We're in!

CCME has worked to improve the quality of care in the Carolinas for more than 25 years. For this quality improvement program, we are participating in a Patient Safety and Clinical Pharmacy Services Collaborative (PSPC) Breakthrough Collaborative that will focus on the Medicare, Medicare Advantage, and dual-eligible populations. To serve this patient group, CCME will form community teams that will be composed of, but are not limited to, local clinical pharmacy representation. They will also include clinicians from the multiple settings utilized by CCME-targeted patient groups (i.e., hospitals, nursing homes, primary care clinics, specialty clinics, federally funded clinics, etc.).

CCME shall coordinate with the Patient Safety National Coordinating Center and the PSPC Collaborative to expand the evidence base for interventions and discuss intervention impact in an all-teach, all-learn forum. Community teams will be formed so that they are positioned to support a minimum of 100 patients.

Recruitment

The QIO beneficiaries recruited for the intervention shall meet one or more of the following criteria:

• Are high-risk patients who have five or more chronic conditions and/or who take eight or more medications on at least a weekly basis
• Are evaluated by two or more providers
• Take the anticoagulant warfarin on a regular (at least weekly and for three months or more) basis
• Take short-acting or long-acting antipsychotics of any class
• Take hypoglycemic medication for diabetes mellitus

Data Monitoring, Tracking, and Reporting

CCME will enable teams to track improvement in health status measures and safety measures in real time in the targeted patient group. The following indicators will be monitored, tracked, and reported quarterly to CMS:

• Number of ADEs
• Number of potential ADEs (prevented because of intervention)
• Number of ER visits, hospitalizations, and/or readmissions where primary or secondary reason for visit was ADE
• Number of patients on or prescribed a potentially inappropriate antipsychotic medication (PIM)

In targeted patients on warfarin, CCME will assist teams to track, monitor, and report on a quarterly basis:

• Patients who had their International Normalized Ratio (INR) drawn at least once in a given month
• Patients whose INR is in optimal (as targeted by their provider) range

In targeted diabetic patients on insulin or an oral hypoglycemic, CCME will assist teams to track, monitor, and report on a quarterly basis:

• Patients with HbA1c in control (< 9 percent)
• Patients whose HbA1c is out-of-control (≥ 9 percent)

Partnering with CCME

CCME’s team of quality improvement professionals will support the work of PSPC teams currently working to improve care or help initiate projects for teams that could benefit from additional resources and assistance.

CCME will provide the following additional benefits for participating teams:

• Root cause analysis
• Process mapping
• Retrospective medical record review
• Patient Satisfaction Survey analysis
• Supporting your work toward Patient-Centered Medical Home certification
• Publishing your success
• Access to local, state, and national content matter experts

Interested in Participation

If you are interested in participating or for more information, please contact: