DEMOGRAPHIC INFORMATION
Plan Name:
Study Leader Name:Title:
Telephone Number: E-mail Address:
Name of Project/Study:Advance Directives
Type of Study:
Clinical Nonclinical
Collaborative HEDIS / Section to be completed by HSAG
Year 1 Validation Initial Submission Resubmission
Year 2 Validation Initial Submission Resubmission
Year 3 Validation Initial Submission Resubmission
Baseline Assessment Remeasurement 1
Remeasurement 2 Remeasurement 3
Year 1 validated through Step
Year 2 validated through Step
Year 3 validated through Step
Type of Delivery System:
Date of Study: January 1, 2008 to December 31, 2008
Number of Medicaid Members Served: 267
Number of Medicaid Members in Project/Study:190
Submission Date:
A. Activity I: Choose the study topic.PIP topics should target improvement in relevant areas of services and reflect the population in terms of demographic characteristics, prevalence of disease, and the potential consequences (risks) of disease. Topics may be derived from utilization data (ICD-9 or CPT coding data related to diagnoses and procedures; NDC codes for medications; HCPCS codes for medications, medical supplies, and medical equipment; adverse events; admissions; readmissions; etc.); grievances and appeals data; survey data; provider access or appointment availabilitydata;member characteristics data such as race/ethnicity/language;other fee-for-service data; or local or national data related to Medicaid risk populations. The goal of the project should be to improve processes and outcomes of health care or services to have a potentially significant impact on member health, functional status, or satisfaction. The topic may be specified by the state Medicaid agency or CMS,or it may be based on input from members. Over time, topics must cover a broad spectrum of key aspects of member care and services, including clinical and nonclinical areas, and should include all enrolled populations (i.e., certain subsets of membersshould not be consistently excluded from studies).
Study topic:
The topic, Advanced Directives, was selected for the performance improvement project because all members of the program are over 65 years of age and are suffering from a chronic disease. Data specific to health plan was analyzed prior to the development of this performance improvement project.Historical data from 2007 indicated that 27 percent of members had an advance directive in place. Although having advance directives in place is advisable for people of all ages, the frail and elderly population would greatly benefit from having their end of life wishes clearly documented. Many of the members have conditions such as dementia, Alzheimer’s Disease, and Parkinson’s Disease. For the family members and caregivers of these frail and elderly members making an end of life decision may be very difficult if not for an existing document with the member’s intended wishes. The Care Managers of the program have a significant opportunity to educate members and caregivers regarding advance directives.
According to the Center for Disease Control web site, effective public health strategies and medical treatment advances have resulted in a 30-year increase in life expectancy during the 20th century. As people are living longer, their expectations about quality of life throughout the lifespan, including at its very end, are increasing. Unfortunately, death itself is ultimately not preventable, and most people will die as a result of chronic disease. The public health field is aware of this issue and plays a critical role in helping Americans to maintain quality of life throughout their lives.
The end of life is associated with a substantial burden of suffering among dying individuals and also has health and financial consequences that extend to family members and society. The data indicates that as many as 50% of dying persons with cancer or other chronic illnesses experience unrelieved symptoms during their final days. Furthermore, recent studies demonstrate an increased likelihood of depressive symptoms and mortality among caregivers of terminally ill patients. Because most deaths occur within hospitals, end-of-life care has been recognized as an important clinical issue needing improvement.
Family members are often asked to make decisions on behalf of a loved one who is seriously ill without having a complete understanding of his or her preferences. To avoid this situation, older adults should discuss their end-of-life wishes with family members and health care providers well before the onset of a serious illness, and they should designate a surrogate decision-maker for health care. According to Later, E.B and King, D. (2007), “less than 30% of Americans had an advance directive”.
The program is designed for persons age 65 and over who meet the eligibility criteria of the program and to provide community-based services, including care management. Care management is conducted by registered nurses or social workers who help coordinate the acute and long-term care and work closely with the primary care physicians to improve the member’s well-being and provide the care that is needed. Care managers act as patient advocates, monitor the health of the enrollee and their ability to function, coordinate follow up care and social services and provide member education.
The study includes all members enrolled in the program for at least 12 months (1 month gap allowed) during measurement period including members with special health care needs.
Source:
CDC Healthy Aging for Older Adults. End of Life Issues. Retrieved from
Later, E.B and King, D. (2007). Advance Directives: Results of a community education symposium. Crit Care Nurse; 27 (31-35). Retrieved on May
20, 2009 from ccn.aacnjournals.org
B. Activity II:Define the study question(s). Stating the question(s) helps maintain the focus of the PIP and sets the framework for data collection, analysis, and interpretation.
Study question:
Do targetedhealth plan interventions improve the rate of enrollees in the Plan that report having an Advance Directivein their case report during the measurement year?
C.Activity III:Select the study indicator(s). A study indicator is a quantitative or qualitative characteristic or variable that reflects a discrete event (e.g., an older adult has not received an influenza vaccination in the last 12 months) or a status (e.g., a member’s blood pressure is/is not below a specified level) that is to be measured. The selected indicators should track performance or improvement over time. The indicators should be objective, clearly and unambiguously defined, and based on current clinical knowledge or health services research.
Study Indicator 1
The percentage of members who report having an advance directive in their case report during the measurement year. / Describe the rationale for selection of the study indicator:
Advanced Directives was selected for the performance improvement project because all members of the program are over 65 years of age and are suffering from a chronic disease. The Care Managers of the program have a significant opportunity to educate members and caregivers regarding advance directives. Central Nervous System conditions, including dementia, Alzheimer’s Disease and Parkinson’s Disease are estimated to be among the top five (5) diagnoses for the membership.To avoid a situation where caregivers are asked to make health care decisions for ailing family members, older adults should discuss their end-of-life wishes with family members and health care providers well before the onset of a serious illness, and they should designate a surrogate decision maker for health care.
Numerator (no numeric value) / Number of members that report having an Advance Directive in their case report during the measurement year.
Denominator (no numeric value) / Number of members enrolled in the program for 12 months with no greater than a 1 month gap in enrollment during the measurement year.
Baseline Measurement Period / January 1, 2008 through December 31, 2008
Baseline Goal / 30%
Remeasurement 1 Period / January 1, 2009 through December 31, 2009
Remeasurement 2 Period / January 1, 2010 through December 31, 2010
Benchmark / No known benchmark available.
Source of Benchmark / Not applicable.
Use this area to provide additional information. Discuss the guidelines used and the basis for each study indicator.
D. Activity IV: Use a representative and generalizable study population. The selected topic should represent the entire eligible population of Medicaid members with systemwide measurement and improvement efforts to which the study indicators apply. Once the population is identified, a decision must be made whether or not to review data for the entire population or a sample of that population.The length of member’s enrollment needs to be defined to meet the study population criteria.Study population:
The study population will include all members enrolled in the Plan, including those with special health care needs, enrolled in the program for 12 months with no greater than a 1 month gap in enrollment during the measurement year.
E. Activity V: Use sound sampling methods. If sampling is used to select members of the study, proper sampling techniques are necessary to provide valid and reliable information on the quality of care provided. The true prevalence or incidence rate for the event in the population may not be known the first time a topic is studied.
Measure / Sample Error and Confidence Level / Sample Size / Population / Method for Determining Size (Describe) / Sampling Method (Describe)
Not Applicable. Sampling is not used in this study.
F. Activity VIa: Use valid and reliabledata collection procedures. Data collection must ensure that data collected on PIP indicators are valid and reliable. Validity is an indication of the accuracy of the information obtained. Reliability is an indication of the repeatability or reproducibility of a measurement.
Data Sources
[ ] Hybrid (medical/treatment records and administrative)
[ x ] Medical/Treatment Record Abstraction
Record Type
[ ] Outpatient
[ ] Inpatient
[ x ] Other The electronic documentation record/case report is reviewed for members’ advance directive status. A medical record is not available for members. Documentation in the electronic record/case report is obtain by personal interviews with the member/caregiver (as detailed at the right)
Other Requirements
[ x ] Data collection tool attached (Attachment 1)
[ x ] Data collection instructions attached (Attachment 2)
[ x ] Summary of data collection training attached (attachment 8)
[x ] IRR process and results attached (Attachment 3, 3a)
[ ] Other Data
Description of data collection staff to include training, experience, and qualifications:
Currently, the team of care managers is made up of five (5) social workers with a total of 5 to 20 years of experience in case management. Inter-rater reliability testing is completed annually with a goal of 100% among care managers. Upon acquisition, care managers were trained on the use of the electronic documentation system. Hands-on time was dedicated to training these individuals as detailed in meeting minutes provided. In addition, technical assistance is available as needed from the vendor for questions/concerns and/or reporting requirements. Upon hire, new care managers are trained on the use of the system and are mentored by veteran care managers, as appropriate. As of August 2009 a training manual for the documentation system has been created. All care managers have received training using the manual and a hard copy manual was provided to all care managers. In addition, a policy and procedure exists to guide care managers in the collection and documentation of advance directive information from members and/or their caregivers. (attachment 5). The care managers’ leader is also available to provide guidance as needed. During inter-department meetings, information is shared with care managers regarding various quality activities, to include performance improvement projects and performance measures. Care managers are made aware of the importance of collecting accurate disenrollment information and how this action is related to QI activities. QI activities are presented quarterly during the Quality Committee meeting. / [ ] Administrative Data
Data Source
[ ] Programmed pull from claims/encounters
[ ] Complaint/appeal
[ ] Pharmacy data
[ ] Telephone service data/call center data
[ ] Appointment/access data
[ ] Delegated entity/vendor data ______
[ ] Other
Other Requirements
[ ] Data completeness assessment attached
[ ] Coding verification process attached
[ ] Survey Data
Fielding Method
[x ] Personal interview
[ ] Phone with CATI script
[ ] Phone with IVR
[ ] Internet
[ ] Other __ Information regarding Advance Directives is collected by care mangers from members/caregivers during routine visits with members. The care manager inquires about the presence of advance directives and power of attorney document during the initial visit with the member/caregiver.
If the member/caregiver states that an advance directive/living will/power of attorney is in place, the care manager documents this response in the electronic record/case report. If the member answers “yes”, a copy of the document is requested and placed in the member’s file upon receipt. If the member answers “no”, the care manager asks the member if they are interested in having information about Advance Directives. If so, a copy of the care document is offered and discussed with the member/caregiver (Attachment 4). The care manager follows up with the member as appropriate. A policy and procedure also exists to guide care managers in the collection of advance directives information from the members and/or their caregivers. (Attachment 5).
Other Requirements
[ ] Number of waves ______
[ ] Response rate ______
[ ] Incentives used ______
F. Activity VIb. Determine the data collection cycle. / Determine the data analysis cycle.
[ x ] Once a year
[ ] Twice a year
[ ] Once a season
[ ] Once a quarter
[ ] Once a month
[ ] Once a week
[ ] Once a day
[ ] Continuous
[ ]Other (list and describe):
The data collection cycle is continuous throughout 2008, specifically January 1, 2008 through December 31, 2008. Care managers collect and input information in the documentation system during the initial assessment with the member. Upon completion of the data collection cycle, ending on December 31, 2008, the documentation system will be queried.
Baseline measurement period: 1/1/08 through 1/1/08
Remeasurement 1: 1/1/09 through 12/31/09
Remeasurement 2: 1/1/10 through 12/31/10 / [ x ] Once a year
[ ] Once a season
[ ] Once a quarter
[ ] Once a month
[ ] Continuous
[ ] Other (list and describe):
Analysis of the data – January 1, 2009 through March 31, 2009.
Discussion of data results, intervention planning – April 1, 2009 through June 15, 2009
The baseline measurement period is January 1, 2008 through December 31, 2008.
Remeasurement 1 data will be analyzed by March 31, 2010 for measurement period January 1, 2009 through December 31, 2009
F. Activity VIc: Data analysis plan and other pertinent methodological features.
Estimated degree of administrative data completeness: __N/A___ percent.
Describe the process used to determine data completeness and accuracy:
Supporting Documentation:
Data regarding Advance Directives is collected from the member/caregiver during the care manager initial visit. Documentation of advance directive status is entered into the electronic system (attachment 1). If the member reports having an advance directive in place, a copy of the document is requested and placed into the record. Study indicator rate for each measurement year will be calculated as described below. Rates between measurement years will be compared using a chi-square test at the 95 percent confidence level as well as to goals. No known benchmarks were found for this study.
The electronic documentation system used to record member data is a program created by a company called XYZ. Programming work necessary for this performance improvement project is outsourced to XYZ and data needed for reporting this PIP is requested from plan. At the end of the measurement period a request is sent to XYZby the Plan Administrator in order to pull data required for submission. A request is sent that includes the definitions of the quality measure, numerator, denominator, continuous enrollment criteria and exclusions as detailed in this document. XYZ queries the system and the requested data is sent to the Plan QM Manager. This data is reported in the Performance Improvement Project submission tool.
G.Activity VIIa: Includeimprovement strategies (interventions for improvement as a result of analysis). List chronologically the interventions that have had the most impact on improving the measure. Describe only the interventions and provide quantitative details whenever possible (e.g., “Hired four customer service representatives” as opposed to “Hired customer service representatives”). Do not include intervention planning activities.
Date Implemented (MMYY) / Check if
Ongoing / Interventions / Barriers That Interventions Address
0109 / x / The plans “Health Care Advance Directives…the patient’s right to decide” document is shared and discussed with members who deny having an Advance Directive in place. / Member and caregiver knowledge about advance directives
Member and caregiver access to appropriate information and documents
0209 / x / Added a pamphlet discussing the reason for advance directivesto the new member orientation materials. / Member and caregiver knowledge about advance directives
0410 / x / Policy and procedure for data entry to ensure accurate data entry. / Availability of data in documentation system
Describe the process used for the causal/barrier analyses that led to the development of the interventions. Please see causalbarrier diagram (attachment 7). Quality improvement activities, to include Performance improvement projects and interventions are discussed during the quarterly Plan Quality Committee with input from the various Committee members. In addition, the Quality Forum meets on a quarterly basis in order to discuss and facilitate integration of operational processes across the organization by planning, analyzing and evaluating quality improvement activities.
G. Activity VIIb:Implement intervention andimprovement strategies.Real, sustained improvements in careresult from a continuous cycle of measuring and analyzing performance, as well as, developing and implementing systemwide improvements in care. Describe interventions designed to change behavior at an institutional, practitioner, or member level.Describe interventions: Continued discussion and analysis of rates, barriers and applicable interventions has been ongoing throughout calendar year 2009. Based on reported rates for calendar year 2008, barriers remain as described in previous submission of this performance improvement project. Barriers are discussed in detail in the attached causal barrier analysis. Member education and support in the form of the plan document has been ongoing. Additional interventions include a change to the documentation system requiring a response to the advance directives status question.