Establishing a health equity strategy isn’t complete until you’ve set step-by-step metrics for its key components.
Your health equity strategy will likely center on interventions driven by risk stratification, including many of the following steps:
Identifying disparities in clinical outcomes and the populations experiencing them
Leveraging all available data to identify and prioritize high-risk individuals
Designing interventions that address specific individual-level risk factors
Delivering interventions via care management teams or community-based organizations
Monitoring your outcomes of interest and reporting your progress to CMS
These steps are a solid foundation, but implementation and execution of such a strategy is complex, given the many dependencies. Unforeseen problems with any individual component of your strategy can dramatically affect downstream steps and the ability to meet your selected goals.
For example, your interventions may be highly effective at improving target outcomes in the right individuals but have minimal impact if your risk stratification frequently produces false positives, wasting limited intervention resources.
Conversely, your risk stratification may be highly accurate, but interventions may be ineffective at addressing the typical risk factors identified.
Without measuring the effectiveness of key steps within your strategy, it may be challenging to determine where problems are occurring and what changes need to be made early enough to avoid poor results at the end of a reporting period.
Success in ACO REACH requires the measuring and monitoring of key steps in your health equity strategy, providing insight into how its individual components impact your targeted health outcomes.
When establishing your strategy, you should consider creating and tracking metrics that quantify:
Your program evaluation tools must help ensure that your risk stratification and interventions are operating as expected, that specific activities are driving impact, and that outcomes can be traced through each step of your strategy.
No strategy is complete without a way to measure whether it’s working. Establishing step-by-step metrics for each part of your strategy is critical when dealing with the complexity involved in improving health equity.
CMS has stated that reducing health disparities and tracking progress will be tied to greater financial risk in future iterations of ACO REACH. Becoming proficient with step-by-step metrics now will directly support long-term success.
PY23 is an ideal time to begin measuring individual processes and activities when financial risk in ACO REACH is still lower.
