DRAFT_SOW_AHRQ-20-10005.pdf

Accelerating Change and Transformation in Organizations and Networks (“ACTION 4”)

Statement of Work

Introduction

AHRQ’s mission is to produce evidence to make health care safer, higher quality, more accessible, and more affordable, and to work with the Department of Health and Human

Services (HHS) and other partners to make sure that the evidence is understood and used. In order to improve the quality, safety, and value of health care and care delivery we rely on our three core competencies: health services research, practice improvement, and data and analytics.

AHRQ carries out this mission in several ways, including field‐based research, quality improvement, and dissemination of evidence‐based practices. A principle vehicle for such projects is the Accelerating Change and Transformation in Organizations and Networks—

ACTION—IDIQ. It is AHRQ’s goal to build and expand on the successful model used to support its mission that was developed under three previous iterations of ACTION and its predecessor, the “IDSRN1”, that have spanned the past 18 years. Specifically, this IDIQ for ACTION 4 is intended to efficiently procure the expertise, resources, and capacities necessary to develop, implement, and disseminate innovative interventions and strategies for improving the delivery of patient care nationwide.

More specifically, this IDIQ will provide AHRQ with a pre‐competed set of highly qualified contractors representing broad‐based, highly‐resourced Partnerships. ACTION 4 Partnerships will be expected to flexibly respond to changing agency‐level needs, interests, concerns, and priorities by drawing on the complementary capacities of their Member Organizations, as well as reaching out to new partners and capacities as needs arise. Examples of topics of interest at this time include those cited under “Scope,” below.

Background Experience has shown that research or implementation in real‐world settings is critical to successfully developing, testing, adapting and spreading interventions that can improve care delivery while meeting the complex challenges faced by healthcare systems. In particular, such field‐based research is essential for answering questions about how, why, and when particular interventions do or do not work. This requirement is designed to enable AHRQ to secure the necessary resources, capacities and expertise needed to conduct field‐based research and quality improvement and to support the dissemination and implementation of findings to promote broad impact.

Key elements of the model that will be sustained in ACTION 4 include:

1 IDSRN = “Integrated Delivery System Research Network” = predecessor to ACTION 2001-2004

A continued heavy focus on field‐based, real‐world informed development, testing and implementation of new approaches for improving care safety and quality;

Use of multi‐disciplinary teams to conduct research and quality improvement in diverse real world care settings

Development of practical tools, guidance and training to support effective implementation and sustainment of new approaches or interventions; and

Use of collaborations of engaged stakeholders from multiple sectors to support broad‐ based implementation and dissemination.

New elements in ACTION 4 reflect AHRQ’s interest in leveraging our core competencies in order to address four emerging objectives and one new role. These are:

Supporting efforts by Learning Health Systems (LHS) to use knowledge and data to support continuous improvement in clinical care and care delivery. This objective would be focused on:

o Investigating how to effectively build the capacity of health systems to integrate external data (e.g. from other systems, organizations, guideline developers and government agencies) and internal data (e.g., clinical, operational, financial, and patient experience data) in ways that allow learning and discovery about how to improve;

o Supporting health systems in their journeys to becoming learning health systems; and o Using data to identify and answer question of particular interest to operational (e.g. C‐suite) leaders and other decision‐makers and stakeholders.

Promoting “whole person, 360° care” across the full spectrum of care and the entire lifespan, including by improving understanding of social determinants of health and strengthening connections between community‐based social services and health services providers, especially for those with multiple chronic conditions and/or socioeconomic disadvantage. In support of this objective, AHRQ would for example, be interested in:

o Generating knowledge about how clinical teams can most effectively elicit and use patients’ values and preferences and personal and social circumstances in formulating care plans;

o Developing methods to capture the information and data needed to foster partnerships and linkages between health care and human service systems (community‐based organizations and public health);

o Developing, implementing and evaluating improvements in care delivery across the whole spectrum of care and across the entire life span, especially for individuals with multiple chronic conditions, disability, cognitive decline or at socioeconomic disadvantage;

o Developing, implementing and evaluating improvements to individual and population health while reducing disparities; and o Investigating and promoting use of technology to narrow gaps in access to care, particularly for rural or other under‐resourced areas.

Advancing data‐driven approaches for population health management and delivery of patient‐centered care. This objective is central to successes of both Learning Health Systems and the advancement of whole person care. While the ability to readily leverage partners’ access to data and analytic capacities has always been a defining characteristic of ACTION projects, ACTION 4 is expected to be more expansive in the types of data that partners would be expected to access and in the novel ways those data might be collected, analyzed, shared, and utilized.

Supporting the transformation to a value‐based health care system that pays for outcomes, rewards efficiency, focuses on prevention of disease before it occurs, and empowers consumers, providers, and purchasers through improved transparency around price and quality, for example by:

o Exploring how value is defined and assessed by consumers, payers and system leaders;

o Developing and validating measures of care quality, cost, and efficiency;

o Assessing the dissemination, implementation, and outcomes of strategies, programs, and methods of enhancing care value including changes in care practices, delivery, overall organization (e.g. ownership of ambulatory practices by hospitals), payment, measurement and reporting;

o Assessing the real world costs of care delivery, including the costs of implementing innovations;

o Developing methods for evaluating cost reductions associated with implementation of innovative approaches for improving care;

o Understanding the influence of social factors on health outcomes when designing value‐based arrangements;

o Conducting economic analyses (e.g., on the relationship between cost and price and price and demand, how market changes affect delivery organizations, and the impact of innovations on efficiency and value);

o Understanding provider perspectives on value‐based payment structures and risk arrangements, including those for optimizing primary care to better address challenges and barriers;

o Evaluating models of care to better understand risk arrangements and usefulness of value‐based payment approaches, such as bundled payments to promote efficient and effective care choices; and o Investigating methods for synthesizing conceptions of both patient‐centered care and efficiency in seeking to deliver high value care.

The new role envisioned for ACTION 4 will be to serve as the preliminary phase of the effort to build a National Test Collaborative (NTC). The purpose of the NTC would be to test Health IT tools in the real world before they are disseminated for use. “Test originators” (e.g., federal agencies) would define health IT testing needs and specify the parameters for testing (e.g., test types, clinical setting options, and patient cohorts). Testing would be conducted by “test executors” (e.g., EHR and other health IT developers, healthcare providers, health systems, public health departments, etc.) in their local test and production environments and share the testing results in the iterative fashion of agile development.

Definitions

For the purposes of this IDIQ, the following definitions shall apply:

ACTION 4 Partners (i.e. ACTION 4 Member Organizations): An ACTION Prime’s “partners” (or “Member Organizations”) are those health care systems, stakeholder or other organizations or associations or any other entities that have provided a letter of commitment to a Prime Contractor/Organization indicating their willingness to serve as subcontractors on one or more task orders issued under the IDIQ. NOTE: ACTION 4 Partners/Member Organizations may be members of more than one ACTION 4 Partnership.

AHRQ Priority Populations: AHRQ’s priority populations, specified by Congress in the Healthcare Research and Quality Act of 1999 (Public Law 106‐129) include: women, children, racial and ethnic minorities, populations with special health care needs (chronic illness, disabilities, and end of life care needs), the elderly, low‐income, inner‐city, and rural populations.

Dissemination: sharing information or knowledge about a particular product or intervention e.g., through publications or web postings; also known as Knowledge Transfer or Knowledge Communication and encouraging adoptions of knowledge, e.g. through academic detailing.

Dissemination and Implementation (Spread): active, planned – and sometimes externally supported – efforts using diverse vehicles and approaches of varying degrees of intensity to change awareness, culture and behavior (e.g., training program, learning collaborative, practice facilitation, coaching, peer to peer learning) to (a) engage and persuade target groups to adopt an intervention and then (b) prepare for and take the necessary steps to facilitate the actual use of the intervention in practice in a care setting. Relatedly, de‐ implementation involves similar approaches to encourage and support steps needed to identify when a practice is not effective and stop using it.

Evidence‐based treatments or interventions: treatments or models of care that have proven successful in improving health outcomes or on‐the‐ground care delivery.

Health Systems: organizations of health care providers that are contractually affiliated with one another or owned by the same organization. Health systems may include organizations of a single type of provider (e.g., hospitals or nursing homes) or bring together diverse types of providers (acute care hospitals, affiliated multi‐specialty practices, ambulatory care centers) or serve low‐income/low‐resource populations (e.g. safety net, federally qualified health centers).

Implementation: active and planned efforts to mainstream an intervention in one or more real world settings.

Interventions: sets of behaviors, routines, and ways of working that are introduced by external or internal change agents in an effort to improve health care delivery, organizations, payment, and practice (referred to hereafter as “health care delivery”) with the ultimate purpose of improving care quality, safety, and health outcomes. Interventions are implemented by planned and coordinated actions, and can include, but are not limited to: changes in the organization of care, work processes or staffing; changes in payment;

introduction of quality improvement and patient safety tools, guides, or other products;

application of new assessment‐measures and methods (including those using electronic health records); public or private reporting of costs or quality data.

Integrated Delivery Systems. A network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population served.

Learning Health Systems (also called Learning Health Care Systems and Learning Health Organizations): health systems that align clinical informatics, patient‐clinician partnerships/ patient and family engagement, incentives, and culture to promote the routine delivery of evidence‐based care and enable continuous and real‐time improvement in both the effectiveness and efficiency of care.

Long term Care: skilled nursing facilities (SNFs), inpatient rehabilitation facilities, and long‐ term acute care hospitals.

Operational Leaders: individuals within health systems responsible for ensuring that organizational processes are effectively carried out on a day‐to‐day basis, monitoring performance, addressing constraints, and ensuring that employees understand what is to be done and are provided with the authority, knowledge and skills to do it.

Pilot Test: introducing on a small scale in a real world setting a previously untested or inadequately tested intervention, approach or method in order to assess its feasibility and potential effectiveness for addressing an identified health care problem.

Post‐acute care: rehabilitation or palliative services that beneficiaries receive after, or in some cases instead of, a stay in an acute care hospital. Depending on the intensity of care the patient requires, treatment may include a stay in a facility, ongoing outpatient therapy, or care provided at home.

Social services: services that improve the well‐being of individuals, families or communities, including for example transportation, housing, education, training, nutrition, wellness programs, senior support.

Sustainability: making an intervention routine until it reaches obsolescence.

Target Audiences: decision‐makers within the arena of health care delivery, including but not limited to clinicians and other health care providers, consumers/patients, insurers, purchasers/employers and policymakers.

Tools, Training, Guidance: informational, educational and/or training materials or resources, including electronic resources (apps, APIS, CDS) that contain and communicate actionable guidance for end users (e.g., front line practitioners, quality improvement personnel, healthcare administrators within health systems; patients and their families;

payers; policy makers. All tools or other resources intended for public use will have to meet applicable requirements of section 508 of the ADA.

Whole person, 360° care: the coordination and integration of health, behavioral health, and social services for individuals in manner that reflects people’s needs, values and preferences across the entire spectrum of care (from promotion and prevention to diagnostic, rehabilitation and palliative care) and at all levels of care (including primary care, acute and post‐acute care, long‐term care, self‐care, home care, community care) and throughout the lifespan (from prenatal care through end‐of‐life), within the context of their communities.

Scope

ACTION 4 research and quality improvement (QI) projects can be expected to target all health care settings across the full spectrum of care providers (including, but not limited to, hospitals, integrated delivery systems, Primary Care Practices and other ambulatory settings, home care, post‐acute long term care settings) as well as transitions between them. No health care setting, type of provider, type of recipient, payer, or health condition will be excluded from consideration with respect to topics that may be undertaken under ACTION 4, although individual Request For Task Orders (RFTOs) may focus on particular types of settings, payers, providers, or patients. ACTION 4 Task Orders may be local, regional or national in scale and will focus exclusively on the US healthcare system.

ACTION 4 Task Orders will focus on practical, applied topics of high interest to AHRQ and the

Department of Health and Human Services as well as to those at the front lines of care delivery and to the patients they serve. ACTION 4 Task Orders will be conceived with end users in mind

(especially health systems and other care providers) and will be focused on topics that will benefit from being researched, developed, tested, evaluated, implemented and disseminated in field‐based/real world settings. Healthcare in the United States occurs within complicated and complex systems of systems. The services and types of tasks/activities likely to be undertaken or executed under task orders awarded under the ACTION 4 IDIQ Contract are expected to propose methodologically rigorous methods for addressing complexity in real world settings.

The different categories of ACTION 4 task orders are described below. Each ACTION 4 task order would be envisioned to encompass at least one of the following broad types of services and many task orders are likely to include individual tasks or activities from more than one of the sets of activities described here.

a. Exploratory Research, Knowledge Synthesis, Analysis: ACTION 4 Exploratory Research task orders may call for: collection, synthesis and analysis of original or available data on the scope of a current challenge and examination of critical factors underlying it; scans of the environment and literature and syntheses of available evidence and experience; consultation with stakeholders, subject matter experts or other key informants; needs assessments; creation of and support for learning communities or learning collaboratives; observation of promising practices in natural settings; simulations; creation and trials of prototypes and/or other design activities. Findings from these types of task orders would be expected to result in recommended future action steps (e.g., further research or for the development of interventions designed to improve care delivery).

b. Development of interventions: Task Orders focused on development of interventions are expected to result in new or modified approaches for delivering, coordinating or integrating care to improve safety, patient‐centeredness, accessibility, and/or clinical outcomes and to advance towards the goal of delivering whole‐person, 360‐degree care or improving population health management and public health. These types of task orders might request, for example, development of new methods or approaches for: reducing threats to patient safety such as healthcare acquired infections and diagnostic error; measuring and benchmarking care quality for the purpose of identifying areas for practice or system level improvement; ensuring rapid uptake of new evidence by health systems or practitioners;

increasing patient and caregiver engagement and shared decision‐making; leveraging technology to understand and meet patient needs; assessing and addressing the needs of patients with multiple chronic conditions in primary care settings through improved care coordination with other community providers; eliciting and utilizing a patients’ values preferences, and social circumstances in the development of care plans; strengthening connections between health care and community‐based social services to improve whole‐ person care. The new interventions may be framed or delivered in any of a number of forms and formats, including but not limited to: tools, guides, training, IT applications; revisions to roles, responsibilities or staffing models. The application of design thinking and patient engagement in development of innovations, interventions, and tools, as appropriate, will be strongly encouraged.

c. Feasibility/Pilot Testing: Some Task Orders may call for testing a previously untested or minimally tested intervention or tool on a small scale in a real world setting. Pilot Testing may be used to assess the logic model underlying the intervention; document whether and how well it worked, and why or why not; examine effects of the context/setting in which an intervention was introduced and the approaches used to facilitate uptake; identify barriers to its use and modifications needed to increase the likelihood of successful implementation and desired outcomes; examine the return on investment (ROI)/business case for its use.

Task Orders aimed at Pilot Testing of one or more interventions commonly require recruitment of appropriate real world implementation sites (ideally from a cadre of sites or a network with whom the contractor has an existing relationship); engagement of onsite champions, stakeholders and operational leaders; appropriate application of diverse qualitative and quantitative methodologies to preliminarily measure impacts and outcomes;

access to clinical information systems such as electronic health records (EHRs) or other health information technologies; and synthesis of findings.

d. Implementation /Implementation Research: Implementation/Implementation Research task orders will involve actual implementation in multiple sites and investigation of ways that context, intervention characteristics, and implementation approach interact to influence uptake of an intervention, treatment or model of care, and its success in achieving desired outcomes for patients. These task orders would be expected to generate valuable knowledge of the feasibility, utility and impacts of a new approach, as well as factors that may be associated with its successful integration into routine use or adaptations/modifications that may be required in response to local conditions. In most cases, the intervention that will be implemented will have already been tested in a limited number (or type) of settings. Examination of costs associated with an intervention, including implementation costs and longer term financial costs of expected savings will also be of interest.

Successful execution of implementation research task orders are likely to require recruitment of appropriate real world implementation sites; engagement of onsite champions, stakeholders and operational leaders; development and provision of training, resources and technical assistance or support to implementers and/or other stakeholders;

support for exchange of knowledge among implementers and stakeholders (e.g., through learning collaboratives surveillance systems, or public health registries)) and appropriate application of diverse and quantitative and qualitative data collection and analytic methodologies. Task Orders of this kind will also typically require syntheses of findings and communication of new knowledge to appropriate decision‐makers/other audiences

(“knowledge communication/knowledge transfer”) using diverse print and web based vehicles.

e. Dissemination and Implementation (D and I/Spread); D and I task orders would be aimed at broadly increasing (e.g., across states, regions, nationally) adoption and use of evidence‐ based treatments or interventions, in support of AHRQ’s dissemination mandate under the

ACA and its role as a leader in promoting nationwide implementation of interventions to reduce HAIs and improve patient safety. Such projects are likely to include an underlying logic model and a set of structured plans that utilize diverse strategies for changing awareness, culture and behavior of relevant target audiences (e.g., executives, front line staff, heath care professionals from health systems, hospitals, and primary care practices).

Such strategies might include use of measurement and performance benchmarking; training programs, facilitation, coaching, peer to peer learning, and academic detailing. The execution of these plans would be expected to require recruitment, training and implementation phases and development and use of print and web based educational and training materials and technical assistance of varying degrees of intensity.

f. Advancing data‐driven approaches for population health management and delivery of high quality, evidence‐based, 360°, patient‐centered care: Task orders with this particular focus would involve study, development, testing or dissemination of innovative methods for health systems’ use of data to better understand and address patient needs. Areas of interest might include: supporting efforts by Learning Health Systems to use internally‐ generated data to support continuous improvement and personalized care; fostering data and knowledge‐driven approaches for population health management; integrating and analyzing diverse sources of to better understand and address social determinants of health; developing and sharing information needed to support partnerships and linkages among health care human service systems (community‐based organizations and public health) to improve whole‐person care; identifying methods for collecting patient reported outcomes (PROs) and information on a patient’s social context and seamlessly providing that information to health care teams; promoting use of information systems and data resources through expansion of clinical decision support for health care professionals, patients and families at the point of care.

g. Measurement. Task orders with this focus might include the identification, development, analysis, testing, evaluation or dissemination of research frameworks and templates, quality of care metrics, methodologies, and tools intended to assess and improve care delivery.

These activities can require innovative use of a variety of complex data sources (e.g., billing/claims data, survey, electronic health records, and laboratory data). Dissemination of metrics, methodologies or tools may require provision of technical support (e.g., provision of guidance about administration and scoring or responses to inquiries from users).

h. Analysis, Assessment, Evaluation: Some Task Orders may call for analysis of outcomes, impacts or sustainability of the types of projects described above (development of interventions, dissemination and implementation projects, or other AHRQ initiatives designed to improve patient care). These services may be procured through a stand‐alone task order or, more often, by inclusion in task orders described in b‐f above. Specific objectives might include assessing whether and how well an intervention achieved its intended objectives; identifying contextual factors that may affect its effectiveness or desired impact; identifying factors that enhance or impede its integration into routine practice; and the studying the effectiveness of specific strategies or approaches for disseminating evidence into practice.

IMPORTANT NOTE: Since the subjects of such assessments or evaluations are likely to be complex delivery interventions, researchers will need to use research designs that explicitly (a) examine how interventions interact with the contexts (themselves complex systems) in which they occur and (b) examine processes that are intended to facilitate adoption of new behavior or practices. Research designs meeting these two requirements contrast with traditional experimental designs that seek to eliminate or control for effects of context and implementation processes in order to identify invariant relationships between an intervention and an outcome (Berwick 2008). The conduct of research that reflects these principles requires the application of mixed methods and a wide range of designs and analysis techniques

(Creswell et al. 2011, Fetters, Curry and Cresswell, 2013, Miller et al, 2013). Where the randomized control trial (RCT) remains the gold standard in clinical research, research methods designed to answer questions about delivery system improvement are likely to include quasi‐ experimental designs and observational studies that draw on a diverse set of both qualitative and quantitative analytic tools and approaches (and software that supports these methods).

These include, for example: comparative case studies, focus groups and key informant interviews, surveys, critical incident analyses, content analyses, process mapping, work flow analyses, interrupted time‐series analyses and stepped‐wedge designs, qualitative comparative analysis, sequence analyses and others (e.g. (AHRQ 2013)). Where appropriate, research and analytic designs for pilot testing or implementation will need to ensure sufficient power for statistically valid detection of change.