Priorities in Action
Priorities in Action features some of our nation's most promising and transformative quality improvement programs, and describes their alignment to the National Quality Strategy (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@ahrq.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.
VA Homelessness: Homeless Patient Aligned Care Teams
Better Health Partnership
GRACE Team Care
The Lourie Center for Children's Social and Emotional Wellness
Wind River Reservation
Boston Children's Hospital Community Asthma Initiative
Blue Cross Blue Shield of Massachusetts Alternative (BCBSMA) Quality Contract
Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center
Colorado Coalition for the Homeless
Building a Healthier Chicago
Connecticut Association of School Based Health Centers
The Minnesota Statewide Health Improvement Program
The California Quality Collaborative
Better Health Greater Cleveland
Wisconsin Collaborative for Healthcare Quality
Camden Coalition of Healthcare Providers
Colorado Beacon Consortium
Healthy Hawaii Initiative
Michigan Health and Hospital Association Keystone Center
Reversing the Trend: New York State Health Foundation's Diabetes Campaign
The Patient Safety and Clinical Pharmacy Services Collaborative
AHRQ’s Patient-Centered Medical Home Resource Center
Healthy Kids, Healthy Communities
HRSA's Flex Medicare Beneficiary Quality Improvement Program
H-PACTs co-locate medical staff, social workers, mental health and substance use counselors, and other staff equipped to deal with homelessness in order to create a comprehensive “one-stop shop” to serve the complex set of health care and social needs of homeless and vulnerable veterans. Located at VA medical centers, community-based outpatient clinics, and community resource and referral centers around the country, H-PACT staff demonstrate special cultural competencies to understand homelessness, appreciate the background of veterans who are homeless, and contextualize their unique care needs.
SisterLove, Inc., was founded as a volunteer organization in 1989 to educate African-American women in Atlanta, Georgia, about HIV/AIDS prevention, self-help, and safer-sex techniques. With a personal understanding of the barriers that kept women, and particularly women of color, out of the forefront of HIV/AIDS education, treatment, and prevention, the volunteers at SisterLove set out to improve access to those same facets of care necessary to improve health.
The Partnership supports numerous programs, including onsite coaching for quality improvement and building team-based care, to advance primary care practice adoption of the patient-centered medical home (PCMH) model. The PCMH model emphasizes care coordination, stronger doctor-patient engagement, improved access to primary care services, and proactive management of chronic conditions. Since 2009, more than 52 practices driving higher-quality patient-centered care at low costs have achieved National Committee on Quality Assurance PCMH recognition with Better Health Partnership's assistance.
The GRACE Team Care enrollment process begins when an elderly individual receives a comprehensive in-home assessment performed by a nurse practitioner and social worker (the GRACE Support Team). This two-person team is responsible for coordinating ongoing care for the person. This team brings information learned at the in-home assessment back to an expanded GRACE team, which is led by a geriatrician and includes a pharmacist and mental health liaison who is typically a licensed clinical social worker. This larger interdisciplinary team puts together a carefully tailored care plan based on evidence-based care protocols for 12 common geriatric conditions ranging from proper medication management to vision and mobility issues to depression. A person who has experienced many falls in the past, for example, will receive recommendations about stopping medications that might contribute to falls, checking their vision, and obtaining a physical therapy referral for strength and balance exercises. This person will also receive lessons on how to avoid falls, if possible, and recover from them when and if they occur.
The Lourie Center for Children's Social and Emotional Wellness is a nationally recognized pioneer, incubator, and disseminator of evidence-based treatments and best practices in the field of early childhood development, prevention of emotional or behavioral disorders, and intervention. The Lourie Center seeks to improve the social and emotional health of young children and families through prevention, early intervention, education, research and training. The Lourie Center serves 4,000 children and families in the Washington, DC, metropolitan area. Approximately 80 percent of the families it serves are enrolled in Medicaid. The Center's programs are designed to strengthen families, help young children and parents/caregivers develop increasingly secure relationships, and support the social and emotional competencies needed for success in life.
The Wind River Reservation is located in the heart of the Northern Plains in southwestern Wyoming, and currently serves as the home of the Eastern Shoshone and Northern Arapaho tribes. Roughly 12,500 residents live on the reservation, approximately 12 percent of whom of have diabetes and 71 percent of whom are clinically obese. In 2009, the Eastern Shoshone Tribal Health Department, in partnership with the Northern Arapaho Tribe, IHS, and Sundance Research Institute, was awarded a 5-year grant to create a community-clinical partnership on the reservation to address barriers to diabetes management and prevention, and create a comprehensive system of care to provide education and support services to assist tribal members with or at-risk of diabetes to manage their condition and improve outcomes.
Boston Children's Hospital Community Asthma Initiative (CAI) selects children for the program based on inpatient admission and emergency department records, and specialty and primary care provider referrals. Children who have been hospitalized or seen in the emergency department are stratified by risk and need for asthma intervention. CAI offers families of at-risk children the opportunity to participate in the program, and the provider explains the program's benefits to the family and develops a personalized asthma management plan.
In 2007, Blue Cross Blue Shield of Massachusetts developed the Alternative Quality Contract (AQC), an innovative global payment model that combines a population-based budget (adjusted annually for health status and inflation) with substantial performance incentive payments tied to the latest nationally accepted measures of quality, outcomes, and patient experience. The AQC arrangement is a 5-year agreement that encourages providers to invest in long-term, lasting improvement initiatives.
In 2004, PatientsLikeMe was founded by the brothers of Stephen Heywood, a 29-year-old architect with amyotrophic lateral sclerosis (ALS). A frequent frustration of people with chronic conditions and their families is the lack of publicly available answers to seemingly simple and rote questions about these chronic conditions. To overcome this, Stephen's brothers and a family friend created an online community where patients, doctors, and organizations could work together to easily and quickly share disease information.
For more than a century, the staff at Children's Hospital of Pittsburgh has delivered safe, high-quality, person-centered pediatric care by emphasizing quality, safety, and innovation. The hospital operates as a standalone teaching hospital within the larger University of Pittsburgh Medical Center system, which includes more than 20 specialized hospitals. UPMC also functions as an insurance company, providing coverage for more than 1.8 million members.
As the only major pediatric system for more than 200 miles, many local children and adolescents may receive all of their inpatient and ambulatory care at Children's and its regional facilities within the larger UPMC network. In 2013, Children's received more than 1 million outpatient visits and had 14,250 inpatient stays. In the same time period, physicians at the hospital performed 24,623 surgical procedures.
For 30 years, the Colorado Coalition for the Homeless has been working to integrate health care and housing services for the homeless based on the principle that safe housing is required to effectively manage the related mental illnesses, substance abuse disorders, and multiple chronic medical conditions. The Coalition takes a multidisciplinary approach to delivering care that combines patient-centered physical care delivery—medical, dental, vision, and pharmacy—with behavioral health care—mental health care and substance treatment services—and supportive housing.
Building a Healthier Chicago (BHC) launched in 2008, when a group of 20 individuals involved in health and health care in Chicago convened a consortium to address the health of Chicagoans. In just over a year, the group grew to several hundred "stakeholders" focused on this effort. Today, BHC's vision is to make Chicago the healthiest place to live in America. To increase its impact, BHC became a 501(c)(3) nonprofit organization in 2014. It continues its rich heritage as a stakeholder organization and works to create a culture of healthy living in major social settings throughout the city including worksites, faith communities, schools, and restaurants.
The Connecticut Association of School Based Health Centers is an advocacy and networking organization committed to increasing access to quality health care for all children and adolescents in Connecticut schools. Connecticut's school based health centers (SBHCs) have delivered comprehensive health care in schools—where students spend 25 percent of their day—for 27 years.
In Minnesota and nationally, the two largest causes of chronic disease and premature death are (1) obesity caused by poor nutrition and insufficient physical activity and (2) commercial tobacco use. The Statewide Health Improvement Program addresses this issue by preventing disease before it starts by helping create healthier communities that support individuals seeking to make healthy choices in their daily lives.
The California Quality Collaborative (CQC) is a health care improvement organization comprising approximately 300 purchasers, providers, health plans, and patient advocacy organizations dedicated to improving health care delivery for 7 million Californians. CQC offers a host of health care improvement programs, ranging from quality improvement training for physicians and hospitals to topical collaboratives centered on disseminating best practices in chronic care and readmissions.
In 2007, northeast Ohio health care systems, health plans, employer groups, and community organizations established Better Health Greater Cleveland to improve health and health care while reducing costs. The collaborative develops and disseminates evidence-based care transformation strategies focused on primary care for chronic conditions, including diabetes, high blood pressure, and heart failure. Across the region, the collaborative's programs have helped more than 700 primary care providers from 12 health care systems adopt patient-centered models of care, use electronic health records more effectively, and regularly measure care to identify opportunities to continuously improve.
The Wisconsin Collaborative for Healthcare Quality (WCHQ) is a voluntary, statewide consortium of physician groups, hospitals, health plans, and employers working together to improve health and the quality and affordability of health care in Wisconsin. WCHQ members publicly report an agreed-upon set of performance measures related to the services that they provide, enabling the collaborative to produce comparative reports on health care quality and patient experience. As a result, practices are able to identify areas for improvement within their own organization and build the capacity to do so through the forums convened and facilitated by the Collaborative to share successes and challenges with others.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Page originally created November 2016