Quality Improvement and Medical Homes
Introduction
Quality improvement is an important way to improve care for patients. Quality improvement, or practice change, is an important component of medical homes. For busy primary care practices however, this can feel like "changing your bike tire while riding the bike. "
The good news is that primary care providers and families across the country have been working together to identify and test successful strategies to streamline and simplify this process for you.
Based on extensive experience, the Center for Medical Home Improvement and the National Medical Home Collaborative have identified what initial steps will make the biggest difference in the "medical homeness" of most primary care practices.
Where to Start from the Center for Medical Home Improvement
Practice-based Quality Improvement Initiatives
Washington State Practice-Based Quality Improvement Efforts
Other Resources
Where to Start from the Center for Medical Home Improvement
PDF of this section 
Center for Medical Home Improvement
Using the Care Model for Child Health in a Medical Home
The change package for Medical Home is based on a conceptual framework, the Care Model for Child Health in a Medical Home, outlining features of the ideal system for Medical Home and a set of evidence-based strategies that have been proven to be effective in achieving improvements (“change concepts”).
The ability to develop, test, and implement changes is essential for any practice that wants to improve. Practices should establish a process for quality improvement, such as the Model for Improvement, to implement the change concepts. After selecting specific changes, practices should run Plan-Do-Study-Act (PDSA) cycles to test a change or group of changes on a small scale to see if they result in improvement. If they do, practices may expand the tests and gradually incorporate larger samples until they are confident that the changes can be adopted more widely across the practice.
The following short list of high-leverage strategies are adapted from the Care Model for Child Health based on the experience of the Center for Medical Home Improvements and the NICHQ Medical Home Learning Collaborative I & II (2004 & 2005). The highlighted areas (#1, #2, #3 and #4) are recommended strategies, in order of importance, most effective when implemented early on in the improvement process.
Care Model for Child Health in a Medical Home
Improvement Ideas
Areas of Improvement Improvement Strategies (start up top 4 are numbered)
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Community |
- Meet with community partners (e.g. “lunch & learn” time)
- Catalog (dynamically) community resources and contact persons
|
Health System |
- Gain commitment of health care system senior leadership to have quality standards in place for meeting the needs of CYSHCN & families
- Establish plan to maximize reimbursement for medical home visits
|
Care Partnership Support |
- #1 Engage parents as partners at the practice level
- Develop a care planning process and plan with families
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Delivery
System Design |
- #4 Develop strategy and identify specific roles for care coordination and communication at the practice level
- #3 Use planned visit encounters
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Decision Support |
- Co-manage care with specialists and choose information exchange method (fax-back, email, web-based systems)
- Select and use evidence based practice guidelines
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Clinical
Information
System |
- #2 Identify CYSHCN {flu list, computer runs, memory, prospectively)
- Build and use a registry to enroll identified CSHCN, use visit reminders, to support care planning process and monitor care needs
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Jeanne McAllister
Co-Director
© Center for Medical Home Improvement, 2005 |
The recommended measurement tools for evaluating the
successful integration of Medical Home in clinical practice are the:
1) Medical
Home Index; 2) CAMHI
Screener; and 3) CMHI’s Medical
Home Family Index and Survey.
Note: For an expanded list of possible activities a primary care practice might consider for each component of the Chronic Care Model see
Care Model Change Concepts and
Quick Pick Change Package from the American Academy of Pediatrics' National Center of Medical Home Initatives for Children with Special Needs, Learning Collaboratives- Medical Home page (www.medicalhomeinfo.org/model/MHLC.html)
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Practice-based Quality Improvement Initiatives
The National Center of Medical Home Initatives for Children with Special Needs - American Academy of Pediatrics
Learning Collaboratives page
Many health care providers and organizations using Learning Collaboratives to improve health care services for children and people with disabilities and special health care needs. Using the methodology of the Institute for Healthcare Improvement's Breakthrough Series Model, The Model for Improvement and the Chronic Care Model, healthcare providers are making a positive difference in the lives of hundreds of thousands of Americans.
www.medicalhomeinfo.org/model/learning.html
The Center for Medical Home Improvement
Hood Center for Children & Families, Children's Hospital at Dartmouth-Hitchcock Medical Center
Developers of the Medical Home Index and other medical home quality mprovement tools. Parent Partner Guide and more.
www.medicalhomeimprovement.org/
Institute for Healthcare Improvement (IHI)Topics:
IHI is a not-for-profit organization created to help lead the improvement of health care systems, to increase continuously their quality and value. Measures of improvement include improved health status, better clinical outcomes, lower cost, broadened access, greater ease of use, and higher satisfaction for individuals and their communities.
www.ihi.org/ihi
- How to Improve
Topics are the core around which content and community are organized on IHI.org. Each Topic features the best available knowledge for improvement in that area, including tools, literature, and changes that you can implement and measure to help speed improvement in your organization. Topics include Chronic Conditions, Office Practices, Improvement and more.
www.ihi.org/ihi/topics
Improving Chronic Care (Chronic Care Model)
A National Program of the Robert Wood Johnson Foundation
Theory and practical tools for how to systematically improve care for persons of all ages who have ongoing health or developmental conditions. Based in Seattle at the MacColl Institute for Healthcare Innovation, Group Health Cooperative Center for Health Studies.
www.improvingchroniccare.org/
National Initiative for Children's Healthcare Quality (NICHQ)
Education and research organization dedicated to improving the quality of health care provided to children. NICHQ's mission is to eliminate the gap between what is and what can be in health care for all children. National collaboratives have been held on the topics of asthma, ADHD, Medical Homes, and epilepsy. A national organization with its home office in Boston, NICHQ also has offices in Vermont and Washington State at the University of Washington's Child Health Institute.
www.nichq.org/nichq
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Washington State Practice-Based Quality Improvement Initiatives
The experience of learning how to incorporate quality improvement activities into primary care offices translates beyond the specific topic worked on. For this reason, we list here quality improvement initiatives in Washington State that have focused on improving health care services for children with special health care needs, children, or adults with special health care needs.
Kids Get Care: Children's Preventive Healthcare Collaborative
The Children’s Preventive Health Care Collaborative is an initiative to disseminate successful approaches—reinforced during the implementation of the Kids Get Care program—for improving the delivery of preventive services to low-income children. A comprehensive, integrated set of preventive services, including medical, dental, developmental and mental health services, is vital for children. This collaborative will focus on integrating oral health and developmental screening and referrals into children’s primary care services.
www.metrokc.gov/HEALTH/kchap/cphcc.htm
The Washington State Collaborative – Diabetes and Cardiovascular Disease
Statewide Collaborative led by the Washington State Department of Health. Patterned after the Institute for Health Improvement’s Breakthrough Series, co-sponsored by the Washington State Department of Health, Pro-West and MacColl Institute for Healthcare Innovation. The pilot, which ran from 10/99 - 11/00, included 17 practices teams, 10 health plans or provider networks, and 12,000 patient pilot population. The pilot set out to improve the quality of care delivered to people with diabetes in a cost-effective manner through partnerships and collaborations using evidence-based practices. Targeted measures include glycemic control and blood pressure control.
www.doh.wa.gov/cfh/WSC/default.htm
Overview brochure for Diabetes and Cardiovascular Disease Collaborative:
www.medicalhome.org/4Download/physicians/wsc_overview.pdf
The Children's Preventive Healthcare Initiative (CPHI)
CPHI was a two-year joint effort of Acumentra Health and Washington Medical Assistance Administration, in cooperation with five Washington health plans.
Launched in October 2002 with a three-clinic pilot test, CHPI’s long-term goal was for all infants, children, and adolescents enrolled in Healthy Options, Washington’s Medicaid managed care program, to receive well-child visits on schedule and be up to date on their immunizations. In the short term, CPHI aimed to improve statewide well-child visit rates by 10 percentage points in each participating clinic by the end of 2005, and produce measurable improvement in immunization rates.
During 2003, 10 clinics in western Washington participated in four interactive Learning Labs on how to plan and implement individual rapid-cycle quality-improvement projects. The labs provided a forum where clinics could exchange success stories with one another and get help with implementation challenges. In 2004, 12 clinics in eastern Washington participated in the four Learning Labs.
Health plans assisted clinics with their projects in various ways. Some provided data, others provided patient reminders, and others sent representatives to the Learning Labs or provided meeting space.
To improve immunization rates, CPHI promoted the immunization module of the statewide CHILD Profile, Washington State’s health promotion and immunization registry. See the CHILD Profile Web site at www.childprofile.org. The Acumentra Health team assisted clinics in implementing this registry.
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Other Resources
American Academy of Family Physicians: Practice Management Tips
Article: Why is QI moving so slowly?
"To date, QI has not permeated the culture of professional medicine, say the authors of "Measure, Learn, and Improve: Physicians' Involvement in Quality Improvement" (Health Affairs, May/June 2005). Drawing upon data from the Commonwealth Fund National Survey of Physicians and Quality of Care, Anne-Marie J. Audet, M.D., and her colleagues found that only one-third of doctors have been involved in any redesign efforts aimed at improving performance. Just a third, moreover, have access to any data about the quality of their own clinical performance, while seven of 10 physicians do not feel the public should have access to quality-of-care data. The survey also revealed surprisingly low use of electronic medical records (EMRs): only about a quarter (27%) of doctors reported using an EMR routinely or occasionally."
www.cmwf.org/publications/publications_show.htm?doc_id=275923
Health Disparities Collaboratives- Bureau of Primary Health Care
www.healthdisparities.net/hdc/html/home.aspx
Unlike the Medicaid disease management initiatives which serve those categorically eligible for Medicaid, the
Bureau of Primary Health Care ( BPHC) program offers disease management for individuals and communities regardless of their ability to pay, and is one method that states can use to address chronic diseases in uninsured populations. Disease management which increases patient’s knowledge and skills in living with a chronic illness generally results in healthier patients, which may offer health cost savings, minimizes the immediate need for access to health care services, and possibly result in a reduction in health disparities across the nation. Eligible participants include all of the BPHC-supported health centers and National Health Services Corps sites, Health Care for the Homeless sites, and health centers in schools and public housing.
Description of the methodology, partnerships and results of the Health Disparities Collaboratives are detailed in a nine minute training video entitled "Health Disparities Collaboratives: Changing Practice Changing Lives" produced by the Institute for Health Improvement and the National Association of Community Health Centers (NACHC) with support from BPHC. For more information: www.healthdisparities.net.
BPHC recently released a Policy Information Notice (PIN), 2002-12, defining the central role of the Health Disparities Collaboratives in carrying out the health center program expectations (PIN 98-23), as well as BPHC's expectations for grantees in participating, implementing and disseminating this initiative through health center delivery systems. To review the PIN 2002-12 visit ftp://ftp.hrsa.gov/bphc/docs/2002pins/2002-12.PDF
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