Linking to Quality Measures
Improving quality of care and general health status for all people is in the forefront of healthcare in the United States. One method to demonstrate this objective is with a common set of quality measures. These quality measures are increasingly used to determine payment to hospitals, physicians, and other healthcare providers.
DSMES is relevant to many important quality measure sets. Brief descriptions and resource links are provided below for some of the most common quality data measurement sets.
The Healthcare Effectiveness Data and Information Set (HEDIS) is one of the most widely used sets of healthcare performance measures in the United States. The National Committee for Quality Assurance (NCQA) measurement development process has expanded HEDIS to include measures for physicians and health plans.
Medicaid Adult Health Care Quality Measures
The Center for Medicaid and CHIP Services’ (CMCS) efforts are guided by the CMS Quality Strategy aims, specifically: better health, better care, and lower cost through improvement. These efforts ensure evidence-based treatment guidelines are followed, where indicated, and assess the results of care. The use of quality measurement helps strengthen accountability and support performance improvement initiatives. https://www.medicaid.gov/medicaid/quality-of-care/index.html
2018 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set)
Medicaid has established a core set of healthcare quality measures for adult Medicaid enrollees. These quality measures seek to measure the degree to which evidence-based treatment guidelines are followed, where indicated, and assess the results of care. The use of quality measurement helps strengthen accountability and support performance improvement initiatives at numerous levels. https://www.medicaid.gov/medicaid/quality-of-care/downloads/2021-adult-core-set.pdf
Medicare Five-Star Quality Rating System
One of the goals of the Centers for Medicare & Medicaid Services (CMS) is to improve the quality of care and general health status for Medicare beneficiaries. Medicare uses a star rating system to measure quality of care.
National Quality Forum’s Measure Applications Partnership (MAP)
The National Quality Forum (NQF) is a not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in healthcare. MAP is a partnership that aids the US Department of Health and Human Services (HHS) in selecting quality and performance measures for federal health programs.
Merit-based Incentive Payment System (MIPS)
MIPS is part of CMS’s Quality Payment Program and was designed to tie payments to quality and cost-efficient care, drive improvement in care processes and health outcomes, increase the use of healthcare information, and reduce the cost of care.
Models of Coordinated Care
The Medicare Shared Savings Program (MSSP) is committed to achieving better health for individuals and populations and lowering growth in expenditures. MSSP led to the creation of a new type of healthcare entity, the accountable care organization (ACO).
Accountable care organizations and patient-centered medical homes (PCMH) are two models of coordinated care with common goals of lowering costs and improving quality.
Accountable Care Organizations (ACO)
ACOs are networks of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high-quality care to their Medicare patients. The goal of coordinated care is to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending healthcare dollars more wisely, the ACO will share in the savings it achieves for the Medicare program. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/
Patient-Centered Medical Homes (PCMH)
The PCMH is a model of care that emphasizes care coordination and communication. NCQA Patient-Centered Medical Home (PCMH) Recognition is a widely adopted model for transforming primary care practices into medical homes. According to NCQA, patient-centered medical homes can lead to higher quality and lower costs and can improve patient and provider experiences of care. https://www.ncqa.org/programs/health-care-providers-practices/patient-centered-medical-home-pcmh/
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a program of the Agency for Healthcare Research and Quality (AHRQ). CAHPS surveys ask consumers and patients to report on and evaluate their health experiences. One survey specifically addresses Patient Centered Medical Homes (see above).
DSMES May Help Meet Quality Measures
There is a link between DSMES and the national quality measures listed above. DSMES may help PCMHs and ACOs meet these standards.
One way to show the value of a DSMES service is to demonstrate how the DSMES service addresses the quality measures that PCMHs and ACOs must meet.
ACOs are required to meet and report on data that are used to calculate and assess their quality performance in four domains (patient/caregiver experience; care coordination/patient safety; preventive health and screening; and at-risk populations).55
DSMES service staff should ensure that PCMHs and ACOs are aware of the full spectrum of DSMES service outcomes recommended in the 2017 National Standards for DSMES that are tracked, monitored, and reported including:
- Behavior change
- Clinical change
- Quality of life
The tables below summarize diabetes and diabetes-related quality measures from the most recognized quality organizations.
|Separately Reported Measures||NCQA’s HEDIS Measures||Medicare 5 Star Quality Rating System||Medicaid Measures (by NCQA)||MAP Family of Diabetes Measures||Consumer Assessment of Health Providers & Systems (CAHPS)|
|A1c||A1c testing||Had A1C test||CAHPS: Survey asks how well health plans and providers meet patient needs; also known as patients’ experience of care|
|A1c in poor control||>9%||>9% or not tested||>9%|
|A1c control||<8% and <9%||<8%|
|BP control||<140/80 mm Hg||ages 60-85: <140/90 mm Hg|
|<140/90 mm Hg|
|Nephropathy monitoring or medical attention||nephropathy monitoring||nephropathy monitoring or medical attention|
|Lipid control||LDL-C screening||LDL-C screening|
|Lipid control||LDL-C <100 mg/dl||LDL-C <100 mg/dl||LDL-C <100 mg/dl|
|Lipid control||LDL-C <130 mg/dl||LDL-C <130 mg/dl|
|Retinal eye or dilated exam||retinal eye exam||dilated eye exam|
|Takes oral DM medications as prescribed||takes oral diabetes medications as directed|
|Diabetes screening||For people w/ schizophrenia or bipolar disorder using antipsychotic meds|
|Composite* DIABETES MEASURES||MAP Family of Diabetes Measures: OPTIMAL||MAP Family of Diabetes Measures: COMPREHENSIVE||ACO Diabetes Measures|
|A1c poor control||>9%||A1c poor control|
|A1c for select populations||<7% for select populations|
|LDL-C||<100 mg/dl||<100 mg/dl|
|LDL-C screening||LDL-C screening|
|LDL-C control||LDL-C <130 mg/dl|
|BP Control||<140/90 mm Hg||<140/90 mm Hg|
|Medical attention for nephropathy||Medical attention for nephropathy|
|Tobacco/smoking||Non-user||Smoking status and cessation advice or treatment|
|Aspirin||Daily use for patients with ischemic vascular disease|
|Retinal or dilated eye exam||Retinal eye exam||Retinal eye exam||Dilated eye exam|
|Body Mass Index (BMI)||Recommended that BMI is addressed||Recommended that BMI is addressed|
Medicare Shared Savings Program Accountable Care Organization (ACO) 2018 Quality Measures [PDF – 555 KB]:
This reference shows the 31 quality measures used to assess ACO quality performance and the quality performance standard for the 2018 performance year for the Shared Savings Program.
NCQA’s Diabetes Recognition Program:
Learn more about quality measures that the National Committee for Quality Assurance’s (NCQA) Diabetes Recognition Program (DRP) supports for clinicians providing care to persons with diabetes.
Diabetes Educators in Accountable Care Organizations:
To learn more about how diabetes educators can assist ACOs, review “Diabetes Educators in Accountable Care Organizations: Meeting Quality Measures Through Diabetes Self-Management Education and Care Coordination.”