In early 2016, a Medicare beneficiary’s family member contacted KEPRO – the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) for that state – with a complaint regarding the patient’s postoperative care. Following hip surgery, the patient had received medication and, a few days later, was found in the hospital room not breathing. The hospital called a Code Blue and transferred the patient to the intensive care unit (ICU), where the patient recovered before being discharged. Afterwards, KEPRO reviewed the case and determined that the standard of care delivered by the hospital needed to be improved. The BFCC-QIO notified the hospital and transferred the case to Alliant Quality – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Georgia and North Carolina – to help the hospital perform a root cause analysis and work through the quality improvement process.

This BFCC-QIO and QIN-QIO collaboration enables complementary steps towards improving quality of care. “The BFCC-QIO’s case review at the national level provides a standardized intake and review process,” says Dr. Adrienne Mims, Vice President and Chief Medical Officer at Alliant Quality QIN-QIO. “Then, when QIN-QIOs work with facilities on quality improvement cases at the local level, we can truly focus on changing processes of care. Facilities are really receptive and engaged with us.”

Alliant Quality guided the hospital’s review process, beginning with a root cause analysis to determine what went wrong, whether the case reflected a pattern, and how the quality of care could be improved. Upon review of the full patient chart, from admission through discharge, the hospital review team found several issues regarding prescription dosage and timing, duplicate ordering of similar medications, and monitoring for slowing of respiration. Further, the hospital performed a retrospective chart review of 30 similar cases and found many instances of these issues.

“We often talk about narcotic abuse, but there’s a whole other area of appropriate and safe use of opioids that’s important to seniors,” says Dr. Mims. “Many seniors are opioid naïve and extra sensitive to opioids, so we unwittingly put them in danger when we treat them the way we would treat a younger person with pain.”

Realizing that they were at risk of endangering patients repeatedly, the hospital stepped up to make big changes. It implemented new process improvements and training for each problem area, including the purchasing of smaller opioid dose volumes, improving pharmacy communication and alerts, and requiring medication instructions and nurse respiration monitoring.‍

The hospital sent the QIN-QIO quarterly reports on its improvement progress throughout 2016, assessing 30 charts on the same four measures. By the third quarter, the hospital had achieved 98 percent success on three of their four measures, and the potential for improvement didn’t stop there. The hospital looks forward to promoting its findings to all 67 medical facilities (hospitals, clinics, urgent care, rehabilitation centers) in their system.

This story is one of 15 that were included in the 2016 QIO Program Progress Report.

Two million people in the United States are infected with antibiotic resistant bacteria each year, and approximately 23,000 people die as a result, according to the Centers for Disease Control and Prevention. Yet, knowledge of antibiotic resistance – what it is and why it matters for health care delivery – has been slow to reach many providers in health care settings, as well as the general public.

“We’re looking at 30 or 40 years down the road; if we don’t have good stewardship now, we’re going to encounter serious difficulties in combating even simple infections in the future,” says Catherine Darnell, the National Health Care Safety Network Enrollment Advisor at Mountain-Pacific Quality Health – the Quality Innovation Network-Quality Improvement Organization (QIN–QIO) serving Montana, Wyoming, Alaska, Hawaii and the U.S. Pacific Territories.

It is this knowledge gap that inspired Mountain-Pacific, in conjunction with the Wyoming Department of Health, to start the 41-member Wyoming Infection Prevention Advisory Group (WIPAG) in early 2015 to help raise awareness of antibiotic use in the state. An Antibiotic Stewardship Subcommittee emerged from this group with the aim of assessing antibiotic programs and use among Wyoming hospitals, and convening stakeholders to improve stewardship practices.

Since starting WIPAG and the Antibiotic Stewardship Subcommittee, Mountain-Pacific has succeeded in helping keep antibiotic stewardship front and center at statewide events like the 2016 Annual Wyoming Infection Prevention Conference, as well as more locally focused webinars and trainings. They also have developed tools for patients and providers, such as a newsletter, brochures and educational booklets. The subcommittee is also in the process of developing a guide for antibiotic stewardship in rural hospitals, which are common in Wyoming.

Mountain-Pacific already has been planning the next stage of its work. The QIN-QIO plans to hire a pharmacist in 2017 who will serve as a local expert on antibiotic resistance and assist area providers across the health care spectrum in creating a uniform policy and standard protocol for antibiotic stewardship, especially among Wyoming’s 26 hospitals.

“We’re focused first on the hospitals, getting buy-in from administrators,” says Darnell. “We think there will be a trickle-down effect from there to providers, clinics, as well as nursing homes and their staff.”

According to Darnell, Mountain-Pacific is seeing an increased interest in WIPAG within the state’s health care community, and this interest is evidence that educational efforts about the importance of developing better protocols for how and when antibiotics are prescribed and used are starting to pay off.

“We believe we’re going to see a lot of our efforts come to fruition in 2017,” she says.

This story is one of 15 that were included in the 2016 QIO Program Progress Report.

Tooth decay and periodontal disease, two preventable chronic infectious diseases, together constitute one of the greatest unmet health needs in America today, affecting up to 50% of the population. The impact of these diseases falls disproportionately on disadvantaged populations, resulting in lost opportunities for education and career advancement, missed work, and preventable medical and dental expenditures totaling billions of dollars annually. Working closely with the National Interdisciplinary Initiative on Oral Health, DentaQuest, the Washington Dental Service Foundation, and the Reach Foundation, Qualis Health has been leading efforts to focus on whole-person care and expand access to oral health by integrating preventive oral healthcare into everyday primary care practice.

Qualis Health developed a conceptual framework, the Oral Health Delivery Framework, which has been endorsed by 21 national professional associations. Nineteen primary care sites in five states tested the framework among patient populations that included children, adults with diabetes, and pregnant women. Participating sites included rural and urban practices, standalone private practices, and federally qualified health centers. Qualis Health provided technical assistance using a “train the trainer” model to guide test sites in defining a target population, specifying the oral health intervention, and measuring its impact using data captured in the practice’s electronic health record.

Results of this program were published in the Oral Health Implementation Guide, designed for use in diverse settings with or without technical assistance. An accompanying Oral Health Tool Kit includes tools for program planning, health IT assessment, workflow optimization, process measure presorting, and development of referral agreements with community dentists.

In June 2017, this program was named a winner in the Wellness Prevention category of the 8^th annual DecisionHealth Platinum Awards, a program recognizing the best in care management and care coordination.

Diabetes is one of the most serious health concerns today, placing physical, emotional and economic burdens on every aspect of society.  Additionally, there is clear evidence of healthcare inequities among racial groups. For example, individuals from African-American, American Indian / Alaska Native, Hispanic, or Asian backgrounds are significantly more likely to have diabetes than individuals who identify as White Non-Hispanic. Individuals living in rural areas also have a higher likelihood of having diabetes.

Diabetes self-management education (DSME) uses an evidence-based intervention for empowering persons with diabetes to take an active role in controlling their disease by acquiring the knowledge and skills necessary to prevent/lessen the severity of complications.

Diabetes self-management education (DSME), specifically Stanford University’s Diabetes Self-Management Program (DSMP), is an evidence-based intervention for empowering persons with diabetes to take an active role in controlling their disease by acquiring the knowledge and skills necessary to prevent/lessen the severity of complications. Small-group workshops are held for 2.5 hours once a week for six weeks, facilitated by two leaders, one or both of whom are peer leaders with diabetes themselves who have successfully completed the 24-hour leader training.

With funding from CMS, Qualis Health took action to increase access to DSME and reduce disparities by expanding the workshops across the state in partnership with 25 community organizations. These workshops were particularly targeted to Medicare beneficiaries with diabetes who belong to racial and minority ethnic groups and/or reside in rural areas. Qualis Health built partnerships with a variety of community agencies to increase the number of Medicare beneficiaries in disparate populations completing the DSMP workshop, resulting in a stronger infrastructure to support improved care and reduce health inequities.

Qualis Health trained over 39 lay leaders to expand the reach of DSME into underserved communities. These lay leaders have gone on to provide the diabetes workshop to over 750 individuals. Internal participant-reported data showed that within 6 months of completing the workshop, individuals who participated in DSME workshops felt more empowered to manage their diabetes-related care in comparison to before the workshop.

For this work, Qualis Health earned an honorable mention in the Wellness/Prevention category of the 2017 DecisionHealth Platinum Awards, a program highlighting the innovations and leadership of healthcare organizations that are creating better ways to bring quality care to patients and populations.

The United States spends upwards of $220 billion annually on low-value healthcare services that confer little or no clinical benefit while exposing patients to unnecessary risk, and research indicates that over 40% of Medicare beneficiaries received low value care.

Choosing Wisely® is a national initiative of the American Board of Internal Medicine Foundation that promotes informed shared decisions between clinicians and patients regarding many types of low-value healthcare. Under a Special Innovation Project awarded by CMS, Qualis Health designed and implemented a project to bolster the Choosing Wisely initiative in Washington, making innovative use of Medicare claims data in Washington State to promote alternatives to low-value healthcare, including a new set of claims specifications to assess treatment of dementia using antipsychotics. Qualis Health selected four low-value services on which to focus based on the degree of variance in clinical practice, the number of Medicare beneficiaries potentially affected, and alignment with local priorities.

Qualis Health identified clinicians who ordered one or more of the selected low-value services at a rate that was statistically higher than the state average. We mailed confidential feedback to 174 high utilizers. First, a generic letter introduced the Qualis Health Choosing Wisely project to raise awareness and create a non-threatening context for the individualized performance feedback. A week later, a second letter was sent that again framed the feedback in non-threatening terms and compared the recipient’s utilization of a low-value service with the Washington state average for using the same service, measured as a percentage of qualifying patients who received the service.

Using administrative data along with individualized clinician performance feedback to promote Choosing Wisely goals will help reduce utilization of low value healthcare services and provide savings in direct annual treatment costs. If the identified high-utilizing clinicians respond to peer comparison feedback by reducing utilization to the Washington average, there would be 166 fewer instances of advanced imaging for syncope or headache (average of about $300 for a CT or MRI scan), 329 fewer prescriptions for antibiotics for URI (with an average cost of $7), and 709 fewer prescriptions for antipsychotics for behavioral symptoms of dementia (average of about $250 per month, $3,000 per year), for a conservative estimate of almost $2,179,103 in total savings of direct annual treatment costs.

Perhaps more important is the avoidance of adverse outcomes. Research indicates that 709 fewer prescriptions for antipsychotics would result in eight fewer strokes and one less injury fall in this population annually. If 329 fewer prescriptions resulted in even one less instance of clostridium difficile infection, as much as $24,000 in hospital charges would be avoided. The probability that an antibiotic prescription will result in an emergency room visit is four times greater than the probability of gaining clinical benefit for treating URI with antibiotics.

Initial responses from clinicians who received feedback from Qualis Health supported the efficacy of this approach in raising awareness of issues.

This project was recognized as a national honorable mention winner in the 2017 DecisionHealth Platinum Awards in the Physician/Clinician Engagement and Education category.

Individuals with complex healthcare needs tend to incur disproportionately higher costs than others, and their healthcare needs are often exacerbated by social determinants of health, such as lack of housing or transportation. Qualis Health’s Emergency Room High-Utilizer Program was established to address the challenges of care for high-utilizing Medicaid members in Anchorage, AK. Those high ER utilizers represent 3% of the state’s Medicaid population but 22% of overall hospital ER costs.

Working with the state, Qualis Health designed a program to provide in-person case management to a targeted population of high ER utilizers to reduce frequent ER use for issues better treated in a primary care setting. The program implemented a team-based approach, which included a licensed clinical lead and two community health workers, with further support by a staff psychiatrist, medical director, and RN case manager consultants. Primary interventions in the program included:

• assisting members to develop a medical home relationship with a primary care provider and accompanying them to appointments
• teaching self-management skills and medication management
• coordinating with behavioral health and social service providers, including shelter and permanent housing programs, transportation assistance, and food security resources
• developing an after-hours plan to reduce avoidable ER visits during nights and weekend hours

Preliminary program results using claims data indicated that ER and inpatient visits and associated costs were significantly reduced post intervention:

• 39% reduction in ER visits
• 49% reduction in ER costs
• 66% reduction in inpatient visits
• 81% reduction in inpatient costs

This program was recognized as the national winner in the 2017 DecisionHealth Platinum Awards in the Care Coordination category.

As one of 20 facilities chosen to participate in the Clostridium difficile (CDiff) Reporting and Reduction Project pilot project beginning in July 2016, Aberdeen Health and Rehab in South Dakota has been successful in implementing effective infection control and prevention practices. What began as an invitation from the Great Plains Quality Innovation Network (QIN) and the South Dakota Department of Health (SD DOH) Health Acquired Infections (HAI) Program to participate in a pilot project led to the best practice of data review to identify high-impact change.

Administrator Megan Kleinsasser commented on the pilot project success, “We incorporated reviewing our infection rate and our CASPER quality measure report in our monthly QAPI meetings.  It is through our QAPI meetings that we prioritize improvement areas for performance improvement projects.  One of the areas of improvement we are working on is reducing CDiff infections in our facility.”

The national CDiff pilot project has five goals:

1. Increase national CDiff surveillance data from 235 nursing homes currently reporting to 2300 nursing homes consistently reporting into CDC NHSN database
2. Determine state/national CDiff baselines for nursing homes
3. Once baselines are determined, identify reduction goals and implement interventions
4. National and state CDI rates will show reduction rates by December 2018
5. Nursing homes will receive education and tools on NHSN, CDiff principles and management and antibiotic stewardship

As of November 2016, Aberdeen Health and Rehab has been providing monthly reporting of CDiff infection data to the Centers for the Disease Control and Prevention’s (CDC) national database, National Healthcare Safety Network (NHSN).

“It was a difficult start jumping through all the technical requirements to allow us to report, but reporting has become a very simple routine now. Our director of nursing is well versed in surveillance of our infections and has included the staff in our infection control and prevention systems,” Kleinsasser stated.

The team approach, including staff and residents, resulted in additional benefits, including a site visit by a certified infection preventionist who offered valuable insight on best practices and areas of improvement.

“We have seen a decrease in CDiff infections and feel better prepared and confident in our infection control and prevention program,” shared Kleinsasser, who has engaged staff and is looking to duplicate their success with antibiotic stewardship.

She intends to participate in the SD DOH, HAI Program’s Antibiotic Consumption Pilot Project for nursing homes, which aims to increase understanding of antibiotic usage, identify specific antibiotic stewardship improvement areas and also aligns perfectly with the new CMS regulations regarding antibiotic stewardship.

Kleinsasser reflected, “My advice to nursing home colleagues is to take advantage of pilot projects when the opportunity presents itself.  Pilot projects typically provide extra education, resources and technical assistance that otherwise might not be so readily available.  As an administrator, I feel our facility is better prepared and equipped to meet the infection control and prevention standards in long-term care today.”

People living in the unhealthiest counties of Kansas are dying too early and at more than twice the rate of those in the healthiest counties. Kearny County Hospital, located in Lakin, Kansas, 50 miles from Colorado, is one of the lead organizations for the Communities of Care work currently underway.

According to the 2017 County Health Rankings, which examines 25 factors that influence health, the efforts of this community to improve health and create meaningful change are paying off. In the past year, Kearny County has skyrocketed up from 83rd to 33rd in health rankings among more than 100 ranked Kansas counties.

Kearny County Hospital is located in a rural area where resources are limited. The impact of reduced resources can be felt across a variety of factors, including access to healthy foods, healthcare and other vital resources that impact community health. As in many communities, the cost of inappropriate healthcare utilization due to resource limitations of community members or access to regular and preventive health services is far reaching. The hospital implemented a new program to gain greater understanding of the issues community members face and to learn more about the utilization of the hospital emergency department.  The program incorporates screening and assistance for citizens with healthcare and financial assistance needs and provides insight into emergency department utilization. Recruiting new medical providers to the community will also reduce unnecessary ER visits by ensuring access to preventive and routine healthcare.

“The Kansas Foundation for Medical Care, Inc. (KFMC) is pleased to be able to partner with the innovative and dedicated team KCH has onboard. Their commitment to improving care delivery and health outcomes for Medicare consumers, and all citizens of their community shines in all they do. Congratulations,” Vanessa Lamoreaux, Project Manager at Kansas Foundation for Medical Care, Inc.

Healthcare can be complicated. It takes more than just the clinicians doing the right thing every time to make a sustainable impact in community health; it takes everyone and every organization working together. Visit our Care Coordination webpage for more details and how to get involved.

To learn more about Kearny County Hospital, visit: www.kearnycountyhospital.com

To learn more about the county health rankings, visit: www.countyhealthrankings.org