Forward Together. Partners in advancing healthcare quality and value. Report to the Community

Transcription

1 Forward Together Partners in advancing healthcare quality and value Report to the Community

2 Mission To generate, apply and disseminate knowledge to improve the quality of healthcare delivery and health outcomes. Vision To be recognized for leadership, innovation and excellence in improving the health of individuals and populations. Core Values Integrity and Professionalism Collaboration Stewardship Qualis Health Services Dear Friends, Care Management We provide a suite of care management services (also known as medical management ) to support cost-effective, patient-centered, high quality care. Utilization Management: We help our clients to be responsible stewards of healthcare resources by avoiding overuse, misuse and underuse of health services. Utilization management assures that patients receive the right care, in the right setting, at the right time. Case Management: Our case managers guide injured and ill patients as they navigate through a complex healthcare system to obtain care. Case management is a systematic approach that includes careful assessment of an ill or injured person s unique healthcare needs, individualized care planning, removal of barriers to the receipt of appropriate medical and social services and continuous monitoring to assure the best possible outcomes. Healthcare Quality, Safety and Efficiency Consulting Our consultants and multidisciplinary teams assist healthcare providers, institutions and policy makers to make positive, transformational changes to more efficient, effective healthcare delivery systems and models. Our approaches emphasize the design of lean, reliable workflow and patient-centered processes. Health Information Technology (HIT) Consulting We provide consulting services to assist providers, healthcare facilities, government agencies and others to leverage health information technology in order to improve care delivery, to support effective business operations and to comply with regulatory requirements. We help clients plan and implement technology solutions ranging from electronic health records in physician offices to statewide Medicaid Management Information Systems. As an organization committed to improving healthcare quality and value, Qualis Health has always looked forward. It has become increasingly clear that the vision guiding our work in recent years is squarely aligned with the contemporary transformation of American healthcare. Even before the passage of the Affordable Care Act in 2010, a number of Qualis Health s key strategic priorities emerged as leading themes in healthcare transformation. A few examples of these priorities and initiatives include: A major emphasis on implementing health information technology Application of cutting-edge, evidence-based strategies to improve quality, enhance patient experience and control costs for millions of Americans through our contracts with public- and private-sector clients across the nation. As organizations rethink how they deliver care, our work over the last two years is giving our clients a head start in areas that are crucial to success in America s changing healthcare environment. Recognized for excellence While our primary objective is to provide value to our clients from their own perspectives, I am particularly proud that the The next chapter No one can predict with certainty how the transformation of American healthcare will proceed as reform takes hold, but there will doubtless be significant challenges as well as enormous opportunity. At Qualis Health, we continue to look forward with our partners in order to overcome the challenges and transform opportunities into success. With gratitude to everyone we have served and with whom we have collaborated, we are proud to share some of our recent accomplishments in this report. We could not have achieved them alone. Sincerely, (HIT), including electronic efforts of our superb staff have CASE IN POINT health records (EHRs) and Medicaid Management resulted in considerable external recognition for our work since Information Systems (MMIS). our last report. We value Jonathan Sugarman, MD, MPH this independent confirmation President and CEO Groundbreaking initiatives that we are serving our Qualis Health Recognized for Delivering Results We are proud of the awards and accolades that Qualis Health has recently received for the work we do to advance healthcare quality and value on behalf of our clients and their patients and we share this recognition with our partners across the healthcare community. to support accelerated implementation of the patient-centered medical home (PCMH) model of primary care, particularly communities in partnership with clients, providers, patients and other key stakeholders. Washington State Quality Award: Leadership Level Case In Point Platinum Award: Medicaid Case Management Program in clinics that serve as a safety net. Case In Point Platinum Award: Utilization Case Management Program MarCom Award: Platinum and Gold Winner Seattle Business Magazine: 100 Best Companies to Work For

3 Transforming Safety Net Clinics into Patient-Centered Medical Homes Bringing to life a new model of comprehensive primary care Policymakers and providers are directing extraordinary attention to a new model of care: the patient-centered medical home (PCMH). It s a team approach to providing comprehensive, coordinated primary care with a focus on the whole person. In partnership with the MacColl Institute for Healthcare Innovation, Qualis Health is leading the Safety Net Medical Home Initiative (SNMHI) a five-year initiative sponsored by The Commonwealth Fund, to accelerate the transformation to the PCMH model in 65 practices serving vulnerable populations in five states. What happens when physicians, nurses, medical assistants and receptionists work collaboratively in a well-aligned, cooperative team? At Idaho s Health West clinics, higher patient satisfaction, higher staff morale and lower turnover are all a result of their transformation to the team-based PCMH model. There s a traditional hierarchy in the medical world, said Mark Horrocks, MD. The doctor is the king at the top, with the nurse below and the receptionist at the bottom. When a patient comes into this kind of setting, all responsibility for care is put on the doctor because everyone else is afraid or feels unempowered to participate. When Qualis Health showed what the PCMH team model could mean for us, it was the green light we needed to change. Within four months, the staff at Health West s Pocatello clinic restructured its approach to patient care together. With coaching from Teri Barker, Medical Home Facilitator for the Idaho Primary Care Association (IPCA),* all staff members are now working at the top of their licensure as a collaborative care team that unites around the patient. The IPCA is one of five regional coordinating centers selected by Qualis Health to provide support to a network of local clinics. If you want to offer the type of preventive care that s part of the PCMH model, you need the whole clinic to support it, Barker said. Health West s leadership provided the environment for everyone to feel comfortable as equal partners. Health West has taken its transformation beyond its three clinics participating in the SNMHI to include all six of its locations in Southeastern Idaho. Health West is a Federally Qualified Health Center dedicated to meeting the healthcare needs of its community regardless of ability to pay. *The Idaho Primary Care Association also received support from the Idaho Blue Cross Foundation for Health. The New Model for Primary Care The patient-centered medical home (PCMH) model represents the country s shared vision for the future of primary care. It reflects the goals of national healthcare reform: greater access, higher efficiency and quality care, improved patient experience and provider satisfaction and better health outcomes. Continuous and Team-Based Healing Relationships Team-based care is foundational to the PCMH model. In order to support a team-based approach, PCMHs: Establish and support care delivery teams. Link the patient to a provider and a care team so that they recognize each other as partners in care. Assure that patients are able to see their own provider or care team whenever possible. Define roles and distribute tasks among care team members to reflect their skills, abilities and credentials. Cross-train care team members to maximize flexibility and ensure patients needs are met.

4 Leveraging Health Information Technology to Improve Care Helping states implement new Medicaid Management Information Systems Qualis Health helps our clients leverage the value of health information technology (HIT) to improve quality, control costs and increase access to care. We bring a unique approach that combines technical expertise in HIT with a track record of results in operational improvement and health system planning. Adopting new HIT is a process that includes selecting, implementing and optimizing technology to meet the business and clinical goals of the organization. We focus on adding value every step of the way. Helping Small Primary Care Practices Master Electronic Health Records Electronic health records (EHRs) are so integral to improving care and costs that the federal government provides Medicare and Medicaid incentive payments when eligible providers adopt EHRs and achieve specific goals of meaningful use. The transition to EHRs can be daunting. With funding from the U.S. Department of Health and Human Services, Qualis Health is leading the Washington & Idaho Regional Extension Center (WIREC) one of 62 centers around the country helping providers to achieve meaningful use of EHRs. We bring a combination of national insight and local expertise in technical assistance and best practices to advance rapid EHR adoption and meaningful use. Everyone can see the dramatic impact of leading-edge technology in clinical settings such as operating rooms and emergency rooms. But information technology advances are just as vital to making healthcare more effective and efficient on the administrative side. For state Medicaid agencies, HIT is crucial to improving quality, increasing access and controlling costs. To that end, Qualis Health is helping these agencies in Alaska and Vermont to design and implement their new Medicaid Management Information Systems (MMIS), with the goal of receiving federal certification. Our information technology consulting division, Outlook Associates, is helping both states usher in the new generation of MMIS. In the past, MMIS were primarily financial and accounting systems for paying provider claims. Today s MMIS provide a more integrated, interoperable solution to more broadly support the Medicaid program in implementing healthcare reform initiatives. In Alaska, we provide comprehensive technical assistance to oversee MMIS implementation and certification. We also work closely with stakeholders to conduct user testing and ensure change management, which is vital to successful adoption of this new technology. In Vermont, we support the planning and procurement of the new MMIS. We provide a variety of initiatives from defining system requirements to leading vision sessions that bring together stakeholders to discuss how the new MMIS can support the Medicaid program as it implements healthcare reform. Ultimately, the value of MMIS are larger than any single state. They will enable the level of data exchange required to support the Medicaid Information Technology Architecture (MITA) a nationwide initiative to foster an integrated business and IT transformation across the Medicaid enterprise. Qualis Health will work with Medicaid agencies as they migrate to MITA, making MMIS the central information repository in supporting Medicaid with standards that improve healthcare outcomes and administrative procedures for Medicaid beneficiaries.

5 Reducing Hospital Readmissions Through Better Care Coordination Leading a patient-centered approach to care transitions Improving care transitions as Medicare beneficiaries leave the hospital is vital to better healthcare and cost control. With one in five Medicare patients back in the hospital within 30 days, unplanned re-hospitalizations cost Medicare over 17 billion annually. Through Stepping Stones: The Care Transitions Project of Whatcom County, Washington, Qualis Health is working with community partners to implement methods that enable safer, more effective transitions. Care transitions coaching is just one of the proven methods that we provide. Stepping Stones provides living proof that when care transitions are supported with strong coordination and communication, they are safer and more effective for the patient. As part of this federally funded initiative, a Qualis Health care transitions coach recently helped a Medicare- and Medicaid-enrolled patient with multiple chronic illnesses who had been hospitalized nine times in just 13 months. Our coach began by working with a concerned relative of the patient, who went from tears of helplessness at the first meeting to feeling empowered and able to support her loved one in better managing her care. Over the course of a month, our coach helped the patient and her caregiver to master the four pillars of care transition:* medication self-management, timely follow-up care, recognizing the warning signs of a worsening condition and using a personal health record. Our coach also linked the caregiver to community services for additional training and support. For seven months, the patient remained in her own home and successfully avoided any return trips to the hospital. In addition to improving her health and quality of life, the care transition coaching resulted in significant Medicare and Medicaid savings. Nine typical re-admissions cost Medicare approximately 84,000. Reducing hospital readmissions is not just a hospital problem, nor is the solution solely a hospital responsibility. By engaging a community of care that focuses on the patient, Stepping Stones is at the forefront of care transition management. The project, which runs through 2011, is an initiative of The Centers for Medicare & Medicaid Services, which contracted with Qualis Health. Local co-sponsors and partners are PeaceHealth St. Joseph Medical Center, the Northwest Regional Council and the Critical Junctures Institute. *Developed by Eric Coleman, MD from The Care Transitions Program. Physician and Community Continuity Family/Patient Self-Management Patient Hospital Discharge Better Care Transitions by Design Improved care transitions depend on solutions that implement change in three domains: family/patient self-management, hospital discharge and physician and community continuity. All are centered on the needs of the patient. The project structure of Stepping Stones embodies this focus, which unites the family and patient, physician and community and the hospital to enable safe, effective care transitions. This material was prepared by Qualis Health, the Medicare Quality Improvement Organization for Idaho and Washington, in part under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

6 Coordinating Care for Those at Highest Risk Helping patients make connections as they navigate through a complex system Healthcare reform promises to improve access to insurance for people with preexisting conditions. While insurance may improve access to care, patients with complex medical needs will continue to require assistance with care coordination as they navigate through the health system. Since 2007, we have provided catastrophic and complex chronic condition case management, as well as utilization review services, to meet the unique needs of the Washington State Health Insurance Pool (WSHIP). Our goal: to improve outcomes and add value. Improving Outcomes, Controlling Costs In addition to improving healthcare outcomes, Qualis Health case management helps the Washington State Health Insurance Pool (WSHIP) control costs. During the fiscal years, our services resulted in average net savings of 9.4 million, with an average return on investment of 7.50 for every dollar spent by WSHIP. In Washington State, our patient-centered approach to case management can change lives. Sometimes it even helps save them. In late 2008, one of our case managers a licensed independent clinical social worker with thousands of hours of clinical practice began working with a patient who was on a liver transplant waiting list due to liver failure from alcohol abuse. The patient also suffered from diabetes, chronic pain and depression. Working closely with the patient, our case manager developed a supportive, trusting relationship with her. She helped the patient begin a multi-faceted treatment plan established by her primary care physician, which drew on our partnerships with a wide community of care providers and case managers. Our case manager conducted intricate and frequent case coordination contacts. By closely adhering to the care plan, which included psychiatric treatment, chemical dependency outpatient treatment services and a women s Alcoholics Anonymous (AA) group, the patient s liver lab results began to improve. Few recoveries occur in a straight line. Our case manager helped the patient deal with a series of medical setbacks and complicated surgeries, supporting the patient s fundamental goal: to stay alive. The patient returned to AA and completed her chemical dependency program. She gradually recuperated, regained her strength and sense of humor and no longer experienced depression. This patient s long-term medical outcome has been excellent. Less than two years after starting case management, her liver lab results were so dramatically improved that she no longer requires an organ transplant. She continues to improve her general health and maintain her sobriety.

7 Serving the Public Good with Our Medicaid Partners Helping Alaska s kids and communities move forward Our Medicaid experience in many states makes Qualis Health a valued partner and collaborator in serving the interests of Medicaid enrollees and the public good. As Medicaid introduces new eligibility requirements, categories of coverage and delivery models, we are helping states ensure that significant change leads to significant improvement in healthcare quality, value and access. In our report we highlighted a bold initiative of the Alaska Department of Health and Social Services to Bring the Kids Home. Through our Medicaid Mental Health contract with the state of Alaska, we help bring home and keep home the hundreds of children being treated in out-of-state psychiatric institutions. In the process, we identify treatment options and resources statewide and control the state s cost for behavioral healthcare. In partnership with Alaska s Division of Behavioral Health, our care coordination program has facilitated the development and implementation of more effective discharge plans. This supports patients and their families in making successful transitions back to their homes in Alaska. In collaboration with out-of-state treatment facilities, we reduced the undesirable trend of sending Alaskan children for psychiatric care outside of their home state. Since contract inception, the number of children in out-of-state psychiatric residential treatment facilities has been reduced by 62%. The program s success is a testament to respecting the importance of place. Qualis Health has care coordinators who live and work in Alaska. They provide the geographic presence, knowledge of local services and cultural understanding essential to successful discharge planning and equitable care. They serve as an important bridge back home, helping to ensure that, when children do come home, they are more likely to receive care that fully meets their needs in their own communities. Keeping More Kids at Home Since Qualis Health joined the initiative in January 2008, improved discharge planning has advanced the trend that everyone wants to see: fewer children leaving their families and communities for treatment Out-of-State Admittances Dropped 85.4% 110 FY 04 FY 05 FY 06 FY 07 FY 08 FY 09

8 Qualis Health At A Glance Locations Senior Management Group Board of Directors Partial Client List Financials Anchorage, Alaska Irvine, California Boise, Idaho Lincoln, Nebraska Seattle, Washington Jonathan Sugarman, MD, MPH President and CEO Marci Weis, RN, MPH, CCM Chief Operating Officer Jennifer Freeman, CPA Chief Financial Officer Mary Sellers, CCP, CPHIMS Chief Information Officer Foster C. Bud Beall Jr., MA Vice President Consulting Services Outlook Associates Michael B. Garrett, MS, CCM Vice President Business Development Debra Naubert Vice President Human Resources Joyce Shaw Vice President Corporate Communications Timothy Frazier, MS (Chair) Hugh Straley, MD (Vice Chair) Karl B. Kurtz (Secretary/Treasurer) Steven Burgon, JD Andrew D. D. Craigie Mabel Ezeonwu, PhD, RN Hilke Faber, RN, MN Ernest H. Kimball IV, MPH Clara (Billie) Lewis, RN Margaret Stanley, MHA Lori Whittaker PhD, MD, MPH, FAAFP Alaska Department of Health and Social Services Centers for Medicare & Medicaid Services The Commonwealth Fund County of San Diego, Health & Human Services Agency Idaho Department of Health & Welfare L.A. Care Health Plan Los Angeles County Department of Mental Health Motion Picture & Television Fund Nebraska Department of Health and Human Services Office of the National Coordinator for Health Information Technology Providence Health & Services Alaska REACH Healthcare Foundation Seattle-King County Department of Public Health Vermont Agency of Human Services 25 % 20 % Revenue by Business Product 11 % Revenue by Market Segment 9 % 6 % 25 % 64 % 40 % Consolidated Revenue (in millions) Care Management Patient Safety & Quality Consulting Health Information Technology Medicaid Public Payers Medicare Commercial Foundations/Nonprofits Washington State Department of Labor & Industries Washington State Department of Social and Health Services Washington State Health Insurance Pool Washington Teamsters Welfare Trust

9 Qualis Health Corporate Headquarters PO Box Seattle, Washington (206) or (800) Fax (206)