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May 13, 2014

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Introducing Nine Levers to Support the Aims and Priorities [Slide 1]

Ann Gordon: Welcome to today's event featuring the National Quality Strategy. My name is Ann Gordon, and I will serve as the facilitator today.

Housekeeping [Slide 2]

Before we get started, I'd like to go over a few housekeeping items. We will be taking questions via the ReadyTalk chat box in the lower left hand corner of your console, which we will answer during the question-and-answer portion of the presentation. Note that if you logged in using the link that was sent to your email address, you can use that same link to log back in if you get disconnected, and same with the toll-free number. We do have technical assistant on the chat box to help with any technical concerns, and if the console is not working or you are having major technical issues, you can contact the ReadyTalk support line at 800-843-9166.

Please note that at the conclusion of today's Webinar, we will have a very brief survey with a few questions to get some insight on your satisfaction on today's event. Please take a few moments to complete it when it appears on your screen. Within 2 weeks, the transcript and a copy of the slides will posted on the Working for Quality Web Site, and you will be notified by email when those are available.

Agenda [Slide 3]

Our agenda for today's event includes a presentation from Nancy Wilson, Executive Lead for the National Quality Strategy. Joining her is Elizabeth Mitchell, President and CEO of the Network for Health Improvement (NRHI). Following their remarks, they'll spend some time responding to your questions and your comments. Nancy, I'd like to turn it over to you.

Nancy Wilson: Thanks, Ann.

The National Quality Strategy and Nine Levers for Program Alignment [Slide 4]

Let me add my welcome and encouragement for your active participation. For those I've not yet had the privilege of meeting, I thought I should tell you a tiny bit about my background. I've been engaged in quality improvement my entire career, both as a Psychiatric Nurse at the University of Pittsburgh and later as a general internist both at Johns Hopkins, where I trained, and a variety of other positions, such as Chief Quality Officer for the Veterans Affairs back in the 1990s and medical director for VHA, Inc. Most recently, I've been Senior Advisor to the Director of the ´óÏóÊÓƵ, and with the passage of the Affordable Care Act, I assumed the lead for ongoing development and implementation of the NQS.

Background on the National Quality Strategy [Slide 5]

I thought it would be helpful to have a bit of background for those of you who might not live and breathe this the way that I've been doing. The charge for the National Quality Strategy as laid out specifically in the legislation was to improve the delivery of health care services, patient health outcomes, and population health—just a small task, mind you. While the Secretary of HHS was given the legislative mandate, it was clear that the Strategy was to be one that all stakeholders embraced and owned across the Nation. Because of that, we've taken the position that this is an ever-improving, iterative, nationwide effort that supports a broad learning system for health and health care.

So what exactly is the Strategy? It is to concurrently pursue three aims: better care, healthy people/healthy communities, and affordable care.

The IHI Triple Aim and NQS Three Aims [Slide 6]

For those of you that have been in the quality improvement arena, this might sound like the IHI Triple Aim, and it should. My colleagues at IHI and I have worked through this and we agree the National Quality Strategy builds and elaborates on the foundational, critical work of the Triple Aim. Whether you have been focusing on the Triple Aim or the NQS three aims, we're really aligned in what we're working towards.

The National Quality Strategy: How It Works [Slide 7]

Today we're really focusing on levers. And this is a high-level slide that shows how the National Quality Strategy works. We're talking about nine levers that can drive progress on six priorities to achieve three aims.

The National Quality Strategy: How It Works [Slide 8]

First, let's think about the stakeholder types. I've already mentioned we really believe that to achieve the greatest impact, all the various players in the large health and health care community pull together. Back in the late 1970s, it seemed that providers and clinicians were really expected to guarantee high quality and value while other stakeholders passively paid for or accepted it. One of the steps forward in the past decade has really been the recognition that other stakeholders can have a positive or negative influence on quality and value. Later you'll hear from Elizabeth about efforts that have come about in building multi-stakeholder coalitions focused on health and health care. And I believe an even more recent example is the growing awareness of the need for health care people to work with public health professionals and social support services in other sectors such as education and housing if we really want to improve health as well as health care. So, there are lots of stakeholders, and there's a role for every one of them to play.

The National Quality Strategy: How It Works [Slide 9]

If we agree that collaboration and alignment of effort is a good thing, and that we're all going in the same direction, the next challenge is what to align and collaborate on. And that's where the priorities come in. These priorities were identified through a consensus-building process that tried to really focus on concerns that affect most Americans; they're cross-cutting for the most part. The priorities address patient safety, person- and family-centered care, care coordination and communication, prevention and treatment of the leading causes of morbidity and mortality, health and well-being, and affordability.

The National Quality Strategy: How It Works [Slide 10]

Next are the levers. We're going to go in-depth on each one of these, but as a whole, the levers represent actions that we feel need to happen if we're going to achieve our three aims and in the process make progress on our six priorities. When we wrote about these levers in the original 2011 National Quality Strategy report, we labeled this section of the report "Policies and Infrastructure" needed to support the priorities. So you can go back and reference that document for the original language and descriptors: it's on our Working for Quality Web site (www.ahrq.gov/workingforquality).

Regardless of what we call these things, they represent a variety of actions a broad array of stakeholders can review and identify which of the levers their core business might support. And if we all do this, we can all strongly align to the National Quality Strategy and drive quality improvement in health and health care.

The National Quality Strategy: How It Works [Slide 11]

Again, with alignment of effort on all the levers, we theoretically arrive at the three aims of better care, healthy people/healthy communities, and affordable care.

Why We're Here Today: Levers [Slide 12]

Now that we've walked through the way the levers fit into the existing Strategy framework, let's take a closer look at each one to see how they can be used to improve health and health care.

Measurement and Feedback [Slide 13]

Our first one up—and these aren't in any particular order—is Measurement and Feedback. Measurement, as we all know, has gotten a great deal of attention these past several years, but measurement for the purposes of improvement requires timely feedback on measures that matter. We have a way to go to design systems that can make that happen.

Measurement and Feedback [Slide 14]

One example of measurement and feedback is a long-term care provider that implements strategies using the Quality Assurance and Performance Improvement data to populate dashboards and identify areas of focus that require quality improvement. Another more recent example that I have had the privilege of observing is a real-time early warning system that identifies patients using risk scores and dispatches proactive response team members before an emergency call from the bedside is needed. From my perspective, that addresses patient safety. Another example is all these apps that are being developed that allow us to monitor our calories, our blood pressure, et cetera. That's all under the category of enabling healthy living, which is one of our priorities. So, again, there's a variety of ways that we can think about how measurement and particularly timely feedback can support the National Quality Strategy.

Public Reporting [Slide 15]

Our next lever is Public Reporting. Originally thought to facilitate driving consumers to better-quality providers, we've learned over time that the factors that drive choice of providers are more varied than the information currently available. Now, public reporting from my perspective is viewed more as demonstrating accountability to society at large and is not expected to drive consumer choice.

Public Reporting [Slide 16]

Of course, one example that you'll hear more about is a regional collaborative requesting its member hospitals and medical practices align the public reports to the National Quality Strategy aims and priorities. I'll move right along because Elizabeth will be discussing this much more in depth later.

Learning and Technical Assistance [Slide 17]

So the next lever is about Learning and Technical Assistance. This is our quality improvement lever. I'm sure many of you have examples of projects you've done, and to the extent those projects address one of the priorities such as care coordination and person- and family-centered care, you're already aligned with the National Quality Strategy. Trickier, of course, is to hardwire process improvement: it's one thing to do a project, but it's another to make it your regular business mode. To digress for a moment, I want to emphasize that process improvement and system design are very important for entities and organizations beyond providers. We recently did a Lean Kaizen event with CMS and the National Quality Forum to improve our HHS contracting process. I don't know why these things surprise me, but just as in my very first process improvement many years ago, one of the first discoveries we made was that there wasn't any clear process specified. It wasn't that we needed to change the process; nobody knew what the steps were and we had to fill in gaps and figure out who was supposed to do what. Anyway, I suspect some of you might have had that experience as well with some of your quality improvement projects.

Learning and Technical Assistance [Slide 18]

I do want to keep jumping beyond providers; I don't want providers to feel like you carry the brunt of this because I think there are lots of opportunities for lots of different types of stakeholders. One of the things that we can recognize is that the entire machinery of the Quality Improvement Organizations is now aligned to the National Quality Strategy.

Certification, Accreditation, and Regulation [Slide 19]

Certification, Accreditation, and Regulation—there's a lot on one slide there.

Certification, Accreditation, and Regulation [Slide 20]

For certification, it can be continuing education, maintenance of certification for physicians, JCHAO accreditation; all of these things can play a role. Actually, with regulation, CMS is driving a focus on the National Quality Strategy by aligning their measurement domains in the Physician Quality Reporting System, for example, with the National Quality Strategy priorities. Just to clear up any confusion regarding the relation between the National Quality Strategy priorities and the Centers for Medicare & Medicaid Services (CMS) domains, we consider them to be the same. The language is a little different because CMS is more focused on clinical effectiveness and efficiency, but we see ourselves as aligned.

Consumer Incentives and Benefit Designs [Slide 21]

Consumer Incentives and Benefit Design can drive progress on the priorities and ultimately the aims.

Consumer Incentives and Benefit Designs [Slide 22]

Discounts on premiums for good behavior—for example, like most of us get on our car insurance—and benefit designs include workforce wellness programs. There's lots of opportunities to think about ways that employers could support progress on the aims and not just enabling healthy living, but also working on our Million Hearts Initiative with cardiovascular disease, blood pressure, and smoking cessation.

Payment [Slide 23]

Paying for high quality and value is of course a huge lever these days. I think there's a lot of focus on this.

Payment [Slide 24]

In addition to CMS' work in value-based purchasing, which is substantial, there are private-sector initiatives that are going on as well, such as Buying Value and Catalyst for Payment Reform. They're working hard to align on the measures that are used to describe the priorities and incentivize performance on those priorities. In the private sector, one must always worry about antitrust issues, but aligning on what to pay for and having shared constructs for what constitutes care coordination, for example, is within the parameters of acceptable collaboration.

Health Information Technology [Slide 25]

We just have a couple more levers now. The next is Health Information Technology. Many people are focused on Meaningful Use, and this clearly has power to facilitate care, although it also has the power to propagate electronic errors far beyond what's propagated in the old-fashioned paper system. But I think everyone agrees that it's time for us to really embrace electronic health records.

Health Information Technology [Slide 26]

One example is clearly getting on board with electronic health records. Another example was when Geisinger opened up their electronic health record system to the providers in the community who were not a part of the Geisinger system. This really did help with care coordination with that stable population in central Pennsylvania.

Innovation and Diffusion [Slide 27]

Innovation and Diffusion is our next lever, and of course, this is critically important because as we talk about alignment and coordination, we also don't want to squelch the great innovative work and new ideas being tested out across the country. Fostering innovation is critical to supporting an ongoing learning system.

Innovation and Diffusion [Slide 28]

The Center for Medicare & Medicaid Innovation is one grand example. I don't know that we know the verdict on accountable care organizations, for example. It is testing various models of a transaction-based system to one that really rewards population health and clinical improvement. So that's a grand example. One of the examples I like from my early days in the patient safety movement was joining a regional collaborative at VHA, Inc. One of the hospitals stood up and said that they instituted this thing called "good catch" and everybody just grabbed hold of that—what a great kind of concept, and that just diffused across all the regional collaboratives very quickly. It's quite interesting what can sometimes take off like wildfire, while other times something you try to get disseminated and adopted can take the average 17 years that innovations take to be adopted across medical practices. So it takes both grand experiments on the national scale and ideas we should support and share that arise at the local level.

Workforce Development [Slide 29]

Workforce Development is last but clearly not least. We've really got to invest in this current generation and also the next generation of people who, through their development and experience, can learn to collaborate and compete in appropriate situations. So, the skills that are needed for a broad learning system are really to build relationships and to work with others that are outside our particular comfort zone. It's critical to be able to work through the issues and find a common ground in addition to very fundamental things such as quality improvement and process improvement. These elements will need to be woven into the curricula for health care professionals in many different sectors.

Workforce Development [Slide 30]

One example of Workforce Development in action is academic medical centers that require their medical residents to do a quality improvement project. I'm happy that some medical schools are now teaching quality improvement as part of the curriculum.

Nine National Quality Strategy Levers [Slide 31]

Here are the nine levers all together. We've described in detail how each can be used for quality improvement. These are not the only things organizations could do to improve the quality of health and health care, but they're the ones that we as a collective group have thought are critically important to align across stakeholders. But it's really up to you to take the pledge and think through how your core business could contribute. I'll pause on that, and turn the microphone over to Elizabeth so we can hear how she's been operationalizing this with some of her members across the country. Afterwards, we'll open up the line for questions and answers, and I would love to hear your questions and comments so we can think together about how to capture information from you about how you're putting the levers into action within your organization, what your challenges are, what your successes are, and how we can help.

Now I'd like to turn the floor over to Elizabeth Mitchell, President and CEO of the Network for Regional Health Improvement, to discuss some of the ways she's seen the levers implemented across her member organizations.

National Quality Strategy Levers in Action [Slide 32]

Elizabeth Mitchell: Thank you, Nancy, and thank you so much to the ´óÏóÊÓƵ (AHRQ) for putting this together. It's so exciting to see this move towards implementation. And not only is your framework for thinking through and understanding the different ways we will get transformation but you're also recognizing that transformation is occurring locally in communities through direct engagement of all stakeholders. We have always been strong supporters of the National Quality Strategy, but to really emphasize now its achievement in communities is a great direction, and we're really pleased to participate.

30 Regional Health Improvement Collaboratives [Slide 33]

So, who is NRHI? We are a member organization with more than 30 member collaboratives around the United States. We currently represent about 40 percent of the United States population. A regional health improvement collaborative is a community-based, regional entity that has multi-stakeholder governance. Most of them are statewide. Some are across multiple States, and some are more concentrated in one community or geographic region. We're all a little different—we're reflective of our local markets, our needs, and our priorities. But we all have a shared mission and approach to improvement and that really is working across our stakeholders. Our members are really accelerating their work through participation in NRHI in part through the multi-region innovation projects. A couple of examples: Partners in Integrated Care, which was actually funded by AHRQ, where four of our members came together to design best practices in integrating behavioral health into primary care. They were able to accelerate that by working together and then implementing it across four different States.

Another example of our work together across regions is the pilot we're doing on behalf of the Robert Wood Johnson Foundation (RWJF) on measuring total cost of care and resource use. Five of our member regional collaboratives are producing transparent, attributed total resource cost data from aggregated claims. This will enable us to have a standard view into commercial costs across these regions, and we're learning together to accelerate that implementation.

We're also aligning with Federal programs and policies. I thought it was great that Nancy acknowledged that not only do we need to align local stakeholders, but we need to align the State and Federal governments. We are able to bring together our network of strong regional entities to implement several of the CMS and other Federal programs: several of our members are Quality Improvement Organizations, regional extension centers, and multi-payer patient-centered medical home demonstrations. So, lots of regional and national alignment happening.

Transformation Must be Founded on Reliable Data and Information [Slide 34]

One of our fundamental approaches is to base all the transformation work we do on reliable, useful, and credible data. It is really the combination of the strategies that you see laid out here that enable transformation, but it all requires trusted information from a common source. Most of our regional collaboratives operate either multi-payer or all-payer claims databases or health information exchanges. In Wisconsin, the Wisconsin Collaborative for Healthcare Quality was the first regional collaborative to be certified as a clinical data registry with CMS. They don't necessarily have the mandate, although one of our members does have a mandate to receive that data, but they tend to also be able to work more directly with the stakeholders, be more nimble, produce meaningful analytics, and really partner with physicians and other actors on the ground to use the data. There was a March Government Accountability Office report that highlighted some of our feedback processes to providers and how they may increase the effectiveness of our public reporting programs by combining the private and public reporting and really making sure that there's physician input into our reports. Those trusted relationships enable greater effectiveness in public reporting.

Ten of our members are qualified entities in the Qualified Entities Program, which highlights the regional collaboratives' unique ability to use data in communities and really leverage their relationships. Data is necessary but not sufficient; it's not just about the data, it's about its effective use.

Regional Health Improvement Collaborative Stakeholders [Slide 35]

So, who are our stakeholders? As Nancy emphasized, there's no single stakeholder group that can transform care alone. It's going to be combined efforts and aligned work. Providers are barraged with conflicting measurement and incentive programs. In many cases, regional collaboratives are able to develop multi-stakeholder measurement programs with an aligned incentive attached. We know providers face huge barriers in our current payment system that make it very difficult to do the right thing for patients and to manage costs. We know we need payment reform, but we need to make sure the payment reform follows what physicians know is the right care design. So bringing the stakeholders together can help design the right payment to incent the right care.

We also know that consumers have to play a critical role and need support for engagement. Many of our members are involved with the Choosing Wisely campaign to help facilitate the provider-patient conversations around resource use. Patients need transparent information to make informed choices. As we move to population health, it's going to require engagement of a broader set of stakeholders and partners. There's still this need for a regional collaborative as a convener or sense-maker. I recently saw regional collaboratives described as the quarterback, with data and trusted relationships. Nancy also mentioned the need to manage conflict—a lot of the role of regional collaboratives is managing tension through very significant change. We're often asking different entities to put aside their organizational interests for the best interests of the community and the patient. It's complex change that requires a forum and leadership to get us through it.

Regional Health Improvement Collaborative Levers [Slide 36]

It was very exciting in our planning to see how nicely the levers mapped to our work and our framework. You could easily interchange the regional collaborative icon in the center for the National Quality Strategy because it's all about bringing these levers together effectively for change. So I actually wanted to test applying these levers to some of the great projects and initiatives that are happening across my membership. There are so many incredible issues, and I'll only give you a very brief overview of a few I thought were good examples of the levers in action.

The Wisconsin Collaborative for Healthcare Quality is a statewide consortium of physician groups, hospitals, plans, and employers working together to improve care. They have about 567 health care practice sites that are all contributing data and receiving feedback on aligned performance measures that are annually selected by their multi-stakeholder board. They then validate the underlying data and generate measures for posting to their Web site for public reporting. This highlights the usefulness of the measurement and feedback lever and the public reporting lever.

Another great example is from the Integrated Healthcare Association in California. They have had the longest running example of data aggregation and standardized results reporting in the country, and do so across a diverse region with multiple health plans. They actually provide this measurement and feedback to providers across much of California. The primary initiative for reaching the goal of reduced cost, now that they have shifted their focus from quality to cost, is for a value-based pay for performance. The shared savings model holds the provider organizations accountable for cost trends and resource use inclusive of all the care provided to their HMO and PSO members. They've invested significant time in reaching consensus across plans and providers on the key parameters of their value-based design. So it really engages the physicians and the plans on a set of common metrics. In all, they've paid out over $450 million on these metrics prior to 2012, and they've really effectively engaged physicians in total cost and resource use measurement. So, we have Measurement and Feedback, we have Payment, Learning and Technical Assistance, and Public Reporting levers all at work here.

Massachusetts Health Quality Partners and Minnesota Community Measurement have had extensive public reporting of patient experience measures, so again the levers are apparent there as well.

In Maine, they have done extensive work with a 10-year, multi-stakeholder public reporting initiative where all the stakeholders came together to select the measures which are publicly reported on by the providers and health plans. Most of the large employers are using those measures in their benefit design to communicate with their employees about identifying high quality facilities. So, again the Measurement and Feedback lever is at work, as well as Payment, Consumer Incentives and Benefit Design, Learning and Technical Assistance, and Innovation and Diffusion.

One other example I wanted to put up here might require a different lever, although it can probably be found across these levers, is consumer engagement. The Institute for Clinical Systems Improvement in Minnesota has been convening forums around the State to bring community members and providers together to talk about the impact of cost on their community. This enables all stakeholders to think collectively how they may want to rethink investments in health care to achieve the Triple Aim, done through true consumer engagement across the community.

So those are just some of our many examples. We have several others I'd love to share. But I was so impressed by how well these levers track to the work that we're doing on the ground and how our work on the ground can inform future iterations and future directions of the National Quality Strategy. Thank you very much for the framework and for including us in making that connection between the national and regional work. I look forward to questions.

How to Find NQS Tools and Resources [Slide 37]

Ann: Great. Thank you, Elizabeth. That concludes the formal remarks for today's presentation. If you have a question, dial 14 on your phone to enter the operator-assisted queue line. If your question is answered before you get to the front of the queue, you can dial 13 to exit.

Before we open up the line, I do want to run through a few of the resources we have available for you. The Working for Quality Web site can be found at www.ahrq.gov/workingforquality. There we have a variety of materials to assist you in communicating about the National Quality Strategy. We update content monthly profiling Priorities in Action in national, State, local examples from all over the quality world. If you have additional follow-up questions, you can contact us at NQStrategy@ahrq.hhs.gov.

How to Find NRHI Tools and Resources [Slide 38]

To get more information from NRHI, Elizabeth's organization, there are a number of tools and resources you can check out on their Web site, . There are publications, a list of the collaboratives, and NRHI in the news that may give you more information about the work that's happening there.

Questions and Answers [Slide 39]

With that, I'd like to begin the question-and-answer session.

Question 1: One challenge in rural America with smaller critical access hospitals and rural health facility clinics is that administrators and CEOs do not see the connection between working on these levers and the reimbursements that will be realized financially if such work is carried out. Any suggestions on how to educate them, help them connect the dots, and realize work needs to be done and allow staff to do it?

Nancy Wilson: I'll start off with that. One of the things that we tried to do with these kinds of Webinars and the materials that we create is to get them up on the Web site where they are available for free. We encourage you to use them to help craft your story about what's happening and where things are headed as a way of encouraging senior leadership to understand the bigger picture. We're also very happy to connect with you and see if there's anything we can do to help offline. We know it's a really important issue. It's helpful to identify opinion leaders within groups and work with them to have them take up and carry the message forward. Sometimes that's as important as what the message is. Thinking about who carries the message is important, and sometimes it needs to be someone external and sometimes it's internal.

Elizabeth Mitchell: I agree with everything Nancy said. I'm from Maine, and I've worked in several rural areas and have certainly seen a different range of interest in the transformation activities. Sometimes it's helpful to join a community and share information about what's happening across the United States, not only as a regional collaborative but also through a collaborative health network such as the one we'll be launching in the next several months to allow individuals to find stories and connect with others who are pursuing this work. So I'd also be happy to follow up with you offline.

Question 2: I work at a State Medicaid agency, and a large challenge for our organization is providing timely data to our providers. Has anyone had experience with this issue of getting the claims in, analyzed, and back out in a timely manner?

Nancy Wilson: I think this is an ongoing challenge. I think one of the analytics that helped several years ago with the Quality Improvement Organization program was running the numbers to see how many months of information did you need to get an answer that was statistically comparable to the result you'd get if you waited the entire time until every single claim came in. With that example, I remember they determined it was 6 months. On the basis of 6 months of data, you could really look and see that this was a good representation of what was going on. One thing is to figure out exactly how long that window has to be with the current rate of data trickling in. This is also where process improvement bridges far beyond inside hospital or clinic walls. It's about how you get claims submitted and turned around in a quick way, looking at who holds the various steps and where can you speed up the process.

Elizabeth Mitchell: It's definitely a challenge across all of our members. I can say that on the commercial side, many of our members are able to turn around usable claims-based reports within 3 months. I can't speak to how applicable that is to Medicaid. I think this really points to a much larger challenge, as we know, that we need to migrate more towards real-time clinical data. Some of our members have been able to start that integration process, but it's a challenge we all share of getting much faster feedback to providers to really take full advantage of that.

Nancy Wilson: I can point you to some State Medicaid groups that have worked to get turnaround time as quickly as possible. We can work on that offline.

Question 3: Can you provide more context around the interaction around regional extension centers and Quality Improvement Organizations in moving the bar forward in terms of meaningful use and health information technology? Related to this, are there any EHR vendors that are members of regional collaboratives to help brainstorm how to integrate electronic measures into clinical workflow?

Elizabeth Mitchell: Several of our members serve as regional extension centers and have been working with practices to change workflow. Pittsburgh Regional Health Initiative is a great example of that. The regional extension center was able to assist over 850 providers through a process of selecting, processing, and implementing the electronic health records and transforming the workflow to improve patient experience.

Another one of our members in Maine works directly with practice groups to transform how they organize themselves around care. We continue to face lots of challenges with EHR implementation. Interoperability is a huge priority for everyone, because we know different tools make it that much harder to move towards aligned measurement and aligned effort. I can help connect you with some members working in that space.

Some of our members are also Quality Improvement Organizations and as we know from the 11th Scope of Work, they're moving more towards the ambulatory care space and connecting with other community supports, which are really closely aligned with lots of what the regional collaboratives have done in the past. Finally, our member in Iowa serves as a hospital engagement network and just through their direct engagement with physicians, facilities, and provider groups they have documented savings of approximately $52 million over the last few months of their initiative from avoiding preventable errors. This is because they are able to engage all of their providers in this transformation towards improvement, and it's having not only a quality benefit but a cost impact as well.

Question 4: What are some examples of next steps for quality improvement and implementation?

Nancy Wilson: I think that one of the next steps is to really think about what levers your business can support. There may be one or multiple ones, but look at the ways that within the work that you do—you could weave in a focus on the National Quality Strategy with the aims and the priorities.

Elizabeth Mitchell: I'll add that the emphasis on quality will remain a critically important effort. There will also be a shift to considering cost. As I mentioned earlier, in five States over the next year we will have transparent, standardized, and comparable total cost and resource use data that will be able to inform next steps on quality because it enables us to identify where the opportunities for improvement are. And we know—it's been 30 years since the Dartmouth Atlas—that that will vary across the Nation. It may be overuse of the emergency department, it may be readmissions, it may be early elective deliveries, but when we have that baseline data it will help us target the quality improvement activities. Then it's about bringing together the different actors to enable the improvement to happen through technical assistance and payment change that needs to accompany clinical redesign. As transparency increases in a meaningful way with engaged physicians, we'll see more and more clarity about where the quality opportunities are.

Question 5: Can the panel share how home health providers can engage on these issues?

Nancy Wilson: I would say that we are venturing forth beyond the traditional walls of health care delivery settings. I have to say that sometimes as clinicians we've perhaps been a bit egocentric towards where our transactions have taken place. So, there is work that we're doing on the national scene in trying to bring people together that don't traditionally talk so much to each other to identify ways to improve the health of people in communities and to find ways to keep populations such as the elderly healthy in their homes. I think of community- and home-based services as part of the social support system that we really need to engage much more systematically if we are going to provide not only health care coordination but support people for staying in their homes.

Elizabeth Mitchell: I think that as we move towards more accountable payment systems, whether it's a bundled payment or a population health payment, there's going to be a growing recognition of community-based providers and long-term-care providers. I was talking to a cardiologist who said for the first time in his career he is now going out to long-term-care facilities because he is participating in a bundled payment arrangement where he's responsible for the entire episode of care. As we move more towards these accountable payment arrangements, I think that there will be more and more interest in aligning with those community resources.

Ann Gordon: Thank you, Nancy and Elizabeth, for your time today. That concludes our Webinar for today. An archive of today's presentation will be posted to the Working for Quality site. We will email you when those materials are available, and again we encourage you to complete the very brief survey at the conclusion of today's Webinar. Thank you again, and we look forward to seeing you on a future Webinar.

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