Health Care Quality for Rural America: Recommendations from the IOM Report Third Annual Western Regi

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Health Care Quality for Rural America
Recommendations from the IOM Report Third
Annual Western RegionFlex Conference

June 9, 2005
Ira Moscovice, Ph.D.
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One in a Series
http//www.nap.edu
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Key Questions

• Why should you be interested in the IOM Report?
• What can CAHs do now in response to the IOM
  Report?

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Specific Charge to Committee

• Undertake an independent, unbiased assessment
  of the condition of health and health care in
  rural America, and formulate an action plan for
  quality-focused rural community health systems.

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Addressing the Quality Challenge in a Rural
Context

• Although the evidence pertaining specifically
  to rural areas is sparse, what does exist
  corroborates the general finding that, as
  documented for the nation overall in the Quality
  Chasm report, the level of quality falls far
  short of what it should be.

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Principles Underlying the Recommendations

• Rural communities should focus greater attention
  on improving population health in addition to
  meeting personal health care needs.
• When care cannot be delivered locally, links
  should be established to services in other
  locales.
• The services available in rural communities
  should be based on the population health needs of
  the local community.

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Principles Underlying the Recommendations

• Provision of rural health services should be
  shaped and guided by local community and rural
  organizations and institutions.
• Rural health care requires a team of well-trained
  health care clinicians, managers and leaders
  working together.

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Principles Underlying the Recommendations

• Health care financing should explicitly address
  the special circumstances of rural areas.
• Efforts to develop local and national health
  information technology infrastructure should
  focus specific attention on rural communities.

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5-Part Strategy to Address Quality Challenges in
Rural Communities

• Adopt an integrated, prioritized approach to
  addressing personal and population health needs
  at the community-level.
• 2. Establish a stronger quality improvement
  support structure to assist rural health systems
  and professionals.

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5-Part Strategy

• 3. Enhance human resource capacity of rural
  communities -
• health care professionals
• rural residents
• Monitor and assure that rural health care systems
  are financially stable.
• Invest in building an information and
  communications technology (ICT) infrastructure.

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Addressing Personal and Population Health Needs
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Need to develop a new cadre of health care
leaders capable of viewing clinical care in the
broader context of population health.
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Recommendation 1

• Congress should provide resources to the DHHS to
  support comprehensive health system reform
  demonstrations in five rural communities.
• Demonstrations should evaluate alternative models
  for achieving greater integration of personal and
  population health services and innovative
  approaches to the financing and delivery of
  health services, with the goal of meeting the six
  quality improvement aims.

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Six Aims for Quality Improvement

• Safety avoid injuries
• Effectiveness evidence based care
• Patient centeredness
• Timeliness avoid harmful delays
• Efficiency avoid waste
• Equity prevent quality differences

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• Establishing a
• Quality Improvement
• Support Structure

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Recommendation 2

• Establish a Rural Quality Initiative in HHS to
  coordinate and accelerate efforts to measure and
  improve the quality of personal and population
  health care programs in rural areas.

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Rural Quality Initiative Agenda

• Apply evidence to rural practice
• Create standardized quality measures for rural
  communities
• Include rural areas in public reporting
  initiatives for fair and meaningful comparisons
• Provide rural technical assistance
• CMS should provide data repositories with
  rural-specific data and benchmarks for quality

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So what could this mean in real life?Examples
from the IOM Workshop

• Bolster the rural health professional workforce
• Create networks of Critical Access Hospitals
• Adopt Electronic Health Records that can talk to
  one another
• Create ambulatory delivery systems that pursue
  and embrace quality in every dimension

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• Strengthening
• Human Resources

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Recommendation 3

• Congress should provide resources to HRSA to
  expand experientially based workforce training
  programs in rural areas to ensure that all health
  care professionals master necessary core
  competencies.

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Core Competencies forHealth Professionals

• Provide patient-centered care
• Work in inter-disciplinary teams
• Employ evidence-based practice
• Apply quality improvement
• Utilize informatics

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The Rural Workforce Pipeline
Locate education and training programs in rural
areas and use rural relevant curricula
Prepare rural students in basic science expose
to appropriate role models
Encourage students to seek employment in rural
areas
Recruit students from rural areas
Sustain the rural workforce!
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Recommendation 4

• Health professions schools should
• Work collaboratively to establish outreach
  programs to rural areas to attract applicants.
• Locate a meaningful portion of education in rural
  communities.

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Recommendation 4 (cont.)

• Make greater effort to recruit faculty with
  experience in rural practice, and develop
  rural-relevant curricula.
• Develop rural training tracks and fellowships
  that
• 1) provide students with rotations in rural
  provider sites
• 2) emphasize primary care practice
• 3) provide cross-training in key areas of
  shortage in rural communities.

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Recommendation 4 (cont.)

• The federal government should provide financial
  incentives for residency training programs to
  provide rural tracks by linking some portion of
  graduate medical education payments under
  Medicare to achieve this goal.

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• Providing Adequate
• and Targeted
• Financial Resources

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Recommendation 5

• CMS should establish 5-year pay-for performance
  demonstration projects in five rural communities
  starting 2006.
• Selected communities should be diverse with
  respect to socio-demographic variables, as well
  as the degree and type of formal integration of
  local and regional providers.

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Recommendation 6

• AHRQ should produce a report no later than FY 06
  analyzing the aggregate impact of changes in the
  Medicare program, state Medicaid programs,
  private health plans and insurance coverage on
  the financial stability of rural health care
  providers.

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Recommendation 7

• HRSA and SAMHSA should conduct a comprehensive
  assessment of the availability and quality of
  mental health and substance abuse services in
  rural areas.
• This assessment should evaluate current funding
  adequacy and analyze alternative options for
  better aligning funding sources and programs to
  improve access and quality of mental health
  services.

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• Utilizing Information
• and Communications
• Technology

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The Building Blocks of an ICT Infrastructure

• The National Health Information Plan
• National data standards
• Electronic health records
• Patient-maintained health records
• Secure information exchange networks

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Strategy to Include Rural Communities

• Include a rural component in the National
  Coordinator for Health Information Technology
  (NCHIT) plan,
• Provide all rural communities with high-speed
  access to the Internet,
• Eliminate regulatory barriers to the use of
  telemedicine,

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Strategy (cont.)

• Provide financial assistance to rural providers
  for investments in EHRs and ICT,
• Foster ICT collaborations and demonstrations in
  rural areas
• Provide ongoing educational and technical
  assistance to rural communities to maximize the
  use of ICT.

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Recommendation 8

• The Office of the National Coordinator for Health
  Information Technology should incorporate a rural
  focus, including frontier areas, into planning
  and development activities.

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Recommendation 9

• Congress should ensure that rural communities are
  able to use the Internet for the full range of
  health-related applications. Consideration
  should be given to
• Expand and coordinate federal agency efforts to
  extend broadband networks into rural areas.
• Prohibit LATAs from imposing surcharges for the
  transfer of health messages across regions.
• Expand the USFs Rural Health Care Program to
  allow all rural providers to participate, and
  increase the subsidy amount.

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Recommendation 10

• Congress should provide direction and financial
  resources to assist rural providers in converting
  to EHRs over the next 5 years. Working
  collaboratively with the NCHIT
• IHS should develop a strategy for transitioning
  all of its provider sites from paper to e-health
  records.

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Recommendation 10 (cont.)

• HRSA should develop a strategy to transition
  CHCs, RHCs, CAHs and other rural providers from
  paper to e-health records.
• CMS and state governments should consider
  providing financial rewards to providers
  participating in Medicare and Medicaid programs
  that invest in EHRs.
• These two programs should work together to
  reexamine their benefit and payment programs to
  ensure appropriate coverage of telehealth and
  other e-health services.

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Recommendation 11

• AHRQs Health Information Technology Program
  should be expanded.
• Resources should be provided to AHRQ to sponsor
  development programs for ICT in rural areas. The
  five-year developmental programs should begin in
  2006 and establish state-of-the-art ICT
  infrastructure, accessible to all providers and
  consumers in those communities.

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Recommendation 12

• NLM, with the NCHIT and AHRQ, should establish
  regional ICT/ telehealth resource centers
  interconnected with the National Network of
  Libraries of Medicine.

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Conclusion

• Rural America can lead in testing strategies for
  improving population health and personal health
  care delivery.
• The Flex Program can serve as a foundation for
  these efforts.

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What can CAHs do now in response to the IOM
Report?

• Link QI to your mission and strategic plan
• Establish an organizational culture that actively
  supports QI
• Reorient QI strategies from patient or
  provider-centered approach to one that also
  embraces a community/population approach
• Define a relevant quality measure set for your
  hospital
• Invest in MIS that supports QI

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What can CAHs do now in response to the IOM
Report?

• Participate in public reporting initiatives
• Develop QI teams in your hospital that address
  quality and patient safety issues
• Work with your support hospital on QI activities
• Join/develop a network that facilitates QI
  activities for CAHs
• Work with your QIO, state hospital association,
  SORH, and universities on QI activities
• Apply for QI-related grants