Spotlight on Special Needs Chronic Care Populations: An Innovative Effort by Senior Whole Health Toward Aligning Quality Measurement and Improvement


By Andrew McClure, Senior Whole Health, and Deborah Paone, Special Needs Plan Alliance

Aligning quality improvement is a key principle of the Special Needs Plan Alliance and its member health plans. One health plan that has been working toward such alignment in an innovative way for several years is Senior Whole Health, part of the Magellan system, located in MassachusettsRecently, Deborah Paone sat down with Andrew McClure of Senior Whole Health, a Magellan company, to discuss his work around aligning quality measurement and improvement. Andrew also presented this information at the Special Needs Plan Alliance Executive Forum in October 2018. This blog post offers insight from Andrew on what they did and what drove the success of this partnership between medical group providers and this special needs health plan.


“Henry” is 69 years old and lives in a transitional housing unit in Boston. He has bi-polar disorder, diabetes, and chronic back pain. He suffered a bad fall at his part-time job in a warehouse ten years ago and is permanently disabled with mobility limitations. Henry did not complete high school. He lives alone. Three years ago, he chose to enroll in a Medicare Advantage special needs health plan that serves people who are approved for both Medicare and Medicaid. Henry had to move and wanted a primary care physician and behavioral health therapist closer to where he lived. His doctors are part of a large medical group. This medical group and the health plan serve many people like Henry.


Henry is not a real person, but he is similar to the members enrolled in a special needs plan (SNP) called Senior Whole Health.  This plan serves more than 15,000 people like him in Massachusetts. These individuals often need to receive care from specialist physicians, primary care providers, and mental or behavioral health providers. In addition, they often require supportive services such as in-home personal care assistance, transportation services, and housing assistance. When considering the multidimensional needs of people like Henry, the health plan and the providers in the network are challenged to align their measures of how well they are doing collectively.

Among providers, health plans, and policymakers, there is awareness of the challenges and costs associated with addressing the multidimensional and interdependent needs of people with complex chronic, disabling, and behavioral health conditions. However, the development of measures and approaches to align quality measurement and improvement has been relatively slow.

Currently, quality measurement and improvement chiefly focus on specific and narrowly defined clinical indicators, care processes, or disease status changes. Even self-reported patient outcome measures pertain to a short window of time or specific treatment episode, setting of care, or experience of care with one clinician. Rarely does measurement bridge across care episodes, settings, disciplines, or programs. Moreover, the field is constrained by the measures that have been developed, tested and validated. Though efforts are underway to connect Medicare and Medicaid programs for dually-eligible people like Henry, the measures used to assess quality of care and performance in these two programs are rarely in sync.

For people like Henry who receive ongoing medical, behavioral, and home- and community-based services, providers often operate with only tenuous ties to each other. Each must collect and report data according to state and federal requirements. The quality measure specifications and data collection/reporting requirements—even the surveys sent to the beneficiaries (people like Henry)—are separate and distinct. Thus, multiple measurement efforts are required from various points of contact, even when all providers are serving the same person. For example, the Medicare program requires health plans and health delivery systems to conduct a survey called Consumer Assessment of Healthcare Providers and Systems (CAHPS). Another beneficiary survey, called the Health Outcomes Survey (HOS), is also required of health plans; some of the questions on this survey are similar to questions found in the CAHPS.

Aligning quality measurement and improvement across plan and providers is a key principle of the Special Needs Plan Alliance. One health plan that has been working toward such alignment in an innovative way is Senior Whole Health, part of the Magellan system, located in Massachusetts.

For quality measurement to be meaningful, focus must start on the people served. Senior Whole Health reviewed the characteristics of its special needs health plan enrolled members, and found they live with many social risk challenges in addition to their physical, medical and behavioral conditions. For example, 76 percent are non-English-speaking, 44 percent did not graduate from high school, and 49 percent cannot read. These characteristics affect how, when, and why individuals seek care and how care treatment and follow-up is managed. These characteristics also affect individuals’ daily self-care habits and impact access to nutrition, housing, and transportation—basic needs which can mitigate the effectiveness of recommended care and treatment.

Successful Partnership Approach

The Senior Whole Health Quality Director, Andrew McClure, crafted an innovative approach to coalescing efforts across the health plan and several key provider groups toward improving care outcomes for these special needs individuals. Andrew and his team created a survey that combined elements of two surveys used by the Medicare program to evaluate quality of care for Medicare Advantage beneficiaries. The Medicare Health Outcomes Survey (HOS) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys are used by the Medicare program to evaluate quality of care for Medicare Advantage beneficiaries and healthcare providers’ Medicare patients. Andrew sought to join provider and plan efforts on quality of care review and improvement for these Medicare beneficiaries around several quality measures on which both the plan and providers are focused. The two healthcare organizations (plan and provider) have similar though not identical quality measures on several key indicators.

To begin, Senior Whole Health identified several of the top medical group providers who were serving many of the plan’s enrolled members. The health plan took the lead and worked in partnership with these key medical groups. They agreed that their efforts would focus on better alignment of quality measurement around certain measures and the specific plan members/provider patients that they had in common. In other words, if five hundred people enrolled in Senior Whole Health were also patients of Medical Clinic A, the collaborative efforts to join quality measurement and improvement efforts would likely yield benefits for both the plan and providers working at that clinic and serving those patients. Under Medicare, both the health plan and the clinic can be held accountable for specific quality measures on clinical screenings, doctor/patient communication, and other aspects of care and the patient experience.

The results of a special survey of these beneficiaries would then be used to inform medical group partners and the health plan of current measure results and help indicate areas of strength as well as performance gaps. These results could help guide quality improvement efforts across the health plan and a set of providers. They could measure year after year and compare their progress. Those who had discovered effective practices or processes for improving on the quality indicators would share these approaches through a collaborative learning model.

In designing the hybrid survey, Andrew and his team reviewed the HOS and CAHPS survey questions and selected measures considered most amenable to delivery system/provider interventions. These measures included: Flu Shots, Monitoring Physical Activity, Improving Bladder Control, Reducing the Risk of Falling, Getting Appointments Quickly, and Care Coordination. These measures were also aligned with some Accountable Care Organization quality measures, such as Access to Urgent and Routine Care, Discussion with the Physician about Physical Activity, Influenza Immunization Rates, and Fall Risk Reduction. In addition, there was potential for additional payer incentives among the medical groups classified as Patient Centered Medical Homes.

Andrew and his team crafted a question set that was as similar as possible in wording and scale to the two instruments. They received approval from the National Committee for Quality Assurance (NCQA) which reviews and accredits the health plan, to use the tool in their quality improvement efforts. They largely followed the CAHPS/HOS methodology in terms of mailing and telephone outreach and conducting the survey in both English and Spanish. The minimum sample size, per medical group, was 500 members. Survey response rates were adequate—from 21-48 percent. This rate mirrors that of HOS response rates

The way Andrew designed the initiative, Senior Whole Health takes on the full costs and administrative duties to conduct the survey. Senior Whole Health invites the targeted groups of Medicare enrollees who are also patients of the partner medical clinics to participate. Senior Whole Health then receives the responses and enters the data for each medical group. There are eight groups (up from five when this began in 2015). These response data are then tabulated and aggregated. The quality team from Senior Whole Health creates a clinic-specific data report for each medical group and includes results trended over multiple years and blinded comparisons to all the other groups to indicate peer group benchmarks. In addition, the reports include measure-specific averages from this beneficiary sample and the Medicare Star measure thresholds for the highest 5-star rating. These thresholds and the Star levels are part of the Medicare Quality Management system used by the Centers for Medicare and Medicaid Services (CMS). In this way, the clinicians reviewing their tailored reports can see their own clinic performance, and how their performance compares to peer medical groups and to national norms for each measure that was surveyed. This information has great value, as it is tailored, targeted, specific, and timely. “The response from the medical groups has been uniformly positive. In the first year there was some hesitation and doubt. But the medical groups stuck with it.”

The value of the work continues from there, as the health plan then facilitates group presentation and discussion to analyze and interpret the data, share effective practices, and work together on quality improvement efforts. There are specific, documented requested action steps and follow-up for each medical group, depending on the results. The health plan also provides targeted education, information, and evidence-based tools or other resources to the medical groups to assist them in improvement.

This effort has grown and developed to the point where there are now established relationships between the quality directors and clinicians of the provider groups and health plan. “The providers really see the value and appreciate that this provides near real-time information and helps bolster their internal quality review and improvement efforts.”

Key Elements for Success

Andrew notes that this partnership approach has several key components that have been important to its success:

  1. Core set of aligned measures: An aligned core set of measures across provider and plan —finding those points of intersection that also have a strong relation to what the plan and the provider separately are accountable for in their CMS measurement systems. Senior Whole Health had to create this core set, but they used validated tools and worked to align with existing measures and measurement processes as best they could.
  2. Peer learning and relationship approach: Working with and across provider groups, Senior Whole Health not only aligned the core measures, but created a peer group approach so that those ahead in one measure would be identifiable. The peer-to-peer comparisons and the solutions facilitated by Senior Whole Health, as well as group learning opportunities, are invaluable. That is, having the same measures, the same time period, and shared learning for medical groups to discuss these measure results and for one group to mentor another. Building effective relationships with open communication was also key.
  3. Ongoing commitment and plan leadership: The health plan has made the commitment to this effort over multiple years, using its own internal resources for managing the survey, aggregating data, performing the analysis, facilitating meetings and group learning, and seeking/sharing tools and resources about effective interventions for quality improvement. This kind of sustained commitment is vital.

As the project concludes its fourth cycle of surveys, there is strong evidence of effectiveness. Specifically, the measures identified as priorities when the project started four years ago – Access to Care, Care Coordination and Advising Members about Activity -- are showing meaningful improvement as measured by the CMS Stars program. Each of these three priority measures has moved from a 1 or 2 Star level to 3 or 4 Stars. Andrew states: “We believe that this targeted, collaborative, and sustained approach has played a big part in generating these results.”