Appendix 1_A3C Example and Template DRAFT 10.4.2023.docx

Michigan A3C Exemplar for Three Sample Sub Aims Hypertension Prevention & Management – Complement Adverse Drug Events – Coordinate Safety Events - Create

Summary: QIOs will use the A3C framework outlined in this template to assess each state within their QIO region and determine their role and approach for working on the 13 sub-aims and 2 foundational aims. The framework consists of the steps described below.

First, conduct the Assessment (A) which consists of 3 Scans:

A. Healthcare Scan: High-level comparative analysis of state health statistics for the 2 foundational aims, and 13 sub-aims in the state B. Quality Scan: Identify key federal, state, local and private sector initiatives in the state C. Partner Scan: Identify key partners related to the 2 foundational aims and 13 sub-aims

Next, based upon the (A)assessment, determine QIO Role (Complement, Coordinate, Create) and describe approach.

Assessment Note: This sample includes an assessment for aims and sub-aims selected by CMS as an exemplar. The terminology used to describe health statistics by race or ethnicity are based upon the source and therefore may not align with the latest Office of Management and Budget requirements.

A. Health Scan Instruction: Conduct a high-level comparative analysis of state health statistics for the 13 sub-aims and 2 foundational aims. Summarize leading contributors of poor health outcomes in the state, to include statistics such as prevalence and mortality rate and compare state performance against national averages. Include information on health disparities related to age, race/ethnicity, and socioeconomic factors.

Summary:

Michigan is the tenth largest state in the U.S. based on population size. In 2022, Michigan’s population was estimated at 10,034,113. The population is 78.8% White, 14.1% Black or African American, 5.7% Hispanic or Latino, 3.5% Asian, 0.7% American Indian and Alaska Native and 2.8% identifying as two or more races.1 Michigan also has more than 300,000 residents who identify as Arab American, with the majority living in the metro Detroit area.2,3 As of 2022, approximately 1.9 million (19%) Michiganders were 65 years of age or older and as of June 2023, over 2.1 million Michiganders were enrolled in Medicare, of which nearly 1.25 million were in Medicare Advantage.1,4 Michigan’s older adult population is expected to grow quickly over the next five years. By 2030, the U.S Census projects that Michigan will have 2.7 million residents who are age 60 and older.2 Given Michigan’s large and growing older adult population, the state is heavily focused on the delivery of age-friendly care. Trinity Health headquartered in Michigan was one of the five Institute for

Appendix 1

Healthcare Improvement (IHI) Age-Friendly Health System pioneers and in 2019, Michigan was designated an AARP Age-Friendly state.5,6 Despite this focus, access to care for older adults is a critical public health challenge in Michigan. The growth of the older adult population has led to strains on the state’s community-based long-term services and supports. According to Michigan Department of Health and Human Services’ 2021-2023 State Plan on Aging, existing resources cannot meet the current demand for services which results in long wait times for care. One reason is a critical shortage of direct care workers, in part due to low wages.2 To address this issue, the State Plan includes a goal to increase the number of well-trained, qualified, and supportive multicultural direct care workers by elevating the workforce, improving retention, and supporting opportunities to increase wages.2 In addition to resource constraints, challenges to accessing quality services include poor coordination and alignment in the provision of care and supports, and a lack of access to reliable and affordable transportation.

Transportation is a common issue identified by older adults generally as well as amongst older adults living in rural areas, such as in Maine and Michigan.7 Nearly two million Michigan residents live in rural areas of the state, which account for almost 94% of the state’s land mass, including most of the northern Lower Peninsula and all of the Upper Peninsula.8 The table below outlines the leading causes of death in Michigan overall and the Medicare population specifically, as compared to the nation. The leading causes of death in Michigan are largely aligned with those seen across the U.S with heart disease and cancer as the most common causes of mortality for both the state overall (all ages combined) and those age 65 and older.

Top 10 Leading Causes of Death – 2018-20219

injuries) Accidents (unintentional injuries)

COVID-19

Diseases Chronic Lower Respiratory Diseases

injuries)

nephrotic syndrome, and nephrosis) Kidney Disease (nephritis, nephrotic syndrome, and nephrosis) Kidney Disease (nephritis, nephrotic syndrome, and nephrosis)

Prevention & Chronic Disease Management Hypertension Heart disease is the leading cause of death for Michigan residents overall and for the Medicare population. In 2020, more than 20,000 Michigan residents 65 and older died of heart disease.9 Residents identifying as non-Hispanic Black have the highest heart disease mortality rate followed by those identifying as non-Hispanic American Indian/Alaska Native, non-Hispanic White, Hispanic/Latinx, and non-Hispanic Asian/Pacific Islander.10 In line with mortality data, heart disease is also more prevalent among Michigan residents identifying as non-Hispanic American Indian and Alaska Native (16.7%) or non-Hispanic Black (10.9) than those identifying as other races or ethnicities.11 Although the rates of heart disease and stroke are decreasing in Michigan, their decline has lagged behind national trends.

Over the past 10 years, age-adjusted heart disease mortality rates per 100,000 residents decreased by 5% in Michigan compared to 10% nationally. During that same time-period, age-adjusted stroke mortality rates decreased by only 1% in Michigan compared to 5% nationally.10 Hypertension is a key contributor to heart disease. Based on BRFSS data from 2017-2019, 53.7% of Michigan residents with heart disease also reported having high blood pressure, making it the most common comorbidity. Based on 2019 Michigan BRFSS data, in line with national data, Michigan adults 65 and older (those of Medicare age) have the highest rates of hypertension; approximately 58% of Michigan adults between 65-74 and over 60% of adults 75 and older reported being told by a health care provider that they had hypertension.12 Prevalence of hypertension is highest amongst Michigan residents identifying as non-Hispanic Black (74.5%) and Hispanic/Latinx (74%), also in line with national statistics. 13 In addition to disparities based on age, race, and ethnicity, hypertension is more prevalent in certain Michigan counties than others. According to CDC data from 2018-2020, hypertension was more prevalent in northeastern counties and in the Upper Peninsula than in the southern parts of the state, which suggests areas for targeted improvement efforts.14 Patient Safety Adverse Drug Events The potential for harm from adverse drug events (ADEs) (e.g., adverse drug reactions, medication errors, overdoses) constitutes a critical patient safety and public health challenge, especially amongst the Medicare population. According to the Centers for Disease Control and Prevention (CDC), adults ages 65 years or older are three times as likely as younger people to come to emergency departments for adverse drug events (over 177,000 emergency visits each year). Older adults are also seven times more likely to be hospitalized after an emergency visit, and these hospitalizations are often linked to a small number of drugs known to require careful monitoring to prevent problems. These include blood thinners (e.g. warfarin), diabetes medications (e.g. insulin), seizure medications (e.g. phenytoin), and heart medications (e.g. digoxin)).15,16 The proportion of ADEs associated with these few medication types indicates an opportunity for targeted improvement efforts.

Emergency departments are just one of many settings in which ADEs can occur. In inpatient settings, data indicates that ADEs are among the largest contributors to hospital-related complications. Research shows that ADEs comprise approximately one-third of hospital adverse events and affect nearly 2 million hospital stays annually.17 In ambulatory settings, studies suggest that ADEs account for over 3.5 million physician office visits and approximately 125,000 hospital admissions annually.17 ADEs are also common in Skilled Nursing Facilities (SNF) and Long-Term Care (LTC) facilities. In 2014, the Office of Inspector

General (OIG) reported that one in three Medicare beneficiaries were harmed by an adverse event or temporary harm event within the first 35 days of their SNF stay, and that nearly 60% of those events were preventable.18 Of the adverse events identified in the OIG report, 37% were related to medication. Data also suggests that transitions of care from one setting to another (e.g., hospital to nursing home) may increase the likelihood of ADEs as information may not be adequately transferred across health care providers or patients may not fully understand how to manage their medications.17 Polypharmacy is one common cause of adverse drug events in older adults. According to the U.S. Department of Health and Human Services’ National Action Plan, a 2006 study found that of approximately 58% of adults 65 years of age or older reported taking five to nine medications and approximately 18% reported taking 10 or more over the course of that year.17 A 2023 study looking at claims data, found the prevalence of polypharmacy in Michigan Medicare beneficiaries to be 40.7%.18 While managing multiple medications is complicated at any age, older adults are particularly vulnerable to adverse drug events. One reason is altered pharmacokinetics, changes that may increase the risk of drug-drug interactions, adverse drug reactions over time, and medication-related hospitalizations. Other reasons include cognitive impairment, declining functional status, and greater fall risk.17,19

Polypharmacy can occur due to both patient and provider/system related factors. Patient-related factors include the need for complex medication regimens (i.e., to manage multiple chronic or mental health conditions) that are managed by multiple specialists, lack of a designated primary provider and residing in long-term facilities.17,20 System-related factors include improper medication reconciliation, automatic medication refills, and poor transitions of care. Understanding the factors leading to polypharmacy helps identify opportunities to reduce the number of medications a patient is taking and, where polypharmacy cannot be avoided (i.e., due to patient’s clinical needs), to implement best practices to improve care coordination reducing the likelihood of ADEs.17,20

Misuse of antipsychotic medications is another common concern related to adverse drug events. In 2011, an OIG report raised quality and safety concerns about the high use of antipsychotics in nursing home residents. Since 2011, Michigan has reduced the prevalence of antipsychotic use in its long-term care facilities. Amongst long-stay residents, Michigan decreased its prevalence from 16.4% in 2011 down to 12.9% by 2018, making Michigan 14th that year in CMS National Partnership to Improve Dementia in Nursing Homes (the National Partnership) rankings.21 Michigan continues to perform better than the national average on use of antipsychotic medication among both short and long stay residents.

According to current CMS Care Compare data, the Michigan average for the percentage of antipsychotic medication use in long stay residents was 13.8% compared to 14.5% nationally, and the Michigan average for percentage of short-stay residents who received antipsychotic medication for the first time was 1.4% compared to 1.7% nationally.22

Safety Events While infection prevention and control receive significant attention, other safety events such as pressure injuries, falls, and venous thromboembolism (VTE) are also serious health issues that occur daily within healthcare facilitates. The Leapfrog Group's 2023 report on hospital safety grades put Michigan at 24th place nationally for preventing harm and medical errors in hospitals. Out of 49 states, this makes Michigan’s overall hospital performance average, indicating room for improvement. Twenty- seven (35%) of the 82 hospitals that submitted data received a “C” grade for safety and four (Detroit Receiving Hospital, Sinai-Grace Hospital, McLaren Flint, and McLaren Oakland) received a “D” grade.

Safety problems, including pressure injuries, patient falls, and other harmful events were common contributions to the low rating of the four poorest performing hospitals and those hospitals scoring a “C” grade.23 A review of the CMS Care Compare hospital data available for 98 of Michigan’s general acute care hospitals indicates that more than half of Michigan’s hospitals have an overall rating of three stars or below.24 Of the hospitals who received a “C” grade for safety by The Leapfrog Group in 2023, nine were rated by CMS as below (two stars) or much below (one star) the national average for overall quality. In addition to the four hospitals receiving a “D” grade, the QIO will focus improvement efforts on these nine hospitals as well.

Table 1: Hospitals with a 2023 Leapfrog Group “C” Rating & CMS Overall Star Rating of Below or Much Below Average

Hospital Name

Beaumont Hospital, Wayne

Beaumont Hospital, Taylor

Bronson Battle Creek

Dickinson Hospital – Iron Mountain

Harper University Hospital

Henry Ford Macomb Hospital

Hillsdale Hospital

Hurley Medical Center

McLaren Bay Region

According to CMS Care Compare data, there are approximately 300 nursing homes in Michigan. Of these nursing facilities, 254 rank at or above the national average in overall care quality. However, 174 rank below average or much below average, indicating a need for improvement in several areas of care, including safety events.24 Looking specifically at quality measures, 39 nursing homes in Michigan were rated below or much below average for quality. Overall, Michigan outperforms the national average for the percentage of long-stay residents experiencing one or more falls with major injury (2.9% compared to 3.4% nationally). Michigan nursing homes perform, on average, in line with national trends for the percent of long-stay residents with a urinary tract infection (2.3% compared to 2.3% nationally) and the percentage of long-stay residents who have or had a catheter inserted and left in their bladder (1.6% compared to 1.7% nationally). However, Michigan nursing homes perform below average for the percentage of long-stay high risk residents with pressure ulcers (8.7% compared to 8.1% nationally), highlighting an area for focused improvement.24 B. Quality Initiative Scan Instruction: Identify key federal, state, local and private sector initiatives in the state (efforts in education, technical assistance, QI projects, other related initiatives) related to the 13 sub-aims and 2 foundational aims. Describe any gaps or opportunities for improvement.

Hypertension Initiatives A review of Michigan hypertension prevention and management activities indicates Michigan is heavily engaged in this space. The Michigan Department of Health and Human Services partners with the American Heart Association of Michigan to participate in the National Million Hearts® initiative and the

Heart Disease and Stroke Prevention Unit within MDHHS has established the Healthy Hearts for Michigan initiative that, amongst other things, focuses on addressing health disparities through interventions for populations disproportionately affected by cardiovascular risk factors and outcomes, including minorities and rural residents. The state also receives CDC funding to improve care for patients with high blood pressure such as through increasing medication adherence and engagement in self- management. In addition to state-led initiatives, community-based organizations such as the YMCA and leading health systems like Michigan Medicine have also prioritized evidence-based interventions to improve hypertension management. To avoid duplication of efforts, the QIO proposes to complement existing hypertension prevention and management interventions, particularly those activities undertaken by the Healthy Hearts for Michigan initiative focused on addressing disparities.

Communities of focus were determined by:

1. Identifying counties with the highest prevalence of hypertension (highest categories – between 38.3-58.7% – based on CDC assessment of hypertension prevalence amongst adults 18+, 2018- 2020).

2. Assessing which of those counties also have the highest number of individuals 65 and older (likely to be Medicare beneficiaries).

3. Of those counties with the highest prevalence of hypertension, selecting ten counties (bold below) based on population age and ensuring inclusion of all four regions so that lower populated areas such as the Upper Peninsula are not excluded.

Counties with highest prevalence of hypertension25

(for purposes of MI QIO work)

· reduce and prevent heart attacks and strokes among Michigan adults through promotion of the use of team- based care, health information technology and the utilization of community health workers.

· promote effective community and clinical strategies to increase the use of electronic health records, data, community health workers, and team-based care.

Michigan's Million Hearts® initiative stakeholders work on a variety of strategies within their communities, organizations, and roles to promote heart health.

· Increase reporting, monitoring, and tracking of clinical data for improved identification, management, and treatment of patients with high blood pressure and high blood cholesterol.

· Increase the use of - and adherence to - evidence-based guidelines and policies related to team-based care for patients with high blood pressure and high blood cholesterol.

· Increase community-clinical links that support systematic referrals, self-management, and lifestyle change for patients with high blood pressure and high blood cholesterol.

· Increase medication adherence among patients with high blood pressure and high blood cholesterol.

· Increase engagement in self-management among patients with high blood pressure and high blood cholesterol.

· Increase participation in evidence-based lifestyle interventions among patients with high blood pressure and high blood cholesterol.

· Addressing health disparities through interventions for populations disproportionately affected by cardiovascular risk factors and outcomes, including minorities and rural residents.

· Establishing emergency room workflows for identification and coordination of care of patients with hypertension through innovative partnership with Wayne State University.

· Building systems for near real-time surveillance of hypertension and blood cholesterol to intervene and offer resources to improve care coordination.

· Facilitates linkages to the Healthy Heart Ambassador Blood Pressure Self-Monitoring Program

With the support of the Michigan Department of Health and Human Services (MDHHS) Heart Disease and Stroke Prevention Program, the State Alliance of the YMCA is working with the YMCA of Greater Flint, the Dow Bay Area Family YMCA, and the Cadillac Area YMCA to pilot a virtual Blood Pressure Self-Monitoring (BPSM) class. The class is a group-based pilot program that spins off the YMCA’s BPSM program and DPP programs.

Program Information:

· At the core of the program are pharmacists embedded in 14 primary care clinics, who work together with physicians to help patients manage high blood pressure. Patients who need extra help are referred to a clinic pharmacist, and they meet with them just like they meet with their primary care physician.

· The program also partners with a large retailer in Michigan, Meijer, to expand access. Patients can visit a specially trained pharmacist at one of three Meijer pharmacies, to avoid a longer trip to their PCP. Those selected pharmacists have access to the patient’s medical records and can document important updates to those charts. In this way the primary care physician and pharmacists are always in sync with the treatment plan.

National Kidney Foundation of Michigan and Michigan State

University. The workshop is open to adults interested in managing their chronic diseases as well as their families or caregivers.

Michigan also offers “Tomando Control de su Salud” for adults who have one or more chronic conditions. It is provided in Spanish and uses culturally appropriate activities and topics.

interventions serve as ‘vehicles’ to drive this work forward and promote equity in opportunity.

Goals related to chronic disease include:

· Increase collaboration and engagement across multisectoral partners to address the burden of chronic disease, including hypertension.

· Integrate a Health in All Policies approach to chronic disease prevention programs.

· Develop an implementation ready SDOH Accelerator Plan to reduce chronic disease social drivers.

· The BMC2 Cardiovascular Consortium is a collaborative consortium of health care providers dedicated to improving quality of care and outcomes for cardiovascular patients across the State of Michigan.

· The Michigan value collaborative is partnership between Michigan hospitals, physician organizations, and Blue Cross Blue Shield of Michigan/Blue Care Network to understand variation in healthcare use, identify best practices, and lead interventions for improving care before, during, and after hospitalization.

Adverse Drug Events Initiatives Michigan has implemented several initiatives to reduce opioid prescribing and misuse, which is a common drug class linked to adverse drug events. Data also show that Michigan, in part through its participation in the CMS National Partnership to Improve Dementia in Nursing Homes (the National Partnership), reduced the prevalence of antipsychotic use and is outperforming compared to national averages. Although nursing homes in Michigan and nationally have reduced their use of antipsychotic medications over the past 10 years, a 2022 OIG report found that during that timeframe the use of anticonvulsants, another category of psychotropic drug, increased.27 This presents an opportunity for the QIO to collaborate with Michigan stakeholders currently engaged in the National Partnership to redirect their focus to anticonvulsants.

Another gap identified related to preventing adverse drug events, is the lack of a comprehensive statewide initiative around polypharmacy, which is a significant safety issue for older adults. The Michigan Health Improvement Alliance (MiHIA) has begun to tackle this issue by establishing a framework for addressing overprescribing, identifying opportunities for de-prescribing, and raising awareness of medication-induced toxicities and nutrient deficiencies. The QIO proposes to collaborate with the MiHIA, utilizing our broad network of stakeholders across the state to implement the framework, share lessons learned and incorporate innovative practices to reduce polypharmacy, where possible. The QIO will also focus on supporting safer care transitions for those requiring complex medication regimens to reduce the incidence of adverse drug events.

toxicities and nutrient deficiencies.

Michigan Medicine – Utilizes a care team model to reduce polypharmacy risks.

antipsychotic medications.

Michigan Center for Rural Health Northern Michigan Opioid Response Consortium Northern Michigan Opioid Response Consortium (NMORC) brings together 50 partners to address the opioid epidemic across a 25- county region in northern Lower Michigan. Partners include healthcare facilities (hospitals, hospital affiliated clinics, Rural Health Clinics, and Federally Qualified Health Centers), Community Mental Health agencies, Local Public Health agencies, prevention and harm reduction organizations, counseling centers, treatment centers, recovery community resources, law enforcement, and EMS.

NMORC utilizes targeted resources to implement core activities through the Rural Communities Opioid Response Program (RCORP) Grant Funding opportunity awarded by the Health Resources & Services Administration.

information on how to safely dispose of unwanted household medications, including drug takeback locations. Routinely disposing of medications can help prevent accidental poisonings, addiction, and overdoses.

The aim of the antimicrobial use initiative is to formally measure and improve the appropriate use of antibiotics including selection of the right antibiotic for the right clinical condition for the right duration. HMS seeks to decrease antibiotic-related complications and decrease antimicrobial resistance on a population health basis.

The MOC was designed to address these gaps in addiction treatment for both providers and patients. An interdisciplinary team of addiction physician specialists and Behavioral Health Consultants (BHCs) came together to support providers all throughout Michigan, provide referrals to services that address barriers to treatment engagement, and provide diverse educational trainings with the goal of increasing access to MOUD.

Regionally located, masters-level Behavioral Health Consultants work in tandem with the physician team to triage consultations, provide support to all Michigan counties, and identify and respond to community needs in a tailored way.

of reducing opioid overdose deaths by 50 percent in five years.

To address the opioid epidemic, the MDHHS and the Opioids Task developed a seven-pillar statewide opioid strategic plan covering prevention, treatment, harm reduction, criminal justice-involved populations, pregnant and parenting women populations, data, and equity initiatives.

Safety Events Assessment of Michigan’s performance on and activities addressing various safety events indicates that falls is an area of focus at both the community and facility-level. All Michigan Area Agencies on Aging have “Matter of Balance” programs and many Michigan YMCAs offer the “Moving for Better Balance” program, both evidence-based interventions for older adults. Review of CMS nursing home data showed that Michigan long-term care facilities are performing above the national average, with fewer long-stay residents experiencing one or more falls with major injury.

While the assessment identifies areas of strength, it also highlights opportunities for improvement. Pressure injuries represent a critical safety issue, particularly for older adults, and an area for improvement for several Michigan nursing homes and hospitals. Pressure injuries can prolong hospital stays, complicate recovery, and may be complicated by pain and infection. In addition, pressure injuries are a marker of poor overall prognosis and may contribute to premature mortality. Given this, the QIO will focus on creating a statewide intervention to increase compliance with best practices to reduce the occurrence of pressure injuries in hospitals and nursing homes.

Description: Michigan State University’s IMPART (Integrated Model for Personal Assistant Research and Training Alliance) project aims to build and strengthen the direct care worker (DCW) workforce through implementation of a new integrated model that will address multiple components of workforce development in a more efficient, systematic, coordinated, and cost-effective way.

The IMPART research project is funded via the Michigan Health Endowment Fund.

UPHCS continues to develop a regional integrated health information system network, the Upper Peninsula Health Information Exchange (UPHIE). UPHIE strives to connect the U.P. hospitals, health systems, clinics, specialists, long-term care facilities, and independent providers. This system provides a cost-effective mechanism to share patient information and streamline patient care delivery.

the quality of health and healthcare through innovation, effectiveness, and efficiency in designing and implementing initiatives that are person-centered and integrated across the continuum of care and services.

In 2018, the MHA Keystone Center partnered with Vlasic & Roth LLC, a firm that analyzes hospital data and provides methodologies and evidence-based interventions to drive high-impact, measurable and sustainable performance improvement. As part of the partnership, an “Implementation Science: Healthcare Performance Improvement” Certification Course is available to all in the healthcare community.

To address the needs of the rapidly growing older population, the MHA Keystone Center launched its first Age-Friendly Health Systems Action Community in October 2019.

Through participation in the VTE initiative, member hospitals have successfully increased rates of VTE risk assessment, pharmacologic prophylaxis in patients at risk of developing a VTE, and mechanical prophylaxis in patients with contraindications to prophylaxis.

Balance” programs that are offered at senior centers and other community-based locations, supported by a health endowment fund grant. “Matter of Balance” is an evidence-based program designed to reduce the fear of falling and improve activity levels among community-dwelling older adults. Since 2015, more than 5,000 older adults in Michigan have completed this program, and benefit from an increased sense of control and fewer restrictions in their lives.

modified especially for falls prevention.

C. Partner Scan Comment by Monteiro, Anita (CMS/CCSQ): I updated this from Stakeholder to Partner. Please scan doc and change all instances of stakeholder to just "partner". Comment by Illies, Shane (CMS/CCSQ): done Instruction: Identify key partners and partners in the existing initiatives related to the 13 sub-aims and 2 foundational aims.

Hypertension Prevention & Management Partners Key Partners

Partners Associated with Highlighted Key Initiatives

· Michigan Department of Health & Human Services (including the Stroke Prevention Unit)

· American Heart Association of Michigan

· Altarum Institute (, contracted through the Healthy Hearts program to offer primary care practices a dedicated practice advisor and resources to help cardiovascular disease patients)

· Wayne State University (WSU)

· University of Michigan - Michigan Medicine

· Michigan State University Extension (PATH)

· Chronic Kidney Foundation of Michigan (PATH – offers for HBP not just CKD)

· State Alliance of the YMCA

Additional Partners Groups to Engage:

Providers

· Health Systems in the identified counties & regions (e.g., UP Health System, Munson Healthcare – Ostego Memorial, Aspirus Ontonagon Hospital, MyMichigan Medical Center Alpena, McLaren Thumb Region, Harbor Beach Community Hospital)

· Primary Care Providers/FQHCs in identified counties (e.g., Health Delivery Thumb Area Health Center, Upper Great Lakes Hancock Family Health Center, Houghton Lake Health Services, MidMichigan Medical Office – Beaverton, Ice Lake Family Health Center).

Associations/Advocacy Organizations

· Michigan Primary Care Association

· Michigan Health and Hospital Association (MHA)

· LeadingAge Michigan (Nursing Homes)

· Health Care Association of Michigan (Nursing Homes)

· Michigan Assistive Living Association

· Michigan Association of Senior Centers

· Michigan Association of RSVP Directors

· Area Agencies on Aging Association of Michigan

· American Association of Retired Persons (AARP) Michigan

· Michigan State Medical Society Community Organizations & Other Associations

· Academic Partners (i.e., Michigan State University IMPART (Integrated Model for Personal Assistant Research and Training) Alliance

· State-level organizations (i.e., Michigan Public Health Institute)

· Michigan Center for Clinical Systems Improvement (Mi-CCSI) (a non-profit member organization and quality improvement consortium that partners to better care. MI-CCSI convenes payers, health systems and other health and healthcare partners to measurably improve the healthcare system.)

Payors:

· Blue Cross Blue Shield of Michigan

Adverse Drug Events Partners Key Partners

Partners Associated with Highlighted Key Initiatives:

· Michigan Department of Health and Human Services

· Michigan Hospital Medicine Safety Consortium

· Michigan Health Improvement Alliance (MiHIA)

· Michigan Center for Rural Health

· CMS National Partnership to Improve Dementia Care in Nursing Homes (Superior Health Alliance and Current participants)

· Michigan Medicine

Additional Partners Groups to Engage:

Providers

· Hospitals/Health Systems: Michigan Medicine, Sparrow Health System, Trinity Health, Beaumont Health/Spectrum Health (Corewell Health), Henry Ford Health, McLaren Health Care, Ascension Michigan, Detroit Medical Center, Bronson Healthcare Group, OSF St. Francis Hospital & Medical Group, Schoolcraft Memorial Hospital

· Nursing Homes (Including the largest with >800 beds across facilities: Trinity Continuing Care Services, Medilodge Group, Bortz Health Care, HCR Manor Care Inc., Sava Senior Care, and Advantage Management Group)

· Primary Care Providers Provider Associations

· Michigan Primary Care Association

· Michigan Health and Hospital Association (MHA), a Patient Safety Organization (PSO)

· LeadingAge Michigan (Nursing Homes)

· Health Care Association of Michigan (Nursing Homes)

· Michigan Assistive Living Association

· Michigan Association of Senior Centers

· AARP

· Michigan Pharmacists Association

· Michigan Society of Pharmacy Technicians

· Michigan Society of Community Pharmacists

· Michigan Society of Health-System Pharmacists Community Organizations & Other Associations

· Michigan Area Agency on Aging

· State-level organizations (e.g., Michigan Public Health Institute)

· Michigan Center for Clinical Systems Improvement (Mi-CCSI) (a non-profit member organization and quality improvement consortium that partners to better care. MI-CCSI convenes payers, health systems and other health and healthcare partners to measurably improve the healthcare system.)

Safety Events Partners Key Partners

Partners Associated w/Current Key Initiatives:

· Michigan State University IMPART (Integrated Model for Personal Assistant Research and Training) Alliance

· Michigan Department of Health & Human Services - Aging and Adult Services Agency (AASA)

· MHA Keystone Center (PSO)

· Area Agencies on Aging

· State Alliance of the YMCA

· Upper Peninsula Health Care Solutions

Additional Partners Groups to Engage:

Providers

· Hospitals/Health Systems: Focus on the 9 identified in the assessment (e.g., Detroit Receiving Hospital, Sinai-Grace Hospital, McLaren Flint, McLaren Oakland)

· Long Term Care Facilities: Focus on the 39 identified in the assessment (e.g., Adira Nursing and Rehab, Arbor Manor Care, Iron River Care Center, Life Care Center of Plainwell, Kith Haven) Associations

· Michigan Primary Care Association

· Michigan Health and Hospital Association (MHA)

· LeadingAge Michigan (Nursing Homes)

· Health Care Association of Michigan (Nursing Homes)

· Michigan Assistive Living Association

· Michigan Association of Senior Centers

· AARP

Community Organizations & Other Associations

· Academic Partners: University of Michigan and Wayne State University

· State-level organizations (e.g., Michigan Public Health Institute)

· Michigan Center for Clinical Systems Improvement (Mi-CCSI) (a non-profit member organization and quality improvement consortium that partners to better care. MI-CCSI convenes payers, health systems and other health and healthcare partners to measurably improve the healthcare system.)

QIO Role (3Cs) Instruction: Summarize, using the 3C’s (Complement, Coordinate, Create), the actions the QIO will take to support each of the 13 sub-aims and 2 foundational aims. (Note: This sample outlines a proposed approach for the three selected sub-aims as an exemplar).

Hypertension Prevention & Management – Complement Hypertension Prevention & Management – Complement

Role (“C”) & Scope: The QIO proposes to complement existing statewide hypertension prevention and management initiatives by focusing on specific regions and counties with high prevalence of hypertension and a high number of Medicare aged residents (identified in the Quality Scan).

Specifically, the QIO will:

· Establish 4 regional collaboratives based the on assessment (MidMichigan, Northeast, Thumb and Upper Peninsula) to share lessons learned and best practices in engaging Medicare beneficiaries in hypertension prevention and management interventions.

· Partner with providers and community organizations in the identified counties to offer:

· Coaching to help enhance shared decision making and patient engagement.

· Assistance to streamline provider-to-provider electronic referrals and linkages from providers to community-based services and supports.

· Assist providers in leveraging their health information technology to improve hypertension management, such as using EMR data to identify at-risk patients and sending patient reminders.

· In partnership with MDHHS and American Heart Association of Michigan, engage not-yet- participating providers in joining the Million Hearts initiative and making hypertension control a priority.

· Support providers and community organizations in the 10 identified counties with on-the- ground support and technical assistance in implementing best practices identified in the Million Hearts Hypertension Control Change Package.

· Support provider tracking of process and outcome measures, promote regular review of progress, and assist in modifying an intervention if a given strategy is not eliciting results in a particular organization or population.

· Increase the number of providers trained in the CDC Hypertension Management curriculum.

· Collaborate with providers and community members in the identified counties to assess engagement in MI PATH (Michigan’s chronic disease self-management program), beneficiary preference for in-person or zoom courses, and the need for expanded in person offerings. Engage with the identified communities to increase beneficiary participation and improve accessibility (frequency and type of course offerings) as appropriate.

Rationale for Proposed Scope: Michigan in actively engaged in hypertension prevention and management initiatives. To avoid duplication of efforts, the QIO proposes to complement existing interventions by focusing specifically on Medicare residents in communities with the highest rates of hypertension. Within the identified counties, the QIO will collaborate with partners to engage Medicare beneficiaries in existing hypertension prevention and management interventions and/or collaborate with local partners to bolster the availability of evidence-based practices and services (e.g., self-management, self-measured blood pressure monitoring, and lifestyle change programs) in their area.

Key Partners:

State-level: MDHHS and American Heart Association of Michigan (Million Hearts co-leads) Providers:

· Health systems in the 10 identified counties (e.g., UP Health System which has 3 hospitals serving the identified counties in the Upper Peninsula; Munson Healthcare – Ostego Memorial Hospital; Aspirus Ontonagon Hospital; MyMichigan Medical Center Alpena, McLaren Thumb Region, Harbor Beach Community Hospital)

· Primary Care Providers/FQHCs in identified counties (e.g., Health Delivery Thumb Area Health Center, Upper Great Lakes Hancock Family Health Center, Houghton Lake Health Services, MidMichigan Medical Office – Beaverton, Ice Lake Family Health Center).

Adverse Drug Events – Coordinate Adverse Drug Events – Coordinate

Role (“C”) & Scope: The QIO will coordinate with the Michigan Health Improvement Alliance, MDHHS, providers, pharmacists, hospitals, nursing homes, and current Michigan partners engaged in the CMS National Partnership to enhance efforts to prevent adverse drug events. Specifically, the QIO will:

· Focus on drug classes known to cause ADEs in the Medicare population: anticoagulants, diabetes medications, and opioids. In line with the 2022 OIG report, the QIO and its partners will also focus on the use of anticonvulsants.

· Enroll ambulatory providers, hospitals, and nursing homes in the statewide polypharmacy initiative with a focus on CMS identified providers.

· Support the use of data to identify nursing homes or nursing home characteristics that are associated with a higher use of psychotropic drugs (i.e., ratios of RNs to residents) and focus oversight on facilities in which trends may signal inappropriate use.

· Support implementation of evidence-based screening tools to identify and assess the safety of polypharmacy in older adults, such as the NO TEARS tool, Beers Criteria or STOPP (Screening Tool of Older Persons' Potentially Inappropriate Prescriptions).

· Assist in improvements to workflows supporting routine medication review to identify and resolve medication errors, optimize therapy, and identify opportunities for de-prescribing.

· Assist in the use of technology (EMR) tools to identify patients on-high risk medications and prompt a standardized set of reconciliation actions at a standardized frequency in line with monitoring guidelines. Encourage use of trigger tools, such as the Nursing Home Drug Event trigger tool.

· Support training of providers on MATCH (Medications at Transitions and Clinical Handoffs) strategies to reduce the risk of adverse drug events in hospital settings.

· Assist providers in developing and using a single medication list shared by all disciplines for documenting the patient’s current medications.

· Standardize the process for when medication reconciliation occurs throughout a patient’s stay and build EHR prompts to support adherence to the process (e.g., reconciliation step presented to physician during admission order entry).

· Develop workflows that support capture of non-prescription medications, as use in combination with prescription medications can pose a serious risk for drug-drug interactions.

· Assist in building (or strengthening) collaborations across participants serving the same community to establish (or enhance) processes that ensure medication reconciliation at all transitions of care from one setting to another.

· Promote workflows that include education of patients and their families or caregivers on medication reconciliation and the important role they play in the process and involve patients in shared decision making.

· Increase the number of CMS-identified providers implementing the Age-Friendly Health System framework, which includes as a key element use of medications that do not interfere with the goals and outcomes of older adults, mobility, or mentation across settings of care.