Four years ago, the Robert Wood Johnson Foundation made a $300 million commitment to improve the quality and equity of health care nationwide. That grant funded the Aligning Forces for Quality program, which is designed to reduce racial and ethnic disparities in health status and provide models for national reform. Today, 17 communities participate in the program, each focusing on different quality and equity-of-care issues. To explore the program's results and where it's headed, Bob Kehoe, H&HN contributing editor, spoke with Robert Graham, M.D., its new national director.
How does the program engage Patients?
Individual consumers are becoming more sensitive to the fact that their decisions—or lack of decisions—have a direct impact on their health status and care. We're supporting initiatives in these communities that engage consumers more in the care process to determine their utilization of services and, most importantly, to acknowledge the role personal behavior plays in health status so that patients can make decisions that keep them healthier.
What can this program do to help keep patients healthier?
One effort in a number of communities is working toward getting adult primary care practices into the patient-centered, medical-home model. That's a model with a high degree of patient engagement in their care. It helps patients acknowledge not only that they have a chronic disease, but also what they need to do to achieve good results.
In some communities, this will take the active involvement of consumers on the boards or decision-making bodies that make resource allocations within the community. Other approaches will be to find ways to communicate information to consumers about quality or cost issues.
In most places it's hard for even motivated consumers to know a lot about their health status and the cost implications for the care they seek or have received.
What quality issues will be most important as we move to value-based purchasing and bundled payments?
If you look at the types of diseases or diagnoses that create the greatest amount of burden and disability to patients and cost to the system, it's a relatively short list: Type 2 diabetes, congestive heart failure, chronic obstructive pulmonary disease, depression, obesity. You can measure and track the state of a population's health according to those five diseases.
These communities want to know where they stand in this area of care and how they can improve it. Some communities are reporting publicly the quality of care for Type 2 diabetics and they're getting a large number of practices to share their results. That motivates the practice to do better and also makes it clear to the patients that they have an important role.
How does this program address equity of care?
Most of the communities in this program are trying to document the status of care for individuals of different socioeconomic backgrounds, race, ethnicity and primary language.
To begin with, the hospitals are asked whether they can determine their patients' race, ethnicity and language preferences. If they don't know, this is a good place to start; once they know, then they see if there are disparate outcomes. It's a little easier to identify patient makeup in a primary care practice because you tend to get to know the patients better over a longer period.
How is care being transformed at the bedside?
For those communities taking on projects relating to care at the bedside, most begin with basic patient safety. If there is a problem, they have an opportunity to look at care processes, how their team is functioning, levels of communication and then perform a root-cause analysis using a variety of tools.
Much of the attention in these communities is turning toward care transition issues. The emphasis we see now from the Centers for Medicare & Medicaid Services and other payers deals with discharged patients who are readmitted. This brings you back to the interface with the primary care community where a lot is happening around patient-centered medical homes, care coordination and care transition.
How are participants in the program improving patient communication?
In the primary care community, some participants are communicating with patients to get them more involved in their own disease management. This is a significant departure from the high-volume, low-contact model of primary care that we have today.
When you change to a medical-home model, the physician has more time to spend with selected individuals who are at particularly high risk for specific problems. The patient communication at that point is not a blanketed communication, but is targeted to what we need to do together to keep the patient healthy.
What will be the most significant outcomes of this program?
We will have learned a tremendous amount about change strategies along a broad array of quality and system transformation issues. We're going to know a lot more about how to effectively get the consumer voice in health care and how to involve consumers in different levels of the health care system. We'll also see more effective communication with the primary care physician—making medical-home transitions better and using better care coordination to link the new primary care space effectively with the inpatient space.