Imagine that you are the vice president for quality improvement in a national DM company with contracts and interests in 26 states across the country. Your health coaches are RNs who work in telephone call centers across the country and focus on patients with gaps in their treatment program. These nurses work under the supervision of clinical managers, who are also RNs with advanced degrees. Quality managers in these local sites are seeking your input and guidance on a matter of measurement. In addition, your company is preparing a balanced scorecard and is interested in monitoring quality in four categories: clinical quality, utilization of healthcare resources, core business processes, and customer satisfaction. Your contracts consistently include patients with diabetes mellitus, COPD, CHF, asthma, and CAD; you serve primarily commercial clients with HMOs and a PPO. You will need access to the Internet for this exercise.
• Name at least two clinical quality or utilization of healthcare resource (condition-specific) metrics for each of the five aforementioned conditions. Choose at least two HEDIS metrics. • Consult the NCQA website and the data that are available which provide percentile rankings. If you were to set a quality goal for the coming year at the 75th percentile using HEDIS guidance for commercial PPO plans, what average score for your two selected HEDIS clinical metrics would your contracts each need to achieve? • Think about how these measures “connect” to the RN/health coach role. What functions does the nurse perform day to day on a call with a patient that drives toward the outcomes you’ve chosen to measure?