structural
Component
Description Range of Designs
Health Coaching /
Care Training
Utilize patient engagement techniques to
coach patient on self-management
• Patient’s self-management skills and motivation
• Social, emotional, and clinical aspects of health literacy
• Disease-focused management
Caregiver Support Provide technical guidance and emotional
support to caregivers;
conduct caregiver assessment
• Caregiving skills and confidence
• Caregiver’s well-being assessment & additional support
such as respite services
Transportation Facilitate transportation to patient
appointments or other locations
• Program vans/cars
• Rideshare services
Home Safety /
Access
Adaptations
Assess and modify the patient’s residence to
improve ability to function safely
• Access ramps and through floor lifts
• internal widening for wheelchair access, grab bars
• Bathroom and Kitchen adaptation
• Security alarms and motion alarms
Homemaker
services
Assist with daily household tasks • Housekeeping Services
• Shopping and errands
• Meal Planning and preparation
• Laundry, Dishes
• Pet care, plant care
“Upstream”
community
programming
Provide services to the community to support
population health.
• Education and health-literacy programs
• Community bereavement program
• Community outreach around key topics (ex. advance
directives)
Developing a Serious Illness Care Framework: DRAFT for Discussion, © 2017 C-TAC 43

Program Structure
Structural
Component
Multidisciplinary
Care Team
Composition
Clinical and non-clinical
resources involved in care
delivery
• Composition of team members involved in care management services
• Informal vs. formal division of responsibilities and coordination between team
members
• Scope and richness of care management interventions is dependent on team
composition
Patient Targeting Operational processes to
identify and enroll eligible
patients
• Strict vs. informal eligibility, exclusion and discharge criteria
• Organized vs. informal identification process
• Access to EHR for clinical information or automated reports
Relationship
Building and
Caregiver
Consistency
Staffing structure to support
relationship-building with
patients, family and usual care
providers
• Patient and provider experience of various team member encounters
• Clarity of main point of contract and team coordination
• Staffing plan must balance efficiency with caregiver consistency
Robust
Communication
Communication between
coordinators, patients, and
providers via multiple channels
• Face-to-face contact on a regular basis
• Telephone outreach (regular/daily)
• 24/7 support line
Days of
Operation
Care access and clinical
response approach based on
days of operations
• Prevention and anticipatory management can be accomplished during
business hours
• Time-sensitive interventions require 7-day or 24/7 coverage (e.g. transitional
care, high-acuity co-management services)

Program Structure, contd.
Structural
Component
Care Delivery
Settings
Direct & virtual patient care
encounters in various care
settings
• Care management strategy and scope is dependent on delivery settings:
nature of advanced care planning varies if delivered in office or hospital vs.
home setting
• Virtual delivery/ telemedicine is effective and efficient but limits hands-on
care
• Physician coordination is facilitated by office/clinical presence
Care
Communication
Platform
Communication tools between
program staff and usual care
providers
• Electronic care notes vs. paper
• Integration and accessibility within dominant EHRs/HIE platforms
• Availability and enforcement of communication guidelines
Decision-support
Infrastructure
Tools to support care team
decision-making process on a
routine basis
• Manual data tracking vs. automated or structured reporting to inform care
progress: daily view to aggregated analyses to monitor performance and
guide improvement
• Use of electronic triggers and status summary to support care manager’s
decision-making process
Program Duration Services strategy and
outcomes are linked to
program duration
• Ongoing vs. fixed time-frame vs. episodic services
• Opportunity for improvement and level of gaps in care are key drivers to
determining scope and duration of services
Continuous Quality
Improvement
Quality and performance
improvement program
• Measure performance toward key metrics
• Implement performance improvement projects
• Conduct root-cause analysis
• Process redesign

Outcomes
Person-centered & Value-based to Define Program Success
Experience
Patient Experience
and Person-
centered
Preferences ↑
Caregiver
Experience ↑
Clinician / Staff
Experience
Quality of Care
and Support
Process
•Critical assessment &
screening
•Appropriate and timeliness
of services
•Patient and family
engagement
Outcomes
•Functionality ↑
•Symptom / clinical
management ↑
•Patient safety
•Care concordance with
goals and preferences
•Self-efficacy
•Mortality / survival
Utilization / Cost
Inpatient &
Other
Utilization ↓
Out-of-pocket
Cost
Total Health
Care Cost ↓
Operation
Market
penetration
Financial
sustainability
Staffing levels
Partner
relationships
: Strong and Consistent Evidence for Impact

Choosing Measures
Selecting Measures
Align measure concepts with
program goals and payment /
regulatory needs
Translate to specific metrics
under various value-based
payment program domains
Consider process, outcomes,
and structure measures
Identify broad measures of
program success and specific
measures for quality and
performance improvement
Consider feasibility of
collecting data
Aligning Measures
SampleProgramsRequiring
MeasureReporting:
Quality Payment
Program (MACRA)
MA 5-Star Rating
System
Medicare Quality
Reporting Programs
CMS/CMMI value-
based programs
47

Sample Measure Concepts
48
Experience
Patient Experience
•Patient feels services reflect goals and preferences
•Satisfaction with and confidence in care
•Patient feels social, emotional and spiritual needs are met
Caregiver Experience
•Caregiver burden
•Confidence in care provided
•Satisfaction in care
•Caregiver health status: physical/mental/emotional
Clinician / Staff Experience
•Turnover and retention
•Employee engagement
Utilization and Cost
Inpatient & Other Utilization
•LOS at each care setting
•Hospitalizations, readmissions
•ER Use, ICU Use
•Unnecessary visits, tests, and medications
Out-of-pocket Costs
•Cost to patient and family
Total Health Care Expenditure
•Provider sector (e.g. hospital) and health system
•Health plan
•Total system: payers & provider
Quality of Care and Support
Process
•Critical assessment & screening
•Appropriateness and timeliness of services
•Patient and family engagement
•Documentation of goals and preferences
Outcomes
•Functionality (physical, mental)
•Symptom / clinical performance
•Patient safety: falls, medication errors, etc.
•Care concordance with goals and preferences
•Self-efficacy
•Mortality / survival
Operation
Market Penetration
•Number of Patients Served
•Geographic footprint
Financial Sustainability
•Net revenue or loss
•Donations or investments
Staffing Levels: Caseload;
Partner/Provider Relationships
•Number of contracts
•Referral patterns

NQF Measure Framework*
Consider when selecting quality measures
Hierarchical Framework
•Parsimonious set of high-impact
outcomes to assess progress as a
nation.
High
Impact
Outcomes
•Prioritized accountability
measures to drive toward higher
performance on high-impact
outcomes.
Driver
Measures
•Priority measures in
specific settings and
conditions that contribute
to high-impact outcomes.
Priority
Measures
•Prioritized measures
to drive
improvement:
standardize & share
Improvement
Measures
NQF Prioritization Criteria
• Outcome-focused
• Improvable and
Actionable
• Meaningful to patients
and caregivers
• Support systemic and
integrated view of care
Serious Illness Care Model Implementation
Framework: For Discussion Only, © 2017 C-
TAC
49
*Content from: Burstin, Bernot, and Tilly. “Strategic Plan: Prioritization of Measures and Gaps”. NQF Annual
Conference Presentation, April 4, 2017

Implementation Considerations
Staffing
Strong/ engaged
organizational
leadership 
Implementation
Project Team
Current Staff 
New Staff
Outsourced Staff
Caseload
Infrastructure
Facilities
IT: hardware,
software, EHR,
interoperability 
Communications 
Transportation
Change
Management*
Stakeholder
Engagement 
Process Redesign
and/or Integration
Policies/procedures
and practice
guidelines
Staff Development
(inc. education) 
Ongoing
“Hardwiring”
Community
Engagement
Partner Outreach 
DTC Marketing
Volunteer Program
Program
Evaluation
Continuous
Learning, QAPI,
PDCA 
Metrics 
Data and Analysis

50
Developing a Serious Illness Care Framework: DRAFT for Discussion, © 2017 C-TAC
 : Evidence-based characteristic, *Consider in relation to organizational culture
Communication 

Designing to Achieve Desired
Levels of Impact
• Staff engagement
facilitates effective
implementation
• Most prominent
advantage is when
programs both:
• Fill previously unmet
needs of specific
populations
• Improve quality of care
and provider efficiency
• Most common barrier
is insufficient or
variable staff buy-in
and participation
• Multiple competing
priorities and demands
on their time and;
• Need for clearer
protocols and
definitions of care
processes and staff
roles and
responsibilities
51

Program Development Risks
•Interoperability and data management are often barriers to implementation
Technology: EMRs, HIEs, Telehealth, mhealth, etc.
•Operational delays, Hiring delays, Protracted development of key program tools, Lengthy
approvals by IRBs
Unexpected Delays
•Examples: misinformation, miscommunication, population too narrowly defined, patient
identification and ability to contact
Outreach, referral, and enrollment challenges
•Participant’s needs and life characteristics
•Participant’s competing social needs and other needs and circumstances
Unanticipated Complexity
•Licensure or related complications
•Delays related to potential approvals required
•Ambiguity slowing implementation
•Potential for structural changes to address issues
Regulatory Challenges
52

Success Factors
Engagement
• Strong staff engagement
• Strong program champions who motivate and support
staff
Experience
• Leverage multidisciplinary expertise and share
learning
• Build on prior experience and past or concurrent
projects
• Repurpose existing tools of partner practices and
organizations.
Team
Development
• Develop high-functioning teams that communicate
effectively.
Iterative Learning
• Flexibility to improve and make modifications
• Adaptability of program components
53

Program Development Pathways
54
Correlation
between
Parameters
Population Needs
Service Intensity &
Scope
Business
Model
Organization
Payment
Regulatory
Population
Health Status
Functional
Status
Psychosocial
Status
Structure and
Services
Care
Management
Services
Program
Structure
Outcomes
Experience
Quality of Care
and Support
Utilization /
Cost
Operational
Implementation
Communication
Staffing
Infrastructure
Change
Management
Community
Engagement
Program
Evaluation

Set vision
for program
Complete
organizational
needs
assessment
Determine
business
model
Select
population
Outline
structure
and
services
ID desired
outcomes
Develop
needed
infrastructure
and staff
program
Develop plan
for program
evaluation
Lead change
management
activities
Conduct
community
engagement
activities
Evaluate program
& implement
sustainability
plan
Developing a Serious
Illness Program
55
Assess
DesignImplement

Lunch Table Discussion
From Innovation to Implementation
56
1. What do you consider to be the most critical components
of the Framework for promoting innovation?
2. What is the most innovative concept you have
encountered in the realm of serious illness?

1. How do you make program or implementation decisions
when evidence is limited?
2. What is the most important piece of advice you would
give to someone developing a new program or expanding
an existing program?
3. Reflecting on today’s conversations, what would make
the framework more useful for creating a successful
program?
57
Panel Discussion
Design and Implementation
Decisions

Next Steps
• This Project
• Complete and distribute White Paper
• Framework Launch Webinar: July 12, 2017
• Foundation for Further Work
• Payment Model Simulator
• Potential for peer-review publications
• Incorporation into a policy and regulatory agenda
• Creation of a research agenda to develop additional evidence
• C-TAC analysis of framework impact on consumers and program access
• Strengthen community engagement components
• Pilot framework use with future programs
• Launch Expert Steering Committee
• Join us at the C-TAC National Summit (Nov. 27-29)!
58

Additional Comments
Please address additional questions and comments to:
Project Manager: Theresa Schmidt (primary contact)
tschmidt@healthsperien.com
202.810.1310
Project Lead: Khue Nguyen
khuen@thectac.org
59

Critical Pathways to Improved Care for Serious Illness - Conclusion

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