PA SPREAD: Spreading Quality Improvement Infrastructure across Pennsylvania

描述(由申请人提供)：PA Spare、PA地区健康教育中心(AHEC)和匹兹堡地区健康倡议(PRHI)提议将8个中小型网络(这项为期4年的赠款中每年2个)转移到以人口为基础的医疗保健系统。通过以人口管理为基础的质量改进，参与网络将努力提高其提供的护理的质量、有效性、效率和安全性。PA传播的目标是：(1)利用与初级保健实践和卫生系统的现有关系，在整个初级保健网络中推广质量改进和人口管理基础，使网络成为能够协调和改善其社区保健和健康的负责任的保健组织。(2)在初级保健网络内建设能力，以促进持续的实践、信息技术支持、变革管理和质量改进。(3)支持以循证为基础的临床指南和护理提供最佳实践的广泛采用，方法是在当地实践促进的支持下，发展区域和全州范围的学习社区。以网络为基础的主要成果包括在参与实践中在4年内将心脏病、糖尿病、高血压和哮喘的国家使用的临床质量衡量标准的实绩提高到最近可用的第90%的HEDIS基准。PA SPED、AHEC和PRHI将通过四种主要干预措施在参与实践和网络中努力发展自我组织能力，以提高质量。学习社区将融合PA SPARD/AHEC和PRHI模式，以允许更频繁的会议，以加速改进，并提供更多机会，帮助网络发展其自组织能力。此外，PA SPED将与PA卫生部合作，在其现有的“最佳做法”网络研讨会的基础上，开发一个全州范围的学习社区，包括任何致力于基于人口管理的质量改进的做法或网络。将为参与网络提供人口管理改进路线图，重点是(1)每次就诊时使用基于团队的主动护理进行计划的护理和风险评估，(2)患者自我管理支持、教育和激活，以及(3)护理协调。除了向实践广告网络提供直接的实践促进支持外，PA传播伙伴关系还将同时努力在每个网络中建立促进能力。在一年内，PA SPARD/AHEC/PRHI促进者将努力将实践促进过渡到基于网络的实践促进者。每月的业绩报告和基准将在实践人群层面上进行，以评估每个实践在其独特的环境、组织、文化和特征的背景下测试和实施变化的成功情况。

DESCRIPTION (provided by applicant): PA SPREAD, PA Area Health Education Center (AHEC), and Pittsburgh Regional Health Initiative (PRHI) propose to move 8 small- to mid-size networks (2 per year of this 4-year grant) towards a population-based health care system. Through population management-based quality improvement, participating networks will work to improve the quality, effectiveness, efficiency and safety of the care they deliver. PA SPREAD aims to: (1) Leverage existing relationships with primary care practices and health systems to spread the quality improvement and population management foundation across entire primary care networks to prepare networks to function as accountable care organizations capable of coordinating and improving the care and health of their communities. (2) Build capacity within primary care networks for ongoing practice facilitation, IT support, change management, and quality improvement. (3) Support widespread adoption of evidence-based clinical guidelines and care delivery best practices by developing regional and statewide learning communities supported by local practice facilitation. Primary network-based outcomes include the improvement of performance rates on nationally-used clinical quality measures for heart disease, diabetes, hypertension and asthma to the most recently available 90th percentile HEDIS benchmark within 4 years in participating practices PA SPREAD, AHEC, and PRHI will work to develop self-organizing capacity for quality improvement within participating practices and networks through four main interventions. Learning Communities will blend PA SPREAD/AHEC and PRHI models to allow for more frequent meetings to accelerate improvement and provide additional opportunities to assist networks to develop their self-organizing capacity. Additionally, PA SPREAD will work with the PA Department of Health to build upon its existing "best practices" webinars to develop a statewide learning community involving any practice or network working on population management-based quality improvement. Participating networks will be provided a population management roadmap for improvement that will focus on (1) planned care and risk assessment at every visit using proactive team-based care, (2) patient self-management support, education, and activation, and (3) care coordination. In addition to providing direct practice facilitation support to practices ad networks, the PA SPREAD partnership will work simultaneously to build facilitation capacity within each network. Within a year, PA SPREAD/AHEC/ PRHI facilitators will work to transition practice facilitation to network-based practice facilitators. Monthly performance reporting and benchmarking will be at the practice population level to enable assessment of each practice's success in testing and implementing changes in the context of its unique environment, organization, culture, and characteristics.