Answering AHA Research Questions - 2010 to 2012
External Resources

Research Question #1 What are the most effective and efficient ways for hospitals and health systems to integrate care and improve performance (financial, clinical, service, patient and staff experience) along the continuum of care (e.g., implementing care coordination across all settings of care)?

Project Name/Study
Summary of Findings
Care Coordination Measures Atlas
Agency for Healthcare Research and Quality
This Care Coordination Measures Atlas is designed to help the health care community measure the success of activities to coordinate care across settings. The guide provides an overview of the current state of coordination measures, lists existing measures,maps them to domains of coordination, and provides a step-by-step guide for selecting the right measure(s) for a project. This resource is a guide for health care organizations considering measures for evaluating the effectiveness of their care transition activities.
Effective Interventions to Reduce Rehospitalizations: A Survey of the Published Evidence
Institute for Healthcare Improvement
This article summarizes the results of a survey of the published literature on evidence-based interventions for reducing rehospitalizations. Study authors reported that the "Foci of studies were variably on: 1) the epidemiology of avoidable hospitalizations and rehospitalizations from specific settings of care (such as from nursing homes, or from home health care); 2) specific service interventions (such as enhanced patient and family education, or use of home telemonitoring); or 3) interventions for patients with specific diseases (such as heart failure, chronic obstructive pulmonary disease, or hip fracture).

The survey found evidence that supported interventions in four areas:

  1. enhanced care and support during transitions;
  2. improved patient education and self-management support;
  3. multidisciplinary team management; and
  4. patient-centered care planning at the end of life.

Examples of the interventions are included in the report.

Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions
Institute for Healthcare Improvement
The purpose of the paper is to provide information to hospitals on the types of strategies available to address the question of how best to coordinate care and reduce rehospitalizations. Fifteen interventions are described including some with a strong evidence-base and others that show promise but require additional testing.
How-to Guide: Creating an Ideal Transition Home
Institute for Healthcare Improvement
This How-To-Guide provides step-by-step instruction for how hospitals can create an ideal transition for patients to home after hospitalization.
Creating an Ideal Transition to a Skilled Nursing Facility
Institute for Healthcare Improvement
This How-To-Guide is undergoing field testing and provides guidance on how to transition patients from the hospital to the skilled nursing facility setting.
Coleman Care Transitions Intervention
California HealthCare Foundation (CHCF)
CHFA funded an initiative in California to improve care transitions by implementing the Coleman Care Transitions Intervention, a program adapted from the work of Eric Coleman. The program is designed to make patients more active participants in their care and is focused on medication self-management, use of a patient-centered health record and primary care provider and specialist follow-up, and patient understanding of red flag conditions and what to do for next steps when this happens.
The Care Transitions Intervention Results of a Randomized Controlled Trial
Archives of Internal Medicine
The results of a randomized control study of the Care Transitions Intervention (see above) found that readmisison rates were reduced and mean hospital costs were lower when patients were encouraged to become more active participants in their care through the use of a transition coach and other interventions.
Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination: A Consensus Report
National Quality Forum (NQF)
NQF endorsed a set of preferred practices and measures for care coordination. This information can be used to help guide organizations in meeting care coordination goals and to help organizations evaluate how successful they are at improving access, continuity of care, communication, and tracking of patients across providers and settings.
Care Coordination Convening Meeting Synthesis Report
National Quality Forum (NQF)
This report focuses on reducing 30-day readmissions, a goal of the care coordination priority. Key themes for reducing 30-day readmission rates discussed include the importance of patient and family experience in measuring success, the role of community engagement and collaboration, and the need to replace the traditional discharge summary with longitudinal care planning. Drivers of change were also identified including accreditation, certification, and professional development.
Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework
The Commonwealth Fund
This report includes a framework for care coordination that includes the characteristics, competencies and functions of care coordination in a high-performing pediatric health care system. The report also provides an approach for implementing care coordination across settings and disciplines.
Care Trek: Reducing Readmissions through Cross-Setting Work Groups
The Remington Report
This report describes the work of the Nebraska Medicare Quality Improvement Organization to improve the sender-receiver relationship between health care providers. The project was one of 14 contracts across the country awarded by the Centers for Medicare and Medicaid Services. The core of the work included improving the transfer of information about discharge instructions and maintaining a current medication list. Five cross-setting workgroups were formed to focus on improvement strategies. The process and strategies developed are highlighted in this paper.
CHAMP - Advancing Home Health Care Excellence for Older People
Center for Home Care Policy & Research
This evidence brief includes the results of a literature review in care coordination, management and transitions for older adults. It summarizes the literature related to care coordination and transitions. It includes examples of interventions, such as a comprehensive geriatric assessment and follow-up and the impact of these interventions on reducing hospitalizations, falls, and emergency department visits. Case management, disease management, and other programs are also discussed.
Readmission Reduction Guide: A Manual for Preventing Hospitalizations
Pittsburgh Regional Health Initiative (PRHI)
In January 2011, the PRHI issued a readmission reduction guide based on Perfecting Patient Care, a team focused process improvement methodology that utilizes Lean and Toyota Principles. The Plan-Do-Check-Act cycle is part of this methodology. The manual includes a step-by-step guide as well as sample forms.


Research Question #2 What organizational characteristics, structures, and processes lead to a high-performing system of care (e.g., the implementation of specific HIT components, specific horizontal and vertically integrated system practices, and clinical and functional integration across a health system that produces benchmark outcomes)?

Project Name/Study
Summary of Findings
Strengthening Primary and Chronic Care: State Innovations to Transform and Link Small Practices
The Commonwealth Fund
This report by the Commonwealth Fund describes the leadership role that states are taking with other stakeholders to better organize and link small practices to deliver primary and chronic care. The six state case studies included in the report are: Colorado, Vermont, Michigan, North Carolina, Oklahoma, and Pennsylvania. While the strategies in each state differ, the common themes for change include: leadership and convening, payment incentives, support for infrastructure, information feedback and monitoring, and certification and recognition.
Organizational Factors Associated with High Performance in Quality and Safety in Academic Medical Centers
Academic Medicine: Journal of the Association of American Medical Colleges (Acad Med)
This study examined factors associated with high performance in quality and safety in 79 academic medical centers and found that a shared sense of purpose, hands on leadership style, accountability systems, a focus on results, and a culture of collaboration were qualities shared by high performing academic medical centers.
Organizing the U.S. Health Care Delivery System for High Performance
The Commonwealth Fund
This report describes the six attributes of a high performing health care delivery system at the community level and provides policy recommendations for making improvements. The report includes a summary of case study systems on desired delivery system attributes.
High Performing Hospitals: Secrets to Success
The Commonwealth Fund
This report describes the factors contributing to success in four high performing hospitals: Beth Israel Deaconess Medical Center; El Camino Hospital, Mission Hospitals, and Jefferson Regional Medical Center. Researchers identified four factors contributing to a successful strategy: "developing the right culture for quality to flourish, attracting and retaining the right people to promote quality, devising and updating the right in-house processes for quality improvement, and giving staff the right tools to do the job."
Achieving Clinical Integration with Highly Engaged Physicians
Clinical Integration and ACOs
This white paper provides a framework for understanding the attributes of clinical integration that engages physicians in process design and care delivery improvements. It describes characteristics of different models of integration that have worked in the past and includes examples of how hospitals can work to achieve succesful clinical integration.
Achieving Better Chronic Care at Lower Costs Across the Health Care Continuum for Older Americans
Engelberg Center for Health Care Reform at Brookings
This paper discusses the challenges facing older Americans with chronic diseases and highlights new opportunities that are on the horizon. Programs that use health information technology to better coordinate care for older Americans with chronic conditions, use of integrated care delivery models that link traditional medical services with social supports, and innovative payment models that help to align incentives are just some of the programs discussed.
Hot Spotters - Can We Lower Medical Costs By Giving the Neediest Patients Better Care?
The New Yorker Magazine
Dr. Atul Gawande describes in the January 2011 issue of the New Yorker Magazine several innovative programs to improve care and reduce costs that includes the "creation of intensive outpatient care to target hot spots."
Changes in Performance After Implementation of a Multifaceted Electronic-Health-Record-Based Quality Improvement System
Medical Care Official Journal of the Medical Care Section, American Public Health Association
This study in the Journal Medical Care evaluated the impact of using electronic health record (EHR) tools to improve quality measurement, improve the accuracy of point-of-care reminders, and provide better clinician feedback for multiple chronic disease and preventive care measures. The results of the study found that use of EHR tools in this way "improved performance and/or accelerated the rate of improvement for multiple measures simultaneously."
Regional Health Improvement Collaboratives: Essential Elements for Successful Healthcare Reform
Essential Elements For Successful Healthcare Reform
This report describes the role that regionally based multi-stakeholder collaboratives can play in health reform and improving health care. It describes the work of 11 collaboratives in performance measurement, payment and delivery system reform, training for providers to improve performance, and engaging patients and families.
Key Principles for Successful Health System Integration
Healthcare Quarterly
The authors conducted a systematic literature review of health systems integration. The literature review was in response to the mandate in Alberta, Canada to implement integrated service delivery systems. While no commonly agreed upon model of system integration was found in the literature, ten commonly cited principles were identified. These principles included: comprehensive services across the care continuum; patient focus; geographic coverage and rostering; standardized care delivery through interprofessional teams; peformance management; information systems; organizational culture and leadership; physician integration; governance structure; and financial management.
Relationship Between Use of Electronic Health Record Features and Health Care Quality: Results of a Statewide Survey
Medical Care
This study evaluated the use of an electronic health record (EHR) and the use of specific EHR record functionality and the relationship to quality of care. Results found that use of specific functions of an EHR by primary care physicians had an impact on quality of care as measured by HEDIS Quality Measures, although the use of an EHR by itself did not impact quality measures. Use of the problem list, visit note, and radiology test results were features with the strongest association to quality measures for women's health, colon cancer screening, and cancer prevention. The authors concluded that to impact quality of care, it will be important for "developers, implementers, and certifiers of electronic health records" to focus on functionality of EHRs versus use of EHRs without attention to functionality.
Effects of computerized clinical decision support systems on practitioner performance and patient out- comes: a systematic review
The Journal of the American Medical Association (JAMA)
This study reviewed controlled trials to determine the effectiveness of computerized clinical decision supports in improving practitioner supports and patient outcomes. A review of the studies that met the investigators inclusion criteria found that computerized clinical decision supports improved practitioner performance in 62 of the 97 studies reviewed that evaluated this outcome. This included 4 of 10 diagnostic systems, 16 of 21 reminder systems, 23 of 37 disease management systems, and 19 of 29 drug-dosing or prescribing systems. in the 52 trials that assessed patient outcomes, 7 trials reported improvements. Studies reviewed found that improved practitioner performance was associated with systems that included automatic prompts and systems that were developed internally.  
Driving Quality and Performance Measurement - A Foundation for Clinical Decision Support
National Quality Forum (NQF)
This National Quality Forum (NQF) Report describes the work of the NQF Expert Panel to develop a Clinical Decision Support Taxonomy. Clinical decision supports are important tools in delivering evidence-based care. The purpose of this taxonomy is to foster compatability in the use of these clinical decision supports.


Research Question #3 What are the most promising practices and system design elements for reducing health disparities, considering all factors such as organizational elements and social determinants?

Project Name/Study
Summary of Findings
Racial and Ethnic Disparities in Healthcare in California: California Fact Book 2010
California Office of Statewide Health Planning and Development
This report uses key quality indicators to evaluate health care disparities in California's hospitals and ambulatory care settings. The results indicate that the most dramatic disparities in care are seen in the outpatient setting. The authors suggest that "high racial and ethnic disparity rates for outpatient care may be due to poor access to care or to the quality of outpatient care, a combination of both factors, or to a high prevalence rate of disease or health conditions among a specific population."
Reducing Racial and Ethnic Disparities in Medicaid Managed Care
The Commonwealth Fund
This toolkit provides approaches for reducing ethnic and racial disparities. It includes case studies and lessons learned in developing patient-centered strategies and ways to collaborate with key stakeholders.
Enhancing Cross-Cultural Communication by Telling Patients' Stories
The Commonweatlh Fund
Doctor-patient communication about treatment options can be problemmatic when patients and families do not speak english or come from different cultural backgrounds. This toolkit includes a series of films and a facilitator's guide to help identify communication problems in 4 case examples and how to resolve them.
Better Diabetes Care for Patients with Low Health Literacy
The Commonwealth Fund

Patients with poor control of Type 2 diabetes received additional forms of support including automated telephone diabetes management and group medical visits. The results of the first phase of this Improving Diabetes Efforts Across Language and Literacy Project were found to increase patient engagement in care. The guide for training Group Visit Facilitators can be found at the link below:

Improving Quality and Achieving Equity: A Guide for Hospital Leaders
The Massachusetts General Hospital Disparities Solution Center
Robert Wood Johnson Foundation
The Massachusetts General Hospital Disparities Solutions Center with support from the Robert Wood Johnson Foundation developed this guidebook to help hospitals implement programs to address racial and ethnic disparities. The guidebook includes an overview of the evidence for racial and ethnic disparities in health care, model practices from hospitals that are working to address this issue, and a set of activities for hospitals to implement.
Creating Equity Reports: A Guide for Hospitals
The Massachusetts General Hospital Disparities Solution Center
Robert Wood Johnson Foundation
The Massachusetts General Hospital Disparities Solution Center with support from the Robert Wood Johnson Foundation developed this guide to provide hospitals with a framework for developing equity reports and shares lessons learned from experiences with developing and using these types of reports.
Reducing Racial and Ethnic Disparities: A Quality Improvement Initiative in Medicaid Managed Care
Centers for Healthcare Strategies, Inc
This toolkit developed by the Centers for Healthcare Strategies, Inc. with support from the Robert Wood Johnson Foundation and Commonwealth Fund includes strategies for identifying disparities in care and programs for addressing them. The information included in the toolkit is based on the experiences of a collaborative workgroup of Medicaid Managed Care Organizations. Case studies focus on reducing racial and ethnic disparities in birth outcomes and immunizations, asthma care, and diabetes care.
Health Disparities and Inequalities Report - United States-2011
Centers for Disease Control and Prevention
This Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report synthesizes the most recent data on disparities, including measures of inequality, gaps in the national data, and potential interventions in specific topic areas that may have an impact on addressing the problem.
Activities to Reduce Ethnic and Racial Disparities in Health Care - A Program Brief
Agency for Health Care Research and Quality (AHRQ)
This AHRQ brief summarizes the scope of the problem, recent improvements in reducing disparities in care, selected publications focused on racial and ethnic disparities by condition (e.g., asthma, diabetes, cardiovascular disease), general publications, current research, grants, and future directions.
Culturally Appropriate Story Telling to Improve Blood Pressure
Annals of internal Medicine
This study published in the Annals of internal Medicine used DVDs to test storytelling as an intervention to improve blood pressure in African American patients with baseline uncontrolled hypertension. The results of this randomized controlled study found significant improvements in blood pressure for patients in the story telling intervention group.


Research Question #4 What is the role of the hospital in a new community environment that provides more efficient and effective health care (e.g., what are the redesigned structures and models, the role and implementation of accountable care organizations, the structures and processes needed to implement new payment models such as bundled payments, and how do organizations transition to this new role)?

Project Name/Study
Summary of Findings
Accountable Care Organizations in California: Lessons for the National Debate on Delivery System Reform
Integrated Healthcare Association
This white paper from the Integrated Healthcare Association summarizes the lessons learned in ACO development in California. The paper highlights ten important factors for successful ACO development.
Transforming Health Care through Accountable Care Organizations - A Critical Assessment
Foley & Lardner LLP
This white paper published by Foley and Lardner, LLP describes the challenges and opportunities of ACO formation. Specific issues discussed include: structural options, financial and practical challenges, legal issues, and how to prepare for participation in ACOs (e.g., pursuing alignments, assuming risk, different payment structures, importance of Information systems, and types of human resources and supports).
Assessing an ACO Prototype - Medicare's Physician Group Practice Demonstration
This New England Journal of Medicine
This New England Journal of Medicine's article discusses the results of a demonstration project funded by the Centers for Medicare and Medicaid that tested whether incentive-based payment methods could foster improved care management and coordination and in the process generate cost savings by reducing avoidable readmissions, emergency department visits, and related hospital admissions.
Physicians versus Hospitals as Leaders of Accountable Care Organizations
The New England Journal of Medicine
This article in the New England Journal of Medicine describes the challenges facing physicians and hospitals in being the lead entity controlling accountable care organizations.
BCBSMA Alternative Quality Contract
Blue Cross Blue Shield of Massachusetts
This website provides a description of the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract. This contract is a model that uses a global budget for paying providers combined with quality incentives. In addition to information about how the Alternative Quality Contract works, the website includes information about the quality measures used and information about the process underway to evaluate its impact.
Bridges to Excellence - Prometheus Payment
Healthcare Incentives Imporovement Institute
The Prometheus Payment model includes bundled payments based on evidence informed case rates and an allowance for potentially avoidable complications. The model is undergoing pilot testing in a number of sites across the country. These pilots are testing this model as a vehicle for paying for care and encouraging physicians, hospitals, and other providers to coordinate and provide care more efficiently and effectively. The website includes information about the model as well as resources and tools.
The Accountable Health Care Delivery: Models and Policy Actions for Massachusetts
The Massachusetts Health Policy Forum
This forum includes presentations and an issue brief Achieving Accountable Care in Massachusetts: Payment Reform to Drive Delivery System Change. It provides an overview of the role of payment in delivery system reform, describes the accountable care delivery model, presents six models in practice and lessons learned, and policy opportunities for one state. The six models highlighted are: Norton Healthcare in Louisville, Kentucky, Tucson Medical Center in Arizona, Mount Auburn Cambridge Independent Practice Association, Hampden County Physicians Associates in Springfield, and Atrius Health in the Boston Metropolitan Area.
Joint Principles for Accountable Care Organizations
American Academy of Family Physicians
In November 2010, four physician membership organizations released joint principles to guide the structure and payment models in the development of ACOs. These principles emphasize that primary care should be the "foundation of any ACO and that the recognized patient and/or family-centered medical home is the model that all ACOs should adopt for building their primary care base."
Center for Healthcare Quality and Payment Reform
Center for Healthcare Quality & Payment Reform
This website includes a number of resources on transitioning to new models of payment and health care delivery systems including papers on the following: Transitioning to Accountable Care: Incremental Payment Reforms to Support Higher Quality, More Affordable Health Care; Using Partial Capitation to Support Accountable Care Organizations in Medicare; How to Create Accountable Care Organization; and Paths to Payment Reform.
Remaking Primary Care: A Framework for the Future
National Network for Health Innovation
This report developed by the National Network for Health Innovation (formerly the New England Healthcare Institute) describes promising innovations to address the crisis in primary care. These innovations focus on service delivery improvements (e.g., patient centered medical homes, chronic care model, open-access scheduling); site of care changes (e.g., home visits, worksite wellness centers); workforce enhancements (e.g., role of primary care coordinators, nurse practitioners); reimbursement changes (e.g., bundled payments, global payments); and health profession education changes (e.g., team training curriculum).
Genesee Health Plan: Improving Access to Care and the Health of Uninsured Residents Through a County Health Plan
The Commonwealth Fund
This is a case study of how a community-based health plan collaborated with community stakeholders, including hospitals to increase access to physician services and engage patients in self-management. These efforts resulted in a 51 percent reduction in Emergency Department visits by the plan's enrollees between 2004 and 2007 and a reduction in hospital admissions by 15 percent between 2006 and 2007.
Rand Compare's Analysis of Bundled Payment
Rand Health
This resource produced by Rand Health, a division of Rand Corporation, synthesizes the literature on Bundled Payments and measures the results against a number of performance dimensions (e.g., spending, waste, patient experience, and operational feasibility).



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