Implement the Care Delivery & Payment Transformation

The Roadmap to Advance Health Equity covers a lot of material about designing a plan to advance equity. But what about implementing the care delivery and payment transformation?

If you’ve worked through the Roadmap, you and your partnering organizations are fostering cultures of equity and have identified a health equity focus together. You’ve created the foundation for successful change that will make implementation much easier, but it doesn’t mean the process will be all smooth sailing. Inevitably, unforeseen issues will emerge. Below are strategies to help you adapt and learn from them.

Because equity is a matter of quality, the best way to implement an overall equity transformation is to incorporate it into existing quality improvement activities instead of siloing it into separate projects and teams. Adapting existing quality improvement activities to address the causes of inequities in your patient populations will reduce the number of times that you have to launch an entirely new project and begin the process of embedding equity into the organization. For example, an existing quality improvement project to improve the overall rate of hypertension control can be adapted to also address inequities in process and outcome data, allowing the use of existing staff and resources.

Rather than making system-wide changes all at once, consider focusing first on small tests of new ideas when making quality improvement changes. Identifying and addressing these changes when the project is operating on a smaller scale is easier than it would be if the project were implemented system wide from the beginning.

Your team knows best what will and won’t work. Keep reading for more information on how implementing a care and payment transformations will be a lot like implementing any other quality improvement change.

Start a PDSA cycle

PDSA—Plan, Do, Study, Act— is one of the best ways to introduce change at a small scale. First, go for the low-hanging fruit and try to gain momentum with a quick win. Take time to plan the change, then do it. Afterward, study its effect and ask your team how they think it went. Use their responses to act: repeat the change with tweaks or implement and move forward.

In addition to running a PDSA cycle (see callout above/below/to the right), your team has a range of options to see how an initiative might work, including pilot testing. Pilot testing is the natural result of PDSA cycles: you test something small, learn from it, adapt, and try something a bit bigger.

Pilot testing can help your team gain early wins, which can motivate the team to continue the effort. It can help ensure that your initiative is successful once you’re ready to roll it out across multiple organizations or sites.

Payer and Care Provider Partnerships

For examples of payer and care provider partnerships to advance health equity, click here to learn more about three of those partnerships and the many lessons they learned working together to advance health equity. See page 37 of the AHE “Lessons Learned” document to learn more about how they:

Assessed the accuracy of the baseline data needed to operate their initiative
Analyzed potential sources of inaccurate data and developed strategies to counteract those inaccuracies
Became aware of potential gaps in data regarding services or treatment received by the initiative’s priority populations.
Ensured that initiative leadership could access data to inform ongoing initiative operations and respond to stakeholder concerns.
Ensured that disparities gaps did not lessen due to care processes or outcome measures worsening for the original advantaged group.

Tips for Pilot-testing Equity Initiatives

Test the activity with the priority populations

You’ve worked hard to tailor the program to their needs, and this is one of the final steps to ensure the care and payment transformations are relevant and successful for them.

Run pilot tests with diverse groups and settings

Remember to consider intersectional identities of historically marginalized groups and how they might be impacted differently. Piloting with a diverse group will help you identify needs that may vary from population to population. For example:

Some older patients may need different versions of forms, possibly with a larger font to make it easier to read.

Some patients who speak a primary language other than English may need tailored support.

Pilot test your data collection

Measuring data can be complicated. You’re likely to run into snags the first time around. Be sure to practice collecting the data you’ll use for ongoing evaluation. The more data collection is built into implementation, the less it will feel like an additional burden as you scale up.

Strike a balance between adherence and adaptability

As you process feedback, try to find a compromise that stays true to your vision while meeting the needs of those requesting revisions. The most successful programs find that balance through an iterative process – the PDSA cycle will help you. Use standardized checklists to monitor adherence and update those lists as the care and payment transformations are adapted. That process is important not just for piloting, but also for maintaining and improving the transformations over time—it’s part of a culture of quality.

Measuring Change

Focus on process measures initially

It takes time to see changes in outcomes, so your early wins will likely be process oriented. Process measures tell you whether a plan is being implemented as it should. That plan could be many things such as a new form asking about patients’ race/ethnicity/language, or timely referrals for a colonoscopy. Process measures will help you understand if and how changes are being put into practice. They will help you demonstrate the impact of your transformations in the short term, before health outcomes improve.

Understand satisfaction scores in their context

When patients are aware that the health system is working towards improvement, their expectations may increase and satisfaction scores may decrease, which is a natural part of raising the bar for everyone. As care transformations are implemented, and patients see the effects of your changes, these scores usually improve.

Plan for the long-term

Moving the dial on clinical outcomes often takes longer than expected: keep in mind how often patients and health care provider organizations will interact with your care and payment transformations (e.g. do most patients come in once every three months?). Develop a reasonable timeline by consulting multiple stakeholders. Work with your team to identify what kinds of improvement you will define as success.

Communicate with your leadership about this timeline so they know what kinds of results to expect when. If you’re rigorously evaluating a care transformation, you may need to track patients for several years to demonstrate statistically significant improvements in health outcomes.

Don’t forget to measure the gaps

The only way to understand how you have improved is to measure change. It’s critical to measure not only overall quality improvement, but also changes in inequities, taking note of where gaps in care and outcomes have been closed—or widened. While overall improvement is promising, it may or may not indicate a reduction in inequities. To promote equitable care and outcomes, you need to consider the causes of identified inequities, design the care and payment transformations that will address those causes, and commit to measuring how your transformations affects those differences in care and outcomes.