6 Optimization Strategies for Quality Improvement

Section 6.1 Optimize Optimization Strategies for Quality Improvement

Use this tool to consider how to ensure that health information exchange (HIE) and health information technology (HIT) leads to quality improvement in your social service agency.

Time needed: 4 hours Suggested other tools: NA

How to Use 1. Review the current state of the art with respect to quality improvement studies in social services in general and with respect to use of HIE and HIT. 2. Using the visioning and SMART goal setting tools (in Section 2.1 Planning for HIE and e- Health), begin to measure your own local outcomes. 3. Collaborate with other social service agencies in your community, with state initiatives, and with professional society initiatives to promote adoption of standards of practice and outcomes measurement. 4. Apply a quality improvement process, such as Plan-Do-Study-Act so that improvements can be planned for, actuated, evaluated, and achieved. 5. Reflect upon how HIE and other HIT can aid in: measuring, reporting, and improving social services outcomes; defining technology requirements to support such activities; and promoting acquisition and adoption of such technology.

Quality Measurement, Reporting, and Improvement in Social Services Quality work is not easy in health care. Some experts suggest that poor health outcomes are hidden from the public on purpose to avoid blame. Poor health outcomes are often considered a moving target, given the complexity of the human condition and the limited influence any single health care provider can have on a patient’s lifestyle factors. Still, by any standard measure of health—infant mortality, life expectancy, etc. —the United States is not producing the best health outcomes for the price we pay (see: http://www.who.int/gho/publications/world_health_statistics/en/index.html). Improving the quality of health and health care is a high priority for the United States in general, and specifically the Centers for Medicare & Medicaid Services (CMS), other payers, state licensing and voluntary accreditation organizations, state departments of health, and—of course—the individuals who are served by the health care community. A number of strategies and processes for quality improvement are available for different health care domains. There is much less published work on measuring and improving outcomes relative to the intersection of social services with health care, or even determining the impact of social services on the health of a population. Some standards of care for social services

Section 6 Optimize—Optimization Strategies for Quality Improvement - 1 are beginning to be published (see the Society for Social Work Leadership in Health Care (SSWLHC) at: http://www.sswlhc.org/html/resources.php). SSWLHC has also published Healthcare Case Management Standards, available at: http://www.sswlhc.org/docs/swbest-practices.pdf. Some goals for quality improvement that include social services are also coming to light in the area of care coordination. To date, the evidence of impact of care coordination on expenditures is not strong http://www.ncbi.nlm.nih.gov/pubmed/19211468), while it is better when it comes to patient and physician satisfaction (see: http://www.mathematica- mpr.com/publications/pdfs/health/award_peikes_brown_chen_AH_2010.pdf). Finally, HIT that blends practice guidelines, decision support, and quality measurement is very new for health care providers and virtually non-existent for social services. At this time, studying the impact of social services’ use of HIT on outcomes is very difficult. The impact of HIE on health care quality also remains largely anecdotal and information on this appears non-existent for social services. (See: The Impact of Health Information Exchange on Health Outcomes by A. Hincapie and T. Warholak (2011) Applied Clinical Informatics. Accessible from: http://www.ncbi.nlm.nih.gov/pubmed/23616891).

The Need for Measuring Outcomes As health care quality and costs continue to be scrutinized ever more carefully as a means to improve health care value, every facet of the industry—including its intersection with social services—should be considered targets for improvement. The Compassion Capital Fund (CCF), administered by the U.S. Department of Health and Human Services, provided capacity-building grants to expand and strengthen the role of nonprofit organizations in providing social services to low-income individuals between 2002 and 2009. As a part of this work, the Strengthening Nonprofits: A Capacity Builder’s Resource Library was compiled. The library includes a number of guidebooks and e-learning resources, among which is one on Measuring Outcomes (see: http://www.acf.hhs.gov/sites/default/files/ocs/measuring_outcomes.pdf), which was updated in 2010. The guidebook suggests it is important to measure outcomes in order to:  Measure the effectiveness of an intervention and whether it is worth continuing or expanding.  Identifying effective practices to build upon and replicate by others.  Identifying practices that need improvement.  Proving your value to existing and potential funders.  Getting clarity and consensus around the purpose of your program—and supporting its continuation. The guidebook establishes some terminology associated with goals, outcomes, and indicators, provides cautionary notes on the limitations of measuring outcomes, and suggests ways to get started on outcomes measurement. It should prove useful for any social service agency looking to start or expand outcomes measurement activities. This may be especially beneficial as social service agencies are increasingly being considered key community service with respect to improving health care quality and lowering cost.

Steps to Measuring Outcomes with HIT

Section 6 Optimize—Optimization Strategies for Quality Improvement - 1 HIT should contribute to achieving your goals—for productivity improvement, better quality of services, lower service delivery costs, etc.—as well as to measuring achievement of your goals. 1. As you consider the nature of HIT you desire, reflect upon your goals and how they can be measured by HIT. Consider the simple example of reducing delay in obtaining clinical summaries which you believe you need to take appropriate action with respect to a client. (Refer to the examples in Section 2.3 Workflow, Process Analysis, and Redesign for HIE and Other HIT.) Some considerations may include: a. Can you work with your community to set a standard response time (even if it is only to indicate whether information is available or can be provided)? b. Can the HIT include an alert when that standard timeframe has been exceeded, so that you may intervene appropriately? Better yet, could it autodial for you to make a call? c. Can the HIT log each request for clinical summaries by provider, and produce a report of “repeat offenders” to work with on improvement? (Or to send quick thank you notes for cooperation to those who are in compliance?)

2. Consider how this simple example could play out in other aspects of your work, especially surrounding the goals you’ve identified for using HIE and HIT. Or perhaps the exercise of looking at outcomes will help focus your goals for your HIE and HIT initiatives.

3. Incorporate all new and refined goals into your planning for HIE and HIT, especially to identify requirements. Also consider where there are no standards of practice, and where they might be needed. Promote development of such standards within your professional community.

4. Refine your description of the outcomes you want to measure so that over time the outcomes will not only reflect internal needs (e.g., productivity gains), but clearly demonstrate changes that reflect better value for the community. For example, consider the Elder Abuse/Neglect Standard of Care available from SSWLHC (referenced above). Specific indicators to measure might include: a. Number of suspected cases referred to social services – are referrals made for all such cases? How do you get the number of cases within your community? Do you need to conduct some outreach to emergency departments and others? b. Number of assessments performed (as compared to number of referrals). Are all referrals accounted for? If not, why not? What can be done to improve? Do you have the HIT to track these numbers? c. Number of cases requiring and getting immediate, on-site counseling. Do these lead to appropriate referrals to shelters, hot lines, other community resources, and reporting to appropriate authorities? If not, why not? What can be done to improve? Would HIT and HIE aid in identifying needed resources?

Section 6 Optimize—Optimization Strategies for Quality Improvement - 1 d. Qualitative assessment of support network. This might even include the availability of home monitoring devices, broadband access, training elderly clients to use the Internet and Direct email to seek help when necessary, and health literacy training in general. (A recent study on the impact of HIT in underserved communities and those with health disparities revealed that there is significantly more Internet access at home among this population than many have believed, and it is growing rapidly. See: http://www.healthit.gov/sites/default/files/pdf/hit- underserved-communities-health-disparities.pdf. A recent Washington Post article [reporting data from 2011 and 2012] suggests that 81 to 85 percent of U.S. adults are online, although the number drops to 53 percent of those over age 65, 57 percent of blacks, and 71 percent of those with household incomes less than $30,000. See: http://www.washingtonpost.com/blogs/the- switch/wp/2013/08/19/the-60-million-americans-who-dont-use- the-internet-in-six-charts/).

5. In outcomes measurement entailing use of HIT, it is important to remember that technology is not the total answer to achieving quality improvement results:

a. Where technology is believed to help, it must be fully deployed. This includes entering structured data that the computer can process. Some new users of HIT continue to type or dictate notes into a computer than to enter data using a template. While some narrative documentation is very helpful and should not be eliminated entirely, alerts, reminders, and reports can only be produced from data entered via a template. b. Where there is not progress as expected in new users, the root cause must be determined. It may be lack of training, inattention to workflow changes, or inadequacies in the product itself. There can also be unwillingness by leaders to expect use of the systems. c. It may be necessary to stage adoption of HIT, especially where there may not be supporting resources. Some communities may not have an HIE organization (HIO), or the HIO is not yet set up yet to support the desired exchange of information. However, these communities can use the Direct protocol for email. d. Another important factor in using HIT is to ensure that the underlying standards of practice reflected in the templates are sound and that professional users are still applying professional judgment to client needs. In the example of elder abuse, there probably is not a perfect protocol for identifying every person at risk; professional judgment is necessary. e. There are many “human factors” that play into the success of using HIT. Just as some non-users of the Internet are not interested, there may be professional users who do not trust it or have other issues that need to be explored and addressed. f. HIT cannot overcome a user who ignores an alert or an administrator who waits too long to bring in additional resources

Section 6 Optimize—Optimization Strategies for Quality Improvement - 1 when guidelines call for them. HIT is not a substitute for a culture of quality.

Tool for Tracking Outcomes Consider using the following tool, aided by your goal setting, to track outcomes: Goal Improvement HIT Baseline Milestone Corrective Strategy Resources Data Results Action Q1 Q2 Q3 Q4

Section 6 Optimize—Optimization Strategies for Quality Improvement - 1