THE MYERS GROUP MEDICARE CAHPS RESEARCH SERIES

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1 THE MYERS GROUP MEDICARE CAHPS RESEARCH SERIES Background Each year, CMS rates each Medicare Advantage plan using a five star rating system. While originally developed to provide members with the ability to compare MA plans, the passage of the Patient Protection and Affordable Care Act (PPACA) tied star ratings to new bonus payments. These bonus payments are meant to offset the reimbursement cuts to MA plans called for by the PPACA. Beginning in 2012, CMS will use the star ratings to assign financial bonuses as a reward for high performing plans, reaffirming a commitment to high quality, patient centered care. This performance based payment offers plans the opportunity to benefit from improving member satisfaction. Additionally, in November 2010, CMS announced a demonstration project that will allow more plans to qualify for the bonus payments. Originally, the health reform law provided bonus payments to plans with at least four stars. The demonstration modifies the rating system to allow plans with at least three stars to receive bonus payments for The purpose is to test whether providing scaled bonuses leads to more rapid and larger quality improvements in MA program quality scores. Furthermore, CMS has announced that in the future it may cancel the contracts of plans that don t score at least three stars. TMG has compiled a three part series of research and analysis to provide plans with additional information and resources aimed at improving member satisfaction scores. Over the next few months, TMG will release papers focusing on: Coordination of care Utilization of services Chronic disease management We believe these areas are important for our plans to monitor, especially given the current emphasis from CMS on care coordination and patient centered care. CMS has recently announced that they will include eight new questions and a new Care Coordination domain on the 2012 surveys next year. Another measure added by CMS for the 2012 star ratings is all cause hospital readmission rates, which can indirectly measure the quality of care coordination after a hospital admission. This, along with the current development of Accountable Care Organizations, further highlights the importance of these measures to CMS. Copyright 2011 The Myers Group 1

2 THE MYERS GROUP MEDICARE CAHPS RESEARCH SERIES PART I COORDINATION OF CARE Coordination of care has recently been front and center in health care research and policy discussions. Because of the potential impact on member satisfaction that may result from improvements in care coordination, TMG has developed this report to provide our clients with further analysis of opportunities in this area. After a thorough literature review, AHRQ developed the following definition of care coordination 1 : Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care. Care transitions represent a huge opportunity for the aging network. In a survey of Americans aged 50 or over conducted by the Campaign for Better Care, 74% of respondents have wished that their doctors talked and shared information with each other 2. A lack of communication and coordination tended to especially affect heavy users of the health care system and people of color. Recognizing the potential opportunities for increased care quality that better care coordination could bring, CMS recently announced its intent to add eight questions focusing on care coordination to the 2012 MA Only and MA PD surveys. These, in addition to some of the care coordination questions already asked on the Medicare CAHPS survey, are being proposed for a new Coordination of Care domain. All Medicare CAHPS Care Coordination Questions: Personal doctor had your medical records Got test results as soon as you needed Took any prescription medicines (Screener) Talked with you about your prescriptions Got care from more than one type of health provider (Screener) Needed help from personal doctor s office managing care (Screener) Got help managing care from different providers Offered office visit notes Personal doctor seemed informed and up todate about the care you got from specialists Personal doctor ordered blood test, x ray, or other test (Screener) Personal doctor s office followed up to give you results of blood test, x ray, or other test 2012 Medicare CAHPS Care Coordination Domain: 1. Personal doctor had your medical records 2. Personal doctor seemed informed and upto date about the care you got from specialists 3. Personal doctor s office followed up to give you results of blood test, x ray, or other test 4. Got test results as soon as you needed 5. Talked with you about your prescriptions 6. Got help managing care from different providers 7. Offered office visit notes 1 Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9. AHRQ Publication No. 04(07) June Copyright 2011 The Myers Group 2

3 The questions not included in the domain are screeners that will gate the question(s) that follow it. For instance, only those members who took any prescription medicines will be asked if they talked about their prescriptions with their doctor. According to the 2011 TMG Medicare CAHPS Book of Business, 91.9% of members filled or refilled at least one prescription medicine in the last 6 months, suggesting that most members will have a chance to report on whether they then talked about those prescriptions. 3 One of the care coordination questions asked on the 2011 survey has been dropped from the 2012 survey: How satisfied are you with the help you received to coordinate your care in the last 6 months? is no longer included. Assumedly this is due to the new questions having a greater degree of specificity. According to the 2011 TMG Book of Business, 84.5% of members reported that they were either Very satisfied or Somewhat satisfied with the help they received to coordinate their care, with H contract results ranging from a low score of 65.9% to a high of 94.3%. In 2010, CMS data reveals that 87.7% of surveyed Medicare Advantage members are at least somewhat satisfied with their care coordination. On the national level, a 2009 survey found that overall, just over four in ten Americans report at least minor problems with coordinating care between their different doctors, while half say this is not a problem at all (see footnote 9). The following Opportunities provide a brief description of some of the programs and tools that may lead to better coordination of care for members, including patient centered medical homes, healthcare information technology, and family/caregiver support. Opportunities Patient Centered Medical Home One of the major movements toward greater care coordination is the patient centered medical home (PCMH). The PCMH is a model for delivering primary care that is patient centered, comprehensive, coordinated, accessible, and continuously improved through a systems based approach to quality and safety. Medical homes may allow primary care doctors to be reimbursed based on overall patient care and quality outcomes, rather than on how many patients they can see in one day. The Atlanta Journal Constitution (AJC) recently highlighted patient centered medical homes and outlined some of the potential benefits for patients. 4 As part of a medical home, patients may: Have expanded access to doctors and nurses through evening hours, weekend hours, e mail and other methods. Set health and wellness goals with their primary doctors versus just getting treatment for their immediate problem. 3 The 2011 Myers Group Book of Business consists of 144 MA PD/MA PPO/MA Only contracts that conducted the Medicare CAHPS survey with TMG in This does not include members in Standalone Prescription Drug Plans. 4 Williams, Misty. Patients profit in team concept. The Atlanta Journal Constitution, May 5, Copyright 2011 The Myers Group 3

4 Receive reminders about upcoming annual screenings, which can catch issues early and help them stay healthier. Have access to Web portals where they can request prescription refills, make appointments and ask nurses questions. The AJC also reported that according to the American Academy of Family Physicians, Pennsylvania based Geisinger Health System, which launched a demonstration project in 2007, saw a 40% drop in hospital 30 day readmissions, and the cost of care for patients in the test group was 7% less than in the control group. Especially relevant considering that CMS has just added hospital readmissions as a star rating measure, implementing a medical home may offer plans the potential benefit of seeing quality improvement in this area. Given that this model is being adopted across the country, the National Committee for Quality Assurance (NCQA), in conjunction with the Agency for Healthcare Research and Quality (AHRQ) just released its new PCMH CAHPS survey. It is based on the Clinician and Group CAHPS survey and will focus on the following domains 5 : Access Information Communication Coordination of Care Comprehensiveness Self management support and Shared Decision Making The Myers Group was selected as an NCQA approved vendor for PCMH CAHPS and will be able to implement the survey protocol for the first data submission date in April Healthcare Information Technology According to a recent survey, 75% of the public thinks that it is very or somewhat important that their health care provider use electronic or computer based medical records instead of paper based records. 6 However, according to the New England Journal of Medicine (2009), only 17% of American physicians have a basic electronic health record system. 7 With thoughtful implementation, HIT (Health Information Technology) can make a difference in transitions of care. The Congressional Budget Office published a paper in 2008 outlining the benefits of HIT 8 : 5 NCQA Press Release, September Available at: txaxvli ny2vz2iacigfjy7tt757boa_ghyacexxbrygrjrwisf7lrzvyqznbjlewuuosezpty1ppdkyfml6stit_v6ueoahsj4f4qn0e0lk3i ufz_vzb5ze9jtsdtmggw%3d%3dps:// compliant_.pdf 6 NPR/Kaiser Family Foundation/Harvard School of Public Health. The Public and the Health Care Delivery System. April Accessed April 6, Health Care and the American Recovery and Reinvestment Act. Robert Steinbrook, MD. Article ( /MEJMp ) published at NEJM.org on February 17, Congressional Budget Office. Evidence on the Costs and Benefits of Health Information Technology. May Quoted in National Transitions of Care Coalition. Improving Transitions of Care with Health Information Technology: Position Paper of the Health Copyright 2011 The Myers Group 4

5 Eliminating paper medical records and expanding the exchange of health information Avoiding duplicate or unnecessary diagnostic tests and radiological services Promoting cost effective use of prescription drugs and avoiding adverse drug events Improving nurse and physician productivity Reducing hospital length of stay Improving quality of care and expansion of the practice of evidence based medicine Generating research data on comparative effectiveness and cost effectiveness of treatments It is important that electronic medical records be implemented thoughtfully across networks. Even though a primary care office may have an EMR, it may not be accessible to other physicians, such as specialists, who may not have the same EMR system. Issues of privacy and security must be taken into careful consideration in the design and implementation of these systems. A nationally representative 2009 survey found that 59% of adults were not confident that personal health information that was stored electronically and could be shared online would remain confidential. Three quarters (76%) of those surveyed were at least somewhat likely to think that an unauthorized person would get access to their medical records. 9 These concerns might be alleviated by proper security protocols. In the same survey, 66% of respondents agreed that we should not let privacy concerns stop us from learning how technology can improve our health care. To encourage medical facilities to implement EMR technology, the American Recovery and Reinvestment Act of 2009 provided hospitals and physician offices $19 billion in reimbursement incentives from CMS for meaningful users of electronic health record technology. Health plans may have network provider groups that would qualify for federal assistance to implement this technology. More information and registration is available at: Medicare Advantage organizations may also qualify to receive payments under the Electronic Health Record Incentive Programs. According to CMS, under the Medicare Advantage EHR Incentive Program, payments are made only to Medicare Advantage organizations that are licensed as HMOs, or in the same manner as HMOs, by a state. These Medicare Advantage organizations may receive incentive payments by way of Medicare Advantage affiliated hospitals (MA affiliated hospitals) and Medicare Advantage eligible professionals. More information is available at: While electronic health records (EHR) focus on health care professionals, personal health records (PHR) focus on individuals and are another potentially promising use of health information technology. PHRs are websites or other electronic records where people can get, keep and update their health information. Ideally, PHRs encourage patient involvement in their health care. Research conducted by the California Healthcare Foundation finds that seven percent of those surveyed have used a PHR. 10 Information Technology Work Group for the National Transitions of Care Coalition. December Available at Accessed April 6, NPR/Kaiser Family Foundation/Harvard School of Public Health. The Public and the Health Care Delivery System. April Accessed April 6, Consumers and Health Information Technology: A National Survey. California Healthcare Foundation. April Accessed April 26, Copyright 2011 The Myers Group 5

6 While this is still a small number, it is double the proportion identified two years earlier. The article reported that As a result of their PHR, users cite taking steps to improve their own health, knowing more about their health care, and asking their doctors questions they would not otherwise have asked. PHRs may become more prevalent among Medicare recipients since there is a new option on the MyMedicare.gov website called the blue button. This allows people to download their claims or medical information to their personal computer and create a PHR. The U.S. Veterans Affairs Department's Blue Button initiative recently launched and as of October 2011, has seen 430,000 veterans download their healthcare claims information, far exceeding the initial prediction of 25, As more Baby Boomers age into the Medicare system, there may be more utilization of online health resources. Currently, 40% of US adults age 65 or over go online, and 29% look online for health information. 12 Another area of technology that is quickly being adopted and integrated into the health care field is social media. Given privacy concerns and marketing regulations, Medicare Advantage plans have inherent limitations on the type of information they can disseminate in this way. However, people generally appreciate timely information from their health plan. The right kinds of communication have the opportunity to leave members with a good impression of their plan and have a positive impact on satisfaction scores. Members choosing to follow a plan on social media might receive information about breast cancer screenings during breast cancer awareness month, timely reminders to receive their annual influenza vaccine, or tips and suggestions about wellness initiatives. In addition to focusing on the member, it may be helpful for plans to make sure that family caregivers are aware of any social media opportunities as well. People caring for loved ones are more likely than other adults to use social network sites to gather and share health information and support. 13 Coordination of Care TMG Recommendations: Consider implementing an electronic medical record (EMR) across the health plan network, with priority focus on linking high volume primary care and specialty providers. Consider offering patients and caregivers a PHR to increase engagement and coordination. Review/revise current referral processes and tools, to ensure better communication and collaboration among providers. Review/strengthen provider contract language regarding care coordination expectations. Conduct Provider training as indicated Ensure timely medication reconciliation following care transitions. Consider adding a custom question to next year s Medicare CAHPS survey to gauge members access, ability, and willingness to use a computer to access health information. 11 Blue Button Use Blows Away VA Expectations. Accessed October 19, The Social Life of Health Information, Pew Research Center s Internet & American Life Project. Accessed October 21, The Social Life of Health Information, Pew Research Center s Internet & American Life Project. Accessed October 21, 2011 Copyright 2011 The Myers Group 6

7 Family Caregiver Support Especially with the aging Medicare population, it is important to recognize the role that family caregivers have in coordinating care. Nonprofessional caregivers can be valuable members of the health care team. It can be imperative to incorporate caregivers into the health care decision making process in order to have the best chance at positive outcomes. The use of PHRs may help to facilitate patient and family engagement. While some members of a Medicare Advantage plan may not go online to access their health information, it could serve as a useful resource for primary caregivers. Furthermore, health plans may have a unique opportunity to provide this type of information. In a recent survey, 50% of adults who do not have a personal health record would be interested in using a PHR if it came from their health insurance plan. 14 In a white paper released by Leading Age, the most pressing challenges facing family caregivers are divided into three categories: Lack of self identification as a family caregiver. When family members begin identifying themselves as primary caregivers, they can take advantage of possible work place support and community programs. Also, physicians should closely integrate family caregivers into discussions about the patient s care needs. 2. Lack of recognition for family caregivers as a critical member of the patient s primary care team. Family caregivers often lack the expertise to be confident that their choices are the best option for their loved one. Acknowledging the role of the caregiver and providing the appropriate support and information can be a crucial component of care transitions. 3. Lack of health care literacy among family caregivers to effectively navigate the health care system. Family caregivers can often be overwhelmed when they take on the role of caring for a loved one. This can be further complicated when the caregiver lacks the skills needed to make appropriate health care decisions. The author notes that having nurse practitioners or care managers as professional advocates to support and counsel family caregivers can be a vital tool for both the family caregivers and their loved one s primary care physicians. When examining care transitions, MA plans should consider engaging with their providers to make sure that family caregivers are given the support they need. Also, there are tools available for physicians to use in order to determine levels of stress and other health related concerns caregivers may be facing. 16 Of note is a recent finding that while hospital and doctor rankings and review sites have not yet become health care decision making tools for most consumers, caregivers are more likely to consult online 14 Consumers and Health Information Technology: A National Survey. California Healthcare Foundation. April Accessed April 26, National Studies in Caregiving: Implications for Providers. Leading Age (Formerly the American Association of Homes and Services for the Aging Available at Accessed April 28, Caregiver Self Assessment Questionaire, American Medical Association. assn.org/resources/doc/publichealth/caregiver_english.pdf Accessed April 28, Copyright 2011 The Myers Group 7

8 rankings than other adults. For example, 21% of online caregivers consult online doctor reviews, compared with 13% of internet users not currently caring for a loved one. 17 The Myers Group Book of Business Results The following table displays results of both CMS national data from 2010 (the most recent year data is available) and the 2011 TMG Book of Business 18 on questions that pertain to care coordination. Measure/Attribute In the past 6 months, when your personal doctor ordered a blood test, x ray, or other test for you, how often did someone from your doctor's office follow up to give you those results? How satisfied are you with the help you received to coordinate your care in the last 6 months? In the last 6 months, how often did your personal doctor seem informed and up to date about the care you got from specialists? SRS 19 Definition Always/ Usually Very/ Somewhat satisfied Always/ Usually TMG Book of Business CMS National Data % 85.3% 84.5% 87.7% 85.5% 84.4% 17 The Social Life of Health Information, Pew Research Center s Internet & American Life Project. Accessed October 21, The 2011 Myers Group Book of Business consists of 144 MA PD/MA PPO/MA Only contracts that conducted the Medicare CAHPS survey with TMG in The 2010 CMS benchmark consists of 411,391 respondents from plans that submitted data to CMS in SRS (Summary Rate Scores) generally represent the most favorable response percentages. Copyright 2011 The Myers Group 8

9 Further analysis of the care coordination questions by segments in our Book of Business yields the following results. While no results are statistically significant, the largest difference in satisfaction is between Local PPOs and other types of plans. TMG Book of Business Profile Tax Status Plan Type Enrollment Years in Business In the past 6 months, when your personal doctor ordered a blood test, x ray, or other test for you, how often did someone from your doctor's office follow up to give you those results? Always/Usually How satisfied are you with the help you received to coordinate your care in the last 6 months? Very/Somewhat satisfied In the last 6 months, how often did your personal doctor seem informed and up to date about the care you got from specialists? Always/Usually Non Profit 86.8% 84.8% 85.4% 31 For Profit 84.9% 84.4% 85.6% 113 Difference 1.9% 0.4% 0.2% HMO or HMO/POS 82.9% 86.6% 85.0% 80 Local PPO 88.4% 81.1% 86.4% 56 Other Type 88.6% 88.5% 85.0% 8 Difference 5.7% 7.4% 1.4% 15,000 or fewer 85.5% 83.2% 85.0% 89 More than 15, % 86.6% 86.4% 55 Difference 0.3% 3.4% 1.4% 1 4 years 84.9% 83.3% 83.9% years 84.2% 83.3% 86.1% years 88.0% 88.6% 87.1% 34 Difference 3.8% 5.3% 3.1% Valid n* *Valid n refers to the number of contracts in each category Copyright 2011 The Myers Group 9

10 Recognizing that it is important for plans to measure member perception of care coordination, TMG included the following question in our Medicare Advantage Satisfaction Survey, which drills down on the Medicare CAHPS composites and other relevant topics during the Medicare CAHPS off season: The following question asks about your experiences with communication and coordination between your different health care providers. In the past 6 months, when getting medical care, was there ever a time when you (Mark all that apply) A. Had to bring an x ray, MRI, or other type of test result with you to a doctor s appointment? B. Had to follow up with your doctor s office to get test results because you had not gotten them? C. Received different instructions from different doctors or health care professionals? D. Had to repeat a test or procedure because the doctor didn t have the earlier test results? E. Had to come back for another appointment because a health professional did not have your medical information available? F. Tried to get two of your doctors to talk to each other and failed? G. Had to go back to the hospital less than 30 days after being discharged? The following pages provide an analysis of each question by examining which subgroups were statistically significant in TMG s Book of Business. Please note that the subgroup analysis for this section examines those groups least likely to be satisfied with their care coordination. According to the 2011 TMG Book of Business, members who gave low ratings to their doctors, their health care, and their health plan were more likely to be dissatisfied with the coordination of their care. Those with fair/poor self assessed overall and mental health were also significantly more likely to rate their care coordination lower than those with better overall and mental health. Interestingly, those members diagnosed as having emphysema, asthma or COPD were significantly more likely to rate their care coordination lower than members who do not have those conditions. Copyright 2011 The Myers Group 10

11 COORDINATION OF CARE TMG 2011 Book of Business* Subgroup Analysis In the last 6 months, when your personal doctor ordered a blood test, x ray, or other test for you, how often did someone from your doctor's office follow up to give you those results? In the TMG BoB, these groups were significantly** more likely to respond "Sometimes" or "Never". Percent Answering "Sometimes" and "Never" TMG BoB 17.0% TMG BoB 13.8% 6.3% 7.5% 69.3% Always Usually Sometimes Never TMG Findings Research on TMG's Book of Business indicates that 86.2% of members report that their doctor's office "Aways" or "Usually" followed up to give them their test results. However, 13.8% of respondents said that their doctor "Never" or "Sometimes" followed up to give them test results. 49.6% of members who gave a low rating to their personal doctor were not given their test results from their doctor's office. Rate personal doctor 0 3 Rate health care 0 3 Rate specialist 0 3 Rate health plan 0 3 Mental health status fair/poor Filled no Rx Drugs Delayed filling a Rx because couldn't afford Health status fair/poor Saw no specialists 21.9% 21.4% 19.2% 18.9% 17.8% 35.9% 34.0% 31.4% 49.6% Members who gave low ratings to their health care, specialists, and health plan were less likely to have hd had someone follow f up on their h i test results than those who gave higher ratings. Also, members who self reported "fair/poor" mental health status were less likely to say that they received follow up about test results than members with better mental health. Under % 3 or more dr/clinic visits 15.5% Emphysema, asthma, or COPD 15.4% *While most analysis of the TMG Book of Business is done at the contract level, this analysis uses respondent level data of all members (n=45,750) who completed an MA PD, MA PPO, or MA Only survey. ** Significant at the 95% confidence level when compared to segments in same category (i.e. age, education). Copyright 2011 The Myers Group Medicare CAHPS Research Series 10A

12 COORDINATION OF CARE TMG 2011 Book of Business* Subgroup Analysis How satisfied are you with the help you received to coordinate your care in the last 6 months? 5.8% 3.5% 6.0% TMG BoB 19.3% 65.4% Very satisfied Somewhat satisfied Neither satisfied or dissatisfied Somewhat dissatisfied Very dissatisfied In the TMG BoB, these groups were significantly** more likely to respond "Very dissatisfied" and "Somewhat dissatisfied". TMG Findings Research on TMG's Book of Business finds that the majority (84.7%) of respondents are "Very" or "Somewhat" satisfied with the help they received to coordinate their care, while 9.5% expressed some level of dissatisfaction. Respondents who are dissatisfied with their personal doctor are most likely to be dissatisfied with their coordination of care. Percent Answering "Very Dissatisfied" and "Somewhat Dissatisfied" TMG BoB 9.5% Rate personal doctor 0 3 Rate health care % 46.3% Consistent with other research, a lack of care coordination tends to affect vulnerable populations such as those with fair/poor overall and mental health and those who had to delay filling a prescription because they could not afford it. Rate health plan % Rate specialist % Delayed filling a Rx because couldn't afford Mental health status fair/poor Filled no Rx Drugs Health status fair/poor Emphysema, asthma, or COPD Under % 11.6% 11.4% 10.7% 9.9% 9.8% *While most analysis of the TMG Book of Business is done at the contract level, this analysis uses respondent level data of all members (n=45,750) who completed an MA PD, MA PPO, or MA Only survey. ** Significant at the 95% confidence level when compared to segments in same category (i.e. age, education). Copyright 2011 The Myers Group Medicare CAHPS Research Series 10B

13 COORDINATION OF CARE TMG 2011 Book of Business* Subgroup Analysis In the last 6 months, how often did your personal doctor seem informed and up to date about the care you got from specialists? In the TMG BoB, these groups were significantly** more likely to respond "Sometimes" or "Never". Percent Answering "Sometimes" and "Never" TMG BoB 26.7% 8.8% 5.1% 13.9% TMG BoB 59.4% Always Usually Sometimes Never TMG Findings The vast majority (86.1%) of respondents said that their personal doctors were "Always" or "Usually" up to date about the care they received from specialists. Of the 13.9% who choose the less favorable options ("Never" and "Sometimes"), those who gave low ratings to their personal doctor, specialist, health care, and health plan were more likely than those who gave higher ratings on those measures to have a personal doctor who was not often informed about the care they received from specialists. Rate personal doctor % Rate specialist % Rate heatlh care 0 3 Rate health plan 0 3 Mental health status fair/poor Delayed filling a Rx because couldn't afford Filled no Rx Drugs Health status fair/poor Under % 19.0% 17.9% 16.4% 16.1% 42.2% 46.1% Members with emphysema, asthma, or COPD, those under age 70, those with fair/poor overall and mental health, and those who had 3 or more doctor visits in the alst 6 months were among those who reported less coordination between their personal doctors and specialists. Emphysema, asthma, or COPD 14.7% Some college or more 14.7% 3 or more doctor/clinic visits 14.4% *While most analysis of the TMG Book of Business is done at the contract level, this analysis uses respondent level data of all members (n=45,750) who completed an MA PD, MA PPO, or MA Only survey. ** Significant at the 95% confidence level when compared to segments in same category (i.e. age, education). Copyright 2011 The Myers Group Medicare CAHPS Research Series 10C

14 The Myers Group, in conjunction with an expert in health care delivery systems, compiled the following list of resources to further aid plans as they seek to improve care coordination for their members. Models of care coordination show promise in offering more efficient and integrated health care delivery, especially for populations with chronic conditions and complex needs. As models such as patient centered medical homes see greater implementation, it will be interesting to see if appropriate payment incentives for coordinating care and integrating benefits can drive improvement in quality and health outcomes. RESOURCES AHRQ "Rapid Referral Programs." The CAHPS Improvement Guide (2011): and Available at: NCQA Quality Profiles: Case Studies. Improving the Referral Process and Referral Redesign. Available at: National Transitions of Care Coalition. Improving Transitions of Care with Health Information Technology. (2010). Available at: National Transitions of Care Coalition. Health Care Professionals Tools. Available at: AHRQ Technical Review 9. "Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies." AHRQ Publication #04(07) , Vol. 7 Care Coordination. (2007). Available at: NCQA Quality Profiles: The Leadership Series. Focus on Supporting Quality Improvement Through Use of Health Information Technology (Nov 2009). Available at: Copyright 2011 The Myers Group 11