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Community Recruitement/Engagement

quoteThe United States does not have a commonplace method by which localities can set priorities and implement improvements. Other countries authorize the County Council, Primary Care Trust, or public health offices to assess the community situation, set priorities, engage in debates among advocates, defend the interests of the vulnerable, and act responsibly in the public interest. In the US, local governments have very limited authority to control payments, services, or patterns of care. Individual state governments have some of these authorities, but they are generally too large to engineer local reform. No other authority usually exists.

Therefore, most localities in the US will need to develop voluntary coalitions to guide change in their own sites. Some can build on organizations or coalitions already in place; others will build from the beginning. Convening competing voluntary organizations is a fragile model on which to build governance.

Building a coalition requires a graceful mix of accommodating powerful entities and maintaining a welcoming attitude for smaller players and laggards. It helps for advocates to know their community very well and what issues, goals, and objectives will likely drive various entities to join. Often reputation, opportunity for growth, and personal commitments are driving forces, rather than monetary income. The leading organization needs to know the players well, offer reasons to share in the coalition, negotiate deals, and deliver. This work should be anchored in the values of the community and be respectful of external structures such as payment and law.

quoteThe CDC has developed a number of resources on coalition building and governance. These resources are primarily aimed at tobacco control, but can be easily targeted toward building communities for a common goal.

The Institute for Healthcare Improvement (IHI) has generated a list of considerations that argue for a major part of health care reform to be anchored in local action. Their reflections are listed below:

  • All the components needed to construct a health system are within a region
  • Common values are more likely to emerge
  • Solutions to problems depend upon context, and context is known most accurately locally
  • Platforms for dialogue exist or can be created
  • Other health determinants are attributes of a region

quoteHealthcareCommunities.org (HC) is a web-based knowledge management system that provides multiple means for the health care quality improvement community to share knowledge and contribute to each others’ QI work. The HC has private areas for organized quality improvement communities that are based around different clinical and operational interests. Community members use password-protected access to community-specific files, forums, calendars, listserves, and other tools and features.

The Emergency Medical Services for Children (EMSC) National Resource Center has developed a guide which focuses on coalition building as part of an EMSC project's strategic plan for growth, impact, and longevity – Reaching Out: A Guide to Effective Coalition Building. While this guide focuses on children and the EMSC project, it includes many pertinent concepts for building communities.

The foundation of successful organizing is leadership development. This includes your own core leadership, your providers, and everyone who takes part in a care transitions initiative. For more information on organizing tactics, please visit the New Organizing Institute.

Community Building Strategies

Community-building strategies typically include convening workgroups, providing data and assisting in intervention measurement. Most initiatives hold large community-wide meetings within the first nine months of the project to drive awareness of the effort, share community-level readmission data, bring experts and intervention designers to speak with participants, provide networking opportunities, and issue a call to action.

A key role of the leader in every community is to facilitate interdependent improvement efforts and build reliable interfaces among project participants. Every participant counts. Community-building activities have generally incorporated one or more of 4 basic techniques, including provider pairs, setting-specific groups, vertical clusters, or steering committees.

Provider Pairs

In some communities, it may be best to partner providers based on direct referral patterns. Assisting provider pairs as a series of separate projects and facilitating sharing of best practices to spread successful innovations can be effective. Rather than convening a large group of providers together, this approach is more focused and directed to the relationship between a sender and receiver, most often a hospital and a nursing home, although this pairing could include a variety of care settings. This pairing often functions with informal leadership or a consensus-based structure.

provider pairs

Setting-Specific Groups

In other communities, the providers may be more effectively grouped by setting type. This entails convening like providers and then working toward vertical integration of efforts. This approach allows for more focused implementation of interventions that are specific to a certain setting. For example, the INTERACT intervention (see Interventions for more information) is targeted specifically to implementation within a nursing home or skilled nursing facility setting. The QIO or largest provider will often serve as a facilitator in this model.

setting-specific groups

Vertical Clusters

Convening vertical clusters of highly interdependent providers first (hospital—skilled facility—home health groups), then working towards merging clusters into a greater community can be effective. This approach allows for multiple projects to occur simultaneously within one community. The vertical clusters are largely based on referral patterns and include providers from various settings (e.g. hospital, three nursing homes, two home health agencies, one hospice facility, etc.). The QIO or hospital will often serve as a facilitator in this model.

Cross Setting Flyer: GAWord Document
This one-page document outlines information for providers about cross-setting groups, including ‘what’, ‘who’, ‘why’, and ‘how’ to get involved in care transitions efforts in the community.

vertical clusters

Steering Committee

Many successful projects are driven by a high-level community-directed steering committee that facilitates deployment of community-targeted priorities and makes final decisions regarding activities and priorities. The QIO and hospital(s) deliberately take the role of participants rather than a controlling element. The Steering Committee structure should be determined by its members, which should be inclusive of all provider setting types and stakeholder or partner groups. The committee should be representative of various staff levels, including leadership and direct care workers. Additionally, it may be helpful to engage partner organizations, physicians, staff, and consumers as part of your Steering Committee structure. From there, your Steering Committee may choose to designate specific action-oriented workgroups to further the effort. These workgroups might focus on areas such as patient activation, communication, measurement, etc.

steering committee

Community Meetings

To be effective, a community needs to be well organized, represented, and have open channels for communication. Additionally, it is helpful to have a formalized structure as noted in the Strategies section. The coalition or community should have diverse membership with clearly delineated roles and responsibilities. The community should also keep sustainability in mind when developing plans and implementing interventions for improvement.

quoteThe National Transitions of Care Coalition (NTOCC) has identified communication as the main driver for improving transitions of care. NTOCC identifies six key elements to an effective transition of care.

  • Sender: The health care professional who is accountable for the sending of key information necessary to ensure continuity of care.
  • Receiver: The health care professional who is accountable for receiving the key information (usually at the next care setting) shared by the sender about the patient undergoing transition.
  • Key Information: Critical information (such as most up to date medical history, medical diagnosis, medication list, time of most recent pain medication or antibiotic, discharge instructions, results from tests/procedures) available in a clear, complete, and timely manner.
  • Action: Obligations and tasks the Receiver of the key information must execute in a timely manner to maintain continuity of care and services for the patient.
  • Verification: A necessary action by the Sender to ensure the key information sent has been appropriately received and acknowledged by the intended health care professional.
  • Clarification: A necessary action by the Receiver to ensure the transition information is clear and if concerns are present enables the Receiver to pose questions to the Sender, in order to proceed with appropriate patient- centered care (Tahan, 2009).

To help address intended results and measures of success, consider using the Before Action ReviewWord Document and After Action ReviewWord Document concepts. The Before and After Action Review was originally adapted from the work of the US ARMY and modified by Society for Organizational Learning.

The Before Action Review addresses the following questions:

  • What is our intended result?
  • What are our success measures?
  • What challenges will we face? (Predictions)
  • What did we learn from last time (if applicable)?
  • What do we think will make us successful this time? (Hypotheses and Experiments)

The After Action Review addresses the following questions:

  • What was our intended result?
  • What were our actual results?
  • What caused our results?
  • What is our next opportunity?
  • What should we take forward next time? (Sustains/Improves/Insights/Experiments)

quote

There are multiple ways to communicate with your community. Initially, it may be helpful to organize a community-wide event to broadly promote your upcoming project or work in transitions of care. This will serve as a forum for gaining attention, support, engagement, and commitment to action. Attendees may be meeting one another for the first time – so consider adding enough time for networking to begin building those community-based partnerships.

If a community-wide meeting is not possible, consider hosting a webinar or teleconference in order to bring potential partners together to get consistent information out into the community. This may be helpful as a follow-up to the community meeting for participants who were unable to attend.

Several QIOs and community coalitions have identified “engaging physicians” as a challenging area in their efforts to mobilize key stakeholders to support community-based efforts to improve care transitions and reduce avoidable rehospitalizations. Physicians can be critically important allies in efforts to lead, facilitate, and participate in a range of activities and practice changes that will improve transitions in care and reduce rehospitalizations.

The ICPC NCC staff along with our physician consultants recently completed the “Engaging Physicians in Improving Care Transitions and Reducing Readmissions—A Practical Guide for QIOs”.  The physician insight included in the guide will give you varied approaches when engaging physicians; this document is intended as a guide and not as a set of recommendations by the NCC.

This guide provides QIOs with some practical strategies to engage physicians.

Additionally, letters of invitation for participation have been helpful, especially for provider and stakeholder leadership (e.g., CEOs, COOs, etc.). This letter may invite various providers to attend, and also serves as an information base for executive buy-in.

Once you have convened your community, it is important to identify a structure that will aid in moving your work forward. Your coalition should identify distinct and specific goals for your work. Consider developing a vision or mission statement, objectives, core values, policy and procedure manuals, or by-laws. All members of your community should be involved in this process. Ongoing meetings and phone calls may be necessary for continued engagement.

Action Team Agenda: COWord Document
This structured meeting template includes topics such as participants, purpose, agenda and action items.

Coalition Charters & Memoranda of Agreement/Understanding (MOU/MOA)

Coalitions charters, letters of intent, participation, or memoranda of agreement (MOA) have also proven to be helpful when engaging specific health care providers. Coalition charters can be developed by the community members and signed to indicate participation and commitment.

quotePublicity/Proclamations

Local media coverage can prove valuable for communicating the progress and successes of your local efforts related to care transitions. Press releases, quotes, stories, interviews, videos, and recordings may be helpful when approaching common media outlets such as television, newspaper, and radio. Visit the ICPC NCC homepage to view media outreach related to the 9th SOW Care Transitions efforts - www.connectedforhealth.org.

When convening your community in a broad setting or annual statewide meeting, consider involving your state Governor. By submitting a request well ahead of time, some states are able to have a day or week identified through a Governor-issued proclamation related to your project. Some states may also issue letters from the Governor in support of your efforts. Check your state government’s website for more information and specific requirements.

Some communities find it helpful to award certificates of participation for all participating community members, organizations, and providers to highlight their commitment and participation in the work. This can come in the form of a framed certificate, poster, or banner.

quoteIt may also be beneficial to establish key messages, goals, and objectives so that all publicity or media have consistent content. Developing talking points or a standardized slide deck can also help when community members are presenting on the status or progress of the project in a public setting.

Widespread dissemination of information on your effort will help to drive progress, support, and interest in the work being completed. Community or statewide newsletters can be targeted to a specific audience, such as health care providers or beneficiaries. List serves can be created for participating community members to discuss challenges and opportunities arising from the work.

Establishing a community brand or identify can also help to unify the effort and bring providers and partners together. A recognizable logo, website, tagline, and mission statement will help to coalesce your efforts.

To further understand challenges and opportunities between provider settings, it can be helpful to set up site exchange visits across settings or even within specific provider types. Walking a mile in another’s shoes is a valuable exercise to understand processes within a current system’s structure and daily routines.

Data/Analytic Tools

quoteData has proven to be an engaging, motivating and necessary element of any successful intervention. Data has been used in the following ways in many initiatives to improve health care:

  • To open doors – to get providers and funders interested
  • To stimulate a movement – an easy-to-remember fact serves to sum up the need for change
  • To block trials of some changes because they did not work in another setting
  • To monitor change and set goals

In the 9th SOW, some QIOs implemented Data Use Agreements to allow data sharing between the QIO and specific healthcare provider. A Data Use Agreement (DUA) is a legally binding agreement between entities (e.g., QIO, contractor, private industry, academic institution, other Federal government agency, or state agency). Please visit the CMS website for more information on data sharing (http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/Privacy/index.html).

It is important to keep stakeholders informed about the culture and state of health care in the community. Data can serve to report problem areas as well as communicate success. While there are many common data sources available to community leaders, the messaging of the data is also essential. This section describes some common, often publicly-available data sources and displays examples and templates from others that have embarked on this work.

Common Data Sources

This list gives some data sources concerning health and health care that are commonly available to communities in the US:

Vital records – Available in every jurisdiction – usually familiar to the Department of Health epidemiologists – can be mined for combinations of age, race, diagnoses, being in hospital/ER/nursing home at the time of death (often requires cross-matching addresses for nursing homes). Vital records are collected in nearly the same way over long periods of time and have few restrictions on use (because the person is no longer living and has no privacy rights per se).

BRFSS – Behavioral Risk Factor Surveillance Survey – available in every jurisdiction – core set of questions is asked throughout the nation – local questions can be added relatively inexpensively – local public health epidemiologists are familiar with it – sampling biases are adjusted by CDC formulae so that annual reports reflect the population (raw data are much harder to work with – many biases). Asked in Spanish and English – and on cell phones – but does not capture people who are institutionalized, people who only speak other languages, people without phones, people who won’t talk on the phone, and others. Furthermore, the cell phone responders can only answer the core questions. The target of the survey is mostly risky behaviors and conditions appropriate for preventive health interventions (smoking, etc) but localities can add others around any topic of concern. The BRFSS includes a question on self-reported health – but only for the respondent. The BRFSS provides estimates for every county and state of the rate at which people rate their health as excellent, good, fair, or poor. Having fair or poor health correlates with being sick, dying sooner, being less productive, and other adverse effects. Using vital records and BRFSS self-rated health status, one can generate a measure that combines the two ideas into a useful indicator of overall health: either life expectancy in good/excellent health or years of life before age 75 in good/excellent health. One tool used for this purpose is the County Health Rankings website (www.countyhealthrankings.org).

MDS and OASIS – Every person who is a resident in a nursing home has a “minimum data set” (MDS) reported to their state and then to CMS at admission, discharge, every 90 days, and with major changes in health status. Every person whose home care is paid by Medicare and most of Medicaid has a similar data set (OASIS) collected and sent to the state and to CMS. (And many home health agencies just collect it on everyone, but analyze the data that includes other payers only internally.) Depending upon the rate of use of nursing homes and home care as after-hospital care settings, your area may have most of the people who are very sick going through nursing homes and/or home care. Since the data is collected on everyone in a standard way, one could generate a number of insights as to the experience of people who are living with major illnesses and disabilities. For example, one could estimate the rate of serious pressure ulcers, the use of restraints, the prevalence of advance care plans, and the status of family caregivers. These databases have been used mostly for regulatory and financial purposes, and not for monitoring quality, so analytic approaches would need to be developed.

Medicare claims – Medicare fee-for-service claims are a rich and well-used source of data. Getting the data requires privacy protections, a good deal of skill in working with the data, and often a substantial delay. One potential source of access to Medicare claims might be through the QIO that serves your area. At present, the QIO would face substantial delays in getting CMS permission to help you with the data, but that may change with the new emphasis on accelerating innovation. Some QIOs have substantial expertise in analyzing Medicare claims, and may have access to programs developed by others. Information on the following items can be learned through Medicare claims: Hospice program use, location at the time of death, utilization of health care over a time period, utilization of ventilators/feeding tubes/high cost treatments/multiple providers, rate of pressure ulcers, rate of CPR efforts (and outcomes), survival after specific interventions, and more. Medicare claims have mostly missed managed care and hospice (other than the fact of enrollment for a period of time), but new requirements are filling in some of the data in those settings.

Medicaid claims – Theoretically, one can do most of what can be done with Medicare with the Medicaid data, but some states may not have the data in an easily accessible and usable format and may not have analysts skilled at looking at Medicaid data. Also, many states have most of their beneficiaries in managed care and get very little data on these patients. Furthermore, eligibility for Medicaid often is intermittent. Nevertheless, dual eligible (Medicare and Medicaid) patients often have substantial Medicaid records, and many states have learned a great deal from examining outlier payments or high-cost codes. Merging Medicare and Medicaid databases might yield a powerful database for local reform.

Chronic Condition Data Warehouse – CMS compiles claims, MDS, OASIS, and a few other databases into a consolidated record for research. Local researchers under contract to a community coalition could generate proposals and get permission to use the CCW data (http://ccwdata.org/). This requires that the researcher submit a data request through the Research Data Assistance Center (ResDAC), which can be costly (http://www.resdac.org/).

RHIOs (Regional Health Information Organizations) – Some areas have cooperative health information interchanges to support better clinical care and surveillance for bioterrorism or epidemics. That activity generates a useful database that some are learning to mine for measures of quality and population health, though this sometimes requires appropriate usage agreements. If the RHIO has most people and services in the community, analyses can illuminate what is happening at a clinical level in that population. This can include all ages and conditions (except for military, veterans, incarcerated persons, and Native Americans who use separate government health care that usually does not participate in the RHIO) In areas without a functioning RHIO, one might still find that some critical elements of the care system are concentrated in one or two providers and that tapping into their data may show important indicators. For example, outpatient laboratory data may be housed by one or two companies, or virtually all patients with a particular illness or disability may use one provider.

Local utilization reporting – Many jurisdictions monitor at least ER and hospital use and sometimes certain laboratory tests in order to detect public health threats. These databases might be mined for additional useful information.

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) and other CAHPS mandated by CMS – These are surveys of patients, sometimes of all adults as in the Hospital CAHPS and sometimes only of Medicare patients who use particular service types. These data are used in the on-line reports of hospital quality (Hospital Compare at http://www.hospitalcompare.hhs.gov/hospital-search.aspx), for example, and thus are available for most hospitals. Similar data are available for nursing homes available at www.medicare.gov/NHCompare) and for home health agencies at www.medicare.gov/HHCompare.

Tumor Registries – Every cancer and brain tumor diagnosed in the country is recorded in the local, state, and national tumor registries, along with demographic information, precise diagnostic information, and initial treatment. Prevention and screening services are not included, only diagnosed cancers and brain tumors. States organize their local registries in different ways, sometimes having only hospital-based and state registries and other times having county or region-based databases as well. You can start with your hospital’s registrar who will know how the system works in your locale. Working with these data usually require either persuading the government epidemiologists to do analyses for you or working with someone who can handle privacy issues (such as an academic researcher), since these data are identifiable and affect living persons.

Census – The United States Census Bureau collects population and housing data every ten years using ZIP Code Tabulated Areas (ZCTAs). These typically correspond to ZIP Codes and can provide a wealth of demographic information at the local level, such as accessibility of transportation.

StateHealthFacts.org – Statehealthfacts.org is a project of the Henry J. Kaiser Family Foundation and is designed to provide free, up-to-date, and easy-to-use health data for all 50 states. Statehealthfacts.org provides data on more than 700 health topics and is linked to both the Kaiser Family Foundation website and Kaiser Health News.

quoteSample Analytic Reports and Templates

The following analytic reports and templates were developed by QIOs participating in the Care Transitions theme in the 9th SOW. All reports were developed for QIOs using Medicare fee-for-service data. These reference materials may be of assistance when developing your community strategy and resources. For additional information, please contact the ICPC NCC (CO-ICPCTechnical@coqio.sdps.org or CO-ICPCData@coqio.sdps.org) or the individual QIO as the developer of the resource. Data displayed in the following reports is “dummy” data and does not reflect actual information or trends for any of the communities in the 9th SOW Care Transitions Theme.

Community Reports

Hospital Specific

Setting Specific

  • Nursing Home Discharge Status: FLExcel Workbook
    These data tables depict discharge status from nursing home to other provider settings. Also includes data on <30 day stays.
  • Nursing Home Monitoring Report: GAWord Document
    This simple data monitoring template is designed for the nursing home to collect specific hospital readmission rates.
  • Skilled Nursing Facility Readmission Summary: TXExcel Workbook
    The skilled nursing facility readmission summary includes data tables and a run chart that compares a specific skilled nursing facility to the other skilled nursing facilities in the care transitions target community.
  • Home Health Readmission Summary: TX Excel Workbook
    This home health agency readmission summary includes data tables and run charts that compares a specific HHA to the other HHAs in the target community. This summary also includes a bar chart with all target community agencies (de-identified) readmission rates.
  • Inpatient Rehabilitation Facility Readmission Summary: TX Excel Workbook
    This inpatient rehabilitation facility readmission summary includes data tables and run charts than compares a specific rehab facility to other facilities in the target community. This template also breaks down 30-readmission rates in detail.
  • SNF/Home Health Readmission Profile: NYExcel Workbook
    This skilled nursing facility/home health readmission profile is detailed and includes LOS, number of days between discharge and readmission, reason for readmission and other information helpful to care transition providers.

Social Network Analysis/ Maps/ Overlap

Social network analysis (SNA) is an evidence-based method for mapping connections, and the quality of those connections, between key participants in a complex interdependent system. It can be used to detect missing but important links that could be intentionally established, and to highlight adverse professional relationships that could be remediated to improve the care delivered to a shared population.

It is often used to assess a network of entities, be they individuals or organizations. SNA allows us to examine specific relationships as well as characteristics of the network as a whole. The basic elements of a network consist of nodes and the connections between them, also known as ties. Ties can be unidirectional or bidirectional depending on the relationship between the two nodes. Ties are represented by arrows with the arrow heads indicating directionality.

The typical social network analysis uses data about trust and interchange among people. It is also possible to use the transfer of patients between providers as the indicator of the relationship. The following diagram depicts a social network analysis using Medicare claims data. It portrays the interdependent relationships involved in hospital readmissions within a single community of health care providers. In this diagram, the red lines represent the bidirectional relationships, whereas the blue lines represent unidirectional relationships. This diagram can be used to target relationships that would most benefit from an intervention.

Social Network Analysis of Readmissions within a Community

Interactive Maps

Maps, metrics and improvement tools designed to primarily serve the needs of local area stakeholder champions are important in community improvement initiatives. Communities attempting to develop rational improvement plans would benefit more from being able to see the extent and location of ac-tual problem occurrence in the population served without reference to any one accountable provider. Such a strategy would eliminate the need to disprove the adequacy of adjustment methods, allow flexibility in assessing local strengths and weaknesses, encourage cooperation among community members who could frame their own communities, issues and initiatives, create simpler methods of tracking improvement, and allow variation to be a source of learning instead of evaluation.

An example of such a map is displayed below. It combines unadjusted Medicare utilization and demographic data by ZIP code. From the data displayed in this map, local users could test hunches and select activities to serve micro-populations with the greatest evidence of need for informing and tracking improvement activities directed at a location-defined population.

The ideal map would be interactive with online access and user capability to manipulate layers of data according to specific interests. A good example of such a map was developed by Netflix to show user movie preferences in metropolitan areas (http://www.nytimes.com/interactive/2010/01/10/nyregion/20100110-netflix-map.html). While the Netflix map is not health care related, it represents an example of how visual data can excite and engage users to explore data at the ZIP code level. This map inevitably provides entertainment for users as hypotheses are generated for why a certain movie is popular in one ZIP Code as compared to a neighboring ZIP Code. Imagine the dialogue if health care data were portrayed in this way?

Colorado Health Care Village website/map

Overlap

There are various ways to segment regions when developing the boundaries of a community. For example, geopolitical boundaries are widely used (e.g., the United States Postal Service uses ZIP code defined areas). The Dartmouth Atlas of Health Care (http://www.dartmouthatlas.org/) uses localization to segment hospital regions. Localization is a patient origin measure that assigns regions to providers using simple patient plurality (majority). Patient origin approaches take into consideration both the residence of the patient and information regarding the provider of interest when constructing impact regions. To create hospital service areas using localization, one can count the number of patients within each ZIP Code that are assigned to each hospital, and the hospital with the greatest number of patients assigned ‘wins’ the ZIP Code. The list of ZIP Codes winning the hospital becomes the hospital’s service area.

Analysts at the Colorado Foundation for Medical Care developed a third approach called overlap. Overlap is essentially localization with a twist—after calculating service areas based on subregional plurality, by which a hospital “wins” the subregion by superlative representation, an extra step is taken to determine if the degree of “winning” is enough to warrant its inclusion into an area where the hospital could be described as influential. This is important for initiatives designed to improve the health or utilization profile of a geographically described population. For example, a hospital may wish to know where its population of greatest impact is located, and not a description of the total area where it has any degree of influence. It is the difference between the area where it has some influence compared to the area where it could be reasonably accountable for population measures.

Calculating the overlap of a community may be important because groups working in highly overlapped communities are able to target more interventions to beneficiaries who reside in the community; therefore, population-based (community) rates are more likely to improve.

The following Venn diagram describes the different patient sets. Overlap is the proportion of beneficiaries who live in a place and also seek their medical care at the hospitals located in that place, depicted by the middle darker blue portion of the Venn diagram.

Venn diagram - patient sets and overlap

People, Place, Provider: Solving the PuzzlePowerPoint Presentation
This power point presentation clearly defines how care transitions communities are formed based on zip codes and the relevance of “overlap”.

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