CMSHealthDisparities

• Alabama - The Alabama Quality Assurance Foundation (AQAF) - The Post Acute Transitions in Healthcare (PATH) Alabama project plan is a portfolio of aligned projects capable of achieving the aim of reducing readmissions of Medicare beneficiaries. The PATH Alabama multi-modal plan is focused on redesigning processes across organizational boundaries, promoting evidence-based care delivery, specific to the various targeted levels of care, and empowering the Medicare beneficiary in self-management strategies.
• Colorado - The Colorado Foundation for Medical Care’s (CFMC) project is focused on engaging a community of providers, community organizations, patients and caregivers in a steering committee to ensure sustainability for the future of this project, as well as, to significantly decrease community re-hospitalizations. Building the community steering committee has been the first step in ensuring the success of the work-plan.
• Florida – Florida Medical Quality Assurance, Inc. (FMQAI) will partner with organizations to promote patient safety through improved care coordination between healthcare providers within a target population of Miami Dade County, Florida. FMQAI activities focus on: Patient Centered Record, Historia Clinica Personal, Physician Follow-Up, Medication Self-Management and Disease Self-Management.
• Georgia – Georgia Medical Care Foundation (GMCF) champions community-care transition interventions to measurably improve post-acute care coordination and reduce re-hospitalization rates within a targeted Georgia community. The interventions may depend on changes in processes of care that engage more than one provider (including hospitals, home health agencies, nursing homes, dialysis centers, and physician offices), as well as, patients, families and stakeholders.
• Indiana – Health Care Excel (HCE) designs customized management solutions and develops appropriate educational programs to significantly improve the delivery of health services and improve quality and safety during patient hand-offs.
• Louisiana – eQHealth Solutions’ project is focused on transition coaching interventions targeted to the diagnosis of pneumonia, with one unit at the local hospital. They are developing Medicare beneficiary tools to include a Personal Health Record, a discharge checklist, a coaching consent form, and a red-flag checklist.
• Michigan – MPRO, Medicare Quality Improvement Organization for Michigan, works with community stakeholders identified as having potential programs that can interface with this project. MPRO conducts individual site visits and phone contact in the targeted community provider settings.
• Nebraska – CIMRO Quality Healthcare Solutions, Nebraska's local project, CareTrek, is bringing together appropriate healthcare providers, stakeholders and community organizations to develop and implement an evolving intervention plan to reduce re-hospitalization among Medicare beneficiaries residing within Douglas and Sarpy counties by addressing patient medication management, patient self-management, post-discharge follow-up and plans of care for patients who move across healthcare settings.
• New Jersey - Health Care Quality Strategies, Inc. is facilitating their initiative with a group of hospitals, nursing homes, home-health agencies, physician offices, inpatient rehabilitation facilities, dialysis centers, hospices, community-based organizations and healthcare stakeholders in southwestern New Jersey. Interventions address issues related to medication management and reconciliation, care-planning and care coordination.
• New York - IPRO, Inc has completed an organizational profile that includes information about census, discharge disposition, re-admission rate, top-five issues/concerns related to patients who are hospitalized and top-five reasons/underlying diagnosis for patients re-admitted to the hospital.
• Pennsylvania - Quality Insights of Pennsylvania is currently working on a community-based, cross-setting project to help hospitals, skilled-nursing facilities, home-health agencies and physician offices improve coordination across the continuum of care. They are including community resources, such as Area Agencies on Aging to aide in the project’s success.
• Rhode Island - Quality Partners of Rhode Island’s approach includes: computerized education and coaching for high-risk patients and systems interventions, involving the project-team working directly with home health agencies, hospitals and nursing homes to implement best practices and foster effective communication among providers.
• Texas - TMF Health Quality Institute’s project is focused on collaborating with the Harlingen Hospital Referral Region project area (cities of Brownsville, Harlingen and Weslaco) to improve patients’ transitions across care-settings to reduce avoidable hospitalizations.
• Washington - Qualis Health is partnering with several local health-care organizations to improve the safety of transferring patients across care settings and to reduce unnecessary hospital re-admissions. Qualis Health is targeting the community of Washington's Whatcom County.

Evaluation:

Each local project must show evidence of improvement in the quality of care and in the implementation of strategies to reduce re-hospitalization rates. The overall evaluation for this Task requires that multiple local projects succeed at reducing re-hospitalization rates through improved quality of care. QIOs will be evaluated on evidence that appropriate strategies were implemented early in the project and, in turn, were carried out through the entire project.

Care Transitions Quality Improvement Organization Support Center (QIOSC):

The Colorado Foundation for Medical Care serves as the QIOSC for Care Transitions.

Care Transitions: 9th SoW Measure Level (10 measures)

• Four types of re-hospitalization rates
• Two patient assessments of hospital discharge performance (Hospital Consumer Assessment of Healthcare Provider and Systems (H-CAHPS))
• One physician visit post-discharge, before re-admission (within 30 days)
• Two measures with Continuity Assessment Record and Evaluation (CARE) tool
• One measure of adoption of interventions

For more information, visit the Statement of Work from the Centers for Medicare & Medicaid Services

In order to achieve these goals, there are two main tasks for QIOs with a clinical focus in the following three areas, each with a corresponding clinical measure:

• Early detection of CKD in Medicare beneficiaries with diabetes,
• Appropriate medication treatment (angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs)) to slow the progression of kidney failure, and
• Adequate counseling prior to initiation of dialysis which leads to placement of an arteriovenous (AV) fistula for hemodialysis patients.

The goals of the corresponding clinical measures are to:

• Increase the screening for nephropathy,
• Increase the frequency of ACE/ARB therapy used to treat individuals with diabetes and earlier stages of CKD, and
• Increase the rate of individuals starting their first dialysis treatment with a mature AV fistula.

The second task is to use collaboration as a means of achieving sustainable CKD system-level changes. Partners involved will include community health centers, community representatives, end stage renal disease (ESRD) Network Organizations, health department diabetes grantees, local chapters of kidney organizations, patient representatives, provider groups, state and county government representatives, among others.

QIOs engaged in the CKD tasks will be required to successfully pass the established targets in all clinical outcome measures in addition to provider recruitment and partner collaboration goals.

CKD QIOs are supported in their work by the Prevention Quality Improvement Organization Support Center (Prevention QIOSC). VHQC, the Virginia QIO, holds the contract for the Prevention QIOSC, and subcontracts with QSource and SoftDev to provide support to CKD QIOs. Please contact Robin Weil, Prevention QIOSC Director, at rweil@vaqio.sdps.org.

CKD QIO Activities:

Florida: FMQAI formed the statewide Florida Chronic Kidney Disease Coalition, comprising 47 broad-based member organizations. FMQAI is providing physicians with free tools to help facilitate early diagnosis of CKD and evidence-based information for tracking CKD stages with treatment modalities and patient educational materials.

Georgia: The Georgia Medical Care Foundation initiated a CKD Community Coalition that includes a number of partner organizations representing various health disciplines, providers and patients. A total of 220 healthcare providers are collaborating to effect system-level changes. Participating providers are awarded with American Board of Internal Medicine (ABIM) or American Board of Family Medicine (ABFM) credit for recertification.

Missouri: The Missouri QIO, Primaris, produced a number of tools and information sheets for providers and Medicare beneficiaries/patients. Physicians and healthcare associations are working to implement system changes to improve the quality of CKD monitoring.

Montana: The Mountain-Pacific Quality Health Foundation co-hosted a conference “Getting There: Pathways to Better and Safer Dialysis” on June 5, 2009. They are partnering with government agencies, state and national organizations, and consumer advocacy groups and are working formally as the Montana Diabetes and CKD Care Partnership.

Nevada: HealthInsight contacted 216 physicians to congratulate them on the high percentage of their Medicare fee-for-service patients receiving appropriate screening to identify early stages of kidney damage. These physicians share insights into how they have achieved screening rates above 88 percent. HealthInsight sponsored a conference “Kidney Learning Day a Partnership between Primary Care and Nephrology” in May, 2009.

New York: IPRO, Inc. is partnering with the ESRD Network of New York Fistula First Steering Committee to increase AV-fistula rates, provide a forum for collaboration, and promote the improvement of overall CKD care utilizing the university continuum of care model to support the chronic care model in conjunction with community outreach education.

Rhode Island: Quality Partners has convened an advisory panel consisting of clinicians who identify interventions for the 30 participating providers to implement a strategic coalition that collaborates and coordinates resources to effect system-level changes. Quality Partners is developing a Practice Assistance Program based upon the Patient Centered Medical Home (PCMH) model of care and incorporating health information technology as a tool to assist with outcome improvement.

Tennessee: QSource has created a state-wide coalition to conduct a needs assessment and to subsequently convene smaller workgroup(s) within the coalition to address disparities in CKD. Interventions include the "Save the Vein" campaign (patient/provider awareness), Fistula First Surgical Toolkit (patient education), automatic eGFR calculation in hospitals for particular patients and physician practice interventions including education and resource/tool distribution.

Texas: TMF Health Quality Institute is collaborating with the CKD Task Force, the National Kidney Foundation, ESRD Network 14, Texas Renal Coalition and Department of State and Health Services in an initiative to promote improvements in CKD quality measures. TMF created "Diabetes and Kidney Disease: Save Their Kidneys," a free one-hour continuing medical education presentation offered in the physician office or as a webinar training event and is also actively promoting other educational seminars that cover a range of CKD-related topics.

U.S. Virgin Islands: Virgin Islands Medical Institute (VIMI) monitors the impact that quality interventions have on disparities in care (e.g. ethnic, racial, socio-economic and geographic), which includes a sufficiently large proportion of the Virgin Islands’ Medicare population (i.e. 85 percent to 90 percent, depending upon the source). VIMI takes rapid corrective action and implements activities to improve the quality of CKD in its Territory.

Utah: HealthInsight is creating a DVD featuring experts as well as a local doctor who was previously featured on a television news segment to discuss important elements of diabetic care in short vignettes. They also produce a monthly Kidney Kronicles information newsletter.