The Importance of QAPI in Value-Based Care

One of the Center for Medicare & Medicaid Services’ first official moves toward value-based care was the Home Health Value-Based Purchasing Model (HHVBP), which started out as a pilot program and broadened nationwide; 2023 is the first full performance year and 2025 will be the first payment year. Under the model, home health agencies (HHAs) will receive adjustments to their fee-for-service Medicare payments based on their performance compared to other agencies of similar size. A key part of success in HHVBP is for agencies to link their existing or new quality assurance and performance improvement (QAPI) programs to HHVBP measures.

Dr. Andrew Awoniyi, vice president of patient engagement and analytics at Axxess, has been advising agencies on how to evaluate and improve their performance since before the HHVBP expansion. Here, he answers questions about how to execute a quality improvement plan in your agency.

HOMECARE: What are the most important things to keep in mind as a company sets out to integrate performance improvement?

AWONIYI: Without leadership buy-in, all efforts will be unsuccessful; leadership sets the culture of your organization and it must be geared toward quality and patient safety. Without the right personnel on board with a mindset of patient safety and quality, and with the rapid changes in health care and in such a heavily regulated industry, utilizing information technology and finding the right technology partner becomes extremely crucial. Setting the agency’s priorities and goals, establishing a culture that’s focused on the patient and on quality, identifying the right partnerships to achieve quality goals, assigning personnel and resources to achieve these priorities and goals, and obviously being interested in monitoring the change efforts and sustaining and spreading these changes over time are all the roles
of leadership.

HOMECARE: Is there a model that organizations can follow as they embark on any kind of performance improvement?

AWONIYI: One of the best and most widely recognized models is the model for improvement as put out by the Institute for Healthcare Improvement. It’s a simple model that starts with the following questions:

• What are we trying to accomplish?
• How will we know that the change is an improvement?
• What changes can we make that will result in an improvement?

Then going through a performance improvement cycle where we plan the improvement, perform, study our activities and then go through this in a continuous manner leads to improvement. We can essentially summarize this in three phases for improvement: initiating the change, managing the change and making it permanent.

HOMECARE: When you talk about leadership, is this a top-down approach?

AWONIYI: Without effective leadership at all levels of the organization, there is no quality improvement project or performance improvement project that can be successful. The role of the home health agency’s governing body is to assume that executive leadership responsibility by ensuring there is a program in place and that it represents all the various complexities of the HHA and that key stakeholders are involved to drive sustainability over time. It involves reviewing contracts and other business relationships that might have an impact on the quality of care that’s being provided by the agency, reviewing the indicators that need to be improved, addressing the HHA’s performance and making sure the appropriate documentation is maintained and is available to surveyors. The governing body should also establish clear expectations for patient safety, address any findings of fraud or waste and ensure the agency is analyzing and tracking quality indicators to determine whether the desired outcomes are being reached.

HOMECARE: Where do you start?

AWONIYI: When initiating change, there are three steps: First, create the performance improvement team; second, identify measures; and third, work on our aim statement—this could be chartered by the home health agency’s governing body, or in smaller organizations, might be the quality improvement team themselves once they have been appointed. There needs to be a lead person on the team, and members should be selected from key areas within the organization—everything from having an executive sponsor to someone who understands the workflow and data aspects, department leads and frontline staff. The times the team will meet and the length of commitment are also ideal items to outline.

Once a quality improvement team has been selected, one of their responsibilities is to review the key data sources or at least identify them and ensure your agency has access to data sources within your organization that will give you insight into your measures. Then they should review various measures that require improvement—particularly those that are high-risk, high-cost or problem-prone—and focus on a couple for improvement. Once those improve and are simply being monitored, you can move on to additional measures to ensure you don’t become overwhelmed. We always want to think about our goal for improvement—what are we trying to accomplish? We need to ensure that all members of the performance improvement team understand the type of change that’s being sought and when it will occur and how it will be measured.

Here’s an example of an aim statement: improving the ability of patients to manage their oral medications so that within the next 12 months the management of oral medications would be improved by at least 50%. Using OASIS data, they anticipate showing an improvement of 25% or more within three months.

HOMECARE: How do you ensure the changes stick?

AWONIYI: We know once we’ve made improvements we’ve gone through multiple performance rounds, we want to ensure we don’t have to do this again, wasting time and resources to revisit processes that we’ve improved. We need to move effective changes into general practice; for example, some organizations do a pilot on a very small area, maybe with one or two nurses, and over time they spread best practices developed to two additional nurses and other areas or other parts of the organization.

HOMECARE: How important is communication and/or documentation as part of this process?

AWONIYI: So, we need to ensure that we communicate our successes by using champions to model and drive our changes, educating remaining staff on the enhanced workflow—clearly delineating what used to occur and what the new process or workflow should look like—and then ensuring that we’re monitoring this improved workflow for ongoing compliance. Monitoring improvements periodically by reporting to key stakeholders and staff in the affected areas and then documenting our process and outcomes of the project are extremely important. And then it’s also critical to identify additional areas for improvement where we can take on a new measure when we retire one that we’ve improved or that’s in maintenance mode. We want to be able to identify additional areas for improvement, essentially retiring measures that we’ve maxed out on their improvement. Being able to celebrate and communicate success is crucial for generating additional success.