improvement program · the cqo also presented a training session on basics of lean management at a...

MEDI-CAL QUALITY IMPROVEMENT

PROGRAM

INSTITUTE FOR POPULATION HEALTH IMPROVEMENT

Desiree Backman, DrPH, MS, RDChief Prevention Officer, Department of Health Care Services and

Program Director, Institute for Population Health Improvement

Kenneth W. Kizer, MD, MPHDistinguished Professor, UC Davis School of Medicine and Betty Irene Moore School of Nursing and

Director, Institute for Population Health Improvement

Interagency Agreement #11-88141 October 1, 2011 to September 30, 2018

FINALREPORTTO THE

CALIFORNIADEPARTMENT OF

HEALTH CARESERVICES

September 30, 2018

IPHI 2018 Final Report, Page 1 of 18

UniversityofCalifornia,DavisInstituteforPopulationHealthImprovementFinalReporttotheCaliforniaDepartmentofHealthCareServices

Medi-CalQualityImprovementProgram,InteragencyAgreement#11-88141October1,2011-September30,2018

IntroductionTheMedi-CalQualityImprovementProgram(MCQuIP)wasestablishedonOctober1,2011,througha5-year,$4.25millionInteragencyAgreement(IA)betweentheCaliforniaDepartmentofHealthCareServices(DHCS)andtheUniversityofCalifornia,DavisInstituteforPopulationHealthImprovement(IPHI).InJuly2016,theIAwasextendedthroughSeptember30,2018.Underthisagreement,IPHI,inclosecollaborationwithDHCS,waschargedwith:

• EstablishingandmaintainingaQualityImprovement(QI)programforthemorethan$95billionperyearCaliforniaMedicalAssistanceProgram(Medi-Cal);

• Developingasystems-levelqualitymanagementstrategy;• Providingongoingtechnicalassistanceforthe$3.7billion,5-yearPublicHospital

RedesignandIncentivesinMedi-Cal(PRIME)program,anditspredecessor,theDeliverySystemReformIncentivePayments(DSRIP)program;

• Supportingthedevelopmentandmanagementoflifestyleprogramsandmembercommunicationapproachestooptimizepopulationhealth;and

• Providingexecutive-levelstrategicadvice,thoughtleadership,andorganizationalchangemanagementsupportwithinDHCS.

MCQuIPproducedtangibleresultsduringthecollaboration,October1,2011throughSeptember30,2018.ThisreporthighlightsthemajoraccomplishmentsachievedforeachdeliverableintheIA,focusingespeciallyonprogramoutcomes.

DeliverableADevelopawrittenqualityimprovementplanwhoseaimsandprioritiesreflectsharedvaluesandbestpractices,andwhichisconsistentwiththefederalDepartmentofHealthandHumanServices’NationalQualityStrategy.Updatethequalityimprovementplanatleastannuallybeginningoneyearafteracceptanceoftheinitialplan.ProvidestrategiccounselandadvancetheDHCSStrategyforQualityImprovementinHealthCare(QualityStrategy).ProvideguidanceonmeasuringtheeffectivenessoftheQualityStrategy,advancinginitiativeswithineachpriorityarea,anddevelopingnewinitiativestoachievethethreelinkedgoals.


OutcomesDHCSStrategyforQualityImprovementinHealthCareInthefirstyearoftheIA,IPHI’sChiefQualityImprovementConsultant(CQIC),KennethW.Kizer,MD,MPH,andChiefPreventionOfficer(CPO),DesireeBackman,DrPH,MS,RD,1workedwiththeformerDHCSMedicalDirector,NealKohatsu,MD,MPH,todevelopthefirstQualityStrategy,2012.TheQualityStrategyservesastheblueprintfortheDepartment’seffortstoimprovethehealthofallCalifornians;improvethequalityofhealthcare,includingthepatientcareexperience,inallDHCSprograms;andreducetherateofincreaseintheDepartment’spercapitahealthcarecosts.Toaccomplishthesethreelinkedgoals,theQualityStrategyissupportedbysevenpriorities,whichinclude:

(1)Improvepatientsafety;(2)Delivereffective,efficient,affordablecare;(3)Engagepersonsandfamiliesintheirhealth;(4)Enhancecommunicationandcoordinationofcare;(5)Advanceprevention;(6)Fosterhealthycommunities;and(7)Eliminatehealthdisparities.

AllsixeditionsoftheQualityStrategycanbefoundat:http://www.dhcs.ca.gov/services/Pages/DHCSQualityStrategy.aspx.BaselineAssessmentTheCPOconductedacomprehensivebaselineassessmentofQIactivitiesinDHCSfromApril-December2012.Thepurposeoftheassessmentwasto:(1)establishaDepartment-widebaselineofQIactivitiesinthreeareas:clinicalcare,healthpromotionanddiseaseprevention,andadministration;(2)identifyqualitymetricsthatwerebeingcollectedbytheDepartmentbutwhichwerenotspecificallylinkedtoQIactivities;(3)identifygapsintheDepartment’sQIactivities;and(4)obtainrecommendationsforadditionalQIefforts.Theassessmentteam,ledbytheCPO,developedandpilottestedaQualityImprovementSurvey(QIS)instrumentthatwasthenadministeredtoalloperationalunitswithintheDepartment.TheBaselineAssessmentforQualityImprovementActivitiesinDHCS:MethodsandResultsisavailableathttp://www.dhcs.ca.gov/services/Pages/DHCSQualityStrategy.aspx.

1DesireeBackmanwasanIPHIemployeeembeddedinDHCS.


QualityImprovementEvaluationSystem

TheCPOandformerQualityScientist(QS),BrianPaciotti,PhD,MS,2developedanevaluationsystemtoassesstheperformanceofexistingQIactivitiesandcollectnewQIactivitiesannually.ThetemplatesanddetailedinstructionswerelaunchedbytheOfficeoftheMedicalDirectorinSeptember2013.InFebruary2016,theCPOinitiatedplanstofurtherstreamlinetheQIevaluationsystem.TheCPO,SocialMediaSpecialist(SMS),RachelRobins,3formerQualityScientist(QS),ZhiweiYu,4andformerResearchCoordinator(RC),RachelAbbott5workedwithstaffthroughouttheDepartmenttocompletetheirQIprojectsummaries.Thesummariesprovideasnap-shotofeachproject’sQIeffortsandresults,todate.ThesesummariesarelinkedtotheQualityStrategy,2018andavailableforpublicreviewathttp://www.dhcs.ca.gov/services/Documents/QIProjects.pdf.QualityImprovementTrainingTheformerClinicalQualityOfficer(CQO),UlfatShaikh,MD,MPH,MS,6presentedacurriculuminQIforinterdisciplinaryDHCSstaffaspartoftheDHCSAdultMedicaidQualityGrant.TrainingcommencedinJanuary2014andcontinuedthroughJuly2015.Trainingsessionsoccurred1-2timespermonthandweredeliveredface-to-facebytheformerCQOininteractivegroupsessions.TheCQOalsopresentedatrainingsessiononBasicsofLeanManagementataDHCSLearningSeriessession.QualityImprovementPresentationsInJune2012,theCPOandformerDHCSMedicalDirectorpresentedontheemergingQualityStrategytoDHCSexecutivestaff.Sincethen,theyprovidedupdatesabouttheQualityStrategytoexecutivestaffannuallyaseacheditionwasreleased.TheyalsodevelopedandimplementedawebinartopresenttheQualityStrategytostakeholdersstatewideinJune2012.

TheCPOpresentedtheQualityStrategy,2012andemergingareasoftheQualityStrategy,2013attheDrugUtilizationReviewBoardmeetinginFebruary2013andtheDHCSnewemployeeorientationinMarch,June,July,andAugust2013.TheCPOandformerDHCSMedicalDirectorpresentedtheresultsofthebaselineassessmentofQIactivitiesandnewQualityStrategyideasatthesupervisorsandabovemeetinginMarch2013.TheCPOalsopresentedthenewelementsoftheQualityStrategy,2013attheManagedCareMedicalDirectorsmeetinginApril2013.InAugust2013,theCPOandformerDHCSMedicalDirectorpresentedtheQualityStrategy,2012andlessons

2BrianPaciottiwasanIPHIemployeeembeddedinDHCS.3RachelRobinswasanIPHIemployeeembeddedinDHCS.4ZhiweiYuwasanIPHIemployeeembeddedinDHCS.5RachelAbbottwasanIPHIemployeeembeddedinDHCS.6UlfatShaikhwasanIPHIemployeeembeddedinDHCS.


learnedduringaNationalQualityStrategywebinarhostedbytheAgencyforHealthcareResearchandQuality.Forslidesandatranscriptofthepresentation,gotohttps://www.ahrq.gov/workingforquality/events/webinar-2013-annual-progress-report-update.html.

InFebruary2014,theCPOwasinvitedbytheformerDHCSMedicalDirectortopresentmodelsofcareduringapanelsessionattheAmericanCollegeofPreventiveMedicineConference,PreventiveMedicine,2014.InOctober2014,theCPOpresentedMovingtheSystemfromSickCaretoHealthCareattheUniversityofCalifornia,DavisDepartmentofPublicHealth’sgraduateseminar.

InFebruary2015,theCPOdeliveredapresentation,titledQualityImprovementintheCaliforniaDepartmentofHealthCareServices:Strategy,Culture&MomentumattheAmericanCollegeofPreventiveMedicineConference,PreventiveMedicine,2015.

InJuly2016,theCPOpresentedelementsoftheQualityStrategyinapresentation,titledAdvancingPreventionintheMedi-CalDeliverySystem,totheCaliforniaPrimaryCareAssociation’sBoardofDirectors.TheCPOandformerDHCSMedicalDirectoralsopresentedtheQualityStrategytoprofessionalsparticipatingintheDHCSAcademy7inAugust2016andSeptember2017.

UsingDatatoDriveQualityImprovementDataSystemRefinementIn2013,theformerQS,BrianPaciotti,workedwiththeDHCSDataResearchCommitteetobuildthecomplexqueriesnecessarytoextractMIS/DSSdatarequestedbyexternalresearchers,andhelpeddefineprocesses(e.g.,privacy,security,forms)requiredtoprovidedatatoapprovedresearchers.Specifically,theformerQS:

• SentdatatoDr.ToddGilmerinAugust2013fortheMedicaidutilizationproject;• CreatedapreliminarydatasetforDr.UshmaUpadhyaytoinvestigatethedistanceto

receiveapregnancyterminationprocedureinMedi-Cal;• CollaboratedwiththeMedi-CalIncentivestoQuitSmoking(MIQS)teamandthe

ResearchTriangleInstitute(RTI)toidentifydatafieldswithinMIS/DSSthatwouldberequiredtosupporttheevaluationofMIQSandprovidedalistoffieldsrelatedtoencounter/claimsdata,eligibility,andprovidersthatcouldbeusedtomeasurespecificprocessandoutcomesofinteresttoRTI.

• WorkedwiththeDHCSPharmacyDivisiontoperforminitialqueriestoevaluatetheprevalenceofsmokingamongMedi-Calmembers;and

7DHCSAcademyisacomprehensivetrainingprogramforDHCSmanagersandsupervisors.ItspurposeistohelppeoplegrowtheirunderstandingofMedicaid,Medi-Cal,andthebroaderhealthcareenvironment,aswellasbuildskillsinpolicyanalysis,fiscalanalysis,measuringperformance,andtransformingDHCSintoamoreefficientandeffectiveorganization.


• AssistedindefiningrequiredfieldsandcreatedSQLcodetoextractdata,linkingCancerRegistrydatawithMedi-Caldata.

QualityImprovementMaturitySurveyTheformerCQOworkedwiththeformerDHCSMedicalDirectorandstafftoidentifyavalidatedquestionnairetoassessthecultureandreadinessforQIatDHCS.ResultsfromtheQualityImprovementMaturitySurveywerepublishedintheDHCSNewsletterandpresentedbytheformerCQOatDHCSleadershipmeetings.

PediatricAsthmaAnalysisTheformerCQOworkedwithDHCSstaffandtheUniversityofCalifornia,DavishealthservicesresearcherstoanalyzedataonpediatricasthmawithintheCaliforniaHealthInterviewSurvey(CHIS).Severalissuesaffectingasthmacareandanumberofpublicpolicystrategiestoremedytheissueswerepublishedinamanuscript,titledPopulationHealthConsiderationsforPediatricAsthma:Findingsfromthe2011–2012CaliforniaHealthInterviewSurvey.ThemanuscriptwaspublishedinthejournalPopulationHealthManagementin2016:https://www.liebertpub.com/doi/10.1089/pop.2015.0015.

ChildHealthandDisabilityPrevention(CHDP)ProgramFromMay2014toJuly2015,theformerSpecialAdvisorforBehavioralHealthIntegration,incollaborationwiththeDHCSManagedCare,SystemsofCare,andMedi-CalDentalServicesDivisions,co-ledaworkgrouptoanalyzetheimpactofmanagedcareandtheCHPDProgramontheprovisionofEarlyandPeriodicScreening,Diagnosis,andTreatment.TheworkgroupconvenedstakeholdermeetingsanddevelopedfinalrecommendationsforDHCSexecutives,whichwerediscussedwithstafffromtheCentersforMedicareandMedicaidServices(CMS)inMarch2015.HealthDisparitiesFactSheetsTheformerQSs,BrianPaciottiandZhiweiYu,andCPOworkedwithaDHCSResearchScientist,PatriciaLee,PhD,toanalyzedataandreviewhealthdisparitiesfactsheets,whicharelinkedtothesevenprioritiesoftheQualityStrategy.TheDHCSResearchScientistcontinuestodevelopfactsheetsthatareavailableat:http://www.dhcs.ca.gov/dataandstats/reports/Pages/DisparitiesFactSheets.aspx.ThesefactsheetscontributetothedeliverablesspecifiedintheDepartment’sIAwiththeCaliforniaDepartmentofPublicHealth’sOfficeofHealthEquity.


DeliverableBProvidestrategiccounselandrecommendationstoimprovepopulationhealthmanagementinMedi-Cal.Activitiesmayinclude,butarenotlimitedto:describingtheepidemiologyofMedi-Calemergencydepartmentsuper-utilizersandtheirhealthservicesutilizationpatterns,andmakingrecommendationsforhowtheirurgentcareneedscouldbemoreeffectivelymet;describingMedi-Cal’stop1,5,and20percentutilizers,asdefinedbyexpenditures,andtheirhealthservicesutilizationpatterns,andmakingrecommendationsforhowtheircarecouldbebettercoordinatedandmanaged;anddescribingmodelsofcarethatconnectcommunityresources,publichealth,andclinicalservicestoachieveoptimal“wholeperson”care.

OutcomesHigh-CostMemberReports("Super-Utilizers")FormerQS,BrianPaciotti,createdSQLqueriesandimplementeddataminingalgorithmstocreateahigh-costmember/”super-utilizer”report.TheformerQSproduceda“super-utilizer”summarythatprofilesvariousdemographic,diseasetraits,andutilizationpatternsamongmembersinvarioushigh-costcohorts.TheCQICworkedwiththeChiefoftheResearchandAnalyticStudiesDivision(RASD)atDHCStocreateapresentationon“super-utilizers”inMedi-Cal,whichwaspresentedataDataSymposiumonHighUtilizersofMedi-CalServicesonMarch4,2015.Thepresentation,UnderstandingMedi-Cal'sHigh-CostPopulations,focusedontrendsinMedi-Caleligibility,enrollment,spending,andcaseload.Becauseofthehighdemandforthisinformation,theCQICandChiefofRASDagainpresentedthefindingsoftheiranalysisinawebinaronJune9,2015.Wellover500personsregisteredforthewebinar,whichcanbefoundat:https://naswcanews.org/webinar-data-presentation-on-high-utilizers-of-medi-cal-services/.

FurthereffortstoimprovepopulationhealthmanagementinMedi-CalPleaserefertoDeliverablesforA,C-E,G-I,andLforeffortstoimprovepopulationhealthmanagementinMedi-Cal.DeliverableCProvideleadership,policydevelopment,andresearchcapabilitiestoachieveeffectiveintegrationandcoordinationofbehavioralhealthservicesinkeyDHCSinitiativessuchasCalMediConnect,thetransitionoftheLowIncomeHealthProgrampopulationsintoMedi-Calmanagedcare,theexpansionofchildlessadultpopulationstoMedi-Calmanagedcare,andimplementationofmanagedcareforMedi-Calmembersinruralcounties.


OutcomesBehavioralHealthIntegrationReportandExecutiveSummaryIPHI’sformerSpecialAdvisorforBehavioralHealthIntegration,EfratEilat,PhD,MBA,8workedcloselywiththeformerDHCSMedicalDirector,DeputyDirectorofMentalHealthandSubstanceUseDisorderServices,KarenBaylor,PhD,LMFT,theCPO,andnationalandlocalexpertstodevelopavisionandactionplan,whichsupportstheintegrationofphysical,behavioralandmentalhealth,andsocialservicesforCalifornians.TheformerSpecialAdvisorworkedwiththeCPO,formerRC,formerDHCSMedicalDirector,andinternalandexternalpartnerstoproduceadraftreport,titledRecommendationstotheCaliforniaDepartmentofHealthCareServicesforBehavioralHealthIntegration.Thisreportwasaccompaniedbyanexecutivesummaryonthetopicin2015.

DeliverableDandEDevelopaSystems-levelQualityManagementStrategyfortheDeliverySystemReformIncentivePayments(DSRIP)programoftheDepartment's1115MedicaidWaiver.ThisstrategyshallmakespecificrecommendationsforDHCSandindividualhospitalsystemstooptimizetheachievementofthemilestonesidentifiedineachhospitalsystemplaninvolvedintheDSRIPprogram.ProvideongoingevaluationoftheDSRIPprogram,includingprovidingatleastsemi-annualreportsthatassessgeneralandspecificareasofimprovement.Thisevaluationshalladdresstheinterventionsidentifiedineachhospitalsystemplansuchas:implementationofelectronichealthrecordsanduseofotherhealthinformationtechnology,implementationofpatientcenteredmedicalhomes,useofevidence-basedpopulationhealthmanagementmethods,deliveryofcomplexcare,implementationofpatientsafetymethods,andintegrationofclinicalservicestoimprovethecoordinationandcontinuityofcare.OutcomesDSRIPBetweenOctober1,2011andSeptember30,2015,IPHIprovidedongoingtechnicalsupporttooptimizeachievementofDSRIPprogrammilestonesforthe21designatedpublichospitalsthatparticipated.Supportincludedprovidingrecommendationsfortheselectionofseveresepsisandstroketargets,andassessmentofinterventionsimplementedbyhospitalsbasedonpublishedliteratureandnationalguidelines.Semi-annualandannualreportsfromparticipatingpublichospitals,aswellasaggregatereportsfromthe

8EfratEilatwasanIPHIemployeeembeddedinDHCS.


CaliforniaAssociationofPublicHospitals—SafetyNetInstitute,wererigorouslyreviewed.Individualfeedbacktohospitalswasprovidedinwrittenformat.Thesefeedbackreportsassessedimplementationofmilestonesandaddressedgeneralaswellasspecificwaystoimprovereportingandimplementation.TechnicalassistanceandmentoringwasprovidedtohospitalsonbestpracticesandstrategiesrelatedtotheirQIinitiatives.TheCQICandformerCQOevaluatedtheDSRIPexperienceandpublishedObservationsfromCalifornia’sDeliverySystemReformIncentivePaymentProgramintheAmericanJournalofMedicalQuality,March2017,whichisavailableathttp://journals.sagepub.com/doi/full/10.1177/1062860617696579.PublicHospitalRedesignandIncentivesinMedi-Cal(PRIME)ProgramIPHIparticipatedinregulardevelopmentandplanningmeetingstoinformthePRIMEportionofCalifornia’s1115MedicaidWaiver,Medi-Cal2020,withafocusonpopulationhealthprojects.Developmentoftheseprojects,ledbytheCPO,includedtheMillionHearts®Initiative,CancerScreeningandFollow-Up,andObesityPreventionandHospitalHealthierFoodInitiative.Intotal,theseprojectsrepresentaninvestmentof$556.7millioninpreventionbyMedi-CalandCMS(http://www.dhcs.ca.gov/provgovpart/Pages/WaiverRenewal.aspx).SincereceivingapprovaloftheWaiverbyCMSonDecember30,2015,theCPOhasprovidedtechnicalsupport,focusingprimarilyonpreventionobjectives.Inaddition,theCPOhasparticipatedinaPRIMETopic-specificLearningCollaborativeforObesityPreventionandtheHospitalHealthierFoodInitiativeonApril24,May29,June26,andAugust28,2018.PRIMEPresentationTheCPOpresentedUnderstandingPerspectivesonHealthandtheObesityEpidemicinCaliforniaCommunitiesatthefirstannualPRIMEEdConferenceinNovember2017.

DeliverableFConveneandleadamulti-disciplinaryMedi-CalPerformanceAdvisoryCommittee(MPAC).MPACshallbecomposedofapproximatelyninepersonshavingdemonstratedexpertiseinrelevantclinicalsciences,systemsthinking,qualityimprovement,and/ororganizationalbehavior.MPACshallroutinelymeetaboutquarterly,andmorefrequentlyifneeded,andissueperiodicreportssummarizingitsfindingsandrecommendations.OutcomesBecauseofthescaleandcomplexityofthescopeofworkundertakenbyIPHI,theCQICproposedandDHCSagreedthatanexternaladvisorygroupcomposedofexpertsinQIand


populationhealthwouldbeveryuseful.TheoverarchingpurposeofMPACwastoadviseIPHIandtheDepartmentonhowtomosteffectivelyadvancehealth,clinicalquality,andoutcomes.SpecificgoalsforMPACmembersincluded:

• ReviewandcommentontheDepartment’sevolvingQualityStrategy;• ReviewandcommentonQIactivitiesbeingpursuedbyMedi-Calandidentifywhere

additionaleffortsmaybeneeded;• AdviseonbuildingacultureofqualityatDHCSandimplementinglarge-scale,

sustainabledeliverysystemreforms;• ReviewandcommentonDSRIPstatusreportsandadviseonhowtooptimize

achievementofQItargets;and• OtherwiseprovideinputontopicsproposedbyDHCSandtheCQIC.

TheCQICsecuredthepanelofexpertsandfourMPACmeetingswereheldbetween2012and2014,witheachmeetinginformingthegoals.ThesemeetingswereespeciallycriticalastheQIstrategieswerebeingformedandputintoaction.ThefinalMPACmeetingwasheldonDecember15,2014.NofurthermeetingsoftheMPACwereheldpursuanttothedirectionoftheDepartment.DeliverableGSupportthedevelopmentandmanagementoflifestyleprogramstooptimizepopulationhealthwithparticularattentionto:smokingcessation,nutrition,physicalactivity,andalcohol/substanceabuse.

OutcomesTobaccoCessationArchimedesModelingIn2013,theformerDHCSMedicalDirectorrequestedthattheArchimedessimulationmodelingtooldevelopedbyKaiserPermanentetopredicthealthoutcomesforavarietyofhealthinterventionsbeusedtoprojectvariousoutcomesassociatedwithsmokingcessationprograms.TheformerQS,BrianPaciotti,andformerRC(thenintern),RachelAbbott,usedthissimulationmodelingtoolandproducedpreliminaryresultsthatcouldhelpMedi-Calshapepoliciesrelatedtosmokingcessationprograms.TobaccoSummittoAdvanceQuitAttemptsTheCPOwasinvitedbytheCentersforTobaccoCessationandCaliforniaSmoker’sHelplinetoattendastatewidetobaccosummitinJanuary2013.Atthesummit,anactionplanwasdevelopedtoincreasethequitattemptrateinCaliforniafrom60.7percentto66.8percentby2014.TheCPOofferedseveralDHCStobaccocessationapproachestotheplan,includingthe


Medi-CalIncentivestoQuitSmokingProgram(MIQS),promotionofMIQSthroughWelltopiabyDHCS,andtheestablishmentofastandardofcarefortreatingtobaccouseintheMedi-CalmanagedcareplansbyimplementingtherecommendationsincludedintheTreatingTobaccoUseandDependence:2008Update,ClinicalPracticeGuideline.TheCPOalsocontinuedcollaboratingwiththeMIQSProgramManagertoprovideupdatesonDHCSprogresstohelpmeetthetarget.IncreasingFoodAvailabilityforMedi-CalFamiliesTheCPO,inpartnershipwiththeCaliforniaDepartmentofSocialServices(CDSS),ledeffortstoincreaseCalFreshenrollmentamongthenearly2millionMedi-Calmemberswhowereeligiblebutnotenrolledinthenutritionassistanceprogram.TheCPO,formerQS,BrianPaciotti,andtwoformerDHCSanalysts,TiannaMorganandJenniferByrne,workedwithCDSStosetatargetofincreasingCalFreshenrollmentby5percentfromJanuary2014throughJanuary2015.ThetargetforthisQIprojectwassurpassedin2015,accordingtoCDSSreports.CentersforMedicareandMedicaidServices(CMS)PreventionLearningNetworkHypertensionControlInlate2013,theCPOsubmittedaproposalto,andreceivedapprovalfrom,CMStoparticipateintheMedicaidPreventionLearningNetwork.TheaimoftheproposalwastoalignDHCSprogramsandservices,measuresanddata,informationtechnology,theMedi-Calhealthcaredeliverysystem,andpublic,non-profit,andprivatesectorpartnershipstosupporttheMillionHearts®initiative(http://millionhearts.hhs.gov/aboutmh/overview.html).TheIPHIteam,ledbytheCPO,andseveralDHCSstafflaunchedaone-yearQIcollaborativetoimprovehypertensioncontrolratesamongnineMedi-CalManagedCarePlans(MCPs).TheQIcollaborativeincludedquarterlywebinarsandlinkstolocal,state,andnationalresourcesthatconsistedofmaterialsandconsultationswithsubjectmatterexperts.ParticipatingMCPsdemonstratedanaverageincreaseof5.0percentagepointsintheirratesofcontrolledhypertension.AdetaileddescriptionoftheQIcollaborativeandpositiveoutcomesarecapturedinthemanuscript,titledImplementingaQualityImprovementCollaborativetoImproveHypertensionControlandAdvanceMillionHearts®amongLow-incomeCalifornians,2014-2015.ThemanuscriptwaspublishedinPreventingChronicDisease,July2017(https://www.cdc.gov/pcd/issues/2017/16_0587.htm).Themanuscriptalsogarneredmediaattention.InJuly2017,KaiserHealthNews(https://californiahealthline.org/news/state-led-effort-helps-improve-blood-pressure-control-among-low-income-patients/)andTheMercuryNews(http://www.mercurynews.com/2017/07/27/medi-cal-hypertension-study-7-of-9-health-plans-saw-improvements/)featuredinterviewswiththeCPOandformerDHCSMedicalDirector.


Inaddition,theCPOpresentedthefindingsoftheQIcollaborativeattheDHCSLearningSeriesinSeptember2017,PRIMEwebinarinOctober2017,andtheGlobalMedi-CalDrugUseReviewBoardinSeptember2018.AspirinPrescribingandUseStudyTosupporttheMillionHearts®initiative,theCPO,formerQS,ZhiweiYu,andformerRCworkedwiththeDHCSPharmacyDivisiontocompleteanaspirinQIstudy.ThepurposeofthestudywastodeterminewhethertherateofMedi-CalmemberswhoareappropriatelyprescribedandtakeaspirinisaccuratelyreflectedinFee-For-Service(FFS)claimsdata.TheformerQSanalyzedresultsfromthesurvey,whichhelpedtoinformtheDHCSPharmacyDivisionandotherQIeffortsintheDepartment.InSeptember2017,theformerQSpresentedtheresultsofthestudyattheGlobalMedi-CalDrugUseReviewBoard.PartnershipstoAdvanceCardiovascularHealthTheformerRCparticipatedontheadvisorycommitteefortheHealthyHeartsCaliforniaCoalition,organizedbytheCaliforniaDepartmentofPublicHealth.TheCPOpartneredwiththeRightCareInitiativeandMillionHearts®atthenationalleveltoadvancecardiovascularhealthamongMedi-Calmembers.Inaddition,MillionHearts®ispartofPRIME.AlcoholAbuseAlcoholScreening,BriefIntervention,andReferraltoTreatment(SBIRT)ImplementationTheformerSpecialAdvisorco-ledamulti-divisionalprojecttoimplementtheAlcoholScreening,BriefIntervention,andReferraltoTreatment(SBIRT)benefitforadultMedi-Calmembersinprimarycaresettingsthroughoutthestate.TheformerSpecialAdvisorsubmittedaproposalandwasawardedagrantfromtheCaliforniaHealthCareFoundationinMay2014to:(1)provide30face-to-facetrainingstoprimarycareproviders,clinicadministrators,medicaldirectors,andothersacrossthestate,onhowtoeffectivelydeliverSBIRTtothosewithalcoholdisorders;and(2)provideathree-partevaluationofthetrainingefforts.TheformerSpecialAdvisormanagedthedevelopmentofasubcontractwiththeUniversityofCalifornia,LosAngeles,IntegratedSubstanceAbusePrograms,whoprovidedthetrainingsandevaluation,andexecutedaseparateagreementwithHarbageConsultingtosupportDHCSwithoutreachandongoingcommunicationwithproviders.TheSpecialAdvisorsupportedthegrantobjectivesfromOctober2014-June2015.


ObesityPreventionBackgroundIPHI,inpartnershipwithDHCS,isdevelopingandtestinga5-year(2015-2020)obesitypreventionproject,calledKoaFamily(formerlyknownasProjectConnect),toreducetheriskandprevalenceofobesityandprojectedhealthcarecostsamonglow-incomeCalifornians.ThisprojectisfundedbytheUnitedStatesDepartmentofAgricultureSupplementalNutritionAssistanceProgram-Education(SNAP-Ed)andCALFIRE,inpartnershipwiththeCaliforniaDepartmentofSocialServices.FormativeResearchBetween2015and2016,allformativeresearchwascompletedforKoaFamily,includingareviewofsystematicreviewsofobesitypreventionandmanagementliterature,keyinformantinterviews,focusgroups,andvideoethnographies.Allresultsfromtheformativeresearchcanbeaccessedat:http://www.dhcs.ca.gov/formsandpubs/publications/Pages/Obesity-Prevention-Project.aspx.ProgramDevelopmentandEvaluationPreparationBasedupontheformativeresearch,theteam,ledbytheCPO,hasdesignedtheinterventionandevaluation,selectedlow-incomemothersasthetargetaudience,andispreparingtoconductaRandomizedControlledTrial(RCT)andeconomicevaluationtotesttheeffectivenessoftheintervention.Atthecoreoftheintervention,KoaFamilyisgroundedinwholeheartedliving,avalues-orientedapproachtolifethatcentersonauthenticity,wherevaluesconstituteanindividual’sguidingforce.Wholeheartedlivingtoucheseveryaspectoflife,fromeatingnourishingfoods,toenjoyingenoughphysicalactivity,tohavingsupportoffamilyandfriendsingoodandchallengingtimes,tojoiningtogetherwithneighborstostandupforpositivechanges,andmore.Unfortunately,formanylow-incomeCalifornians,theideaofwholeheartedlivingisanaspirationandnotareality.KoaFamily:Strong,Healthy,Wholeisanapproachdesignedtomakewholeheartedlivingavailableforall.KoaFamilyisa6-monthjourneytoestablish“micro-communities”ofmotherssupportingoneanotherinhealthy,wholeheartedliving.Thefoundationofthisapproachisanew,custom-designedWholeHealthProgram(WHP)thataddressesmind,body,andspirit.Low-incomemotherslivinginthesamecommunitywillmeetweeklytoexperiencehowtocultivatewholeheartedlivingthroughhealthfuleating,physicalactivity,mindfulnessandmeditation,copingwithstress,connectingtolocalresources,buildingagrowthmindset,andmore.Thegoalistosupporthealthierandmoreresilient,mindful,andempoweredmothers.Theweeklyexperienceswillprovideasafeplaceandtouchstoneformothersto


navigatetheirjourneys.Theweeklyexperiencesareinformed,inpart,bytheCentersforDiseaseControlandPrevention’sNationalDiabetesPreventionProgram,FamilyHui,SNAP-Ed,andnewapproachesbytheIPHIandDHCSteam.Thispartoftheinterventionhasbeendevelopedandrelevantcomponentshavebeenfieldtestedwithlow-incomemothers.MothersintheWHPwillreceiveadditionalencouragementandaccesstolocalresourcesthroughatextmessagingcampaign.AsecureFacebookgroupwillserveasavirtualmeetingspaceformotherstocontinuetheirjourneysbeyondtheweeklysessions.Finally,motherswillbeinvitedtotakepartinaneighborhoodtreeplantingcampaigntocreatereal,long-lasting,healthychangestotheenvironmentinwhichtheylive.Thisactivitywillalsobuildempowermentamongtheparticipantsandfosteragrowthmindset.TheteamisintheprocessofcompletingthecommunicationarmoftheinterventionandtheCPOsecuredfundingfromCALFIREtosupportthetreeplantingandstewardshipeffort.KoaFamilywillbeintroducedintheMackRoadneighborhoodofSacramentoandtheCityofWoodlandfromFebruary-August2019.Itwillbeevaluatedforeffectivenessamong190low-income,SNAP-EdeligiblemothersusingaRCTstudydesign,thegoldstandardofevidence.OutcomesincludechangesinBodyMassIndex,diet,physicalactivity,andqualityoflife,measuredat3,6,9,and12monthsfrombaseline.Aneconomicanalysiswillassessthecost-effectivenessofKoaFamily,whilequalitativemethodswillidentifymediatingfactorsrelatedtothestudyoutcomes.TheIPHIteamhasdevelopedandfieldtestedtheevaluationinstruments,andhasdevelopedallrecruitmentmaterials,screeners,andconsentforms.Theyalsosecuredapprovalforthestudyprotocolfromthestate'sCommitteefortheProtectionofHumanSubjects(CPHS)onJanuary11,2018.AnamendmenttotheCPHSapplicationdescribinganewqualitativecomponentwasapprovedJune19,2018.Inaddition,theteamobtainedapprovalfromtheUniversityofCalifornia,DavisInstitutionalReviewBoardonJune29,2018.TheteamwillcontinuetoprepareforthelaunchoftheRCTandcoordinateallstudylogisticswiththeirevaluationpartner,Westat;WHPpartner,Lead4Tomorrow;communicationpartner,MarketingbyDesign;andtreeplantingpartner,DaveyResourceGroup.AftertheinterventionendsinAugust2019andthe9-and12-monthfollow-updatacollectionhasbeencompleted,theteamwillanalyzethedata,createareportofthefindings,andidentifyrecommendedactionstepstoinformevidence-basedpracticeandpolicyatthelocal,state,andnationallevels.

KoaFamilyPresentationsMembersoftheKoaFamilyteamhavepresentedtheformativeresearchandinterventionapproachattwoSNAP-Edconvenings,alegislativebriefing,andtwoAmericanCollegeofPreventiveMedicineConferencesfrom2016-2018.


DeliverableHandIEvaluateandanalyzethedeliveryofclinicalpreventiveservices;developandimplementstrategiestoimprovenetworkperformanceinqualitymeasuresinthisdomain.Identifyandencourageadoptionofeffective(i.e.,improvehealthwhilereducingcost)populationhealthstrategiesbyDHCScontractedplans,includingbutnotlimitedto:recommendationsforastandardizedHealthRiskAppraisal,minimumstandardsofpreventivecare,andrecommendationsforhowtheeffectivenessandutilityoftheseservicescouldberoutinelymonitoredandevaluated.OutcomesMedi-CalManagedCarePlanHealthPromotionSurveyTheCPO,CQIC,formerQS,formerDHCSMedicalDirector,andaformerDHCSAnalystconductedastudytoinventoryhealthpromotioninterventionsdeliveredthrough21MCPs;identifyattributesoftheinterventionsthatplansjudgedtohavethegreatestimpactontheirmembers;anddeterminetheextenttowhichtheplansrefermemberstocommunityassistanceprogramsandsponsorhealth-promotingcommunityactivities.ResultsshowedthathealthpromotioninterventionsjudgedtohavethegreatestimpactonMedi-Calmembersweredeliveredinvariousways;educationalmaterials,one-on-oneeducation,andgroupclassesweredeliveredmostfrequently.Behaviorchange,knowledgegain,andimproveddiseasemanagementwerecitedmostoftenasmeasuresofeffectiveness.Acrossallinterventions,medianeducationalhourswerelimitedandmedianMedi-Calmemberparticipationwaslow.Mostinterventionswithgreatestimpactfocusedontertiaryprevention.Thereweremixedresultsinreferringmemberstocommunityassistanceprogramsandinvestingincommunityactivities.Amanuscript,titledHealthPromotionInterventionsforLow-IncomeCaliforniansThroughMedi-CalManagedCarePlans,2012,waspublishedinPreventingChronicDisease,November2015(http://www.cdc.gov/pcd/issues/2015/pdf/15_0269.pdf).TherecommendationsfromthestudysuggestthatDHCSshoulddetermine:(1)howMCPsassesshealthrisksamongMedi-Calmembersandhowrisk-relateddataareusedtoinforminterventiondelivery;(2)thebestapproachtosetQItargetsandaccountabilitysystems,startingwiththeleadingcausesofpreventablemortalityandillness,toensurethatevidence-basedinterventionsaredeliveredtoMedi-Calmembersinatimely,prudent,andeffectivemanner;(3)methodstooptimizethedeliveryoftheUnitedStatesPreventiveServicesTaskForceAandBrecommendationsandotherevidence-informedbestpracticeinterventions;(4)opportunitiestoensurethathealthcareandcommunitypreventioneffortsareavailable,integrated,mutuallyreinforcing,andaddressmultipledeterminantsofhealth;and(5)methodstoimplementamonitoringsystemfortrackingthedeliveryand


performanceofhealthpromotioninterventions.Suchasystemcouldhelpdecision-makersdeployresourcestothemosteffectiveprogramswhilecurtailingineffectiveprograms.TheCPOandformerRCattendedquarterlyHealthEducation,CulturalandLinguisticsWorkgroup(HECLW)meetings,representingallMCPs,andengagedindiscussionswiththeHealthEducatorsandothersonthebestwaystoadvancethefiverecommendations.StayingHealthyAssessmentTheCPOandformerRCconductedareviewoftheDepartment’sversionofaHealthRiskAssessment,calledtheStayingHealthyAssessment(SHA),whichisadministeredbyproviderstoMedi-Calmembers.TheCPOandformerRCworkedwiththeformerDHCSMedicalDirectorandmanagedcarestafftomodernizetheSHAbyidentifyingandprovidingacoresetofvalidandreliablequestions.TheformerRCalsoparticipatedinHECLWmeetingstoredesigntheSHA.Medi-CalManagedCarePlanPerformanceonHEDISMeasuresTheCQIC,workingwiththeCPOandformerQS,analyzedMCPHEDISperformancemetricresultssince2005.Ofthe40measuresforwhichdatahadbeencollected,datawereavailablefor17measuresthathadnotchangedinhowtheywerecalculated,werestillbeingmonitored,andhavefiveormoreyearsofresults.Usingathree-yearmovingaverage,thesedataweretrackedovertimeandshowedoverallmixedresultswithfewexamplesofclearlyimprovedoutcomes.TheCQICpresentedthesedatatomorethan200MCPrepresentativesatameetingoftheCaliforniaAssociationofHealthPlansonFebruary24,2016.DeliverablesJandKFosterpartnerrelationshipsbetweenDHCSandmembersbystrongbi-directionalcommunicationwithrespecttoneeds,responsibilities,andpreferencesrelatedtohealthylifestyle.Designastrongmembereducation,communication,andinterventionplatformthatdrivesimprovementinpopulationhealth(e.g.,arobustwebsite,theuseofsocialmedia).OutcomesWelltopiabyDHCSFacebookPageTheCPOledefforts,withsupportfromateam,tobuild,pilottest,andimplementaDHCSwellnessFacebookpage,titledWelltopiabyDHCS.ThepurposeoftheFacebookpageistoengageCalifornians,especiallymothers,intheirwell-beingandtohelpthemrealizetheir


full,healthfulpotential.Italsocreatesaspaceforcommunitymemberstosharetheirideasaboutwholeheartedliving.TheSMSandformerDHCSAssistanttotheMedicalDirector,CamlynMcCracken,developedpostsfortheFacebookpagewithoversightfromtheCPOandformerDHCSMedicalDirector.TheFacebookpage,locatedatwww.facebook.com/DHCSWelltopia,waslaunchedonApril24,2013,withthegoalofachieving10,000“likes”byDecember31,2013.Theinitialgoalwasexceeded,aswereallannualgoalssetthereafter.Thepagecurrentlyhasover114,000“likes”and112,000followers.PopulationHealthImprovementWebsiteAsaresultoffeedbackreceivedfromroundtablediscussionswithlow-incomeCaliforniansinAugust2013,theCQIC,CPO,andIPHI’sChiefAdministrativeOfficer(CAO),AllynFernandez-Ami,MPH,secured$50,000fromtheCaliforniaHealthe-QualityProgramtodevelopandimplementapopulationhealthimprovementwebsitethatsupportsWelltopiabyDHCSandenhancestheavailabilityofpreventionandwellnessresourcesforMedi-Calmembers.Thewebsite,foundatwww.MyWelltopia.com,launchedinFebruary2015.Thewebsitefeaturessixareaswhereuserscanfinduseful,trustworthyinformation,includingWellBody,WellMind,WellSpirit,Jobs&Training,HealthCare,andBasicNeeds.TheSMSandformerRCcontinuouslymonitoredandevaluatedthesite'sactivityusingGoogleAnalyticsinordertoassessthesite'sreachandusefulness.Thesitereceivedpositivefeedbackandattractedattentionandcontentfromlocalandstatepartners,includingtheCaliforniaDepartmentsofPublicHealthandSocialServices.Thesitehasreceivedover88,675pageviews.Thewebsite’ssuccessandhigh-qualitywasrecognizedwiththeDigitalGovernmentAchievementAward,2015fromtheCenterforDigitalGovernment,Government-to-CitizenStateGovernmentCategory:http://www.govtech.com/cdg/digital-government-achievement/Best-of-the-Web--Digital-Government-Achievement-Awards-2015-Winners-Announced.html.ChoosingWisely®PublicDeliberationswithMedi-CalMembersFrom2015-2016,theCPOchairedtheCenterforHealthcareDecision’s(CHCD)DoingWhatWorks(DWW)AdvisoryCommittee,whichpartneredwiththeChoosingWisely®initiativetoengageMedi-Calmembersandthosereceivingcommercialinsuranceinapublicdeliberationprocessaboutoveruseandmisuseofmedicalservices.ThepartnershipbetweenDHCSandCHCDrepresentedthefirsttimeDHCSengagedMedi-Calmembersusingapublicdeliberationprocess.TheCPOco-authoredamanuscriptdetailingthedeliberationprocessandoutcomes,titledAssessingSocialValuesforCalifornia’sEffortsto


ReducetheOveruseofUnnecessaryMedicalCare.ThemanuscriptwaspublishedinHealthExpectations,November2017:https://onlinelibrary.wiley.com/doi/full/10.1111/hex.12644.DeliverableLSupportastrongpreventionfocusacrossallDHCSprograms.OutcomesDeliverablesA,D-E,G-K,andMdemonstrateIPHI'seffortstosupportastrongpreventionfocusacrossDHCSprograms.DeliverableMProvideexecutive-levelstrategicadvice,thoughtleadershipandtechnicalassistancethroughin-person,teleconferenceandothermeans.OutcomesTheIPHIteamprovidedexecutive-andprogram-levelstrategicadvice,thoughtleadership,andtechnicalassistanceinthefollowingareas:

• TheCQIC(KennethW.Kizer,MD,MPH)metwithDHCSleadershipandstaffregularlyforstrategicandtacticaldiscussionsonallaspectsofMCQuIP,andprovideddirectiontotheCPO.

• TheCPO(DesireeBackman,DrPH,MS,RD)metwithDHCSleadershipandstaffdailytoprovideleadershipandsupportontheQualityStrategy,preventionandhealthpromotionsystem-wide,obesityprevention,membercommunicationapproaches,researchandevaluation,andIPHIadministrativematters.Shealsoprovidedday-to-dayoversightoftheRS,PE,SMS,andallformerteammembers.

• TheCAO(AllynFernandez-Ami,MPH)providedtechnicalassistanceandfiscalmanagementoftheIA.

• ThePE(OrionStewart,PhD,MUP)providedsupportonallaspectsoftheobesitypreventionproject,withanemphasisonprogramevaluation,andadvisedonQI.

• TheSMS(RachelRobins)providedsupportforallIPHIprojects,withanemphasisonhealthpromotioncommunication.


DeliverableN:ProvidethoughtleadershipandanalyticalsupporttoadvanceDHCSpoliciesandprograms,suchastheCaliforniaStateInnovationModelgrantandthe1115Waiver.OutcomesLet’sGetHealthyCaliforniaandCaliforniaStateInnovationModelTheCQICservedasamemberoftheGovernor’sLet’sGetHealthyCaliforniaTaskForce,andtheCPOprovidedstaffsupportonDHCSassignmentsrelatedtotheTaskForce,includingweeklymeetingsandhealthindicatordevelopment.TheLet’sGetHealthyCaliforniaTaskForceFinalReportwasreleasedDecember12,2012(http://www.chhs.ca.gov/LGHC/___Let%27s%20Get%20Healthy%20California%20Task%20Force%20Final%20Report.pdf).TheCPOservedasaDHCSliaisonfortheCaliforniaStateInnovationModel(CalSIM)Workgroup—LivingWell:PreventingandManagingChronicDisease.TherecommendationsfromthisandfourotherworkgroupswereusedtoinformthedevelopmentofaStateHealthCareInnovationPlanproposal.TheCPOalsoservedonaCalSIMworkgrouptodefinetherolesandresponsibilities,skillsandcorecompetencies,andreimbursementoptionsforCommunityHealthWorkersinthehealthcaresystem.Inaddition,theCQICservedastheprincipalinvestigatorandseniorscientificadvisorontheCalSIMPlanningGrant(throughaninteragencyagreementwiththeCaliforniaHealthandHumanServicesAgency)andprovidedfeedbackontheinnovationplanproposal.FurthereffortstoadvanceDHCSpoliciesandprogramsPleaserefertodeliverablesA-MforadescriptionofIPHI’scontributionstoadvancingDHCSpoliciesandprogramsinmultipleareas,includingthe1115Waiver.