If You Want to Know How Mrs Smith is Doing, Ask Her! KP’s Improved Medicare Total Health/Social Risk Assessment


Tracy Lippard, MD, FACP; Carole Gardner, MD, AGSF;
Matt Stiefel, MPA, MS; Ranu Pandey, MHA;
Juliana Oronos, MPH


Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Program Office, Colorado, Georgia

Background: Older adults are an important growing member demographic. Of the US population, 20% will be age 65 years or older by the year 2030. Our recommended approach for the Medicare Total Health Assessment (MTHA) aims to improve members’ physical, mental, social, and functional health and well-being and positively impact what matters most to them. Our approach aligns with Kaiser Permanente’s mission to provide high-quality care while managing utilization and cost. It has the potential to improve Health Outcomes Survey (HOS) performance. Because the MTHA responses are highly correlated with HOS items, the MTHA serves as a reasonable proxy for the HOS, enabling examination of factors associated with HOS performance, prediction of HOS scores, and evaluation of interventions.
Methods: The MTHA collects self-reported information about Medicare members’ overall health and functional status, health conditions/symptoms, behavioral and psychosocial risks, and activities of daily living. The current version does not include a robust social risk assessment, but we need and value this information for providing quality care and to help identify interventions to support HOS performance to address issues identified by the MTHA, a systematic approach to follow-up and documentation is recommended. The intervention includes use of the revised MTHA questionnaire (integrating social needs items, simplifying language) and implementation of a systematic approach to follow-up and documentation. The comparison is the MTHA version 1.0 or no MTHA. Outcome measures include member-reported health risks and health outcomes including Kaiser Permanente’s Your Current Life Situation questionnaire or HOS.
Results: The MTHA has demonstrated the ability to identify older adults struggling with urinary incontinence, pain, sleep problems, mental/emotional health issues, increased fall risk, and food insecurity. The revised version will expand screening for social/economic risks and health literacy/numeracy issues that can negatively affect health, patient activation, and self-care. A survey of physicians and staff using the current MTHA found that 56% of primary care physicians and 78% of nurses and medical assistants believe that having members complete the MTHA before the annual wellness visit is extremely or very valuable. Additionally, 70% of members surveyed believe that health issues not typically addressed by their primary care physician were discussed during their annual wellness visit because of the MTHA. MTHA data are also being used for population health management (eg, assessing and reporting prevalence of health-related functional and social/economic risks), quality improvement, and predictive analytics.
Discussion: The MTHA is a tool for population management, highlighting risks that may not otherwise be identified in a standard visit. It was developed to meet Centers for Medicare and Medicaid Services requirements for the annual wellness visit-covered benefit that provides health-risk assessment and a personalized prevention plan. The MTHA collects self-reported information about overall health, functional status, health conditions/symptoms, and behavioral and psychosocial risks. It identifies important health issues, social concerns, and functional disabilities for clinical, operational, and research purposes. Using the revised MTHA and enhancing processes to address positive triggers, will even further enable identification of important medical and nonmedical risks, positively impact HOS measures, and allow us to improve the lives of our members.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


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