Child and Adolescent Health and Health Care Quality Measuring What Matters (2011) / Chapter Skim
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5 Measures of Quality of Child and Adolescent Health Care
5 Measures of Quality of Child and Adolescent Health Care
Pages 135-174
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From page 135... ...
However, the development of quality measures for child and adolescent populations has been slow to emerge from the private sector because enhanced quality is unlikely to produce short-term reductions in health care costs (in contrast to the results as sociated with quality improvement efforts for adults and older adults)
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From page 136... ...
Func tional status measures for children and adolescents are not standardized, however, and frequently rely on parental reports rather than comparison of a child's behavior or skills with those of others with similar health conditions. • V ariations in the definitions of race, ethnicity, and primary language in state databases are major obstacles to the develop ment and use of heath care quality measures for children and adolescents.
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From page 137... ...
Although the Secretary's report provides an important benchmark for assessing the current status of quality measurement of child and adolescent health care services, it also highlights key barriers and challenges that have yet to be resolved. In summary, the Secretary's report offers the following key findings: Measurement and Reporting • A lack of uniformity and substantial variation in data reliability exist in state-based quality metrics, demonstrating a need for stan dardized data collection formats.
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From page 138... ...
The review highlights how the findings from the 2010 HHS Secretary's report might be considered in light of persistent areas of need and emerging opportunities for improving the measurement of health care quality, particularly for children and adolescents enrolled in Medicaid and CHIP health plans. The focus is on five key questions: • What is the purpose of health care quality measurement for chil dren and adolescents?
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From page 139... ...
Thus they provide the ability to hold health care state systems and health plans accountable for their performance. • Quality improvement -- Quality measures can be useful for provid ers and others who are seeking to improve the quality of care.
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From page 140... ...
The creation, selection, and certification of quality measures are driven by multiple public- and private-sector efforts aimed at accomplishing one or more of the above three objectives. Providers have tended to focus on opportunities for clinical improvement, while employers and other private payers have tended to place more emphasis on improving the effectiveness and efficiency of clinical services for prevalent, high-cost conditions that often require interactions with multiple health care providers and health care settings.
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From page 141... ...
• Because many important services and conditions other than health care, such as educational services and community nutrition pro grams, contribute to child health outcomes, a framework that explicitly acknowledges this shared accountability is especially im portant for child health. Measures that reflect this shared account ability, such as school readiness, can be constructed and used for quality improvement programs, but they are more difficult to apply within the narrow context of health care accountability.
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From page 142... ...
Only seven quality measures for children and adolescents are reviewed in that report, and those measures are used in only 30 states and only for those enrolled in Medicaid managed care programs. As a result, the nation is far from having a performance measurement system that can foster the incorporation of the above features into the development and use of quality measures for child and adolescent health care.
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From page 143... ...
measures that had been developed as part of quality improvement efforts among private health plans -- efforts focused largely on adult health care quality. During the past two decades, CMS worked with multiple partners to develop quality measures that could be used to assess and improve health care services for children and adolescents enrolled in Medicaid and CHIP health plans.
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From page 144... ...
The authors also examined how existing health care quality measures are distributed across the different purposes of health care -- acute care (getting better) , preventive care (staying healthy)
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From page 145... ...
. Congress also directed that child health care quality measures specifically address mental as well as physical health care, care across the full spectrum of child development, care integration and access as reflected by accessibility of care in inpatient and outpatient settings, and the duration and stability of health insurance coverage.
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From page 146... ...
Title IV also mandated a study by the National Academies "on the extent and quality of efforts to measure child health status and the quality of health care for children across the age span and in relation to preventive care, treatments for acute conditions, and treatments aimed at ameliorating or correcting physical, mental, and developmental conditions in children." That study is the subject of this report. The CHIPRA legislation represents a landmark in its emphasis on quality of care for the nation's children, reflecting a drive toward achieving quality measures that can provide common data elements and facilitate consistent reporting by the states, with allowance for flexible use to address each state's individual needs.
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From page 147... ...
These additional pieces of legislation placed further emphasis on issues of access (to both insurance coverage and health care services) , quality, and cost in the health care system.
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From page 148... ...
The Obama Administration's National Quality Strategy, announced by the Secretary of HHS, strives to align federal efforts with those of the states and the private sector and to foster collaborative partnerships wherever feasible. The ACA directs the Secretary of HHS to integrate these efforts into a cohesive strategic plan with priorities for improving the delivery of health care services, patient health outcomes, and population health.
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From page 149... ...
outlining which agency will take the lead role for various provisions in Title IV of CHIPRA. According to the MOU, AHRQ is leading the implementation of four provisions: the identification of the initial core measure set, the establishment of a quality measures program, the development of a model EHR, and the IOM study that is the basis for this report.
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From page 150... ...
. The ultimate goal is to support states in their efforts to adopt consistent, standardized statewide health and health care quality measures; encourage the use of existing data sources, including both population health surveys and administrative records; and provide a basis for comparing provider and health plan performance in contributing to the achievement of national and statewide health goals for children and adolescents.
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From page 151... ...
. As noted in Chapter 2, different data sources are used for different objectives, and the nation lacks effective mechanisms that can link the health indicators generated by population health surveys to privately and publicly funded quality improvement efforts focused on measuring health care processes and outcomes in clinical care settings.
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From page 152... ...
CMS has piloted a pediatric measure program to develop and evaluate the core quality measures, as well as created a strategy for states' voluntary collection and reporting of data on the performance measures. CMS also has developed a compendium of quality measures to give states options to consider in identifying quality measures that best support their specific quality strategies and address the needs of their populations.
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From page 153... ...
Based on recommendations by AHRQ National Advisory Council for Healthcare Research and Quality Subcommittee on Children's Healthcare Quality Measures for Medicaid and CHIP Programs (SNAC)
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From page 154... ...
Finally, it will be necessary to determine how states use health care quality measurement to improve outcomes for these children and adolescents, and how these outcomes compare with those of other populations of children and adolescents, such as those who are uninsured or are enrolled in private health plans. The process initiated by AHRQ and CMS in identifying a small set of core measures for use by the states is an important beginning.
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From page 155... ...
. Ultimately, the process used by the SNAC members to identify the initial core set of measures took into account validity, feasibility, and importance (AHRQ, 2010g)
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From page 156... ...
Now that the initial core set of measures has been developed, AHRQ and CMS are moving into the next phase of development for the core set of pediatric quality-of-care measures under a Pediatric Quality Measures Program. This program is charged with improving and strengthening the initial core set of measures by continuing to evaluate those measures, as well as increasing the portfolio of evidence-based measures that can be used by purchasers, providers, and consumers of health care for children (AHRQ, 2010c)
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From page 157... ...
. Under care coordination, for example, combining treatment plans for a parent's mental health disorder with preventive services for the parent's child(ren)
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From page 158... ...
and early in young children (e.g., stage mental disorders; Screening for physical parent management in-home EBP treatment and learning disabilities, training) , parental (e.g., multisystemic mental health, substance treatment for psychiatric therapy [MST]
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From page 159... ...
Timeliness Prevention and All-hours access for screening: immunizations childhood diseases; and screening exams on timely referral schedule Patient/ Parent and adolescent Parent and adolescent Supports to children Family-Centeredness assessments of assessments of with special health communication of communication, care needs and their information about child's responsiveness to parents/caregivers; developmental status, preferences, etc. in communication of child's needs to maintain acute care; child/parent treatment plans and healthy development; participation in decisions prognosis; child/ parent education at about treatment type parent participation each developmental in treatment planning, stage to foster cognitive, implementation, and emotional, and social monitoring functioning Access Regular source of Ability to obtain Availability of needed care; primary care and treatment for acute services for children with schools as portals of illness; insurance special health care needs; entry to care; primary coverage for all youth; access to specialty care care providers trained support for access to for major depression, to assess mental health/ care (transportation and including medication substance abuse child care)
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From page 160... ...
) Individualized team-developed care plans, tracking of modifications, and family input Integration of information and treatment among health care providers, schools, and other human services, especially child welfare and juvenile justice Infrastructure Integration of data systems across all systems of care, comprehensive medical/developmental record; systems for referral Mental health content in electronic and medical records Feedback systems that report reduction in symptoms, improved functioning, and corrective actions Measurement of outcomes by child's age and race/ethnicity, including family indicators and family experience with treatment
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From page 161... ...
While many states lack these capabilities, a few are taking steps toward building the technical resources and analytical skills that address these objectives. The use of quality measures in state-level reporting may be enhanced by greater national benchmarking efforts and efforts to achieve more transparency in the state-based reports and other information presented to AHRQ and CMS.
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From page 162... ...
This focus on quality improvement as part of clinical practice offers fertile ground for the introduction and use of relevant quality measures. Monitoring of Care Transitions and a Life-Course Perspective Understanding of child and adolescent health has evolved to embody a life-course perspective, as discussed in Chapter 2, an approach that recognizes that children are in a constant state of development; that they have different needs from health care providers at different points in their development; that disease prognosis and treatment are affected by developmental factors; and that in this unique stage of life, children are perhaps even more susceptible to environmental influences on their health and well-being than are adults (IOM and NRC, 2004)
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From page 163... ...
This gap may be especially acute for adolescents with special health care needs or with chronic health care problems, who have a critical need to find new doctors that serve adults, as well as find other forms of insurance coverage (Callahan et al., 2001; Scal et al., 1999)
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From page 164... ...
. Measuring child and adolescent health care requires having the ability to look across visits and services to determine whether all required components of care were delivered for a particular age (Scholle et al., 2009)
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From page 165... ...
for use in their quality improvement efforts (CAHMI, 2010) , and its results can be used to create community-specific assessments of adolescent health.
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From page 166... ...
. Both the ABCD initiative and the PHDS-PLUS effort have developed quality measures that states can use as baseline information systems to improve their efforts to implement preventive and developmental services for children served through Medicaid managed care plans.
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From page 167... ...
Opportunities to Link National Databases Improved outcomes for populations of children and adolescents may be monitored through efforts to link to more national databases. The potential to link files across two or more national databases holds promise for providing further insight into contextual factors that constitute important health influences for children and adolescents, demographic variables that may be correlated with the use and quality of health care services, important outcomes for populations of children and/or adolescents, and improvements at the community and national levels.
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From page 168... ...
. Jurisdictional Issues Among Federal Agencies One persistent barrier to efforts to achieve an optimal national measurement system for child and adolescent health and health care quality involves jurisdictional issues among federal agencies.
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From page 169... ...
. Indiana: Child Health Improvement through Computer Automation System The Child Health Improvement through Computer Automation (CHICA)
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From page 170... ...
This type of innovative practice requires expertise in working with multiple population health and administrative data sources, as well as statistical methods for comparing and analyzing data trends over time for selected populations. Rhode Island: Asthma State Plan One compelling example of a state-based partnership that uses data from multiple sources to address a chronic health problem is the Asthma State Plan adopted by the state of Rhode Island (RIACC, 2009)
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From page 171... ...
Asthma Database. The Rhode Island Asthma State Plan demonstrates that federal and state-based data systems can be used to support collective action and quality improvement efforts designed to address child health problems.
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From page 172... ...
. SUMMARY This chapter has provided an overview of child and adolescent health care quality measures, emerging opportunities to improve the development and use of measures, and unresolved difficulties that continue to challenge both the measurement of quality and the delivery of high-quality care for children and adolescents.
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From page 173... ...
As noted in the previous chapter, there is no agreement on the appropriate domains for these measures, and little is known about the sensitivity of most such measures to medical care interventions. This chapter has highlighted a number of emerging opportunities to improve the development and use of child and adolescent health care quality measures.
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From page 174... ...
awards authorized by the CHIPRA legislation offer two important opportunities to build the evidence base for health care access and quality measures and to fill critical gaps, especially those gaps that address the specific characteristics and needs of younger populations. New initiatives associated with HIT and the creation of EHRs also offer substantial opportunities to foster the incorporation of children and adolescents into efforts to build the next generation of data sources and data collection methods.
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