When Americans go to the doctor, it’s essentially a coin toss as to whether they’ll receive the care medical experts recommend for their conditions. Measuring the quality of care is a critical starting point to close these gaps. After all, we cannot improve what we do not measure. Publicly reporting about the performance of physician practices allows patients to make informed choices about their care, helps health care professionals see where they can improve, and allows purchasers to know the value of the care they are buying.
This issue brief examines lessons from RWJF Aligning Forces for Quality alliances that have made information about the quality of care local physicians provide publicly available to everyone who gets, gives, or pays for care.
MN Community Measurement, an Aligning Forces for Quality alliance, measures and publicly reports provider performance data. State practices and hospitals, including Entira Family Clinics, are using these data to inform efforts to improve care and patient outcomes for conditions including depression and diabetes.
Julia Freeman, 51, is a woman who knows how to get what she wants. She has worked as a labor organizer for more than a dozen years, and is currently the Senior Organizer for Racial Justice at a Minneapolis-based non-profit organization that trains community organizers. Yet she struggled for 17 years with her type 2 diabetes, unable to get to goal despite frequent clinic visits.
“I was diagnosed with type 2 diabetes in 1996,” recalls Freeman. “Year after year, I was told by doctors that I needed to get my diabetes under control, but without the knowledge or tools to do so, I always failed. I felt like I was constantly disappointing my doctor, and so every few years, I would change clinics, hoping for a better outcome. My A1C was sometimes as high as 15, and never below 11.”
Freeman said she was particularly troubled by the prospect of having to take insulin, since she was under the impression that insulin was a step toward even poorer health and, ultimately, death. “Both my parents were diabetic, and I have lost aunts, uncles and cousins to diabetes,” she says. “They were all insulin dependent. In fact, my dad died on his way to dialysis. It was something that I experienced first-hand, so that’s why I believed it.”
So in late 2012, when Freeman decided to change clinics yet again, she was hopeful, yet not optimistic. She chose a clinic right around the corner from her residence, the HealthPartners Midway Clinic in St. Paul. Initially unaware that it was certified as a health care home, she soon realized this clinic would give her a better experience than she had ever had before, and with a better outcome.
Minnesota’s health care homes, also known nationally as medical homes, are an important component of Minnesota’s comprehensive, nation-leading 2008 health reform law. The health care homes initiative – a joint effort between the Minnesota Department of Health and the Minnesota Department of Human Services – represents a transformative change in the delivery of primary care; patients and families are at the center of their care, and the right care is provided at the right time, in the right place. In addition, the 2008 legislation includes payment to primary care providers for partnering with patients and families to provide coordination of care.
For Freeman, seeking treatment at a health care home was life changing. Her doctor first worked with her to dispel the myths she had about diabetes and its treatment. She was then introduced to a nurse who specialized in diabetes treatment, something she had never had before.
“My doctor, my nurse and I met as a team and co-created a plan for me,” explains Freeman. “They said to me, ‘the key person in this is you. We can help you, but you are the key.’ I felt for the first time that I wasn’t in this alone. The responsibility was on me, but I felt as though I had a whole team dedicated and committed to helping me turn around my numbers. For the first time I was really educated about the disease and what it does to my body. Not in a way that was fearful, but in a way that I felt I could conquer it.”
Freeman’s diabetes management plan included insulin, a concept that she had become more comfortable with as she learned more about its role in controlling diabetes. She was also compelled to start testing her blood sugar regularly, a habit she had previously believed to be unnecessary. In February, she and her care team had established several goals to meet by summer, including weight loss, lower cholesterol, lower blood pressure and decreased A1C. By May, she had met or exceeded all of her goals, and is still improving.
“I’m someone who thinks that knowledge is power, and you can be proactive if you have the knowledge,” says Freeman. “I’m in the best health I have ever been in my whole entire life, and with the knowledge that I have now, I know that my children and grandchildren will never be diabetic. I’ve talked to them and shared with them what I’ve learned. Now we all know what to look for and how to combat diabetes. We’ve become a real proactive anti-diabetes family.”
Expectations of certified health care home clinics in Minnesota
The design principles for health care homes in Minnesota focus broadly on the continuum of health and incorporate expectations for engagement of the patient, family and community. Expectations of health care homes include:
Patient- and family-centered care is foundational to the health care home program in Minnesota. Patients/families/consumers are involved in all aspects of program development.
Quality improvement teams are required at the practice level. A health care home has an active practice-based quality improvement team that includes patients/families as equal team members.
Participation in a learning collaborative to support and foster practice-level change is required.
Financial structures must be aligned to promote this transformation and must include adequate risk adjustment for medical and non-medical complexity.Recertification is based on outcomes. Minnesota is moving to an outcomes-based system in its recertification of health care homes. In the certification and recertification process, a balance is sought between fidelity to the model (criteria) and flexibility for innovation. A goal of the program is to maximize clinic flexibility to achieve all of the outcomes.