Choose a topic or population to measure and analyze

Choose a topic or population to measure and analyze

You and your leadership team can focus on a single topic or population to measure and analyze using data you have or can get easily.

It may be tempting to measure health, patient experience, and cost for many topics—for example, hypertension, diabetes, prenatal care—or for your entire patient population. However, data across all three aims is not easy to capture for everything and everyone. Community health centers may want to begin their efforts to measure the Triple Aim from the “bottom up.” That is, focus on a single topic or population where you already have some health, patient experience, or cost data. It is also important to remember that this process is iterative and takes time.

If you are puzzled by how to pick a topic or population, the following suggested tactics and short case study about a quality improvement program targeting hypertension can help you develop a plan.

Think synergistically

Choose a topic or populations where you are already gathering data for reporting purposes. Examples include Health Resources and Services Administration Uniform Data System (UDS) or Centers for Medicare & Medicaid Services (CMS) meaningful use requirements.

Or, start with a topic or population your community health center is already targeting through existing quality improvement programs. Your strategy should build on work you are already doing and data you already have—there is no reason to start from scratch. 

Align with payer priorities

Choose a topic or population that is important to payers. For example, you may want to pick the highest cost patients as a starting population to measure and analyze. A starting topic also might be one of six priority areas for Value Based Pay for Performance in California: prevention, cardiovascular, diabetes, maternity, musculoskeletal, and respiratory conditions. Or, there are indicators for asthma, behavioral healthcare, cancer screening, chlamydia screening, diabetes care, heart care, and maternity care that are publicly reported in California, by health plan and medical group.

Aligning with payer priorities may also open doors to payers sharing data with you to advance their priorities. For example, payers may be able to analyze claims, emergency department, inpatient utilization, and pharmacy data to help you identify and target the highest cost patients.

Or, payers may be calculating avoidable emergency department utilization among patients with chronic conditions. These data can anchor your measurement approach (discussed in Step 3). Getting data from payers can be challenging—don’t let that deter you. Start now to build mutually beneficial relationships with key contacts at health plans.

In this video, Dr. Boutwell talks about selecting a topic or population to measure by identifying payer incentives, such as avoidable emergency department use or avoidable readmissions.

Determine prevalent conditions in your area

You might also pick a prevalent condition in your area to measure and analyze. To identify health status and other indicators among community residents, you can use a community health needs assessment. Community Commons creates free reports that show health indicators (e.g., disease prevalence, incidence, and mortality), clinical care, health behaviors, demographics, social and economic factors, and physical environments by county. 

Case study part 1: Hypertension quality improvement program

The following case study is continued in subsequent sections of the toolkit. Part 1 will demonstrate how to choose a single topic or population, based on data you already have and/or can get easily.

As your community health center’s quality improvement officer, you have been tasked with preparing for value-based payment across all nine clinic sites that comprise your health center organization. You want to analyze value—not just health or quality measures like in the past. But analyzing value is new, so you decide to test the waters with a small project. The first step in getting started with Triple Aim measurement is deciding what the project should focus on.

From looking at your UDS and meaningful use data and thinking about the patients you serve, hypertension control comes to mind. You see from Community Commons that your county’s age-adjusted death rate for heart disease and stroke is higher than in neighboring counties and California. Looking further, you see that heart care is one of the six priority areas for the Integrated Healthcare Association’s Value Based Pay for Performance program in California. And, an important quality improvement initiative at your community health center has been a blood pressure control program for patients with hypertension. 

From all of these considerations, you decide to focus on the hypertensive patients in the new blood pressure control program at all nine clinic sites within your health center organization. It’s a discrete population for which you are already collecting some data. In part two of the case study, you assess available or easily obtainable health, patient experience, and cost measures to help you demonstrate value for the patients in the hypertension control program.

See what your colleagues are doing

Open Door Community Health Centers has developed an emergency department transition program to ensure patients receive needed follow-up care. A community health center care manager works with hospital discharge planners to identify center patients seen in emergency departments and assure smooth transitions of care and timely follow-up treatment. By measuring health, patient experience, and cost for this program, the community health center can document the value of the program.

Asian Health Services’ strategy involves focusing on a prevalent condition in a specific population.  The center targets hepatitis screening and treatment because Asian and Pacific Islanders make up less than 5% of the total U.S. population but account for more than 50% of Americans living with chronic hepatitis B. Because hepatitis transmission can be prevented with a vaccination and treatment can minimize liver damage, it is a prime target for quality improvement and measurement.