Working with Primaris, Missouri’s Quality Improvement Organization (QIO) through July 2014^*, a 60-bed nursing home in Southwest Missouri reduced the use of restraints among its residents from 28.9 percent to 2.3 percent in just over a year (2012-2013).

Once seen as tools to help prevent nursing home residents from injuring themselves, restraints are now recognized as presenting serious health risks to residents, contributing to circulation problems and pressure ulcers. Primaris collaborated with nursing homes to reduce restraint use, leading to improved quality of life and health among residents.

Using Primaris data reports compared to data collected from clinical assessments of patients, restraint count inconsistencies were identified. For example, some residents were being counted as restrained when fastening their wheelchair seatbelts as the resident’s own security measure.

Primaris helped Cassville Health Care & Rehab in Cassville, Mo. develop alternatives to restraint use, starting with using the Primaris’ Restraint Reduction toolkit and conducting staff education.

Cassville Health Care & Rehab used different equipment and expanded care planning to include therapy, activities staff and other nursing staff to devise ways to reduce restraints. Nursing home staff also reached out to residents’ families to discuss any reservations about removing restraints utilizing the Primaris patient and family brochure that provides education about the hazards of restraint use.

When Primaris began working with Cassville Health Care & Rehab, the nursing home had the highest restraint use in the state. Since working with Primaris, the home has maintained a restraint rate at near or below the Missouri state average of 2 percent.

The positive impact on residents’ quality of life has, in turn, improved employee morale. Nursing home leadership to certified nursing assistants, and families and community members are all pleased with these changes. The staff at the facility remains committed to sustaining their low average while striving for zero restraints.

^*In spring of 2014, CMS determined to separate the consumer type protection activities – case review, beneficiary complaint and appeals – from the quality improvement work for the QIO program going forward.  As of August 1, Missouri is represented by two Quality Improvement Organizations. Beneficiary and family centered care services are now provided by KEPRO. Primaris in Missouri has joined TMF Health Quality Institute to form the TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) to provide quality improvement work in Missouri.

In its work assisting physician practices to leverage electronic health records (EHRs) for quality measures reporting, Health Services Advisory Group of California, Inc. (HSAG of California), the Medicare Quality Improvement Organization for the state, observed that reported tobacco screening rates for Medicare beneficiaries among some practices were far lower than other similar practices.

Specifically, some 88 physician providers using a particular certified EHR reported an average 6 percent of Medicare beneficiaries were being screened for tobacco use, but  given the providers’ attention to smoking cessation best practices  in Q1 2013, the QIO knew right away that something was amiss.

HSAG of California determined that physician practices that initiated screening activities at or near the front office reported higher screening and counseling activity than did practices that initiated such activities in exam rooms. As a result, the QIO designed a workflow model to empower mid-level providers at doctors’ offices—specifically, health care professionals with some supervisory responsibilities—to conduct screening activities at the front office. A screenshot of this workflow can be accessed here. The QIO also prescribed which front desk staff could initiate tobacco screening among visiting Medicare patients and conducted comprehensive onsite training on screening and EHR documentation for physicians and staff.

After implementing the new workflow, 80 percent of patients were reported as having been screened for tobacco use by Q2 2013. That is, the providers’ prior screening efforts, which had previously been undocumented, were captured, fully reflecting their dedicated efforts to help beneficiaries quit smoking. This rate of successful documentation has held through early 2014, proving that the efforts of the practice staff have made the workflow changes sustainable over the long term.

The Oklahoma Foundation for Medical Quality (OFMQ), Oklahoma’s QIO through July 2014^*, worked with partners to reduce key heart disease risk factors among the state’s more than 300,000 Native Americans.  Heart disease is a leading cause of death for most ethnic groups in the U.S., and is second only to cancer for Asian Americans or Pacific Islanders and American Indians or Alaska Natives, according to the Centers for Disease Control and Prevention.

Through its Cardiac Learning and Action Network (LAN) initiative ─ a Centers for Medicare & Medicaid Services (CMS) project ─ and other outreach events, OFMQ and the Oklahoma City Area Inter-Tribal Health Board have helped spread the importance of heart health and the goals of the Million Hearts™ campaign to the Oklahoma Native American population. The Million Hearts™ campaign is a national public-private initiative of the Department of Health and Human Services that aims to prevent 1 million heart attacks and strokes by 2017.

As part of the Cardiac LAN efforts, OFMQ staff conducted support calls and site visits with Native American clinics to help them more meaningfully use electronic health records (EHRs) and standardize data collection on blood pressure, aspirin therapy, smoking cessation, and other cardiac-related measures. OFMQ also helped the clinics identify best practices and areas of improvement to promote continued improvement in these measures.

OFMQ gathered its baseline data for the LAN in June 2011, and its most recent re-measurement data was reported in December 2013. Overall, the clinics participating in the LAN, which represent 347 physicians and more than 50,000 cardiac patients, showed improvement on cardiovascular measures. LAN participants reduced LDL cholesterol by 5.8 percent, improved tobacco cessation counseling by 8.9 percent, and increased the appropriate use of aspirin therapy by 8.2 percent. The strongest performance within the LAN came from Oklahoma’s Choctaw Nation Health System, which includes nine clinics and 122 physicians serving more than 17,000 cardiac patients.  The Choctaw Nation showed 6.5 percent improvement for LDL cholesterol reduction, 10.3 percent improvement for tobacco cessation counseling, and 12.4 percent for increased appropriate use of aspirin therapy. 

^*In spring of 2014, CMS determined to separate the consumer type protection activities – case review, beneficiary complaint and appeals – from the quality improvement work for the QIO program going forward.  As of August 1, Oklahoma is represented by two Quality Improvement Organizations. TMF Health Quality Institute has partnered with the Arkansas Foundation for Medical Care, Primaris in Missouri and the Quality Improvement Professional Research Organization, Inc. in Puerto Rico to form the TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) to provide quality improvement work throughout Arkansas, Missouri, Oklahoma, Puerto Rico and Texas. Beneficiary and family centered care services are now provided by KEPRO.

As part of its work to improve cardiovascular health and health literacy in the Arkansas Delta, AFMC – the Quality Improvement Organization for Arkansas through July 2014^* – partnered with seven public libraries to create health hubs in the libraries.

With assistance from AFMC:

• The participating libraries hosted Heart Health 101 events and other health-focused learning sessions for patrons, including free health screenings.
• Three libraries were selected to receive blood pressure monitors from the Arkansas Department of Health and set up permanent blood pressure stations.
• The libraries created displays featuring books about healthy eating and heart health.
• Three libraries incorporated the Million Hearts initiative in their summer reading programs. 
• The libraries provided free health tools for patrons, such as a blood pressure wallet card from AFMC.

The libraries embraced the partnership, which began in July 2012 and ran through July 2014. In the three libraries with blood pressure stations, librarians took an active role in encouraging patrons to use the monitors.

Some of the positive results of the program included:

• An increase in the check-out rate for health-related books the librarians say would otherwise stay on the shelf.
• A patron of a library in Dumas brought her 85-year-old mother, Gracie, to the library to check her blood pressure because she wasn’t feeling well. The monitor showed Gracie’s blood pressure was very high, and the librarian encouraged Gracie to follow up with her physician. Gracie’s blood pressure medication was adjusted and her blood pressure is now under control.

View an AFMC video profiling several of the libraries’ individual efforts to promote heart health here.

^*In spring of 2014, CMS determined to separate the consumer type protection activities – case review, beneficiary complaint and appeals – from the quality improvement work for the QIO program going forward.  As of August 1, Arkansas is represented by two Quality Improvement Organizations. TMF Health Quality Institute has partnered with the Arkansas Foundation for Medical Care, Primaris in Missouri and the Quality Improvement Professional Research Organization, Inc. in Puerto Rico to form the TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) to provide quality improvement work throughout Arkansas, Missouri, Oklahoma, Puerto Rico and Texas. Beneficiary and family centered care services are now provided by KEPRO.

In the city of Meridian, Miss., Information & Quality Healthcare (IQH), the Medicare Quality Improvement Organization for Mississippi, has worked to help reduce complications associated with diabetes, particularly within the African- American community.

In the U.S., 18.8 million people have been diagnosed with diabetes, and some 7 million remain undiagnosed, according to the Centers for Disease Control and Prevention 2011 National Diabetes Fact Sheet.

The special year-long project, which began in October 2012, engaged 54 providers to refer eligible Medicare patients to diabetes self-management education (DSME) classes using tools provided by IQH.  These tools include chart sticker reminders, monofilaments (for detecting neuropathy), and personal health records that encourage foot and eye exams for people with diabetes. The nurses recruited beneficiaries from the providers and from the community.  Providers were given the names of their patients who completed the classes.

IQH nurses taught two-hour DSME classes for three to four weeks depending on various factors including literacy levels and size of classes.  Classes were held in different settings across Meridian, from senior housing and activity centers to churches and Housing and Urban Development (HUD) sites and parks. The interactive sessions covered topics such as medications, nutrition, and monitoring foot and eye care. The nurses conducted fun demonstrations using visual aids – for example, they use sugar, lard, and salt to help illustrate the amounts of unhealthy ingredients in fast food.

A total of 178 targeted Medicare beneficiaries graduated from the classes.  After the graduation, participants received a series of three calls from an IQH Healthline coach to reinforce the education and to collect information on follow-up visits with healthcare providers.  Graduates received certificates and were featured in photographs in a local newspaper reaching more than 20,000 homes in the Meridian area. The coverage has helped to increase ongoing interest in the program.