National Strategy for Quality Improvement in Health Care (continued)

1. Partnership for Patients—Care Transitions Objective.
2. A Partnership for Patients goal is to reduce 30-day rehospitalizations by 20 percent over 3 years.
3. Medication errors and poor communication and coordination between providers from the inpatient setting and home or other postacute care settings have resulted in a 20 percent 30-day readmission rate for the nation.
4. The Partnership for Patients was created as a national campaign to support public/private partnerships to achieve the overall aims.
5. 30-day readmission rates for all patients nationally.

1. Everyone With Diabetes Counts.
2. To decrease health disparities and promote health equity by improving health literacy for Medicare beneficiaries with diabetes in vulnerable underserved populations.
3. Diabetes outcomes are worse in vulnerable populations, including those with low literacy and minority populations.
4. Quality Improvement Organizations (QIOs) are contracted to recruit Medicare beneficiaries with diabetes in underserved, vulnerable populations and encourage them to complete diabetes self-management education classes. These classes are taught by community health workers in the communities where the beneficiaries reside; therefore, partnering with State, local, and community groups is critical to success.
5. Clinical data results of the diabetes measures (Hemoglobin A1c, Lipids, and Eye Exams), as well as Medicare claims data to evaluate both utilization of these measures and potential cost savings.

1. Community-Based Care Transitions Program (CCTP) (Section 3026 of the Affordable Care Act).
2. CCTP provides funding to test models for improving care transitions for high-risk Medicare beneficiaries through a comprehensive community effort. This program supports the Partnership for Patients goal of reducing 30-day hospital readmissions for Medicare fee-for-service (FFS) beneficiaries by 20 percent.
3. Medication errors and poor communication and coordination between providers from the inpatient setting and home or other postacute care settings have resulted in a 20 percent 30-day readmission rate for the nation.
4. CCTP allows applicants to propose a plan to implement care transitions interventions, including a per eligible discharge rate that needs to result in measureable savings to the Medicare program.
5. CCTP measures include 30-day readmission rates for hospitals and communities, admission rates, and intervention level measures (process and outcome specific to the intervention implemented).

1. Million Hearts/Physician Quality Reporting System (PQRS).
2. PQRS is a program providing payments to Medicare physicians and other eligible professionals who report quality measures data to CMS. CMS worked with CDC to select measures for use in the Million Hearts initiative that are currently in use in PQRS.
3. Cardiovascular disease is the leading cause of morbidity and mortality in the United States. Several preventive strategies have been shown to reduce the risk of development of cardiovascular disease.
4. By including measures related to the ABCS in the PQRS measure set and designating them as core measures, this will hopefully encourage reporting on the measures and provide information on the extent to which care related to the ABCS is being provided by physicians and other eligible professionals.
5. Measures for screening for and treatment of high blood pressure, high cholesterol, smoking cessation, and aspirin use for individuals with ischemic heart disease.

1. Medicaid Incentives for Prevention of Chronic Diseases (MIPCD).
2. MIPCD is an Affordable Care Act-mandated program of grants to 10 States to provide incentives to Medicaid beneficiaries to participate in prevention programs and demonstrate changes in health risk and outcomes, including the adoption of healthy behaviors. Each State program addresses one or more of the following issues: tobacco cessation, controlling or reducing weight, lowering cholesterol, lowering blood pressure, avoiding onset of diabetes, or improving management of diabetes in those who already have it. Each State proposes a structure of incentives designed for their populations.
3. Tobacco use is the largest cause of preventable morbidity and mortality in the United States, accounting for more than 430,000 deaths per year. It has been estimated that 300,000 deaths per year may be attributable to obesity, and in 2008 the estimated health care cost of obesity was $147 billion. More than one-third of U.S. adults have two or more major risk factors for heart disease, a leading cause of morbidity, mortality, and health care costs. Diabetes is the seventh leading cause of death in the United States, with almost 24 million Americans having diabetes, at an estimated cost in 2007 of $116 billion.
4. Improving participation in preventive activities requires finding methods to encourage Medicaid consumers to engage in and remain in such efforts. A review of the effects of financial incentives on consumer health behaviors, primarily in commercial insurance programs, showed them to be effective about 73 percent of the time. Few data are available for Medicaid populations.
5. Each State uses a somewhat different set of interventions and incentive structures, so specific metrics will differ. Overall, CMS will evaluate use of health services, quality improvements and clinical outcomes under the programs, ability of special populations (such as adults with disabilities and children with special health care needs) to participate in the programs, level of satisfaction of Medicaid beneficiaries with accessibility and quality of the health care services provided, costs incurred by the States to administer the programs, and cost savings resulting from the programs.

1. Pioneer Accountable Care Organization (ACO) Model and Medicare Shared Savings Program.
2. These ACO models share the goal of reducing expenditures for Medicare FFS beneficiaries while maintaining or improving quality through outcomes-based payment arrangements that link incentives to quality measures and total costs of care in Medicare Part A and B.
3. Poor coordination of care and communication leads to duplication of medical services, rehospitalizations, and increased costs.
4. These models incentivize providers and institutions to work together to coordinate patient care through payment arrangements that are linked to performance outcomes.
5. Metrics include several outcome, process, and patient experience metrics that are aligned with other CMS programs, such as PQRS.

To be determined by HHS leadership.

1. Health Center Person-Centered Medical Home (PCMH).
2. The goal is to improve the quality and coordination of care in health centers by supporting all health centers to achieve recognition as a PCMH by The Joint Commission, National Committee for Quality Assurance, or other national recognition body.
3. Health centers provide care to nearly 20 million medically underserved people through more than 8,100 service delivery sites in every U.S. State, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the Pacific Basin.
4. Development of a PCMH requires the organization's commitment to systematically change the ways it delivers care to better meet the needs of the patients and community it serves.
5. By September 30, 2013, 25 percent of Federally Qualified Health Centers will be nationally recognized as a PCMH.

1. Maternal, Infant, and Early Childhood Home Visiting Program.
2. The Home Visiting Program aims to identify and provide evidence-based comprehensive health and social services to improve outcomes for families who reside in at-risk communities.
3. In at-risk communities, the maternal and child health outcomes are significantly worse than those in other communities with more resources.
4. The program, established under the Affordable Care Act, aims to reduce risk factors and enhance protective factors to improve maternal and child outcomes.
5. States will select/define performance measures for each of 35 constructs (e.g., maternal depression, employment status of enrolled adults) identified for tracking and improvement.

1. Medicare Beneficiary Quality Improvement Project (MBQIP).
2. The primary goal is to help Critical Access Hospitals (CAH) implement quality improvement initiatives to improve their patient care and operations through participation in Hospital Compare.
3. There are more than 1,300 certified CAHs located throughout the United States providing hospital services to rural patients. Literature has suggested that the clinical quality received in rural hospitals is not commensurate with that of nonrural hospitals.
4. MBQIP assists CAHs in supporting public reporting for core clinical quality measures to Hospital Compare to allow better tracking of their performance and to provide assistance in how to improve these rates.
5. By 2012, participating CAHs will report pneumonia and congestive heart failure measures to Hospital Compare. By 2013, participating CAHs will report all outpatient measures to Hospital Compare and Hospital Consumer Assessment of Healthcare Providers and Systems. By 2014, participating CAHs will report the following non-Hospital Compare measures: pharmacy review of orders within 24 hours and outpatient emergency department transfer communication of 100%. In addition, CAHs will achieve a participation rate in quality improvement initiatives reported to their respective States of 75 percent by fiscal year (FY) 2013 and 100 percent by FY 2014.

1. Partnership for Patients Community-Based Care Transition Program.
2. The goal is to prevent complications during a transition from one care setting to another in an effort to decrease hospital readmissions.
3. Hospital readmissions are a national problem that has been identified by the National Priorities Partnership. Many of these readmissions result from complications because of transition from one care setting to another.
4. To date, HRSA has engaged 954 rural hospitals, including 448 CAHs, in supporting safe care transitions.
5. By 2013, preventable complications during a transition from one care setting to another will have decreased so that all hospital readmissions will be reduced by 20 percent.

1. HIV/AIDS Bureau Sponsored Project: Partners in Care (within a national quality improvement campaign on retention).
2. The program focuses on engaging patients in their care delivery. The goal is to train patients on self-management practices and engage patients and providers in quality improvement activities.
3. The program focuses on patient and provider engagement to help reduce the spread of HIV and improve health care outcomes.
4. HIV is a major public health problem in America and abroad. More than 1.2 million people are living with HIV in the United States and more than 50,000 are exposed each year.

1. HRSA Patient Safety and Pharmacy Collaborative (PSPC).
2. PSPC is a national quality improvement effort driven by community-based organizations and supported by partnerships to help improve care coordination regarding medications and integrate medication management.
3. Adverse drug events are the leading cause of death and injury in the United States. For patients with chronic disease, the lack of coordination across health care providers increases these patients' risk of adverse drug events such as polypharmacy, duplication of therapy, or incorrect drugs or dosages.
4. PSPC has new federal partnerships with CMS and QIOs that will actively engage new teams for PSPC 4.0. In PSPC 3.0, there were 128 teams in 43 States (including the District of Columbia and Puerto Rico).
5. Increase care coordination for people with chronic disease to reduce adverse drug events.

1. Quality Measures Alignment.
2. Quality Measures Alignment works to align the use of quality measures across HRSA and HHS, starting with cardiovascular disease.
3. Cardiovascular disease causes one in three deaths reported each year in the United States, with annual direct costs estimated at $273 billion.
4. By aligning the quality measures for cardiovascular disease, all of HHS can help support and track improvements resulting from the Million Hearts campaign.
5. The goal is to prevent 1 million heart attacks and strokes in the next 5 years.

1. Healthy Weight Collaborative.
2. This is a cooperative agreement with the National Initiative for Children's Healthcare Quality to support national teams to prevent and treat obesity among children.
3. In 2008, more than one-third of children and adolescents were overweight or obese. Obese youth are likely to have risk factors for cardiovascular disease and prediabetes, and are at greater risk for bone and joint problems, sleep apnea, and social and psychological problems.
4. The collaborative will support at least 50 multisector, place-based teams from all over the country that will provide community-based interventions using quality improvement techniques to prevent and treat obesity among children.
5. The goal is to establish innovative partnerships between public health, primary care, and community organizations, and support sustainable change and foster collaboration through technology.

1. PCMH Recognition for HIV/AIDS Bureau Grantees.
2. This program provides opportunities for HIV/AIDS Bureau grantees to receive technical assistance in applying for PCMH recognition.
3. HIV/AIDS Bureau grantees provide comprehensive services for people with HIV/AIDS who need care but cannot afford it. Since 1981, HIV has infected 1.7 million people in the United States.
4. The aim of this new model of care delivery is the provision of comprehensive care, patient-centered care, care coordination, accessible services, and quality and safety. When these aims are realized, costs may be contained for all parties involved.
5. The goal is for more HIV/AIDS Bureau grantees to be accredited as a PCMH.

1. Advanced Primary Care Practice Demonstration.
2. This demonstration assesses the quality and cost-effectiveness of health centers in providing care to Medicare beneficiaries through a medical home model.
3. Health centers provide care to at least 200 Medicare beneficiaries in a 12-month period. All beneficiaries are eligible to enroll, including dually eligible beneficiaries, as long as they are not in hospice care, under treatment for end-stage renal disease, or enrolled in Medicare Advantage.
4. CMS and HRSA will work together to develop a national technical assistance and training strategy to assist health centers in the transformation to medical homes, enhancing patient-centered comprehensive and coordinated care.
5. The goal is to realize cost savings and improved clinical outcomes by September 2014.

1. National Health Service Corps Scholarship and Loan Repayment.
2. These programs address a nationwide shortage of health care professionals by providing recruitment and retention services in the form of scholarship and loan repayment programs. They include the National Health Service Corp (NHSC), Nursing Education Loan Repayment, Nursing Scholarship, Faculty Loan Repayment, Native Hawaiian Health Scholarship, and State Loan Repayment programs.
3. The NHSC uses mass media to support efforts to increase visibility among prospective Corps members using media stories, Twitter, Webinars, and advertisements in trade and professional publications.
4. As of December 2011, there are over 17,000 scholars across the United States.

To be determined by HHS leadership.