Project Grant G2047063

SMALL HEALTH CARE PROVIDER QUALITY IMPROVEMENT - HOLZER HEALTH SYSTEM, ON BEHALF OF THE APPALACHIAN COMMUNICATION CONSORTIUM (ACC), SEEKS FUNDING FROM THE HRSA SMALL HEALTH CARE PROVIDER QUALITY IMPROVEMENT PROGRAM (HRSA-22-093) FOR ITS COMMUNICATIONS IMPROVEMENT PROJECT (CIP) TO REDUCE HOSPITALIZATIONS AND IMPROVE RURAL HEALTH OUTCOMES FOR ADULTS 60 AND OLDER. WITH ITS PROPOSED QUALITY IMPROVEMENT MODEL CENTERED ON TEAMSTEPPS, THE ACC WILL ENHANCE TEAM COMMUNICATION AS A FOUNDATION FOR STREAMLINING CARE TRANSITIONS AND COORDINATION, BUILDING SERVICE CAPACITY, ADDRESSING SOCIAL DETERMINANTS OF HEALTH, AND ADVANCING READINESS TO EXPAND PAYMENT AND REIMBURSEMENT STRATEGIES FOR SUSTAINABILITY. CIP WILL CREATE A MULTIDISCIPLINARY QUALITY INFRASTRUCTURE THROUGHOUT OUR CONSORTIUM THAT IS PRIMED FOR IMPROVEMENT INITIATIVES AND CAN CREATE COST SAVINGS THAT CAN SUSTAIN AND GROW THE MODEL IN OUR REGION. WE WILL FOCUS ON REDUCING HOSPITALIZATIONS (ADMISSIONS AND READMISSIONS) FOR SOME OF THE MOST COMMON AND COSTLY CAUSES OF HOSPITAL ADMISSIONS FOR OLDER ADULTS IN OUR EIGHT-COUNTY REGION OF SOUTHEASTERN OHIO AND WESTERN WEST VIRGINIA. OUR OLDER ADULT PATIENT POPULATION IS PRONE TO HIGH LEVELS OF PNEUMONIA, CONGESTIVE HEART FAILURE, SEPSIS, AND OTHER CHRONIC DISEASES THAT ARE AMONG THE LEADING CAUSES OF AVOIDABLE HOSPITALIZATIONS, READMISSIONS, AND DEATH. WHILE THIS PARTNERSHIP SEES POTENTIAL TO APPLY THIS QUALITY IMPROVEMENT STRATEGY ACROSS MANY MAJOR CONDITIONS OF CONCERN, OUR PROJECT WILL FOCUS OUR COMMUNICATIONS QUALITY IMPROVEMENT MODEL ON PNEUMONIA, CONGESTIVE HEART FAILURE, AND SEPSIS IN YEARS 1 AND 2, THEN APPLY THE MODEL TO COPD AND UTI IN YEARS 3 AND 4. TO DO THIS WORK IN A COORDINATED, CROSS-SYSTEM FASHION, HOLZER HEALTH SYSTEM WILL FORMALLY PARTNER WITH OHIO VALLEY PHYSICIANS (OVP), AND THE AREA AGENCY ON AGING DISTRICT 7 (AAA7) TO COMMISSION AND TRAIN MULTIDISCIPLINARY QUALITY IMPROVEMENT TEAM(S) TO EXTEND A SUITE OF SERVICES TO DEFINED SETS OF OLDER ADULT PATIENTS 60 AND OLDER. OUR GOAL IS TO ENABLE EXCELLENT COMMUNICATION AND COORDINATION ACROSS PROVIDER TYPES AND WITHIN MULTIPLE LEVELS OF CARE, TRANSITIONING AND STABILIZING OLDER ADULTS THROUGH CARE SERVICES AND INTO THE COMMUNITY. MULTIDISCIPLINARY TEAM COMPOSITION SHOULD REPRESENT A CROSS-SECTION OF STAFF ACROSS LEVELS OF CARE, INCLUDING ACUTE, POST-ACUTE, AMBULATORY, PRIMARY CARE, HOME HEALTH, SPECIALISTS, AND COMMUNITY-BASED SERVICES. THE ACC WILL 1) DEDICATE STAFF CAPACITY TO CROSS-SYSTEM MULTIDISCIPLINARY QUALITY IMPROVEMENT TEAMS (INCLUSIVE OF CARE MANAGERS AND DISCHARGE PLANNERS) TO IMPROVE TRANSITIONS OF CARE AND EXPAND SERVICES FOR INDICATED OLDER ADULT PATIENTS; 2) TRAIN TEAMS IN PROVEN COMMUNICATION QUALITY IMPROVEMENT MODELS LIKE TEAMSTEPPS, TEACH BACK AND ENHANCED CARE MANAGEMENT METHODS; 3) TEST AND EXTEND EFFECTIVE QUALITY IMPROVEMENT PRACTICE CHANGES, CARE HANDOFFS AND DISCHARGE PLANNING THROUGH SERVICES TO OUR PATIENTS; 4) LINK ELIGIBLE PATIENTS TO THE AAA7'S HOSPITAL2HOME SERVICE AND OTHER SOCIAL SERVICE REFERRALS; AND 5) EXPAND AND EXPLORE PAYMENT AND SAVINGS STRATEGIES TO SUSTAIN THESE ENHANCED SERVICES FOR OLDER ADULTS. WE BELIEVE THESE ACTIONS WILL RESULT IN POSITIVE OUTCOMES IN EACH OF THE THREE REQUIRED IMPACT AREAS: 1) IMPROVED HEALTH OUTCOMES EVIDENCED BY OLDER ADULTS LIVING HEALTHIER LIVES AT HOME, AVOIDING UNNECESSARY HOSPITALIZATIONS AND READMISSIONS FOR PNEUMONIA, CHF, COPD, SEPSIS AND UTI; 2) EXPANDED CAPACITY FOR ESSENTIAL HEALTH CARE SERVICES BY INCREASING CARE MANAGEMENT SERVICES WITHIN A SUSTAINABLE COMMUNICATIONS AND QUALITY INFRASTRUCTURE FOR OLDER ADULT PATIENTS; AND 3) INCREASED FINANCIAL SUSTAINABILITY DEMONSTRATED THROUGH NEW OR EXPANDED BILLING OR PAYMENT INCENTIVE STRATEGIES AND POTENTIAL COST SAVINGS FROM REDUCED ADMISSIONS AND READMISSIONS. WE BELIEVE THAT THIS INITIATIVE WILL SERVE AS A CRITICAL STEPPINGSTONE FOR OUR HEALTH SYSTEMS TO BENEFIT FROM THE VALUE-BASED OPPORTUNITIES OFFERED BY CMS AND OTHER ENTITIES OVER TIME.