NQF’s report builds on work launched earlier this year by The SCAN Foundation to identify the four Essential Attributes of a high-quality system of care for adults with complex care needs, including individuals with multiple chronic conditions and functional limitations that impact health status and quality of life. By identifying these Essential Attributes, The SCAN Foundation aims to help guide efforts to transform delivery systems and develop quality measures that capture an individual’s goals, preferences, and outcomes.

In its report, supported by a grant from The SCAN Foundation, NQF found that while few communities exemplify more than one of the four attributes, a number of communities are using data and measurement tools to achieve the first Essential Attribute: identifying and regularly re-evaluating an individual’s medical and nonmedical needs and goals on an ongoing basis.

NQF identified Geneva Tower Health Collaborative (Cedar Rapids, Iowa), the Alliance of Chicago Community Health Services, and Supports and Services at Home (Vermont) as case studies of communities that exemplify the first Essential Attribute. Applying these case studies, NQF was able to identify measurement gaps for further exploration and outlined lessons learned to help guide the development and use of quality measures to improve services for adults with complex care needs.

“This initiative reflects NQF’s commitment to healthcare that aligns with the goals and preferences of individuals, their families, and caregivers,” said Kathleen Giblin, RN, NQF’s senior vice president for quality innovation. “The findings in this paper provide new knowledge for NQF’s Measure Incubator and our efforts to facilitate measure development in much-needed areas, such as care for people with complex needs.”

NQF found that while many communities are working to improve quality, most are in the early stages of learning how to access or integrate various data sources and are not yet at the point of measuring the quality of care. Additional findings include:

• Communities that excel at care planning are using data in innovative ways, particularly to identify high-need individuals;
• The success of interventions to improve the quality of care is often still defined in terms of medical outcomes, rather than through patient-reported outcomes and other nonclinical measures that reflect an individual’s experience;
• Community collaboration is essential to establishing a trusted continuum of care services;
• Data-sharing capabilities vary widely among providers, which limits the ability to integrate healthcare and social services data into care planning.

“This paper is an important contribution toward understanding what matters most for adults with complex care needs,” said Bruce A. Chernof, MD, FACP, president and chief executive officer, The SCAN Foundation. “Our goal is to advance a coordinated and easily navigated system of high-quality services that continually puts individuals at the center of decisions about their care.”