Quality Performance

Quality health care is safe, effective, patient-centered, timely, efficient, and equitable. At OneCare Vermont, our quality team has three core functions to support improved population health outcomes, while linking to incentive programs that stabilize health care spending:

  1. Capture OneCare network performance through annual reporting on standard, national quality measures
  2. Create and implement focused, high impact payment incentive programs to drive change on established quality measures.
  3. Facilitate targeted, data-driven quality improvement initiatives in partnership with our network participants.

Quality is the foundation that we really want to invest in to take our already high-value care to the next level.

Alicia Jacobs, MD

Practicing Physician at Colchester Family Medicine, Vice Chair and Associate Professor in Family Medicine at the Larner College of Medicine at the University of Vermont, and Physician Liaison for OneCare Vermont

1. Capturing Network Performance

Value of Monitoring Annual Quality Measures over Time

OneCare’s annual quality measures monitor network performance over time, tracking our progress on improving the quality of care delivered to Vermont.

This chart, “Rates of Screening for Clinical Depression and Follow Up” is an example of monitoring a quality measure over time. The chart shows that, based on data from 2018 to 2021, rates of screening for clinical depression and follow up are generally increasing for two of OneCare’s payer programs: Medicare and Medicaid.

This chart shows that, based on data from 2018 to 2021, rates of screening for clinical depression and follow up are generally increasing for two of OneCare's payer programs: Medicare and Medicaid

OneCare currently monitors 21 annual quality measures. These measures are established by Medicaid, Medicare, and MVP—payers OneCare contracts with on behalf of our network participants—and provide insights into the quality of care delivered by our network.

Our Annual Quality Measures Fall into These Categories:

Preventive Care for both Adults and Children

Screening for and Treatment of Chronic Disease

Treatment for Mental Health / Substance Use Disorder

Self Reported Patient and Caregiver Experience

Hospital Utilization

Annual Year-by-Year Quality Measures

Find details on select annual quality measures across all payers for which OneCare is contractually obligated to monitor, measure, and report on the performance of our network in improving quality of care delivered to Vermonters (click on each year below to view the list of quality measures for that year).

Quality Scorecards & Shared Savings

Each year OneCare works with our payer partners to produce annual quality scorecards. These scorecards provide a summary of health care quality across our network of providers. When our provider network performs well on our annual quality measures and reduces cost of care, we have “shared savings” which OneCare distributes back to participating providers. For example, if OneCare has the potential to earn $1.00 in shared savings, but network quality scores are low we may only capture $0.50 of that shared savings. Similarly, outstanding performance on quality measures can offset shared loss. Achieving high scores on annual quality measures is best for patients and allows OneCare to collect and redistribute the greatest amount of shared savings back to our network.

For more information about Vermont’s progress toward achieving the All-Payer Model Agreement targets, click here for reports on the Green Mountain Care Board website.

Capturing Network Performance Spotlight:

OneCare’s Mental Health Strategy – Integrating Quality and Finance

OneCare monitors our network’s performance on mental health care through our nine mental health and substance use annual quality measures. These measures provide insight into current network performance and cover the following domains:

  • Screening and Follow Up for Depression in Primary Care Settings
  • Follow-Up After Emergency Department Visits for Mental Health or Alcohol or Other Drug Dependence
  • Initiation and Engagement in Treatment for Alcohol and Other Drug Dependence
  • Follow-Up After Hospitalization for Mental Illness

2. Incentivizing Performance Improvement

Our annual quality measures provide the foundation for OneCare’s quality payment incentive and care delivery improvement efforts. Each year OneCare works with our network made up of participating hospitals, providers, and collaborators across the continuum of care to co-create priorities that align with our mission and our overall quality strategy.

To identify areas for network quality improvement with the goal of improving the health outcomes of Vermonters, each year we:

  • Leverage our unique data set abstracted, compiled, and analyzed by our quality measurement experts to evaluate our network performance relative to national benchmarks and identify opportunities for greatest impact on the health of our population.
  • Incentivize selected areas of opportunity through our payment reform programs by linking quality measures to performance-based payments. 
    • Currently OneCare incentivizes quality performance on measures that address:
      • For adults: management of hypertension, diabetes, avoidable emergency department visits, and annual wellness visits
      • For children: screening for developmental milestones, child and adolescent well visits, management of hypertension, and avoidable emergency department visits.
  • Engage our network, board of managers, committees, and workgroups to align with quality improvement work happening around the state and ensure our strategies and practices are informed by representatives across the continuum of care.

Incentivizing Performance Improvement Spotlight:

How Providers May Use Funding from OneCare to Improve Care

Providers are incentivized to add value, not so they can make more money, but so they can provide better care. To offer some examples, a provider can utilize shared savings, funding from Population Health Model, care coordination funding, and/or fixed payment revenue  from OneCare to:

  • Hire a care coordinator to help ensure their high-risk patients’ providers are communicating with one another about a holistic care plan.
  • Employ a social worker to help connect patients with food, housing, transportation, mental health care, etc., as a means of improving their overall health and well-being.
  • Incorporate a “lifestyle medicine” nurse practitioner into the practice staffing model to help patients with diabetes make lifestyle changes to lower their blood sugar levels, or to help those at risk of serious cardiac events improve diet, exercise, and stress management.
  • Use creative staffing models funded by value-based care to continually improve quality of care, leading to better health outcomes while flattening the cost curve.

3. Quality Improvement Collaborations

OneCare’s quality improvement team works with individual providers, hospital systems, and community partners to create data-driven quality improvement initiatives. OneCare’s quality team offers our partners:

Data Interpretation

Share practice and health service area data to inform local quality improvement work and identify areas of strength and opportunity across the network.

Subject-Matter Expertise

Participate in existing quality improvement efforts led by partner organizations and provide additional leadership capacity as needed to support local initiatives.

Community of Practice

Convene network participants to spotlight local successes, share best practices, and foster a culture of continuous quality improvement

Having OneCare be part of our collective improvement around transitions of care has been invaluable to our community. The Quality Improvement Specialist at OneCare has helped us stay focused on implementing small changes in our systems to make big improvement in transitioning patients from one setting to another.

Denise Smith, MS

Director of Population Health Programs and Strategy, Northwestern Medical Center

Quality Improvement Collaboration Spotlight:

Reducing Readmissions in St. Albans

Working closely with members of the St. Albans health service area, OneCare’s Value-Based Care team identified ways that data from OneCare and Northwestern Medical Center could collectively guide improvements in delivery of care. A joint review of data identified hospital readmissions as an opportunity for improvement. OneCare data indicated a particular challenge in readmissions within the first seven days after discharge. Reducing hospital readmissions is one of OneCare’s annual quality measures and also a hospital priority, making it a natural fit for a joint quality improvement project.

The following initiatives were implemented as part of this project:

  • A ‘Transitions of Care Committee’ was formed to standardize the process of patient transitions, timely primary care follow-up, and medication reduction.
  • The NMC care coordination team established goals and adapted workflows and discharge documentation to support this effort and improve communications.
  • The NMC rehabilitation team incorporated changes to their documentation to further facilitate a team approach to discharge planning, optimizing cross-departmental next site of care discussions.
  • NMC staff initiated a process change around patient mobility to reduce decline in function during hospital stays to prevent re-hospitalization following discharge.

This project provides an example of how the quality team at OneCare can support aligned quality improvement initiatives and improve outcomes across our network.

Our Quality Team

Shawntel Burke

Shawntel Burke

Quality Measurement Program Coordinator

Shawntel leads OneCare’s quality measurement work, which includes coordinating data collection and reporting data collection for OneCare’s annual quality measures and incentive programs.

Kathy Camisa

Kathy Camisa

Data & Collection Specialist

Kathy is a liaison to data and analytics and she also facilitates data collection for OneCare’s annual quality measures and incentive programs.

Esther Halden

Esther Halden

Quality Improvement Specialist

Esther partners with local health care providers on quality improvement work in the northern half of Vermont.

Danielle Palmer

Danielle Palmer

Data & Collection Specialist

Danielle facilitates data collection for OneCare’s annual quality measures and incentive programs.

Emmy Wollenburg

Emmy Wollenburg

Quality Manager

Emmy provides leadership and supports implementation of the team’s strategic priorities.