by Beth Blevins
In the quest for hospital quality improvement, the Michigan Center for Rural Health (MCRH) is playing a unique role, serving as a liaison between independent Critical Access Hospitals (CAHs) in the state and the state’s hospital association.
“Usually we hear of SORH (State Office of Rural Health) Flex programs subcontracting work to their local hospital association,” said Crystal Barter, MCRH Director of Performance Improvement. “This is the opposite situation—the hospital association subcontracts with our Flex program. Due to the nature of our work, we have a robust relationship with all 21 of the independent CAHs in the state—our Flex program acts as an improvement liaison for them—so it makes sense for MHA (Michigan Hospital Association) to leverage that relationship as they work to improve patient safety and quality across the entire State of Michigan.”
In September 2016, MHA’s Keystone Center was awarded a Hospital Improvement Innovation Network (HIIN) contract by the Centers for Medicare and Medicaid Services (CMS). The goals of HIIN are focused on reducing the rates of readmissions and hospital-acquired conditions (HACs) such as pressure ulcers, sepsis, and surgical site infections. Under the contract, the Keystone Center partnered with the Illinois and Wisconsin hospital associations to form the Great Lakes Partners for Patients HIIN, with the aim of reducing HACs by 20 percent and readmissions by 12 percent from a 2014 baseline.
“The Keystone Center is a national leader in quality and patient safety,” Barter said. “We’ve had a long partnership with them on a variety of initiatives, but this is the first time they’ve formally sub-contracted with us to ensure that the independent CAHs in our state have a resource outside of their entity to work on HIIN.”
The program builds on what Barter calls a “long-standing quality network” that MCRH, with Flex funding, supports for all CAHs in the state. MCRH hosts quarterly meetings, a listserv, and strategy group meetings for the quality network. “We want to make sure that HIIN work is engrained in the quality network and they don’t feel like they are two separate initiatives,” she said.
Barter continued, “When we talk about HIIN work, it’s more of a cultural change within an organization versus a specific initiative that we’re working on and then move away from. We want it to be the foundation for all of their other patient safety work as well.”
HIIN requires hospitals in the program to follow a matrix, submitting monthly data with the goal of improving their baseline. “What I do on a regular basis,” Barter said, “is monitor the data submission metrics, then work with Keystone staff to put improvement actions into the hospitals based upon the data.”
In addition, Barter meets with MHA staff regularly and they attend the quarterly network meetings. “There’s that face-to-face communication that happens quite often,” she said. “We sit down and look at the data and determine if it’s something that can be improved upon by either bringing in a consultant or learning from their peers, or we determine what an appropriate resource might be and go from there. At the end of the day it’s up to the MHA staff to give it the final say because they have the funds, but they do keep us looped in on that conversation and appreciate the insight that we can provide.”
Kristy M. Shafer-Swadley, coordinator of patient safety and quality at MHA Keystone Center, praised the strong partnership between the MHA Keystone Center and MCRH. “We continually apprise each other on any updates, needs, or initiatives,” Shafer-Swadley said. “MCRH and the MICAH Quality Network have established trust within the group of CAHs, and members feel safe to share and collectively help and support one another. Working together helps our members know we’re a unified team and they can come with questions to either of us. MCRH and MHA Keystone Center interact with CAHs in different areas at various times, therefore it’s beneficial for us to support each other in order to best support our hospitals.”
Barter said she hopes other SORHs will consider this kind of arrangement because it offers financial benefits. “Absolutely other SORHs could do this,” she said. “SORHs may be used to taking an aspect of their Flex grant and sub-contracting it to the hospital association to implement, and not vice-versa. SORHs can leverage their value and reputation among rural providers to obtain the sub-contracts themselves and get additional revenue.”
Another benefit, Barter said, is the learning opportunities this arrangement affords. “I’ve been able to learn a ton about the concepts within patient safety that before I only knew of in a broad fashion,” she said. “It’s a good opportunity for SORHs to build internal capacity as well.”
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By: Beth Blevins
The goal of Accountable Care Organizations (ACOs) is to reduce costs while improving patient care. The Michigan Center for Rural Health (MCRH) is helping two ACOs in their state do just that.
“This is all about changing from volume to value in primary care outpatient settings for Medicare fee-for-service beneficiaries,” said John Barnas, executive director of MCRH. “It’s a care coordination primary care model where primary care providers work together to reduce costs and improve the health outcome.”
After CMS released the guidance for ACO Investment Model (AIM) grants in November 2014, which provided $114 million in federal grants to help rural facilities make the transition to ACOs, MCRH went to work to promote the idea in their state. “Between November until the deadline at the end of May 2015, we did a lot of outreach,” Barnas said. “We emailed and called a lot of people and held meetings.” As a result of their advocacy, two rural ACOs were formed in January 2016, the Southern Michigan Rural ACO and the Greater Michigan Rural ACO.
Barnas is listed as the Executive Director of both ACOs. On a day-to-day basis, that means MCRH assists the ACOs in project management and is a meeting convener for them. “We coordinate all the board meetings and minutes and run ad hoc meetings,” Barnas said. “And we set up listservs for every group involved.” In addition, the ACOs can tap into all of MCRH’s resources. For example, he said, if there is a recruitment issue, they can get help from Rachel Ruddock, MCRH’s physician recruiter or, if they need distance education, they can get help from Victoria Lantzy, who runs MCRH’s webinars.
One reason for the success of their partnership with the rural ACOs, Barnas said, is that MCRH is one of only three non-profit State Offices of Rural Health. This gives them “the latitude and freedom to partner on other projects.”
Caravan Health provides backroom analytics for the ACOs by merging a patient’s electronic health record with Medicare claims-based data, a necessary requirement of being an ACO. Through those analytics, Barnas said, “They can see exactly how many times a patient in one of the ACOs has seen the physician, where they’ve seen the physician, the diagnoses, the cost, and number of co-morbidities they have. In this way, they can start identifying high-cost patients whose care they want to coordinate to drive down the costs. Without the claims, you’re just guessing.” In addition, Caravan offers quarterly training for care coordinators and provides a financial consultant that reviews each ACO’s financial data and how it’s doing on the 34 ACO quality metrics.
A year into the rural ACO program, both ACOs are seeing benefits. One of the ACOs decreased Medicare spending by 3 percent.
“There’s an increased focus on those patients who need it the most,” said Sara Wright, MCRH’s Rural Health Improvement Coordinator. “The patients who overuse the ER, or are using it in an inappropriate fashion, and the patients who have multiple co-morbidities are finally getting a care coordinator who can focus on them. We also are starting to have more conversations about what factors outside clinical care affects their health, such as their home environment.”
According to Barnas, another benefit of this ACO program is that it allows waivers for transportation, durable medical equipment, and medication. For example, a transportation waiver lets hospitals help patients get to and from appointments.
“Here’s a true story,” Barnas said. “There was a diabetic patient who continued to go to the ER three or four times a month. The care coordinator did a home visit and found out that the patient’s refrigerator continuously shut down and her medication was going bad. A waiver allowed them to buy a small dorm fridge to keep her insulin safe. So the hospital spent $79 on a refrigerator instead of hundreds of dollars on continued ER visits.”
Going forward, Barnas said, because this is a three-year demonstration project, the facilities will have to decide if they want to remain in the ACOs. “If so,” he said, “we have to find a funding mechanism to continue paying Caravan Health. We’ll start engaging them in that conversation at some point this year.”
Crystal Barter is the Director of Performance Improvement for the Michigan Center for Rural Health. She came to the Center through an AmeriCorps position a little over 6 years ago. Crystal grew up in the “Asparagus Capitol of the Nation” in Hart, MI on Lake Michigan.
Q. What is the most interesting thing you are working on right now?
We are working on three innovative projects that I am very excited about right now.
The MCRH is a partner in a Practice Transformation Network Award. As part of this three state initiative, we will be working with rural healthcare providers, including certified RHCs and rural private practices in achieving large-scale health transformation. This includes sharing, adapting and further developing comprehensive quality improvement strategies and operational efficiencies.
The MCRH is partnering with the Michigan Health & Hospital Association Keystone Group to participate in the Hospital Engagement Network 2.0. The MCRH will work with the 20 independent CAHs in Michigan as a quality improvement coordinator. The work focuses on the culture of patient safety within an organization.
The MCRH assisted in submitting two CMS ACO Investment Model applications as part of the Medicare Shared Savings Program. The ACO participants include 17 rural hospitals and 1 rural FQHC. They had their first joint meeting of rural ACOs in August and will be hosted their second one in November.
Q. What is one characteristic that you believe every SORH leader should possess?
Flexibility. Every day we are presented with new challenges and opportunities, so it’s important to be willing to change your planned course of action if it’s needed. Also, I think that building and maintaining partnerships is a vital characteristic of successful SORH leaders.
Q. What are you doing to ensure you continue to grow and develop as a SORH leader?
Saying yes to new opportunities and looking at them as learning opportunities instead of increased workload is something I strive to do. It’s important to view new challenges as a way to build skills.
Q. What is the biggest challenge facing SORH leaders today?
I think prioritizing is one of the biggest challenges. There are so many resources that SORHs can offer, and so many competing priorities that one must be able to analyze and determine what makes the most sense for their state. Also, in my position, I cannot be a subject matter expert on everything and sometimes I find it frustrating not being able to answer a very technical question. But, working with partners, I know that we will be able to find the correct answer and get back to our SORH audience.
Q. What are your top three goals for 2016?
Peer-to-peer sharing is one of the benefits of the Michigan Rural Health Clinic Quality Network (MI RHC QN), sponsored by the Michigan Center for Rural Health (MCRH). What started as a small, informal quality network with only 15 active members in June 2011 has continued to grow and gain enthusiastic members. Today, representatives from over 50 of Michigan’s 170 clinics participate in the network and attend its quarterly meetings held in Mt. Pleasant, Mich.
“When members want to talk about quality improvement initiatives in their clinics, we make sure they’re on the agenda,” said Crystal Barter, MCRH Health Systems Development Coordinator, who coordinates the network. “It doesn’t matter what initiative they choose, as long as it has made an impact in their clinic and they feel their peers would benefit from listening to it.”
The quality network is part of the MCRH’s recent effort to ramp up their work with RHCs, which also includes a focus on ICD-10 and practice management, according to John Barnas, director of the MCRH. In the past year, MCRH has been going through a process of getting clinics to collect a cohesive set of data, Barnas said. This has become increasingly important because insurance companies are giving RHCs incentive payments based on data and because of the implementation of meaningful use standards for Medicaid patients.
MCRH looked at a core group of RHCs in the quality network and compared what they were doing with various initiatives, and came up with a set of Quality Assessment Performance Improvement Measures. The measures include three core measures that network members must collect at minimum—for high blood pressure, tobacco use, and BMI (body mass index). (An Excel file of the measures is available on the RHC section of the MCRH web site).
Participation in the MI RHC QN and its quality collection is voluntary. “There’s no monetary incentive right now,” Barnas said. “These people are driven to do the right thing. We pay for their travel and buy them lunch. They like having the chance to get together. But we think eventually CMS is going to require this type of thing—to prove you’ve had some kind of impact.”
If other SORHs are interested in sponsoring a RHC quality network, Barnas suggests that they use their annual rural health conferences to convene a meeting for it. There’s a tool already out there for them to dump and track their data in real time, he said, called Quality Health Indicators (QHi).
John Barnas is the Executive Director of the Michigan Center for Rural Health (MI SORH) and is the Past President/SOC of the NOSORH Board.
You just finished writing your grants for next year. What are two or three things that your Office is doing well and that you intend to continue and/or expand next year?
The cornerstone of our SORH is distance education. We’re housed inside the Michigan State University College of Osteopathic Medicine and considered an affiliate organization. Because of this, we’re able to knock on doors and ask faculty to put together distance learning sessions. We just did a social work grand round, presented by a faculty member, which offered continuing
education credits (CEUs). That means that someone who lives near Lake Huron, 90 minutes from an urban area, can take the course at noon in the hospital’s distance learning room and get the CEUs she needs (social workers must earn 36 CEUs every three years). Last year we provided 3,500 CEU hours. The topics are relevant because we have asked the providers what they need,
and it’s a retention tool–it provides CEUs so people don’t have to move from a rural area to get better access to education. Currently, we offer CEU courses in social work, nursing, geriatrics, pharmacy, oral health, psychiatry and EMS.
Another project we started last summer is the “rural road trip,” where we grabbed 1st and 2nd year medical students, and took them to a rural area to visit the downtown, tour the hospital, tour a family practice and have lunch with the medical staff. We’re going to extend this to the Nurse Practitioner students on campus this summer. We also sponsor “breakfast with a rural doc.” A
physician comes in and meets with the students who have committed to rural, and they ask her questions like “what’s it like to run into a local patient at the grocery store?” and “what kind of patients do you see?” This is important because when you’re in an urban area, and you have a diabetic patient, you send them off to an endocrinologist. But in a rural area, you’re the endocrinologist for that patient.
Finally, we have created and run listservs. We currently have them for hospital CEOs, CAH CFOs, another for our CAH Quality Network and another for the RHC Quality Network. We plan to start a new listserv for billers and coders because we recently identified it as a need.
How do you come up with goals for your Office or identify needs?
Every January we clear the table of all responsibilities from the grants we manage and come up with a list of priority activities. Then, we look at the priority activities every two or three months at our Monday staff meetings to see if we are accomplishing what we set to do.