The Atlantic Quality Innovation Network (AQIN) – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving New York, South Carolina and the District of Columbia – has committed to changing the way South Carolinians think about immunizations.

Seeking to build on its ongoing vaccination efforts, AQIN, in partnership with the South Carolina Department of Health and Environmental Control (DHEC), launched a coalition in early 2015 of nearly 40 organizations in the state, including the South Carolina Office of Rural Health, the South Carolina Academy of Family Physicians, the South Carolina Pharmacy Association, and the Medical University of South Carolina. Now the coalition has started reaching its goals of sharing best practices, tools and resources in an effort to increase immunizations, and to encourage providers to document and report immunization rates.‍

“We knew from the start that community outreach would be the key to success, so we incorporated immunizations into our other quality improvement work and engaged partners that helped attract new collaborators,” said Melinda Postal, Quality Specialist at AQIN-South Carolina. “That led us to our initial work with the Governor’s Office.”

With encouragement from AQIN, former South Carolina Governor Nikki Haley issued a proclamation that recognized Senior Vaccination Season and the need for expanded vaccination awareness efforts across the state. According to Postal, this recognition was an important tool that helped draw attention to the coalition’s work.

The partnership developed educational bookmarks that have now been distributed to approximately 15,000 seniors and nearly 200 public libraries statewide. One side of the bookmark focuses on flu prevention and the other side on shingles, which also impacts seniors at alarming rates. Coalition members also started a vaccine-awareness monthly newsletter that is disseminated to stakeholders across the state. It aims to encourage providers to prioritize vaccinations, implement best practices and collaborate with peers.

The coalition’s efforts yielded dramatic results during the 2015 flu season, and early numbers for the 2016 season are expected to be equally impactful. From August 2014 to March 2015, 29 out of the 40 counties in South Carolina saw an uptick in influenza immunization rates, and from January to December 2015, all counties achieved higher pneumonia immunization rates.

Nevertheless, barriers still exist. Many seniors aren’t able to access clinics because they lack transportation, and more education is needed – particularly around the fact that Medicare Part D covers many vaccinations.

Given these needs, the coalition is looking to expand its efforts, using county-level data to determine where to target efforts.

In the fall of 2016, coalition members launched the next phase of their strategy, a partnership with Walgreens to host immunization clinics in rural areas. Through collaboration with Walgreens and other local stakeholders, the coalition has been successfully hosting three community events per quarter, with topics ranging from immunization awareness to assisted living options. They also have begun preparations for 2017 events, including a State Immunization Resolution, championed by pharmacist and Senator Ronnie Cromer, in March, and a statewide immunization day in August.

The coalition views culture-specific messaging as critically important moving forward, as it strives to continue the upward trend in immunization rates. “Family is very important in the South, especially among rural populations,” said Postal. “We’re finding that when we’re talking to seniors about getting vaccinated, it really hits home to say, ‘Do it for yourself, but also do it for your family and grandkids.’”

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

Providing Diabetes Self Management Education (DSME) to people with diabetes can significantly decrease the symptoms of the disease.

As the nation grows more culturally diverse, QIN-QIOs are facing new challenges in providing DSME resources to Medicare beneficiaries through the Centers for Medicare & Medicaid Services’ Everyone with Diabetes Counts (EDC) program. English is not the primary language of many beneficiaries across the nation. Often, a lack of English proficiency can inhibit a person’s ability to understand educational resources like DSME classes. Disparities in diabetes care have been attributed to cultural and language barriers.

Health Services Advisory Group (HSAG) – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving Arizona, California, Florida, Ohio and the U.S. Virgin Islands – has addressed this changing cultural climate through language initiatives to provide comprehensive DSME to Medicare beneficiaries.

In states with large Hispanic populations like Arizona, California and Florida, providing DSME resources in both English and Spanish is now common practice for many DSME programs. The biggest challenge lies in providing resources in other languages for increasingly diverse populations. In California, HSAG has seen an increase in Asian language speakers. To meet their needs, HSAG coordinated the translation of DSME materials and classes for many languages, including Vietnamese, Mandarin, Hmong, Korean and others.

In California and Florida, certain Native American communities prefer to learn from teachers within their own communities. HSAG provides the training and support that Native American health ambassadors need in order for them to go back to their respective communities to educate beneficiaries about DSME.

‍In addition to accommodating the language needs of beneficiaries, HSAG’s outreach methods include high-touch strategies like conducting weekly phone calls, sharing facilitator cell phone numbers and sending handwritten greeting cards to increase retention rates in the program.‍

“High touch is a really important part of the Diabetes Empowerment Education Program,” says HSAG’s Laura Gamba, who works to recruit and provide DSME resources in Florida. “When someone is supposed to get a meter [to monitor blood sugar], for example, we follow up to make sure they know how to use it.” HSAG also has met beneficiaries in person at public locations to provide catch-up sessions if they missed a class.

HSAG recently partnered with the Food is Medicine program in the Tampa Bay area of Florida to encourage beneficiaries in lower-income communities to attend DSME classes. The Food is Medicine program offered $10 vouchers to each DSME class attendee for local fruits and vegetables from its Food is Medicine truck. This helped stimulate initial interest in the class, as well as improve retention rates, because people were given access to healthy foods in an accessible manner.

In total for 2016, HSAG graduated 5,201 beneficiaries from DSME programs, 4,736 of whom were Medicare beneficiaries.

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

According to the Centers for Disease Control and Prevention (CDC), approximately 22 percent of Americans ages 65 and older have diabetes.

Diabetes Self-Management Education (DSME) is an ongoing process that facilitates the knowledge, skills and abilities necessary for diabetes self-care. Empowering people with the knowledge and ability to self-manage their diabetes through DSME can significantly improve their quality of life and long-term health.

atom Alliance – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving Alabama, Kentucky, Indiana, Mississippi and Tennessee – has implemented a high-touch, community-oriented approach to promote DSME in both rural and urban coverage areas, through the Centers for Medicare & Medicaid Services’ Everyone with Diabetes Counts (EDC) program. Additionally, atom Alliance has identified community centers and locations at which beneficiaries frequently gather to enable ease of access to DSME programs. 

“One of the ways we engage beneficiaries is by going to their health care providers,” said Anthony Culver, Communication Specialist at atom Alliance. “However, meeting people where they are, like in community centers, libraries and senior centers, is often the best way to reach them.”

With this in mind, atom Alliance partnered with Methodist Healthcare’s Congregational Health Network in Memphis, Tennessee to promote DSME programs through its wide-reaching network of more than 600 congregations across the state of Tennessee.

atom Alliance works directly with 10 of Methodist’s health liaisons that are connected to the broad-reaching network of church groups, to promote various health engagement and education programs to the faith-based communities.‍

atom Alliance has found faith-based communities to be particularly effective in spreading the word about its DSME classes. “When we launch DSME at a new church, 10 or 15 people might show up,” said Debra Bratton, Quality Improvement Advisor at atom Alliance. “But when we host the second week of class, all those people bring a friend.” Bratton says the smaller, more intimate communities enable people who have benefited from DSME to become ambassadors for the program.

In rural Mississippi, providers have had difficulty getting beneficiaries to return to classes week after week to finish DSME courses. Often, lack of retention is due to barriers involving transportation or literacy. Through high-touch methods, atom Alliance has helped improve retention and provide necessary information to beneficiaries who do not have access to resources to attend the classes.

“You kind of have to be a detective,” says Trannie Murphy of atom Alliance-Mississippi. Dropout rates in rural areas can be high due to lack of transportation, so Murphy says the QIN-QIO calls individuals to remind them not to miss class and ensure they have a way to get there. Murphy says they also try to fill absentees in on what they missed or visit them at home to ensure beneficiaries are getting access to useful information.

Through these high-touch methods, atom Alliance has trained 370 beneficiaries in the state of Mississippi since the EDC program began coordinating DSME classes in 2015. As a QIN-QIO, atom Alliance has successfully educated 2,231 DSME graduates and trained 116 DSME trainers across all five states.

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

The New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO) – the QIN-QIO serving Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island and Vermont – works closely with the New Hampshire Department of Health and Human Services (NH DHHS) to implement Million Hearts® strategies across the state. As part of the regional New England Home Health Collaborative, together the New England QIN-QIO and NH DHHS have worked to implement smoking cessation – one of the “ABCS of Heart Health” – at the state level in New Hampshire.

One of the original challenges facing NH DHHS was a lack of home health clinician knowledge about smoking cessation resources for patients, and clinician uncertainty about how to approach the subject with them.

Through the New England QIN-QIO’s partnership with the NH DHHS, 11 home health agencies were connected to the New Hampshire Tobacco Prevention and Cessation Program. A tobacco treatment specialist offered to provide on-site education at the agencies to increase awareness among clinical staff about the health risks of smoking. The partners worked to connect clinical staff directly with patients.

‍Cornerstone VNA, a home health agency serving 35 communities in southern New Hampshire and Maine, spearheaded the smoking cessation initiative within its organization. A key manager at Cornerstone VNA was identified to enter patient data into the Home Health Quality Improvement (HHQI) National Campaign’s Home Health Cardiovascular Data Registry. Initially it was challenging for the manager to identify appropriate resources and the steps necessary to accomplish the goals. To help streamline the process, home health staff at the New England QIN-QIO created the “Road Map to Success Implementation Checklist” tool to help agencies better navigate the registry and its deadlines.‍

To implement the smoking cessation initiative, a dedicated quality improvement team at Cornerstone VNA identified the data needed based on the quality improvement measure it chose. In particular, team members needed to collect two pieces of information: whether the patient had been screened for tobacco use and whether smoking cessation education had been provided for at least three minutes. Once this data was collected, Cornerstone VNA was able to implement specific clinician interventions into a patient’s care plan.

Through the New Hampshire Tobacco Prevention and Cessation Program, Cornerstone VNA received a customized referral form to refer patients to the New Hampshire Tobacco Helpline. The program also provides smoking cessation patient education booklets, which the New England QIN-QIO shares with providers. “We are connecting patients with resources that we never knew were available. Clinicians are more comfortable asking about smoking cessation with patients and connecting them with the resources they need to be successful,” said Jennifer Gullison, RN, MSN, Clinical Director at Cornerstone VNA. 

Cornerstone VNA closely monitors HHQI data on a monthly basis to identify what additional education is needed for its patient population. The staff educator at Cornerstone VNA brings concerns to the clinical director and works to reeducate staff – all of whom are trained on the initiative – when they see numbers begin to rise. Since implementing the initiative, 100 percent of Cornerstone VNA patients have been screened, and patients who agreed to quit smoking have received education and resources.

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

The TMF Quality Innovation Network – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving Texas, Arkansas, Missouri, Oklahoma and Puerto Rico – has partnered with Greater Grace Church and a large health care provider system in the St. Louis area to reduce hypertension within the community using the American Heart Association’s (AHA) Check.Change.Control blood pressure program. Check.Change.Control focuses on educating participants about blood pressure and how to monitor and manage it.

The TMF QIN’s staff in Missouri works with churches and other faith-based organizations to provide tools and resources to educate their parishioners and others in the community about how to correctly monitor their blood pressure, what constitutes a heart-healthy diet and other tips. The QIN-QIO’s staff coordinates with church volunteers to help conduct blood pressure screenings and works with health care system staff to identify local and AHA resources to help church members live a healthier lifestyle.

Following initial blood pressure screenings, local volunteer health mentors, which TMF QIN staff have trained, follow up with participants and encourage them to continue monitoring their blood pressure and tracking their numbers. As a complement to the screening, the QIN-QIO offers diabetes self-management education through the Health for Life – Everyone with Diabetes Counts initiative, since high blood pressure is a risk factor for developing diabetes. 

During the first phase of the project, starting in August of 2015, 45 church members took advantage of the Check.Change.Control program. The second phase of the project began in the spring of 2016. During the “Spring into Better Health” session the program grew to 67 members, with a majority of the participants coming for more than one visit.

Following this success, Mercy Clinic East, a branch of the Accountable Care Organization representing Missouri, received the Million Hearts “Hypertension Control Champion” award for its activities in surrounding communities, in which Greater Grace and TMF QIN played a big part. The team used proven methods to accomplish these goals, including timely data, quick interventions, involving the patient in communication, and effective tools for comprehensive management of care.

TMF QIN’s staff in Missouri, along with partners under the Million Hearts® campaign, hope to continue improving population health with the launch of a diabetes self-management program in the spring of 2017.

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

Behavioral health is a critical issue for the Medicare population. According to the Centers for Disease Control and Prevention(CDC), roughly 20 percent of older Americans experience a mental health condition such as anxiety, depression or bipolar disorder. In addition, the inappropriate use of prescription drugs and alcohol are becoming increasingly common, especially among older men. That group in particular experiences alarming rates of suicide. The CDC reports that men 75 and older have the highest rates of suicide per 100,000 people.  

HealthInsight – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving Nevada, New Mexico, Oregon and Utah – is working in each of its states to better support primary care practices with resources and education to increase behavioral health screenings.

With over 800 practices spread out over a large geographic area, coordination is key. Throughout its network, HealthInsight has increased collaboration with local, state and national partners such as the National Alliance on Mental Illness (NAMI), Project ECHO™ (Extension for Community Healthcare Outcomes) programs, and government mental health authorities.

The QIN-QIO also has worked to raise awareness about the important role of primary care providers in the delivery of behavioral health screenings and other behavioral health services, especially in rural areas.

“Many Medicare beneficiaries feel more comfortable receiving mental health services from their primary care providers versus going to a community mental health center,” said Joan Gallegos, Project Manager at HealthInsight. “It’s been helpful to link primary care providers with the larger mental health services community to share resources and increase the level of service available to beneficiaries.”

To better support care providers, HealthInsight created a Practice Intervention Toolkit, a step-by-step guide of best practices, screening tools, and evidence-based strategies. They’ve also hosted a series of webinars for practices across all four of their states. Moving forward, the QIN-QIO is exploring ways to spread the word about the importance of screenings and the serious nature of behavioral health.

“We’re looking for spokespersons for behavioral health who can help get the message out in our states,” said Gallegos. “There’s so much stigma around these issues. To take this work to the next level, we need more education with the public about the impact and prevalence of behavioral health and substance abuse.”‍

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

When a Medicare beneficiary with stage 5 chronic kidney disease (CKD) entered hospice in early 2016, the beneficiary’s family was concerned to learn that the necessary medications used for comfort care (known as a Comfort Kit) were not available when the patient had an increase in pain and shortness of breath the day after admission. The beneficiary’s family member subsequently contacted Livanta – the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) for that state – with a complaint about the lack of availability of the Comfort Kit and the resulting delay in comfort care. Livanta confirmed the quality of care concern and referred the case to Qualis Health – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving Idaho and Washington – to help the hospice provider review the case and evaluate its improvement plan.

After performing a root cause analysis and a retrospective audit to identify any similar delays in medication access for comfort measures, the hospice quality team determined that the complaint represented a single isolated occurrence of a family’s dissatisfaction with the symptom management provided. The team consulted the Medicare Conditions of Participation and the state’s hospice and palliative care association, and determined that their organization was meeting national standards and its own standards of care. Yet, despite the absence of a systemic process problem, the team took the complaint seriously and assessed additional opportunities for quality improvement.

‍As they examined the process to acquire the Comfort Kit, hospice quality team members looked for opportunities to shorten the length of time between admission to hospice and the family’s receipt of a Comfort Kit. Originally, specialists and primary care physicians within the health care system ordered medications for hospice patients – a decentralized process that led to communication gaps and delays. Under the new streamlined process, the hospice physician group began ordering all scheduled drugs for hospice patients to improve efficiency. The hospice quality team also identified an alternative process for delivery of the Comfort Kit, using the health network’s transportation system to enable delivery within hours.‍

Improvements in acquisition and delivery processes further enabled the hospice provider to help families receive all medications in a timelier manner – not just Comfort Kits, but any medications urgently needed before the kit arrives or once drugs are initiated. Once hospice nurses assess the need for any urgent medications at the initial visit (and all ensuing visits), they can implement different delivery options based on need. Using a courier service, pharmacies close to the family’s residence, and volunteer staff, urgent medications can be processed and delivered in as little as one to two hours.

The hospice provider sent the QIN-QIO monthly reports monitoring patient complaints and has registered no complaints related to delays in receiving medications or concerns with symptom management for hospice care since the implementation of their plan.

“It’s important to recognize how a single complaint led to looking at an overall process – the process of ordering, receiving and delivering medications for all patients, beyond the Comfort Kit and beyond one family’s concern,” says Evan Stults, Communications Director for Qualis Health. “One complaint opened a window to identify and implement fundamental process revisions, and to share improvements in medication ordering and delivery within the whole system.”

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

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.