We agree with Hughes et al that the State Innovation Model initiative (SIM) provides a much-needed catalyst for health system transformation.[1] Among the innovative strategies employed by states participating in SIM, integration of home and community based services (HCBS) plays an essential role in keeping the health system functioning given that long-term supports and services (LTSS) provide 8 out of 10 hours of paid services to the elderly and people with disabilities.[2] However, several barriers impede LTSS providers’ ability to handle the complexities of the rapidly emerging healthcare system, which may pose an acute hindrance to SIM’s mission to advance broad-based health system transformation through rapid cycle improvement.
One barrier impeding LTSS providers is their limited capacity to implement quality improvement (QI) initiatives. QI is important to rapidly discover and validate novel delivery models. It also facilitates the formation of partnerships between LTSS providers and clinical providers by creating a common language for collaboration. We commend the SIM initiative for providing technical assistance (TA), however TA efforts for SIM and other CMMI initiatives have not provided adequate support to build enough systemic QI infrastructure among LTSS providers.
Another barrier to achieving the aim of the SIM initiative is the lack of adequate quality measures to evaluate the impact of LTSS-based QI initiatives. A prerequisite of improving a process is being able to measure it; standard quality measures overly emphasize medical rather than LTSS. We recommend that CMMI reinforce efforts like the National Quality Forum’s creation of a committee on HCBS to expedite development of quality measures more appropriate for LTSS providers.
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A third barrier to LTSS providers being able to fully contribute to the SIM aim is the lack of guidance during the selection of technology to support QI. With the proliferation of digital health technologies and only 23% of them having evidence to support their claims, LTSS providers are faced with a poor signal-to-noise ratio when selecting technology.[3] We recommend that SIM plans include systematic approaches to technology procurement that help narrow the ecosystem of apps to a select few.
Experimentation is essential and the SIM initiative’s support of rapid cycle testing is prudent and commendable. But without addressing the barriers to LTSS providers’ full participation, the learning laboratory that SIM is trying to create may lack the catalyst it needs to get the healthcare transformation experiment off the ground.
Andrey Ostrovsky, MD | CEO. Care at Hand.
Karen Matsuoka, PhD | Design Fellow. Stanford Design School. Former Maryland Health Dept. Former White House.
Carol Marsiglia, MS, RN, CCM | Sr. VP. Strategic Initiatives and Partnerships. The Coordinating Center. Maryland.
References
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Andrey Ostrovsky, MD Website Physician and social entrepreneur. Creating disruptive technology to better health for vulnerable populations. Specializes in applying Lean Startup Thinking and Design Thinking to discovering social and commercial value of innovations in healthcare. Andrey blog's at www.disrupthealthcare.org. He is the CEO and Co-Founder of Care at Hand, Inc (www.careathand.com). He practices as […]
1. Hughes LS, Peltz A, & Conway P. State Innovation Model InitiativeA State-Led Approach to Accelerating Health Care System Transformation. JAMA Mar 2015.
2. Foster et al. Improving The Quality Of Medicaid Personal Assistance Through Consumer direction. Health Affairs. 2003.
3. Ostrovsky A, Deen N, Simon A, & Mate K. Digital Health Selection Framework. Institute for Healthcare Improvement. 2014.
Physician and social entrepreneur. Creating disruptive technology to better health for vulnerable populations. Specializes in applying Lean Startup Thinking and Design Thinking to discovering social and commercial value of innovations in healthcare.
Andrey blog's at www.disrupthealthcare.org. He is the CEO and Co-Founder of Care at Hand, Inc (www.careathand.com). He practices as a pediatrician at Boston Children's Hospital and Boston Medical Center.
