Improve Population Health

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Improving Cardiac Health, Preventing Stroke and Reducing Cardiac Disparities

Heart disease and stroke are, respectively, the first- and fourth-leading causes of death in the United States for all demographic groups, according to the Centers for Disease Control and Prevention (CDC). The disproportionate impact of these diseases on racial and ethnic minorities is a key target of QIN-QIO work with Medicare beneficiaries and their families, providers, and community stakeholders.

In alignment with the HHS Million Hearts® initiative, QIN-QIOs focus on improving the ABCS of cardiac risk reduction (Aspirin when appropriate, Blood pressure control, Cholesterol management, and Smoking cessation). The Million Hearts® initiative also created a priority focus on blood pressure measurement and control. High blood pressure has long been considered a “silent killer” in that many people do not demonstrate signs and/or symptoms of the disease. As part of this national effort, the QIO Program is targeting blood pressure measurement and control as essential to preventing heart attacks and strokes and decreasing the number of Americans who die unnecessarily as a result of untreated hypertension.

Reducing Disparities in Diabetes Care

In the United States, nearly one-fourth of adults 65 years and older have diabetes, according to the CDC 2014 National Diabetes Statistics Report. Diabetes is the most common cause of blindness, kidney failure, and amputations in adults, and is a leading cause of heart disease and stroke.

The Centers for Disease Control and Prevention (CDC) reports the incidence of diagnosed diabetes is higher among American Indians/Alaska Natives, African-Americans, Hispanics, and Asian-Americans than among Caucasians. Targeting these populations and Medicare beneficiaries of any ethnicity living in rural areas, QIN-QIOsthrough the Everyone with Diabetes Counts (EDC) programhelp patients and families, and communities, address this serious chronic condition and its disproportionate effects on racial/ethnic and rural populations.

QIN-QIOs work with familiar and trusted people and organizations within communities to provide diabetes self-management education where it is convenient; for example, by holding classes at a local senior center. This community-based approach encourages participation and provides a structure to support people in their ongoing commitment to self-management. By working with health care providers, practitioners, certified diabetes educators, and community health workers, people with diabetes can acquire the knowledge and skills necessary to improve the quality of their lives, by preventing or lessening the severity of complications resulting from diabetes.

Improving Adult Immunization Rates

Influenza and pneumonia are vaccine-preventable diseases. However, according to the CDC, together they were the 8th leading cause of death in the United States in 2012, with 90 percent of influenza deaths occurring in adults 65 and older. Immunization rates among adults have historically been low, and data show a disparity in rates among racial and ethnic minorities. In addition, there is evidence that annual influenza immunization decreases morbidity and mortality in people with cardiovascular disease.

In collaboration with key partners and stakeholders, QIN-QIOs work with providers and Medicare beneficiaries to implement evidence-based practices and systems changes in the 37 states showing the greatest need for improvement. Following current Advisory Committee on Immunization Practices (ACIP) guidelines outlining the Standards for Adult Immunization Practice, QIN-QIOs are focused on improving routine assessment of patients’ vaccination status, improving immunization rates, especially in minority and underserved populations, and increasing documentation of Medicare beneficiary immunization status in immunization registries where available.

Improving Identification of Depression and Alcohol Use Disorder in Primary Care and Care Transitions for Behavioral Health Conditions

Depression and alcohol use disorder are common behavioral health conditions in the Medicare population and are frequently under-identified in primary care settings. Major depression is a leading cause of disability in the United States, complicates the treatment of other serious diseases and is associated with an increased risk of suicide. Alcohol use disorder is the most prevalent type of addictive disorder in those 65 and older and is often associated with depression. Additionally, challenges in effective care transitions for these and other behavioral health conditions contribute to high readmission rates and problems in treatment adherence.

Six regional QIN-QIOs provide technical assistance and educational interventions to help primary care providers screen for and increase the identification of people with depression or alcohol use disorder. In addition, QIN-QIOs work with inpatient psychiatric facilities to improve transitions of care and reduce readmissions for these and other patients after discharge. Assistance includes developing processes for successful transmission of discharge information to the follow-up clinician, helping Medicare beneficiaries and their family/caregivers understand medications and treatment instructions, and coordinating communication between the inpatient facility, outpatient providers and Medicare beneficiaries.