The following three Key Driver Diagrams are designed to help guide states, health plans and health systems in implementing strategies to improve TCD screening among children with sickle cell anemia (SCA). These Key Driver Diagrams can be adapted and tailored for use by other organizations at each level. Regardless of the organization using these diagrams, the strategies must be accompanied by a more comprehensive understanding of the many barriers faced by families and the broader activities and resources necessary to facilitate improved delivery of comprehensive preventive care for children with SCA.
- The State Key Driver Diagram (PDF, 103 KB).
- The Health Plan Key Driver Diagram (PDF, 112 KB).
- The Health System Key Driver Diagram (PDF, 110 KB).
The three diagrams provided in this toolkit focus on TCD screening and reflect a subset of the 35 potential interventions at all levels of the health care system and six key drivers of high-quality preventive care for children with SCA identified during multi-stakeholder meetings convened by QMETRIC beginning in December of 2017 and continuing through May of 2020.
Lessons Learned in Using TCD Measure at Multiple Levels
As part of the PQMP grant, QMETRIC sought to implement the sickle cell measures at the state, health plan and provider levels. It became quickly apparent that the resources to implement the TCD measure varied markedly both across and within levels. Provider groups had very limited resources to devote to quality improvement efforts in general, and to this measure specifically. Health plans had systems in place for using care management to improve care for chronic diseases, but these resources were rarely devoted to children and only to those areas for which their performance was contractually required or to those that created a large financial burden for the plan. The states control financial incentives for Medicaid health plans, but this has historically been reserved for those measures in either the Child Core Set, HEDIS or the annual PIPS. With these challenges in mind, specific insights at each level are provided below.
Health System Insights
QMETRIC’s partner sickle cell clinics that implemented the TCD measure are not in freestanding children’s hospitals but are part of larger hospital systems. As such, fewer resources tended to be made available for issues affecting pediatric populations relative to those affecting adults. All of the sickle cell clinics with which QMETRIC worked were underfunded and under-resourced, and therefore had limited capacity to devote to quality improvement. In fact, one of the initial three collaborating health systems (sickle cell center) withdrew from the project as they reported they had “absolutely no resources” to devote to quality improvement (QI) because they could barely keep up with the clinical demand for those who presented for care.
QMETRIC met individually with the two remaining partner healthcare providers and staff on multiple occasions to review clinic processes, identify barriers to care for patients, and assess capacity to implement QI strategies. Clinic performance data was shared and improvement plans were developed. Examples of this activity are provided in the Improvement Data section of this toolkit. While both centers were able to adopt some improvement strategies, they were still limited by staff changes and shortages. As outlined in the Health System Key Driver Diagram and Health System Strategic Road Map, a significant amount of clinic staff time is required to implement most suggested improvement strategies.
The Health System Key Driver Diagram is available for download (PDF, 110 KB). The Health System Strategic Road Map is available from the Quality Improvement Strategies section. In order to successfully implement the Strategic Road Map, an institutional commitment to invest in these centers in general, and specifically in QI, for this population is required.
Health Plan Insights
Health plans have many competing priorities. These are generally focused either on improvement in the areas for which financial incentives have been created or for which they are required to report (HEDIS measures). Other priorities are in high cost areas that are almost exclusively in the adult population.
The QMETRIC team met repeatedly with the collaborating health plans to assist in moving forward a quality agenda for the sickle cell disease patient population. Individual meetings with QI teams from each health plan partner focused on developing an understanding of each of their approaches to QI in general and any previous activity they may have conducted for the sickle cell disease population. QMETRIC also shared health plan performance data and discussed improvement strategies. It was determined that health plan care managers are best positioned to address gaps in care for these members. Care managers are able to assist members by identifying barriers to accessing healthcare and resolving the issues that create these. Care management is critical to the success of the QMETRIC Health Plan Strategic Road Map.
Health plan levels of engagement with the QMETRIC team varied depending both on competing priorities and on staff turnover. Successes in this area required intensive effort on the part of the QMETRIC team and extraordinary personal commitments by specific individuals at the health plans.
State Medicaid programs set contracts with health plans for Medicaid beneficiaries. These contracts contain expectations for reporting and performance for specific conditions. These conditions are uniformly contained in HEDIS measures or those on the Child Core Set of Quality Measures. Conditions which are not a part of either of those systems are unlikely to become priorities of any State Medicaid Program. Because states report their performance on measures in the Child Core Set as well as HEDIS measures, their priority is to devote resources to improving performance on those measures. This means incentives are provided to the health plans to focus improvement efforts on those specific areas. Measures which are not a part of the Child Core Set or of any other extrinsic imperative may struggle to gain attention or traction.
QMETRIC met with the Quality Improvement & Program Development Section at the Michigan Department of Health and Human Services Managed Care Plan Division to understand the mechanisms behind the financial incentives they had in place to drive health plan performance and their methods of communication of priorities to the plans. QMETRIC also shared state-wide performance data and discussed strategies for how they might attempt to improve care. The Director of Quality, who was greatly moved by the personal stories of parents and patients with sickle cell disease at the expert design meeting, was also concerned by the very low measure performance rates for these patients. Additionally, there was a strong sense of a social justice imperative for these children among the staff in that office. The group was clearly committed to improving care and acting on that commitment. Other states trying to implement similar QI initiatives, especially without financial incentives, will face significant challenges but will improve their chances of success by having a dedicated champion of the initiative in a leadership position at the state level.
QMETRIC assisted the state in the development of a regionalized improvement collaborative for health plans. The state will use financial incentives to create an environment for plans within a specific Medicaid region to work collaboratively to improve measure performance for all children in that region, regardless of their plan affiliation. This “first in the nation” health plan collaborative for the care of children with sickle cell disease launched in Summer 2021. The fact that the state is willing to devote a portion of the financial incentive pool to this and other measures is unique and has great potential to substantially improve the health and lives of these children.