In 2019, CMS issued a request for proposals to support community-based primary care and specialty care clinicians in quality improvement projects. There are 4 focus areas of these new projects:
Aim 1 • Improve behavioral health outcomes, including a focus on decreased opioid misuse.
Aim 2 • Focus on patient safety and reducing all-cause harm including medication documentation, high-risk medications, dementia safety concerns, and antibiotic stewardship.
Aim 3 • Chronic disease management and prevention (cardiac and vascular health, diabetes, and kidney disease).
Aim 4 • Improve community-based care transitions to reduce hospital admission.
In support of these efforts, KHC is part of a pending proposal.
Should KHC's proposal be accepted, these projects will be open to all Kansas medical providers, including rural health clinics, community health centers, FQHCs, and Indian health centers. Requires commitment to one or more of the aims as well as to patient and family engagement. Also requires participation in monthly data submission on select quality improvement measures.
Clinician Quality Improvement Goals
Aim 1 – Improve behavioral health outcomes, including a focus on decreased opioid misuse.
- Including Focus on Decreased Opioid Misuse
- Decrease opioid-related adverse events (including deaths) by 7%, with a focus on the Medicare population.
- Decrease opioid prescribing (for prescriptions > 90 MME daily) across outpatient facilities by 12%.
- Increase access to behavioral health services by 15.7%, including access to care for those who need mental health services but are not receiving them.
Aim 2 – Focus on patient safety and reducing all-cause harm including medication documentation, high-risk medications, dementia safety concerns, and antibiotic stewardship.
- Reduce all-cause harm in hospitals by 10%.
- Reduce readmissions by 5.4%.
- Reduce Adverse Drug Events (ADEs) in community settings serving high-risk FFS Medicare beneficiaries by 6.5%.
- Reduce the rate of ADEs by 7.8% in clinical practices.
- Reduce hospitalizations for community-onset C. diff by 6.5% based on 50% reduction of inappropriate antibiotic prescribing.
- Increase antibiotic stewardship programs in outpatient settings by 6.5%.
Aim 3 – Chronic disease management and prevention (cardiac and vascular health, diabetes, and kidney disease).
- Achieve at least 80% performance on the ABCS clinical quality measures (Aspirin as appropriate, Blood pressure control, Cholesterol management and Smoking cessation).
- Achieve at least 48.3% participation initiation rates among those eligible for cardiac rehabilitation.
- Assist practices in the adoption of electronic and clinical workflows that establish home or out-of- office BP monitoring for hypertensive patients.
- Achieve a 13.8% reduction in smoking prevalence among Medicare beneficiaries treated by targeted clinicians.
- Prevent Medicare beneficiaries from developing diabetes.
- Improve management of diabetes for Medicare beneficiaries.
- Screen, diagnose, and manage individuals with CKD to prevent progression to ESRD by identifying patients at high risk for developing kidney disease and improving outcomes for those patients.
Aim 4 – Improve community-based care transitions to reduce hospital admission.
- Improve community-based care transitions to reduce hospital admissions by 4.1% and readmissions by 5.4% nationally.
- Monitor access to care that leads to hospital utilization.
- Reduce potentially avoidable admissions, readmissions and super-utilization in Medicare Advantage beneficiaries.