Health Quality Innovators (HQI) is collaborating with Maryland partners in the counties of Prince George’s, Calvert, Charles and St. Mary’s to promote the adoption of clinical protocols, implement training and technical assistance of decision-support tools, promote care models and screening tools, assist practices on workflow design, and help practices use technology including telehealth for population health management and referrals.
HQI’s Physician Services team is partnering with Prince George’s County Health Department on PreventionLink of Southern Maryland, a comprehensive, five-year cooperative agreement awarded by the Centers for Disease Control and Prevention (CDC) to improve the prevention, treatment, and health outcomes for patients at risk or suffering from diabetes, heart disease, and stroke.
Project goals include
- Developing an innovative model that is sustainable and scalable for preventing,
- Treating and managing chronic disease,
- Creating a new infrastructure to better identify individuals at risk for developing or with chronic disease, and
- Facilitating improved communication and collaboration across the care continuum.
If you are a primary care practice and interested in learning more or participating in this initiative, contact Karen Shiner at firstname.lastname@example.org.
RVA Community Cares – An Accountable Health Community
The needs of patients often go beyond the walls of a provider’s office. Unmet health-related social needs may raise the risk of developing chronic conditions, reduce the ability to manage these conditions, increase health care costs, and lead to avoidable health care facility visits. RVA Community Cares, an Accountable Health Community (AHC) funded by the Centers for Medicare & Medicaid Services (CMS), is helping beneficiaries overcome these social barriers in the Richmond region.
The five-year project connects area residents with the services they need to thrive and improve health outcomes as well as potentially reduce health care costs. RVA Community Cares’ bridge organization, Health Quality Innovators (HQI), coordinates efforts of multiple health care delivery and community service organizations covering Chesterfield County, Hanover County, Henrico County and the City of Richmond.
Clinical Delivery Sites offering screenings to determine eligibility include:
- Bon Secours Health System
- Bremo Pharmacy
- Capital Area Health Network
- Daily Planet Health Services
- National Counseling Group
- Richmond Behavioral Health Authority
- Richmond City Health District
- VCU Health
Modifiable Factors That Influence Health
“Social and Economic Factors” include education, employment, income, community safety, and family and social support. “Health Behaviors” include tobacco use, diet and exercise, alcohol and substance use, and sexual behaviors. “Clinical Care” includes access to care and quality of care. “Physical Environment” includes environmental quality, housing and transit.
Statistics according to County Health Rankings www.countyhealthranking.org/explore-health-rankings/what-and-why-we-rank
Want to be a part of RVA Community Cares?
RVA Community Cares is currently recruiting practices to conduct screenings during clinical visits to identify Medicare and Medicaid beneficiaries in need. These screenings are used to create a customized referral summary that the patient can use to connect with services to assist with their needs. In some cases, patients will be contacted by their own personal navigator. A navigator is a person who will guide the patient to connect with community service providers and follow up with patients to ensure the connection was made.
Click here for additional information to get started.
How We Help Our Community
To encourage alignment between clinical and community services and ensure this vital assistance is available and responsive to the needs of eligible beneficiaries, RVA Community Cares promotes collaboration through three core activities, which include:
- A screening tool helps identify certain unmet health-related social needs, which include housing, food, transportation, utilities, and addressing interpersonal safety.
- When applicable, screened beneficiaries are offered a tailored community referral summary of local providers that may be able to address each of the needs identified through the screening.
- High-risk beneficiaries with unmet health-related social needs are offered navigation services that might assist them in resolving health-related social needs that were identified.
The Role of a Screener
- Determine if an individual is a community-dwelling Medicare or Medicaid beneficiary.
- Administer the screening tool.
- If there are unmet needs, use the resource directory to connect an individual to local community providers.
- Offer navigation services to high-risk beneficiaries.
The Role of a Navigator
- Conduct personal interviews.
- Develop patient-centered action plans.
- Perform ongoing follow-up and assistance.
- Collect data and document encounters.
Some Qualifications for Participants
- A qualified individual must reside in Chesterfield County, Hanover County, Henrico County or the City of Richmond.
- A qualified individual must be a community-dwelling beneficiary (i.e., not living in a nursing home, assisted living facility or incarcerated).
RVA Community Cares Goals
- Complete at least 75,000 screenings of beneficiaries each year
- Reach 51% of the region’s Medicare/Medicaid population in five years
- Reduce avoidable emergency department visits
- Reduce avoidable admissions/readmissions
- Decrease unnecessary use of outpatient services
- Reduce total cost of care
- Improve the provider and beneficiary experience
My Weight, My Way
Health Quality Innovators’ (HQI) “My Weight, My Way” initiative, funded by the Centers for Medicare & Medicaid Services (CMS), assists health care providers with implementation of Intensive Behavioral Therapy (IBT) for obesity. The program consists of screening for obesity using body mass index (BMI) measurement, dietary assessment and intensive behavioral counseling through high-intensity interventions on diet and exercise. Using behavioral counseling to deliver diet and exercise recommendations and IBT can be very useful for patients trying to achieve weight management goals.
HQI and about 180 clinicians are working together to save a total of $5.2 million per year by improving control of obesity-related chronic conditions, which contributes to meeting Medicare Quality Payment Program goals.
HQI is working with health care providers participating in the initiative to:
- Use electronic health records (EHRs) to identify their region’s population of Medicare patients who are obese
- Develop workflows to recommend and deliver IBT, perform follow-ups, and keep patients engaged
- Train clinicians to recommend IBT in an effective manner
- Train designated clinicians to deliver IBT using an evidence-based approach, which also can be applied to smoking cessation counseling and cardiovascular risk reduction
- Train clinicians and staff in EHR documentation and billing procedures for IBT for obesity
- Promote IBT to patients using customizable marketing material and outreach strategies
- Identify and form relationships with community organizations that support healthy weight loss
- Develop an effective plan for sustaining IBT for obesity as a revenue-generating service
For more information about this program, please contact Jennifer Hayes at email@example.com.
Practice Transformation Network (PTN)
The Health Quality Innovators (HQI) Practice Transformation Network supports more than 1,400 office-based clinicians looking to expand their quality improvement capacity, share best practices, and achieve common goals of improved patient care, better health outcomes and reduced cost in an effort to prepare for successful participation in value-based care or alternative payment models.
HQI assists practices with Merit-based Incentive Payment System (MIPS) participation and population health management initiatives such as increasing preventive care, reporting and analyzing clinical performance data, risk stratifying patients and implementing care management programs, including chronic care management for patients with multiple chronic conditions and transitional care management for patients returning to their home from an inpatient hospital stay.
CMS EHR Incentive Program
As Virginia’s Regional Extension Center (REC) for the Office of the National Coordinator (ONC) and a contractor for Virginia’s Department of Medical Assistance Services, HQI’s Physician Services team provided free outreach and education for the Center’s for Medicare and Medicaid Services’ (CMS) EHR Incentive Program, also known as the Promoting Interoperability Program (formally Meaningful Use).For more information, please contact the Virginia Medicaid Promoting Interoperability Program System’s help desk at (877) 589-9113.
Through this initiative, Physician Services successfully assisted more than 3,500 providers select, adopt, implement or upgrade their electronic health record (EHR) system and helped 3,000 providers earn Promoting Interoperability incentives.
Physician Services offered practices various levels of support by providing the following assistance:
- Determining program eligibility
- Generating reports from Practice Management Systems and EHRs and troubleshooting any technical issues
- Educating staff on best practices
- Optimizing documentation and workflow processes and to ensure clinicians met the program requirements
- Completing HIPAA Privacy and Security Risk Assessment
- Producing documentation to support audits
- Preparing for successful program attestation
- Assisting in pre- and post-payment audits
Heart of Virginia Healthcare
As a member of the Agency for Healthcare Research and Quality’s (AHRQ) EvidenceNOW initiative, a Virginia-based cooperative called Heart of Virginia Healthcare (HVH), HQI served as the practice facilitators to 249 small-to mid-sized primary care practices focusing on quality improvement to boost four cardiovascular prevention measures.
HQI assisted primary care providers with improving health care quality improvement and boosting performance on measures know as the “ABCS,” which includes recommending Aspirin for high-risk individuals, Blood Pressure monitoring, Cholesterol management and Smoking cessation. HVH emphasized joy in practice and offered strategies to address provider burnout. HQI assisted participating practices with workflow redesigns to enhance patient care and practice efficiency, which resulted in better processes, communication and teamwork.