scholarly journals Understanding What Influences Community-Based Care Coordination Improvement: Interpreting Variation in a Medicare Hospital Readmissions Reduction Program Using the Consolidated Framework for Implementation Research (CFIR)

2020 ◽  
Author(s):  
Jane Brock ◽  
Brianna Gass ◽  
Alaina Brothersen ◽  
Lacey McFall ◽  
Kati Walsh ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Care Coordination ◽  
Hospital Readmissions ◽  
Successful Implementation ◽  
Readmission Rates ◽  
Improvement Program ◽  
Community Based ◽  
Implementation Framework ◽  
National Quality ◽  
Outer Setting

Abstract Background Quality Improvement Networks Quality Improvement Organizations (QIN-QIOs) developed community coalitions to align care coordination efforts for Medicare beneficiaries in order to reduce readmission rates within geographically defined communities. This CMS (Centers for Medicare & Medicaid Services) funded national quality improvement program worked with 380 coalitions from 2014-2019, facilitating a variety of interventions within each community. Baseline readmission rates among communities, calculated from claims data, varied from 17.7 to 112 readmissions/1000 beneficiaries. Program results ranged from +40.7% (high performance) to -35.8% (low performance) relative improvement.We applied an implementation framework (CFIR) to the QIN-QIO efforts to define common characteristics of interventions, implementation strategies, and contexts in which improvement efforts took place. We identify features associated with successful and unsuccessful intervention implementation, and with changes in readmission rates.Methods We selected 22 communities representing a range of relative improvement, geographic characteristics and baseline readmissions rates. We measured the QIN-QIO’s perception of influence of individual CFIR constructs on community readmission rates over time using a written assessment and elicited details and mechanisms through structured interviews. Two independent reviewers qualitatively coded transcribed interviews. Final ratings for the influence of each CFIR construct on community performance were assigned by consensus, ranging from -2 (strong negative influence) to +2 (strong positive influence).Results Some adaptation of the CFIR, such including codes in a coalition domain, and adding constructs to the outer setting domain, such as healthcare market characteristics, helped fit the framework to the QIN-QIO work. The characteristics of individuals domain was less applicable to this study. Several constructs were found to be associated with improvement, or lack of, in readmission rates in communities.Conclusions The CFIR is an appropriate taxonomy for understanding implementation of care coordination interventions in the QIN-QIO communities, with constructs from the Outer Setting and Process domains having the most influence on successful implementation. Communities effectively reducing readmissions had coalitions with favorable implementation climates, robust stakeholder engagement strategies, and interventions aligned with local concerns and capabilities. The CFIR can help guide, monitor and evaluate community-based improvement initiatives, although further development some constructs is needed.

scholarly journals Understanding What Influences Community-based Care Coordination Improvement: Interpreting Variation in a Medicare Hospital Readmissions Reduction Program Using the Consolidated Framework for Implementation Research (CFIR)

2020 ◽  
Author(s):  
Jane Brock ◽  
Brianna Gass ◽  
Alaina Brothersen ◽  
Lacey McFall ◽  
Kati Walsh ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Care Coordination ◽  
Hospital Readmissions ◽  
Successful Implementation ◽  
Readmission Rates ◽  
Improvement Program ◽  
Community Based ◽  
Implementation Framework ◽  
National Quality ◽  
Outer Setting

Abstract BackgroundQuality Improvement Networks Quality Improvement Organizations (QIN-QIOs) developed community coalitions to align care coordination efforts for Medicare beneficiaries in order to reduce readmission rates within geographically defined communities. This CMS (Centers for Medicare & Medicaid Services) funded national quality improvement program worked with 380 coalitions from 2014-2019, facilitating a variety of interventions within each community. Baseline readmission rates among communities, calculated from claims data, varied from 17.7 to 112 readmissions/1000 beneficiaries. Program results ranged from +40.7% (high performance) to -35.8% (low performance) relative improvement.We applied an implementation framework (CFIR) to the QIN-QIO efforts to define common characteristics of interventions, implementation strategies, and contexts in which improvement efforts took place. We identify features associated with successful and unsuccessful intervention implementation, and with changes in readmission rates.MethodsWe selected 22 communities representing a range of relative improvement, geographic characteristics and baseline readmissions rates. We measured the QIN-QIO’s perception of influence of individual CFIR constructs on community readmission rates over time using a written assessment and elicited details and mechanisms through structured interviews. Two independent reviewers qualitatively coded transcribed interviews. Final ratings for the influence of each CFIR construct on community performance were assigned by consensus, ranging from -2 (strong negative influence) to +2 (strong positive influence).Results Some adaptation of the CFIR, such including codes in a coalition domain, and adding constructs to the outer setting domain, such as healthcare market characteristics, helped fit the framework to the QIN-QIO work. The characteristics of individuals domain was less applicable to this study. Several constructs were found to be associated with improvement, or lack of, in readmission rates in communities.ConclusionsThe CFIR is an appropriate taxonomy for understanding implementation of care coordination interventions in the QIN-QIO communities, with constructs from the Outer Setting and Process domains having the most influence on successful implementation. Communities effectively reducing readmissions had coalitions with favorable implementation climates, robust stakeholder engagement strategies, and interventions aligned with local concerns and capabilities. The CFIR can help guide, monitor and evaluate community-based improvement initiatives, although further development some constructs is needed.

scholarly journals ASSESSING THE IMPACT OF A NUTRITION-FOCUSED QUALITY IMPROVEMENT PROGRAM IN CARDIOPULMONARY PATIENTS

2019 ◽  
pp. 1-7
Author(s):  
M.R. Costanzo ◽  
S. Kozmic ◽  
S. Sulo ◽  
F. Dabbous ◽  
B. Warren ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Nutrition Education ◽  
Hospital Readmissions ◽  
Univariate Analysis ◽  
Hospitalized Patients ◽  
Readmission Rates ◽  
Improvement Program ◽  
Oral Nutritional Supplements ◽  
Improvement Programs ◽  
The Impact

Background: Patients with cardiopulmonary diagnoses are at high risk for hospital readmissions and prolonged hospitalizations. Nutrition-focused quality improvement programs (QIPs) can improve the care of malnourished hospitalized patients. Objectives: Data collected previously was analyzed to evaluate the impact of a nutrition-focused QIP on health outcomes in patients with cardiopulmonary diseases. Design: The QIP consisted of malnutrition risk screening, prompt initiation of oral nutritional supplements (ONS), and nutrition education. Setting: A total of 4 hospitals implemented the QIP–2 teaching hospitals and 2 community hospitals. Participants: Eligible QIP participants were hospitalized patients with any diagnosis, 18 years of age or older, at risk for malnutrition at admission, and able to consume food and beverages orally. Measurements: Data collected from the QIP patients was compared to data from historical controls to assess differences in readmission rates and length of stay (LOS). Results: Patients were mainly older adults (66 ± 17.4 years) and non-obese (85%). Univariate analysis showed significant reductions in 30-day readmission rates for the QIP group when compared with the controls (13.9% for QIP vs. 26.4% for controls), with the QIP group experiencing a 55% reduction in the odds of being readmitted (OR = 0.45, p = 0.006). Similarly, a significant reduction in LOS was reported for the QIP group (5.4 ± 5.7 days for QIP vs. 6.8 ± 5.7 days for controls) corresponding to a relative risk reduction (RR) of 20% (RR = 0.80, p = 0.0085). Logistic regression adjusting for patient characteristics showed that the QIP patients were 33% less likely to be readmitted (p = 0.33), and had a 6% RR (RR = 0.94, p = 0.55) in LOS versus controls. Conclusions: Malnourished hospitalized cardiopulmonary patients participating in a nutrition-focused QIP experienced fewer readmissions and improved LOS compared to controls. These results underscore the importance of nutrition-focused interventions as a key part of treatment for cardiopulmonary patients.

Upper Extremity Free Flap Transfers: An Analysis of the National Surgical Quality Improvement Program Database

2020 ◽  
Author(s):  
George A. Beyer ◽  
Karan Dua ◽  
Neil V. Shah ◽  
Joseph P. Scollan ◽  
Jared M. Newman ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Upper Extremity ◽  
Free Flap ◽  
Quality Improvement Program ◽  
Readmission Rates ◽  
Improvement Program ◽  
Surgical Quality ◽  
Flap Transfer ◽  
Free Flap Transfer ◽  
Reoperation Rates

Abstract Introduction We evaluated the demographics, flap types, and 30-day complication, readmission, and reoperation rates for upper extremity free flap transfers within the National Surgical Quality Improvement Program (NSQIP) database. Materials and Methods Upper extremity free flap transfer patients in the NSQIP from 2008 to 2016 were identified. Complications, reoperations, and readmissions were queried. Chi-squared tests evaluated differences in sex, race, and insurance. The types of procedures performed, complication frequencies, reoperation rates, and readmission rates were analyzed. Results One-hundred-eleven patients were selected (mean: 36.8 years). Most common upper extremity free flaps were muscle/myocutaneous (45.9%) and other vascularized bone grafts with microanastomosis (27.9%). Thirty-day complications among all patients included superficial site infections (2.7%), intraoperative transfusions (7.2%), pneumonia (0.9%), and deep venous thrombosis (0.9%). Thirty-day reoperation and readmission rates were 4.5% and 3.6%, respectively. The mean time from discharge to readmission was 12.5 days. Conclusion Upper extremity free flap transfers could be performed with a low rate of 30-day complications, reoperations, and readmissions.

Abstract 186: Improving Identification and Assessment of Readmission Risk for Acute Myocardial Infarction and Heart Failure Patients Following Implementation of a National Quality Improvement Program

2018 ◽  
Vol 11 (suppl_1) ◽  
Author(s):  
Ty J Gluckman ◽  
Nancy M Albert ◽  
Robert L McNamara ◽  
Gregg C Fonarow ◽  
Adnan Malik ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Acute Myocardial Infarction ◽  
Quality Improvement ◽  
Improvement Program ◽  
Patient Level ◽  
Transition Care ◽  
National Quality ◽  
The Impact ◽  
Readmission Risk

Background: Optimal transition care represents an important step in mitigating the risk of early hospital readmission. For many hospitals, however, resources are not available to support transition care processes, and hospitals may not be able to identify patients in greatest need. It remains unknown whether a coordinated quality improvement campaign could help to increase a) identification of at-risk patients and b) use of a readmission risk score to identify patients needing extra services/resources. Methods: The American College of Cardiology Patient Navigator Program was designed as a 2-year (2015-2017) quality improvement campaign to assess the impact of transition-care interventions on transition care performance metrics for patients with acute myocardial infarction (AMI) and heart failure (HF) at 35 acute care hospitals. All sites were active participants in the NCDR ACTION Registry. Facilities were free to choose their transition care priorities, with at least 3 goals established at baseline. Pre-discharge identification of AMI and HF patients and assessment of their respective readmission risk were 4 of the 36 metrics tracked quarterly. Performance reports were provided regularly to the individual institutions. Sharing of best practices was actively encouraged through webinars, a listserv, and an online dashboard with display of blinded performance for all 35 hospitals. Results: At baseline, 31% (11/35) and 23% (8/35) of facilities did not have a process for prospectively identifying AMI and HF patients, respectively. At 2 years, the rate of not having processes decreased to 8% (3/35) and 3% (1/35), respectively. Among hospitals able to identify AMI and HF patients, there was high patient-level identification performance from the outset (91% for AMI and 86% for HF at baseline), with added improvement over 2 years (+2.2% for AMI and +9.3% for HF). At baseline, processes to assess readmission risk for AMI and HF patients were only completed by 26% (9/35) and 31% (11/35) of facilities, respectively. At 2 years, AMI and HF readmission risk assessment rose to 80% (28/35) and 86% (30/35), respectively. Similar improvements were noted at the patient-level, with 34% (52% --> 86%) and 16% (75% --> 91%) absolute 2-year increases in the percentage of AMI and HF patients undergoing assessment of readmission risk, respectively. Conclusions: Implementation of a quality improvement campaign focused on care transition can substantially improve prospective identification of AMI and HF patients and assessment of their readmission risk. It remains to be determined whether process improvement lead to reduction in 30-day readmission and/or improvement in other clinically important outcome measures.

scholarly journals “We understand our community”: implementation of the Healthy Eating Healthy Aging program among community-based organizations

2020 ◽  
Author(s):  
Judy Leong ◽  
Sou Hyun Jang ◽  
Sonia K Bishop ◽  
Emily V R Brown ◽  
Eun Jeong Lee ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Healthy Eating ◽  
Healthy Aging ◽  
Successful Implementation ◽  
Evidence Based ◽  
Semistructured Interview ◽  
Community Based ◽  
Community Based Organizations ◽  
Outer Setting ◽  
Inner Setting

Abstract Cardiovascular disease is the second leading cause of death in the USA among Asian Americans and Pacific Islanders (AAPIs) over the age of 65. Healthy Eating Healthy Aging (HEHA), an evidence-based heart health program, can provide culturally appropriate nutrition education to decrease the risk of cardiovascular disease. Community-based organizations (CBOs) are optimal settings to implement community-based programs. However, there is inadequate research on how evidence-based interventions like HEHA are implemented in CBOs. This study examined processes that facilitated the implementation of HEHA among CBOs serving older AAPIs. Twelve representatives from CBOs that implemented the HEHA program were recruited to participate in a semistructured interview. All the participants were CBO directors or senior managers. A semistructured interview guide was created and informed by the Consolidated Framework for Implementation Research (CFIR) to capture how HEHA played into the five domains of CFIR: (a) intervention characteristics, (b) outer setting, (c) inner setting, (d) characteristics of the individuals, and (e) process. Data analysis captured themes under the CFIR domains. All five CFIR domains emerged from the interviews. Under intervention characteristics, three constructs emerged as facilitating the implementation of HEHA: (a) the participant’s beliefs around the quality of the HEHA program and its ability to promote healthy eating, (b) HEHA’s adaptability to different AAPI subgroups, and (c) perceptions of how successfully HEHA was bundled and assembled. Under outer setting, the participants described the community’s need for healthy eating programs and how the HEHA program meets that need. Four constructs emerged under inner setting: (a) the CBO’s structural characteristics and social standing in the community; (b) resources dedicated to the implementation and ongoing operations, including funding, training, education, physical space, and time; (c) the culture of the CBO; and (d) the participant’s commitment and involvement in marketing, promotion, and implementation of HEHA. Under characteristics of individuals, participants’ described their desire to learn the content of HEHA and deliver them successfully. Under process, participants described strategies to engage relevant individuals to facilitate HEHA implementation. The interviews with CBO representatives provided insights into CFIR domain constructs that facilitated the implementation of HEHA. CBOs are key settings for community health education. Understanding processes that lead to the successful implementation of evidence-based interventions among CBOs is critical for accelerating the dissemination and implementation of best practices.

Improving the Bilirubin Management Program in the Newborn Nursery: Background, Aims, and Protocol

Neonatology ◽  
2020 ◽  
Vol 117 (3) ◽  
pp. 358-364
Author(s):  
Timothy M. Bahr ◽  
Julie H. Shakib ◽  
Carole H. Stipelman ◽  
Kensaku Kawamoto ◽  
Kelly Cail ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Hospital Readmissions ◽  
Management Program ◽  
Evidence Based ◽  
Change Analysis ◽  
Improvement Program ◽  
Improvement Project ◽  
University Of Utah ◽  
Bilirubin Encephalopathy ◽  
Intermountain Healthcare

<b><i>Background:</i></b> Practices to detect and manage hyperbilirubinemia in newborn nurseries are highly variable. American Academy of Pediatrics guidelines in 1999, 2004, and 2009 have generated, perhaps unintentionally, divergent practices that might not all be of equivalent value. Evidence-based progress is needed to define less invasive, less expensive, uniform, and safe methods to reduce ER visits and hospital readmissions for jaundice treatment and bilirubin encephalopathy. <b><i>Objectives:</i></b> This research briefing is intended to inform readers of a new prospective quality improvement program aimed at testing the value of specific changes in newborn nursery hyperbilirubinemia detection and management. This new program includes predetermined means of assessing those specific changes, which relate to diagnosis, safety, outcomes, and cost. <b><i>Methods:</i></b> In this briefing, we present the perceived problems in our present bilirubin management system, as voiced by stakeholders. We report our proposed means to test minimization of those problems utilizing already acquired data on approximately 400,000 well babies in the Intermountain Healthcare system of hospitals in the western USA. We then describe our methods of assessing specific outcomes in a pre- versus postpractice change analysis. <b><i>Results and Conclusions:</i></b> The University of Utah Newborn Nursery will implement a quality improvement project in bilirubin management during 2020 to test the feasibility and effectiveness of several changes to our current bilirubin management program. We maintain that the improved understanding generated by this project will be a step toward new evidence-based strategies for reducing ER visits and hospital readmissions for jaundice treatment and preventing bilirubin encephalopathy.

Peer review in radiotherapy (RT): A national quality improvement initiative.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 221-221 ◽  
Author(s):  
Michael Donald Brundage ◽  
Brenda H Bass ◽  
Sophie Foxcroft ◽  
Ross Halperin ◽  
Thomas McGowan ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Peer Review ◽  
Quality Indicators ◽  
Radiation Oncology ◽  
Preliminary Evidence ◽  
Steering Committee ◽  
Perceived Barriers ◽  
Quality Improvement Initiative ◽  
Implementation Framework ◽  
National Quality

221 Background: Peer review (PR) in Radiation Oncology has been shown to be effective in improving quality of treatment by detecting and correcting deficiencies in proposed treatment plans prior to treatment. PR is also effective in: guiding departmental treatment planning policies and processes; reducing variation in practice; providing a venue for multi-disciplinary communication, and increasing staff and trainee awareness of evolving treatment processes. The importance of PR is reflected in the inclusion of 3 PR-specific quality indicators in the Canadian Partnership for Quality Radiotherapy QA Guidelines for Radiation Oncology programs. Given this endorsement, we aim to enhance PR implementation across all Canadian cancer centres using a knowledge-translation and implementation framework. Methods: This project will facilitate increased uptake of PR in Canadian RT programs by implementing the top-down model used with success in Ontario. This model has several key components, including: a) engaging the leadership of provincial cancer agencies to promote PR at every Provincial cancer centre; b) providing modest financial support for the acquisition of the required hardware and/or staff time for coordinating PR activities; c) systematic collection of each centre’s baseline PR activities, perceived barriers and potential facilitators of PR at each centre; d) creation of a continuous quality improvement cycle by monitoring PR quality indicators over time; e) systematic knowledge and information sharing regarding effective PR processes. Results: Funding for this initiative was obtained from the Canadian Partnership against Cancer (CPAC) in April 2014. A steering committee consisting of stakeholders from across Canada has been struck and provincial launches, based on the tenets used in Ontario, have commenced in 7 of 13 provinces with others expressing interest. A national survey to obtain baseline data relating to PR activities, perceived barriers, and facilitators is underway and will be reported. Conclusions: Preliminary evidence suggests a “snowball effect” of increasing PR uptake across Canada. The implementation model could be applied in other jurisdictions interested in increasing PR in radiation oncology.

Abstract T MP44: Secondary Stroke Prevention Prescribing in a National Cohort

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Karen Albright ◽  
Amelia K Boehme ◽  
Virginia Howard ◽  
George Howard ◽  
Suzanne Judd ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Racial Differences ◽  
Urban Areas ◽  
Stroke Prevention ◽  
Hospital Death ◽  
Secondary Stroke Prevention ◽  
Improvement Program ◽  
National Quality ◽  
National Cohort ◽  
Improvement Programs

Background and Purpose: Secondary stroke prevention medications (SSPs) have been shown to prevent recurrent stroke, but few national reports of prescribing SSPs are available from hospitals regardless of their participation in national quality improvement programs. We examined SSP prescribing at discharge following hospitalization for adjudicated incident ischemic stroke (IS) in a large national cohort and unselected hospitals. Methods: We performed a retrospective review of incident IS admissions within the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort; admissions were to unselected hospitals. Exclusions were history of stroke, hospital death, missing data, and prevalent use of the medication of interest. Race, sex, age, rurality of residence (as defined by Rural Urban Commuting Area codes) were obtained at REGARDS baseline. Admission and discharge medications were obtained from hospital records. Associations between characteristics and discharge SSP prescriptions were examined using logistic regression adjusting for race, age, sex, and rurality. Results: From 2003-2011, of 657 IS, 429 met inclusion criteria. Mean age of participants was 73 (42% Black, 49% female, 27% non-urban). Antithrombotic therapy (antiplatelet/anticoagulant) was prescribed for 87%, statins 36% (10% 80mg), and ACE-I/ARB for 16%. We observed no statistically significant differences in prescribing antithrombotics or statins by race, sex, age, or rurality. Participants in non-urban areas had lower odds of ACE-I/ARB at discharge (OR 0.38, 0.15-0.98), with no differences by race, sex, or age. Conclusions: The majority of participants with incident IS within REGARDS were newly prescribed antithrombotics at discharge but alarmingly few were newly prescribed statins or ACE-I/ARBs. Our findings among incident SSP users differ from previous reports among prevalent users within hospitals participating in a national quality improvement program. More studies of quality of care after IS at unselected hospitals are needed.

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