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Better care, better population health

and lower costs through improvement.

Hawaii’s QIO: Current

and Future Initiatives

February 21, 2019

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Mountain-Pacific

• Headquartered in Montana

• CMS Quality Improvement Organization (QIO)

– Hawaii and US Territories in South Pacific

– Montana, Wyoming and Alaska

• Staff of 11 in Hawaii office

• Staff of 3 Staff in Guam

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Hawaii Office Staff

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• Mark Marabella – Director

• Maggie Okey, RN, BSN – Project Manager

• Cathy Nelson, RN – Practice Transformation Lead

• Barry Major – CPC+ Practice Facilitator

• James Roberts – Diabetes Project Manager

• Leticia Wilson, RN – Diabetes Educator

• Tina Morishima, CPC

• Carl Barton – Healthcare Transformation Consultant

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CMS Contract Work

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11th scope of work → 12th scope of work

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Addtional Contract Work

• Comprehensive Primary Care Plus (CPC+)

– Lewin Group

• QPP – SURS

– HSAG

• Center for Disease Control (CDC)

– Hawaii Department of Health – Chronic Disease

Division

– University of Hawaii – Office of Public Health Studies

• Health Resources and Services Administration (HRSA) –

Geriatric Workforce Enhancement Program

– UH - John A Burns School of Medicine

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Examples of Our Scope of Work

• MIPS education and technical assistance (D.1)

• Community Coalitions (C.3)

• Integrated Pharmacists for Comprehensive

Medication Management (1305)

• Algorithm Development for HIT platforms (1305)

• Cardiac Toolkit (B.1)

• Diabetes Education Empowerment Program

(DEEP) (B.2)

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MIPS Hawaii 2018

• Small, Underserved and Rural Practices (SURS) –

over 400 eligible

– Reached 100% eligible

– Over 80% intend to participate

• Large Practices (D.1) – 219 NPIs

– Reached 100% of eligible

– Over 90% intent to participate

• Over 100% satisfaction on Technical Assistance

• 72 sum total of webinars / presentations / blogs

and newsletters

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B.2 – Diabetes Care, DEEP

• Over 450 eligible beneficiaries have completed

• Approximately 80% in HI and 20% in Guam

• 37 Community Health Workers trained as DEEP

trainers

• Mountain-Pacific hosts the Hawaii American

Diabetes Association support group

• Physician Group Care Manger integration project

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C.3 Hawaii Coalition Communities

Currently there are six officially recruited Communities designated

specific ZIP codes

– Windward, West Oahu, Maui and Saipan, Kauai and

Honolulu

– Community Coalitions have structure, partner

commitments and established leadership

✓Signed community coalition charters

✓ Identified coalition leadership - leads/co-leads

✓Signed sharing agreements (Mountain-Pacific)

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Who Participates?

• Acute Care Facilities

• Pharmacies

• Payers

• Skilled Nursing Facilities

• Hospice

• Home Health Care

• Assisted Living

• Rehabilitation

• Ambulatory Clinics / Physician Organizations

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Coalition Goals

a. Improve care coordination and communications

b. Reduce 30-day readmissions, admissions

c. Reduce inappropriate utilization of ER

d. Improve number of days in the community –safely

in the home setting

e. Improve medication safety

f. Engage patient’s with activation, education and

self-management

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The big picture is that collaboration at the community level

makes for better care transitions.

• Collaboration provides community level solutions, bridges

care gaps, empowers providers and patients’ families and

improves self-care management

• Community-based partnerships improve communication,

enables better coordination of care

• Coalition partners work together to build community care

networks to improve health care delivery. It’s all about

impacting patient lives

Coalition Success

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Hawaii State: Averted Readmissions/Cost Savings

MPQH states estimated cost savings from avoided 30-day hospital readmissions for

Medicare FFS beneficiaries

Source: 9/13/18 NCC Progress Report

2018 Medicare FFS Hawaii State Data provided by MPQH

Comments from Community Partners:

• “Business relationships are now more personalized. We know our contacts for

transfers, discharges, provider communications and care overall has improved….

• “Having face to face meetings regularly with hospital and skilled facilities has helped

foster an ‘all for one’…. We have made progress in helping care for patient

transitions and continue to work with each other to improve our processes.

• We have the contacts and rapport…I am committed to the coalition. It’s been great

to have all of the resources in one room to communicate with each other and

hearing that everyone else has issues that impact patient care/transitions.”

Community Collaboration – Perspectives

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CPC+

• Hawaii CPC+ Practices

• Mountain-Pacific’s scope of work

• Care Delivery Requirements

• Trends and outcomes

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Future initiatives

• 11th scope of work

– Evaluations

– Data Strategy

– Admissions / Readmissions

– Adverse Drug Events

– Diabetes Education

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Future initiatives

• 12th scope of work

• Additional contracts

– Continuing CPC+ - 2019 - 2021

– Diabetes and Heart Disease

– Geriatrics

– Integrated pharmacists and comprehensive medication

management

– Blood Pressure Self-management

– Supporting effective use of HIT

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Questions?

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Healthcare

Transformation

Consultant

cbarton@mpqhf.org

(808) 440 – 6015

1360 S. Beretania Street,

Suite 501

Honolulu, HI

96814

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