A Federal Government Web site managed by the Agency for Healthcare Research and Quality
Priorities in Action features some of our nation's most promising and transformative quality improvement programs, and describes their alignment to the NQS' six priorities. Updated monthly, these programs represent private sector, Federal, State, and local efforts.
We want to hear from you! If your program aligns with the priorities, email NQStrategy@ees.hhs.gov with details.
Inclusion in the Priorities in Action program listing does not constitute endorsement by the U.S. Department of Health and Human Services.
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Studies by the Agency for Healthcare Research and Quality have shown that the sickest 5 percent of U.S. patients account for over half of the country's health care costs. These "high utilizers" often suffer from multiple chronic conditions and take many medications. The Camden Coalition of Healthcare Providers (CCHP) provides a model for effective, efficient care for the highest utilizers in the community it serves, improving the health of the community while reducing the cost of care. The CCHP has accomplished this by identifying high utilizers through analyzing local claims data and providing them with well-coordinated care through a personalized care management system. By combining typical health care services such as primary care and chronic care management with social support and behavioral health interventions, the CCHP addresses the full spectrum of factors that influence health.
Each day, the CCHP receives a feed from the local health information exchange with a list of the patients from all three of Camden's health systems who have been admitted three or more times in the past 6 months. The CCHP's staff triages the list, focusing on patients taking multiple medications and with language or social barriers. Nurses then visit the patients in the hospital to start the conversation about the health issues these patients have been facing. They then invite the patient to enroll in the home visiting program. If the patient accepts, the home-visiting intervention is deployed.
The first visit at the home occurs within 3 days of the person's discharge from the hospital. The goal is to help the person receive a primary care appointment within a week. The CCHP health team accompanies the individual to the primary care appointment to help build or rebuild his or her relationship with the primary care provider. After that, the CCHP health team follows up with weekly home visits with a personalized set of staff members based on the patient's needs,including family physicians, nurse practitioners, medical assistants, or social workers. The ultimate goal is to graduate socially and medically stable individuals who are connected to their primary care provider within 3 months.
This intervention has been successful in reducing the health care costs by half and hospitalizations by 40 percent for the individuals it serves.The Robert Wood Johnson Foundation expanded the model into six different Aligning Forces for Quality communities in 2012 to evaluate whether the results in Camden could be replicated across the nation.
These efforts promote effective communication and care coordination, promote wide use of best practices to enable healthy living, and make quality care more affordable.
The Board of Directors that governs CCHP includes three hospital systems, two Federally Qualified Health Centers, independent provider offices, social service and behavioral health organizations, and resident advocacy organizations. More information is available at http://www.camdenhealth.org/ .
The Colorado Beacon Consortium brings together physician leaders, hospitals, a community-based health information exchange, and a local payer to develop and implement new ways to improve the quality and patient experience of health care while controlling costs. The region-wide alliance strengthens the existing health information technology infrastructure and advances patient-centered primary care, to provide better care for the 320,000 patients the Consortium serves.
The Colorado Beacon Consortium engages more than half of the region's primary care practices through Learning Collaboratives and onsite consultations, leading the medical practices forward in their ability to report quality measures and take action on the results. The Consortium accomplishes this through team-based improvement in two complementary but distinct tracks. The first initiative is intended to transform primary care practices by enabling them to achieve meaningful use of electronic health records (EHRs) under the Medicare and Medicaid EHR Incentive Programs, which in Stage 1 requires meeting a set of objectives to capture and exchange clinical data. Onsite consultants help the practices redesign their clinical workflow to integrate health information technology for quality measure reporting, and the Learning Collaboratives allow practices to share common challenges and successes.
The second initiative is intended to expand health information exchange throughout the region. Through a regional health information exchange, the Quality Health Network, the Colorado Beacon Consortium bolstered existing health information exchange architecture to enable it to support advanced population health management functions and improved clinical decision support systems. Over the past year it has increased the number of providers connected to the exchange by 25 percent, bringing the total to 765 providers. By the end of 2012, more than 80 percent of practices in the Consortium were using an EHR system and more than 100 providers qualified for meaningful use through the support of the Consortium's Regional Extension Center. The Consortium also evaluates models of integrated primary care and behavioral health care that reduce costs through payment reform schemes such as global payments.
Nine practices in the Consortium also participate in the Centers for Medicare & Medicaid Services' Comprehensive Primary Care Initiative (CPCI), and will continue participating in that program even though the Beacon Communities grants have concluded. There are two additional tracks for other practices in the Consortium: a Masters program for Beacon graduates who are not participating in CPCI, and a Foundations program to bring in practices that did not participate in the Beacon Community.
These efforts promote the following NQS priorities: person- and family-centered care, effective communication and care coordination, and making quality care more affordable. Evaluation for this program includes tracking against several Beacon milestones, and assessing progress against health information technology, quality improvement, and practice transformation benchmarks. The 2012 Annual Report details the Consortium's results, accomplishments, and lessons learned.
The Colorado Beacon Consortium was one of 17 Beacon Communities selected by the Office of the National Coordinator for Health Information Technology to demonstrate the value of health information technology investments while achieving the National Quality Strategy's three-part aim. More information is available at http://www.healthit.gov/policy-researchers-implementers/colorado-beacon-community .
Launched in 2000, the Healthy Hawaii Initiative is a statewide effort to prevent and control chronic disease, extend and increase the quality of Hawaiians' years of life, and address health disparity. The program targets behavior change at the individual level, and addresses the social determinants of health that are influenced by organizations and the community. The initiative is made up of five interrelated components that promote healthy and active living among Hawaii's 1.4 million residents, targeting schools, community organizations, and organizations involved in public and professional education. The program also works to improve detection, treatment, and management of heart disease, stroke, cancer, diabetes, and asthma.
The Healthy Hawaii Initiative supports healthy lifestyles by implementing policies and programs to create sustainable changes in Hawaii's communities, schools, and workplaces. The prevention areas focus on reducing three core behaviors: smoking, inactivity, and poor diet. Numerous education campaigns such as "Step It Up Hawaii" and "You Gotta Start Somewhere" inform Hawaiians about lifestyle interventions they can take to improve their own health. State and county physical activity and nutrition coalitions, spearheaded by the initiative, are demonstrating best practices in community health promotion by hosting workshops, forums, and summits on obesity prevention and tobacco use cessation. The initiative also sponsors farmers markets throughout the State, and is conducting a campaign to discourage the use of sugary drinks and promote healthy eating. As a result of the initiative's efforts, wellness guidelines, physical activity guidelines, and health awareness tools have been added to nutritional guidelines for meals at public schools in Hawaii. A collaboration with local partners has increased the number of bike trails in Honolulu and has kicked off a bike-sharing program.
Healthy Hawaii produces "Health of Your District Reports" to help residents and policymakers see how their communities' health compares with that of their neighbors. The initiative also formed the Hawaii Health Data Warehouse to standardize and collect health data across the State. The Hawaii Health Data Warehouse produces a series of reports on the prevalence of chronic diseases and the adoption of healthy lifestyle behaviors, and also features detailed reports for 80 different Healthy People 2020 objectives across 30 topic areas.
Efforts such as these promote wide use of best practices to enable healthy living. The initiative is evaluated annually by partners at the University of Hawaii using prevention and healthy living process measures. The Healthy Hawaii Initiative also conducts an annual telephone survey to poll residents on the types of healthy living messaging they were exposed to over the past year.
The initiative is directed by the Hawaii State Department of Health. More information about it can be found at http://www.healthyhawaii.com/ .
In 2003, the Michigan Health and Hospital Association (MHA) Keystone Center, with funding from the Agency for Healthcare Research and Quality (AHRQ), organized a large-scale collaboration effort among Michigan's health and health care stakeholders, including hospitals, State government, payers, and employers. With these partners, the MHA Keystone Center forged evidence-based solutions that improve the quality of care offered to Michigan's residents. Many of the patient safety interventions developed by the MHA Keystone Center are now being used throughout the nation and around the world.
This group of stakeholders developed clinical interventions that Michigan hospitals implement to improve quality and patient safety in a variety of care settings and treatment scenarios. These include care transitions, emergency rooms, organ donations, hospital-associated infections, intensive care units, obstetrics, safe care, and surgery. One such example is the Comprehensive Unit-Based Safety Program (CUSP), which provides each hospital with a framework for intervention and integrates communication, teamwork, and leadership improvements to help create a culture free of patient harm. The MHA Keystone Center supports hospitals' transition into the CUSP by offering more than 3,000 annual learning opportunities including workshops, webinars, conference calls, and individual meetings.
The first broad-scale application of CUSP was in Michigan, under the leadership of the Michigan Health and Hospital Association, where it was used to significantly reduce central line-associated bloodstream infections (CLABSIs) in that State. Following that success, CUSP was expanded to 10 States and then nationally through an AHRQ contract with the Health Research and Educational Trust, the research arm of the American Hospital Association. This project is the largest national effort to combat CLABSIs to date, and involved hospital teams at more than 1,100 adult intensive care units in 44 States over a 4-year period. Hospitals participating in this initiative used CUSP to prevent more than 2,000 CLABSIs, a 40-percent reduction in the rate of CLABSIs. This reduction saved more than 500 lives and avoided more than $34 million in health care costs, according to results released in 2012.
Efforts such as these make care safer by reducing the harm caused in the delivery of care. The MHA Keystone Center's interventions improve the safety of patients, as demonstrated with their success in reducing central line-associated bloodstream infections by nearly 58 percent and ventilator-associated pneumonia by 62 percent since 2004.
The MHA Keystone Center is supported by Blue Cross Blue Shield of Michigan, the Centers for Medicare and Medicaid Services Partnership for Patients Hospital Engagement Network, the Michigan Department of Public Health, and Michigan hospitals. Find more about the MHA Keystone Center at http://www.mhakeystonecenter.org/ .
The New York State Health Foundation's Diabetes Campaign, "Reversing the Trend," seeks to address one of the State's most pervasive epidemics—diabetes. Nearly 10 percent of New Yorkers—or 1.4 million—are afflicted with this disease, and almost 4 million more suffer from prediabetes, causing harm to a significant portion of the State's population. Additionally, diabetes costs the State almost $13 billion a year in health care costs and productivity losses. The New York State Health Foundation, or NYSHealth, developed a three-pronged strategy to attack diabetes: (1) improve the way New York physicians treat chronic disease, (2) develop community-based prevention and management initiatives, and (3) progressively transform the chronic care system to a pay-for-performance mode.
NYSHealth has made significant strides in improving chronic care management in New York. To promote effective diabetes care, the campaign has helped more than 2,000 physicians achieve National Committee for Quality Assurance (NCQA) and Bridges to Excellence (BTE) Diabetes Recognition Certification. To mobilize communities to improve diabetes prevention, screening, and management, NYSHealth has established more than 200 diabetes prevention and self-management programs across the State. These programs change how health centers currently provide chronic care through the adoption of the Chronic Care Model and a more patient-centered approach. Also critical to these efforts is the establishment of adequate preventive measures to mitigate future adverse effects.
NYSHealth recently launched the next phase of its diabetes campaign, called "Meeting the Mark." This program builds upon existing efforts, and encourages additional primary care practices and health systems to apply for funding to help physicians receive NCQA and BTE Diabetes Prevention Recognition. This will help the program reach its goal of 3,000 newly NCQA- or BTE-certified physicians and health care practitioners in New York State.
NYSHealth has succeeded largely because it secured support from a wide range of stakeholders—payers, providers, and elected officials—to build a collaborative and comprehensive solution to diabetes prevention. Additionally, NYSHealth partners with Health Care Association of New York, Community Health Center Association of New York State, American College of Physicians—New York State Chapter, the Institute for Leadership, the Alliance of New York State YMCA, Inc., and the Institute for Health. These partners are instrumental in helping to improve diabetes prevention and reducing the human and financial toll of diabetes.
This campaign is aligned to two National Quality Strategy priorities: it promotes the most effective prevention and treatment practices for diabetes, and works with communities to promote wide use of best practices to enable healthy living.
This program is directed by the New York State Health Foundation, and more information can be found at: http://nyshealthfoundation.org/priority-areas/improving-diabetes-prevention/ .
The Patient Safety and Clinical Pharmacy Services Collaborative (PSPC), organized by the Health Resources and Services Administration, or HRSA, improves health care quality by providing patients suffering from complex conditions with evidence-based clinical pharmacy services. Now in its fifth year, PSPC works with teams of community health care providers to advance their medication and care management systems and improve patient safety.
Patients with complex conditions often receive care and medication from multiple providers. A lack of coordination among these providers could lead to adverse drug events or a duplication of therapy and interactions. Therefore, it is critical that these doctors, specialists, and nurses work collaboratively to provide effective health care.
The PSPC enables this collaboration by helping to spread practices that improve patient safety and health outcomes. PSPC equips teams with a “change package,” a set of field-tested best practices developed by expert national faculty and adapted from high-performing organizations. Provider teams also participate in integrated learning sessions that teach the Institute for Healthcare Improvement (IHI) Model for Improvement, allowing teams to measure, share, and track their progress.
Additionally, PSPC helps participating providers integrate their clinical pharmacy services into a Primary Health Care Home model. Each team of providers has a designated lead Primary Health Care Home, which reduces the complexity of managing patient information and health care services by integrating them into a central location. It enables providers and pharmacists to effectively coordinate care for a defined population of patients.
As of May 2013, 344 teams of community health providers participated in PSPC, representing more than 885 organizations of community-based health care providers across 48 States, the District of Columbia, Puerto Rico, and the Virgin Islands. By 2015, PSPC aims to have 400 teams in 3,000 communities across the country participating in the program.
Efforts such as these make care safer by reducing harm caused in the delivery of care and promote effective communication and coordination of care. Evaluation of this program is completed by the teams themselves, who share their progress monthly on multiple improvement measures, which include health outcomes and reductions in adverse drug events.
The Patient Safety and Clinical Pharmacy Collaborative is sponsored by the Health Resources and Services Administration. You can learn more at http://www.hrsa.gov/publichealth/clinical/patientsafety/index.html.
The Patient-Centered Medical Home (PCMH) model holds promise as a means to improve health and health care in America by transforming how primary care is organized, delivered, and funded. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) envisions the PCMH as a model of primary care that delivers patient–centered, high–quality care safely and efficiently through improved communication and coordination.
In order to facilitate widespread PCMH transformation, AHRQ established the PCMH Resource Center to give researchers and health policy makers the information they need. The Web site defines the PCMH and provides a series of in-depth white papers, focused policy briefs, systematic evidence reviews, and guides to innovative evaluation methods. These resources cover topics ranging from care coordination to patient engagement to health information technology. In the past year, the site has expanded to include more practical tools to support implementation of complex practice change.
The "Developing and Running a Primary Care Practice Facilitation Program: A How-to Guide" (PDF: Plugin help) provides instructions and resources for state and regional organizations with an interest in primary care quality improvement. The Guide highlights the potential of practice facilitation as a strategy for supporting widespread, systematic practice improvement across communities. It addresses important considerations for practice facilitation programs, such as administration, workforce management, financing, and evaluation, and details the steps necessary to address these issues. Four additional in-depth case studies of successful practice facilitation programs complement the lessons of the How-to-Guide. AHRQ established the Primary Care Practice Facilitation Learning Community to allow organizations interested in practice facilitation share their experiences and learn from one another.
AHRQ also facilitates and convenes the Federal PCMH Collaborative, bringing together partners from across the Federal Executive Branch to share lessons learned in work related to PCMH transformation.
Efforts such as this drive the transition of new delivery models forward, and support multiple NQS priorities, including patient safety, delivery of person- and family-centered care, effective communication and care coordination, and making quality care affordable.
The program is directed by the Agency for Healthcare Research and Quality, and more information can be found at: http://pcmh.ahrq.gov/.
Initiated in late 2009, this grant-funded program seeks to help reverse the childhood obesity epidemic, especially in lower-income communities and in populations at greatest risk. It provides four years of grant funding and technical assistance to 49 multidisciplinary partnerships across the country to implement policies, systems, and environmental change strategies to create sustainable community change.
Partnerships focus on different venues, such as neighborhoods, parks, and public housing developments to engage a range of strategies. These include developing and implementing farmers' markets, healthier corner stores, community gardens, healthy vending policies, physical activity and nutrition standards, complete streets and joint-use policies, and safe routes to schools and parks.
These efforts promote healthy living and well-being and work to improve the social, economic, and environmental factors within each of the grantee communities, directly aligning with one of the six NQS priorities: community health. Evaluation for this program includes tracking work plan milestones, assessing policy and environmental changes, engaging in group model building in each community, and conducting cross-site analyses among communities that are working on similar issues. A final report will be released in 2014 that addresses results, accomplishments, and lessons learned.
The program is directed by the Healthy Kids, Healthy Communities National Program Office, which is part of Active Living By Design at the Gillings School of Global Public Health at the University of North Carolina in Chapel Hill, NC. More information is available at www.healthykidshealthycommunities.org/ .
In 2010, the Health Resources and Services Administration (HRSA) launched the Flex Medicare Beneficiary Quality Improvement Program to improve the quality of care for Medicare beneficiaries served by critical access hospitals (CAHs). CAHs are rural community hospitals that have 25 or fewer inpatient beds, are at least 35 miles from another facility or are designated as a necessary providers, and receive cost-based reimbursement from Medicare and, in some states, Medicaid. This program helps CAHs prioritize quality measurement and improvement despite their limited resources and staff. In the post-health reform environment, CAHs may soon be compared with their urban counterparts to ensure public confidence in their quality of health services. This initiative enables CAHs to demonstrate the quality of care they provide.
The Flex Medicare Beneficiary Quality Improvement Program supports quality improvement initiatives through increased reporting on quality measures that are relevant to rural health care. Through expanded public reporting, the program allows for clear benchmarking of hospitals' performance and the identification of best practices. The program assists CAHs in developing their quality improvement and patient engagement efforts. The program also supports health system development and community partnerships, helping hospitals make the most of their funding and identify stakeholders to collaborate with on quality improvement activities. Currently, more than 1,200 of the 1,331 CAHs located in 45 States are voluntarily participating in the Flex Medicare Beneficiary Quality Improvement Program, and the program continues to strive for 100 percent engagement.
These efforts promote person and family engagement in care and work to improve the experience of care related to quality, safety, and access. Evaluation for this program includes tracking CAH participation, quality improvement measures, patient satisfaction, and outcome measures for each CAH in the program. The Medicare Rural Hospital Flexibility Monitoring team, which is made up of the Universities of Minnesota, North Carolina-Chapel Hill, and Southern Maine, provides monitoring and evaluation support.
The Flex Medicare Beneficiary Quality Improvement Program is directed by the Health Resources and Services Administration. More information is available at the National Rural Health Resource Center, at http://www.ruralcenter.org/tasc/resources/medicare-beneficiary-quality-improvement-project-mbqip .