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QI Outside the Hospital: Improving Care for Home- and Community-Based Service Providers

By Kimberly Mitchell | Wednesday, April 22, 2015

By Andrey Ostrovsky, MD, Care at Hand, CEO, and Lori O’Connor, RN, Director of Nursing, Elder Services of Merrimack Valley.

Health care is changing rapidly. For health care organizations to adapt to external changes, they need to effectively improve internally. While quality improvement (QI) is well known to medical providers, it is less commonly used in the non-medical part of the health care system that focuses on functional supports. Home- and community-based service (HCBS) providers do some of the most important work in health care providing 8 out of 10 hours of paid services to the elderly and people with disabilities,1 and yet they are the least equipped to use QI.

Some early adopting HCBS providers are defying expectations with their improvement efforts. Elder Services of Merrimack Valley (ESMV), for example, is a Massachusetts-based area agency on aging (AAA) that uses QI to diversify their traditional lines of services beyond case management and home-delivered meals to include care transition services.

With immense pressures for accountability, ESMV’s existing and new lines of business depend on performance data and rapid innovation. Under these circumstances, they have little bandwidth for inefficient experimentation. The following are two examples of how ESMV is using an analytics platform as the data engine to drive their QI initiatives.

The delivery process in place at ESMV is a care transition program whereby non-clinical coaches follow a patient for 1 month. The coach performs an in-person visit immediately after discharge and three follow-up phone calls for the following month. Coaches perform risk-stratifying surveys at each interaction with the patient and elevated risk alerts are sent to a supervising nurse to ensure appropriate triage and care coordination.

The graphics below highlight that effective QI is not about always proving the initial hypothesis is right, but rather achieving validated learning quickly.


Beyond QI

By ti
me-stamping their PDSAs on their run-chart dashboards, ESMV is able to keep track of which experiments are correlated with performance changes. They also use these dashboards as a common QI language with their referral partner hospitals and managed care plans.


ESMV has used rapid-cycle testing and reporting to secure and maintain delivery models beyond traditional AAA services. Their work has been recognized by the Robert Wood Johnson Foundation as pioneering.2 But improvement science is not rocket science. It can be effectively done by any organization with a cultural will to improve and some basic technical assistance. Improvement science with a gentle application of digital health could be the key to help HCBS providers keep up with and maybe stay ahead of the rapidly evolving healthcare system.

1. Foster et al. Improving The Quality Of Medicaid Personal Assistance Through Consumer direction. Health Affairs. 2003.
2. Aligning Forces for Quality (AF4Q) program. Care Transitions Programs: Creating a Behavioral Health Intervention. Robert Wood Johnson Foundation (RWJF). Jan 2015.

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