# Presentation: 016403

## Quality Improvement Approaches in Community and Primary Care SettingsThe American Heart Association’s interactions and collaborations in the setting

**Cortney Nicolato **
**Senior Manager, Strategic Alliances & Health IT**
**CDC HDSP Meeting**
**September 19****th****, 2007**

## About the AHA

**Committed to reducing CVD/stroke risk and death by 25% by 2010**
**By building healthier lives, free of cardiovascular disease and stroke**
**22.5 million supporters**
**29,000 multidisciplinary professional members**
**8 Affiliates serving the nation**
**National Center in Dallas, TX**
**3600 employees nationwide**
**$650 million raised last fiscal year**

## Markets We Serve

**General Public**
**Donors**
**Public Officials**
**Researchers/Scientists**
- Healthcare **(Patients, Providers, Channels/Partners/ Influencers)**
**Increase adherence to guidelines for primary prevention, secondary prevention, acute event and rehabilitation **
**Help physicians/patients make good decisions based on our science**
**“****Raise the bar” on quality of care**
**Interested in systems change that will trigger behavior change**

## Pay for Quality

**Promote health care that is safe, effective, patient centered, timely, efficient, and equitable. **
**Use rigorous methodological approaches to measure quality of care. **
**Promote quality-of-care systems and quality infrastructure. **
**Implement evaluation mechanisms. **

**Notes:**
Payment-for-quality programs should be designed, implemented, and evaluated to ensure that financial incentives are aligned with the delivery of high-quality care that is in the best interests of all patients. Quality-of-care measures should be updated in a timely manner. Programs should be reevaluated periodically and be responsive to changes in evidence-based research, including consensus-based treatment guidelines. Payment-for-quality programs should be coordinated with the demands of the marketplace to provide incentives that are aligned with the cost of providing improved care for the maximum number of patients.  
Quality-of-care measures should be risk adjusted, standardized, and evidence based. Rigorous methods should be used to measure quality, and these methods should include defining data standards and providing for consistency of measures. Quality measures should be based on clinical data to the greatest extent possible. If administrative data are used, then quality measures should be validated against higher-quality clinically derived data. Use of the highest-quality methodological approaches will minimize the likelihood of misrepresentation of quality. The alignment of incentives with these measures should be transparent. The AHA is committed to the science of quality improvement, including evidence-based clinical practice guidelines,3–6 data standards,7,8 performance measures,9,10 and methodological standards for developing all of these.11–14  
Financial incentives should be aligned to support systems-focused healthcare delivery. Programs should encourage the coordination of care across specialties, providers, and facilities. Incentives for implementation and maintenance of health information technology should be explored, so that at a minimum physicians and hospitals can comply with reporting requirements. At the same time, payment-for-quality programs should address the burden of documentation on the healthcare delivery system and base levels of increased compensation on the costs of the development and operation of new systems. Payment-for-quality programs should balance incentives for developing infrastructure and data collection against incentives for developing and maintaining quality-of-care measures.  
Payment-for-quality programs should include evaluation mechanisms that determine whether program goals are achieved or whether inadvertent adverse consequences result. Monitoring of the program is needed to build an evidence base for payment-for-quality program outcomes. Evaluation is also necessary to ensure that payment-for-quality programs do not increase disparities (eg, racial/ethnic, socioeconomic, regional) in health care and do not have unintended consequences either at the patient (eg, impact on populations such as older persons with multiple comorbidities) or provider (eg, administrative burden placed on physicians and hospitals) level.  

## National P4P practices

**Pay for Performance is alive and well**
**Over 100 varieties of P4P programs currently implemented nationwide**
**Focus’**
**Health IT**
**Quality Measures**
**Recognition of national quality and evidence-based programs, like AHA/NCQA’s Heart Stroke Recognition Program**
**Bridges to Excellence**

## AHA’s interaction with Health Plans

**AHA works with the majority of the 1300 health plans nationwide through a variety of channels**
**Pay for Performance**
**Get With The Guidelines****	**
**AHA/NCQA Heart Stroke Recognition Program**
**National Registry for CPR**
**Key Message collaboration**
**Cause Initiatives**
**Go Red For Women**
**Power To End Stroke**
**Start!**
**Alliance for a Healthier Generation**
**Patient Education**
**Disease Management**
**Health Information Technology**
**Sponsorship**

## AHA/NCQA Heart Stroke Recognition Program

**Created in partnership with the NCQA**
**Launched July 30, 2003**
**Voluntary; report only physicians who earn Recognition **
**Use nationally recognized reliable, valid measures**
**Approximately 1100 ****physicians and **
**groups engaged and growing**

## Quality Counts

**Physicians **– Gain recognition for quality, financial rewards, growth in patient panel
**Consumers/patients** – Need and want more information on doctors
**Employers **– Want to realize quality’s positive impact through decreasing costs
**Health Plans**– Use the programs for quality incentives, information for members and their own proof of quality

## HSRP Measures & Performance Standards

- 	      **   **_**Required % of**_
**	**_**Measure:**_**	****                                ****	****         **_**Patient Sample**_
**Blood pressure control <140/90 mm Hg****	****75%**
**Complete lipid panel****	****	****	****	****80%**
**LDL control <100 mg/dl****	****	****	****50%**
**Use of aspirin or another antithrombotic****	****80%**
**Smoking status and cessation advice****	****	****80%**
**	****and treatment**
**Measures apply to Ischemic Vascular Disease:  CAD (AMI, Stable Angina, Percutaneous Coronary Intervention, CABG); Peripheral Arterial Disease; and Cerebrovascular Disease (Ischemia, Stroke, and Atheroembolism)**

## HSRP Performance Evaluation

- Performance evaluated based on 35 self-abstracted medical records per individual physician
- 25 patients/physician for groups of 2 to 8 physicians
- Alternate methodology required for groups of 9 or more physicians
- Data from an electronic medical record, registry or administrative system acceptable

## Who may apply?

- Individual physicians or physician groups
- To be eligible, applicants must:
- have current license: doctor of medicine (MD) or doctor of osteopathy (DO)
- provide continuing care to patients with ischemic vascular disease (IVD) for at least 12 months
- have had face-to-face contact with and submit data on a sample of patients with IVD

## Application Features

- Web-based platform
- secure access to all program materials
- easy to use patient data collection sheet in Excel format
- Confidential readiness evaluation to determine performance
- Determine performance prior to submission

## Steps to Recognition

**Review program information**
**Purchase the Survey Tool**
**Review Survey Tool and download Excel workbook**
**Pick a “start date” and identify eligible patients for sample**
**Abstract medical record data**
**Enter data into the Excel workbook**
**Submit completed materials to NCQA**

## Physicians who achieve recognition

**Receive:**
**letter of recognition**
**posting to the Recognized Physician Directory**
**comparative data**
**certificate of recognition**
**media kit/marketing and advertising guidelines**

## Measurement leads to improvement

**Physicians Achieving Diabetes Physician Recognition **
**Show Substantial Improvement In Key Clinical Measures**
**    **

## How Health Plans are promoting HSRP

**Recognized Physicians Highlighted**

## How Health Plans are supporting HSRP

**Supports practices with data collection**
**Blue Care Network (MI)**
**BTE (KY, MA, OH, NY)**
**Oxford (NY)**
**United (4 areas)**
**Support practices with reimbursement**
**Anthem (VA)**
**Blue Care Network (MI)**
**BTE (KY, MA, NY, OH)**
**Blue Cross Blue Shield of South Carolina/Companion Health Plan**
**Actively steers patients to recognized providers**
**Bridges to Excellence (KY, OH)**
**Oxford (NY)**
**Use recognition for network entry**
**Aetna**
**Cigna**

## Get With The Guidelines

**In-hospital continuous quality improvement process designed to improve treatment and prevent future cardiovascular and stroke events.**
**Takes advantage of a “teachable moment” at point of discharge**
**Patients discharged according to guidelines**
**Received an HHS award for innovation in healthcare**
**Total contracted hospitals now @1,800**

## Get With The Guidelines

- Components:
**Web-based Patient Management Tool (PMT)***
**Prospective/retrospective data collection and decision support**
**Benchmarking against peers/reports**
**QI consultants (field infrastructure)**
**Collaborative market-based CME workshops**
**Best practice sharing**
**AHA is impartial convener**
**Recognition from AHA for meeting goals**
***Challenges in EMR environment; need to drive guidelines, measures, etc. into tools that are in the physicians’ work flow**

## NRCPR

**The National Registry of CardioPulmonary Resuscitation (NRCPR®) is an international database of in-hospital resuscitation events sponsored by the American Heart Association and managed by Digital Innovation, Inc. **
**Initiated in 2000**
**NRCPR® is the only national registry of in-hospital resuscitation events**
**over 100,000 resuscitation events in over 430 participating hospitals in the US, Canada, Germany, Japan, and Brazil **

## QI in the PCP arena

## Aligning with PCP Professional Member Organizations

**American Board of Internal Medicine (ABIM)**
**175,000 board certified physicians**
**AHA is supporting ABIM’s cardiovascular and stroke related Practice Improvement Modules (PIMs)**
**Integration of AHA programs, products and services to ease physicians in their action planning.**
**First collaboration is in progress **
**Hypertension module**
**Supporting Quality Improvement in collaboration with AAFP, AANP, etc.**

## QI in the community

## Mission: Lifeline

**National initiative to improve quality of care and outcomes in heart attack patients by improving the health care system readiness and response to ST-elevated myocardial infarction (STEMI) patients. **
** **

## Mission: Lifeline

**Addresses the following components:**
**EMS system assessment and improvement**
**Establishment of local STEMI systems of care task forces**
**Evaluation of existing STEMI models by a national expert panel**
**Development of a national certification program**

## Health IT

**AHA is actively working in and supporting the Health IT arena**
**Personal Health Records**
**Working with major players to increase presence **
**Encouraging Americans to access and maintain a personal health record**
**Consumer Empowerment**
**Co-Chair of AHIC Consumer Empowerment Committee**
**Board of Directors of eHealth Initiative**

## Health IT

**Ambulatory**
**Continuity of Care Record**
**Electronic Medical Records**
**Demonstration Projects around Quality Improvement through patient lifeline and or treatment cycle**
**Continuing to grow electronic communication channels with AHA initiatives (i.e. GWTG, HSRP)**
**AHA Health IT related initiatives**
**Heart Profilers**
**Go Red Health Check-up**

## Discussion Questions

**How is your state supporting quality improvement in the practice setting?**
**How is your state supporting quality improvement in collaboration with health plans and/or through programs like Bridges To Excellence?**
**What are some best practices in your state around quality improvement and pay for performance?**

## Questions?

**Thank you!**