Beginning first with diabetes, pediatric asthma and hypertension, AF4Q plans to build and implement a sustained effort to improve ambulatory care and avoid preventable ED and hospital use. All three conditions have high rates of prevalence in the Greater Boston area, with higher rates of incidence in minority populations. Using several tools, including performance measurement and reporting, quality improvement, payment reform and health information technology, GB AF4Q will implement a sustained effort to improve ambulatory and hospital care services around these conditions.
Goals:
1. Reduce rates of non-urgent emergency department (ED) use by understanding and addressing patient drivers and reducing system and population-based barriers to primary care;
2. Reduce preventable ED visits, hospital admissions and readmissions for patients with ambulatory care sensitive conditions;
3. Increase compliance rates with recommended treatments and measurably improve outcomes for diabetes, pediatric asthma and hypertension;
4. Improve care experiences and patient engagement in ambulatory settings;
5. Improve collection and use of standardized race, ethnicity, language and level of education (RELE) data for ambulatory care patients to reduce disparities in care and outcomes.
The Aligning Forces communities are models of health care improvement. The community organizations working on this effort have pioneered ground-breaking concepts that are also being explored through federal reform and have attracted bipartisan support, such as physician performance reports, patient-centered medical homes, and of late, payment reform.
Working with health care organizations to give clinicians the tools to identify individual care practices needing improvement, including chronic disease management, ED utilization and improved outcomes for patients. Educating stakeholders about ongoing payment reform activities in Massachusetts. GB AF4Q will develop strategies to ensure that the priorities of performance measurement and public reporting, quality improvement, consumer education and reducing disparities are part of payment reform in Massachusetts. GB AF4Q will launch a campaign to educate the public about the goals of payment reform and how it can improve the state’s health care delivery system. Spearheading statewide efforts to create a common vision and language around the role that patients and the public play in creating a patient-centered system of care. This includes the development and implementation of targeted campaigns to increase the use of patient portals and personal health records, and educating patients about using primary care resources instead of emergency departments.
