Quality Improvement & Care Coordination
Working with the Community to Improve Health Outcomes: Investing in Quality Improvement
By: Grant Botley, HCGC Central Ohio Pathways HUB Data Administrator
HCGC’s Care Coordination Program, the Central Ohio Pathways HUB (the HUB) has experienced exponential growth since we began managing it in March of 2019. As a result of the increase in community need indicated by the continuous increase in clients served, HCGC seized the opportunity to introduce a quality improvement process designed to better serve HUB clients and maintain the viability of the Pathways HUB Model. HCGC has historically incorporated quality improvement principles into all of our organization’s work, and is excited to continue this process with the HUB. HUB staff have selected a variety of Quality Improvement (QI) initiatives, with the goal of increasing capacity to serve more clients from referral QI processes being implemented by our Care Coordination Agency’s (CCAs) under the leadership of HUB staff at HCGC.
Implementing a QI process for the HUB is multifaceted. The primary goal for all the CCAs is to maintain an acceptable ratio of billable to unbillable services by increasing enrollment rates of clients that are being referred into the HUB. We know that the longer it takes to be contacted by a CHW, the less likely a potential client is to continue with the enrollment process. Without adequate billable services, the Pathways HUB model is not sustainable, leaving our most vulnerable populations at further risk of poor health outcomes due to lack of access. Implementing a 48-hour time frame from referral to enrollment by a CHW is vital to ensuring that at-risk clients are welcomed into the HUB and begin the process of being connected to vital care and services to set them on a course to success.
CCAs have selected agency specific approaches to impact their billable to unbillable ratios. These quality improvement initiatives should increase the likelihood that clients are receiving timely high-quality service, evidence-based care coordination, and agencies are appropriately reimbursed, thus remaining viable entities with the capacity to serve more clients.
To impact the billable to unbillable ratio, some CCAs have intentionally opted to focus on increasing enrollment rates of referred clients, reducing the time it takes to make an initial contact with a client after they are referred to the HUB.
CCAs are embracing the Model for Improvement via the Plan-Do-Study-Act (PDSA) cycle. The PDSA cycle is a system by which organizations can test for change by establishing a plan to test the change (Plan), executing the test (Do), reflecting on and learning from the outcomes of the test (Study), implementing any changes that should be made to the initial test (Act)1. The PDSA cycle is a simple and powerful tool for accelerating quality improvement. This scientific method is used for action-oriented learning.
Our hope is that through this experiential QI process, CCAs will develop a culture of continuous improvement with the ultimate goal of building QI capability rendering each CCA the efficacy to identify and achieve their unique improvement goals on an ongoing basis.
HCGC’s team is committed to supporting HUB supervisors and CHWs to the highest degree possible. One aspect of that support includes daily engagement in the HUB data management system, Care Coordination Systems (CCS), to review data from the very beginning stages of an individual client to the time of the client’s discharge from the HUB. The HUB staff takes this manual review of all client data very seriously, as it is vital in ensuring that the important work of our CCAs and CHWs out in the community is reflected in our billing and quality processes on the backend.
HCGC and the HUB staff team are very much looking forward to working through this new QI initiative with our valued CCAs. Recognizing how much growth has occurred to get us here, we also know that there is always room to grow and improve. The HUB staff is confident that this process will allow the HUB to continue to serve HUB clients with dignity and respect, while providing them a quality service that will set them on the path to success and well-being.
For more information on the Central Ohio Pathways HUB, or on this QI initiative, please contact HUB CEO, Jenelle Hoseus at jenelle@hcgc.org.
1 http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx
