Performance Measurement for People With Multiple Chronic Conditions: Conceptual Model
Published Online: October 22, 2013
Erin R. Giovannetti, PhD; Sydney Dy, MD; Bruce Leff, MD; Christine Weston, PhD; Karen Adams, PhD, MT; Tom B. Valuck, MD, JD; Aisha T. Pittman, MPH; Caroline S. Blaum, MD; Barbara A. McCann, MSW; and Cynthia M. Boyd, MD, MPH
One-fourth of Americans have 2 or more chronic conditions, yet this population accounts for more than half of overall healthcare expenditures.1 Having multiple chronic conditions (MCCs) can negatively affect quality of life,2 ability to work,3 disability,4 and mortality.5 Despite the high prevalence of MCCs and corresponding negative consequences, care for people with MCCs is often fragmented, incomplete, inefficient, and ineffective,4,6,7 resulting in potentially avoidable inpatient admissions,8,9 adverse consequences of therapeutic interactions,10 and postoperative complications. The Department of Health and Human Services has identified “fostering healthcare and public health system changes to improve the health of individuals with multiple chronic conditions” as one of 4 goals in an overall strategic framework to improve the health of individuals with MCCs.1 Various agencies, including the Centers for Medicare & Medicaid Innovation Center, Centers for Disease Control and Prevention, and Administration on Aging, are funding projects centered around healthcare quality improvement for individuals with MCCs. However, existing healthcare quality measures used in many of these projects are inadequate for measuring quality improvement for this population.1
Existing quality performance measures are often limited by a disease-specific focus,7,11 do not account for patient and family preferences and goals,12,13 and often focus on a single setting such as hospitals. Performance measurement has been largely guided by a single disease heuristic that does not address challenges common to MCCs such as disease interactions and treatment interactions, and little evidence exists to support development or adaptation of performance measures for people with MCCs.14 To improve quality and efficiency of care for people with MCCs, performance measures need to address the heterogeneity and scope of care, individuals’ priorities and care preferences, the high risk of uncoordinated care across settings, and the high risk for adverse health outcomes in the presence of comorbidities. Currently, few measures meet these criteria, and those that exist require further development.7,15
There is a need to develop new performance measures and refine existing measures to address the complexity of care experienced by patients with MCCs and their families over time. Such development efforts would be facilitated by an appropriate conceptual model. Existing conceptual models of quality of care address some of these issues but do not address the broader perspective of people with MCCs.16,17 To help advance development of new performance measures and implementation of existing measures in this area, the Department of Health and Human Services requested that the National Quality Forum convene a multistakeholder steering committee to develop a measurement framework for individuals with MCCs. As part of this effort we developed the Performance Measurement for People with Multiple Chronic Conditions (PM-MCC) conceptual model based on reviews of the literature and existing conceptual models of performance measurement,17-22 input from experts on the National Quality Forum Steering Committee, and input through an open public comment period.
This conceptual model centers on a patient with multiple conditions, represented by overlapping circles (see center circle of the Figure). Included are traditional diseases, but also conditions such as symptoms, disability, substance abuse, and hearing impairment that fall outside the traditional disease model.Any given condition may affect the patient to a greater or lesser magnitude at any one time, and may or may not be a dominant condition (ie, a condition so complex or serious that it eclipses the management of other conditions23). The patient and the family or friends who care for him/her have goals and preferences for care of these diseases and conditions. Performance measurement should center on these goals and preferences.
The first circle surrounding the individual at the center of the model represents shifting sites and providers that support and care for the individual’s healthcare needs. These sites could include the ambulatory, hospital, postacute, nursing home, community, home (including formal home-based primary and skilled nursing care as well as informal care), and pharmacy settings. This list is not exhaustive; rather, it is intended to be illustrative of the possible sites of care for people with MCCs. At any given site, multiple types of providers may be providing care over time.
Moving outward from the sites and providers circle, there is a circle representing the types of care an individual may receive at any given site of care. The types of care patients receive (eg, screening, prevention, diagnosis, treatment, management, secondary prevention, community services, management of an acute exacerbation, rehabilitation, palliation, end-of-life care) are not necessarily linear or mutually exclusive. For example, a patient with congestive heart failure may be seen in the hospital for an acute exacerbation while receiving ongoing care for diabetes and depression at the same time.
The outermost circle represents the domains of measurement that apply across sites and types of care. These domains are not mutually exclusive, and a given measure could fall into multiple domains; however, measures can be categorized under the 6 priority areas of the National Quality Strategy for improving healthcare: (1) health and well-being, (2) effective prevention and treatment, (3) person- and family-centered care, (4) patient safety, (5) effective communication and care coordination, and (6) affordable care (Figure). These domains intentionally align with the National Quality Strategy to promote harmonization across public- and private-sector programs supporting this population and to provide a way to track progress n filling of critical measure gaps. In each measurement domain there are non–disease-specific measures such as pain screening (which would apply to all patients within a certain opulation regardless of their condition) and disease-specific measures such as management of antidepressant medications (which would apply to patients with certain conditions).
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