Patient health outcomes as a cornerstone in seeking the Quadruple Aim

By Jason Foltz, DO, family physician and chief medical officer, ECU Physicians/Brody School of Medicine, East Carolina University, foltzj@ecu.edu; Drillious Gay, RN, BSN, MSN, director of quality and analytics, ECU Physicians/Brody School of Medicine, East Carolina University, gaym@ecu.edu; Martha Dartt, RN, MSN, FNP, chief nurse executive, ECU Physicians/Brody School of Medicine, East Carolina University, darttm@ecu.edu; and Robert J. LaGesse, MSM, FACHE, interim executive director, ECU Physicians/Brody School of Medicine, East Carolina University, lagesser15@ecu.edu.

At ECU Physicians, our quest for the Quadruple Aim continues despite the challenges of the evolving healthcare landscape. This pursuit began with a strategy for improvement focused on exceptional patient experience (as outlined in past MGMA articles).1,2 The second arm of that strategy is achieving better health outcomes for our patients.

Striving for better health outcomes aligns with our core purpose to “provide the highest quality, most compassionate healthcare to the patients of Eastern North Carolina, while educating the next generation of health professionals to do the same.”

Background

In 2015, ECU Physicians developed a strategic team focused on preparing for value-based healthcare. We were preparing to enter our first MSSP accountable care organization (ACO) participation agreement with our partner clinical integrated network (CIN). To be successful under MACRA and resulting value-based programs, we knew we would need to add resources while changing our culture. At the same time, North Carolina transformed its state Medicaid plan to a managed care platform with five prepaid health plans with a focus on pay for value. The basis for this transformation involved the formation of advanced medical homes with a focus on quality and outcome metrics.  

Methods

Preparing to succeed in value-based care involved following our strategic goals with structured annual tactics. Our desire to not settle for being “good” and instead strive to be “great” became the rallying cry throughout the practice. To achieve our goals, we focused on the following steps:

• Develop top-of-license nursing protocols
• Create physician, clinic and enterprise-level quality dashboards/report cards
• Deploy a monthly quality calendar with a specified focus each month
• Expand our quality team
• Create a culture of quality improvement through quarterly competitions
• Work at-risk patient lists
• Hire health coaches and annual wellness nurses for each of our primary care clinics.

Top-of-license nursing protocols

Developing top-of-license nursing protocols started with each team member understanding their role in quality measure outcomes. We developed checklists for primary care and specialty care certified medical assistants (CMAs) to complete at every patient encounter. Best practice advisories (BPAs) were added to the EHR to guide CMAs through each patient’s care needs. This empowered the CMAs to take ownership of their quality goals. To foster this, we met with CMA and nurse quality champions each month to share best practices and educate on the “why” behind what we are measuring versus a “checkbox” mindset. 

Quality dashboards

To become a data-driven organization, we invested in developing and operationalizing physician, clinic and enterprise-level quality dashboards. This allowed us to identify “bright spots” in our organization to share strategies for improvement with others. It also fostered a dose of healthy competition to help change the culture:

• Quarterly quality areas of focus for our primary care and specialty clinics led to top-performing clinics winning free lunch.
• We share all quarterly reports for all clinics at monthly committee meetings.
• Simple recognition events via thank you notes, “challenge coins,” certificates and recognition during leadership team rounds helped drive organizational pride and a sense of ownership.

Monthly quality calendar

To ensure we did not lose focus of the multiple competing quality performance measures, we developed our core “quality spotlight” measures and featured them in a custom monthly calendar for primary care and specialty care clinics.

Expanding the care team to close gaps

To be successful, we invested in key positions early in our transformation. The Office of Quality and Analytics hired two nurse specialists and a data analyst to support our clinical teams. The nurse specialists work closely with their assigned clinical leadership to ensure staff and providers understand how to close care gaps and provide data needed to show their clinic’s progression toward meeting quality benchmarks. The nurse specialists provide monthly reports for all clinics, highlighting comparisons of success for each measure. The reports also note specific trends so that clinics can adjust workflows to increase efficiency and reach their quality goals. In addition, provider scorecards are distributed monthly so all providers can monitor their success in meeting patient care quality goals. Goal setting, monthly presentations and support for the clinics by the quality team ingrain quality performance as a part of the organization’s daily workflow.

Next, the organization implemented a Medicare wellness program at ECU Physicians and hired annual wellness nurses for each of the primary care clinics to provide health promotion, counseling and education to our Medicare patients.

Our Medicare wellness program model has a centralized program coordinator who ensures patients’ Medicare eligibility prior to the visit and reviews all billing upon visit completion to maximize revenue potential for the program. This model has allowed the program to be self-sustaining and revenue-producing for each of the clinics.

When Medicare wellness nurses identify a patient care educational opportunity, they refer patients to a health coach, and family teaching is supplemented between physician visits. In addition, we found that our Medicare wellness nurses play a vital role in closing care gaps for our Medicare patients. In a review of all Medicare patients seen in 2019, we found a direct positive correlation between Medicare wellness visits and care gap closures.

The last group of nurses hired were our health coaches. Registered nurse (RN) health coaches were hired for every primary care clinic. They focused on the health of all patients initially and then, with improved reporting from the EHR, were provided lists of all ACO patients in their clinics. Their initial priority was ACO patients who missed follow-up visits or had high A1c numbers. The health coach also ensured that care gaps were closed for all patients they encountered. In addition, they serve as a partner to the annual wellness nurses and quality nurse specialists in understanding and communicating the quality goals.

While each of these specific nurse specialist groups have a different emphasis on providing better health for our patients, we quickly realized that collaboration among the nurse groups, as well as dividing quality work among our teams, contributed to our quality success. Whether team members work to close care gaps during a patient appointment, by phone or messaging a patient via our MyChart patient portal, the emphasis is on better health. As care gaps are closed and quality goals are met, the quality team and administration celebrate the work of the staff with clinic luncheons and recognitions such as the annual quality award presented by leadership to top quality performing nurses during our annual nurses’ celebration banquet.

Results

Through the changes made since 2015, we achieved shared savings in our partner MSSP ACO and are well prepared to transition into the Center for Medicare & Medicaid Services’ (CMS’) Pathways to Success program in 2022. Our quality analytics program is well prepared for our state’s Medicaid Managed Care transformation starting in July 2021. Because of our successful transformation, we are now entering an agreement to participate in a CIN focused on commercial payer value-based agreements.

Through it all, we successfully made the work of quality improvement and performance more enjoyable by working together as clinic-based teams to achieve our quality goals. We are confident this quality framework and these team-based strategies are helping our organization better prepare for our next steps in value-based healthcare.

Conclusion

Quality is clearly a team sport. Having a core purpose focused on high-quality care and setting a strategy around meeting each arm of the Quadruple Aim has prepared our organization to be successful in achieving better health outcomes for our patients. The organization understood the need for investment to achieve a dramatic change in culture to accomplish this level of success.

Notes:

1. Foltz J, Hopkins PD, LaGesse RJ. “Healthcare’s Holy Grail: The quest for the Quadruple Aim.” MGMA Connection. March 2, 2020. Available from: mgma.com/ecu-quad-aim.
2. Foltz J, Hopkins PD, Thompson J, LaGesse RJ. “Patient satisfaction starts with effective, efficient communication.” MGMA Connection. Sept. 1, 2020. Available from: mgma.com/ecu-quad-comm.