Forward Together Partners in advancing healthcare quality and value

Report to the Community 2009–2010

Dear Friends,

As an organization committed to

improving healthcare quality and

value, Qualis Health has always

looked forward.

It has become increasingly

clear that the vision guiding our

work in recent years is squarely

aligned with the contemporary

transformation of American

healthcare. Even before the

passage of the Affordable Care

Act in 2010, a number of Qualis

Health’s key strategic priorities

emerged as leading themes in

healthcare transformation.

A few examples of these

priorities and initiatives include:

• A major emphasis on

implementing health

information technology

(HIT), including electronic

health records (EHRs) and

Medicaid Management

Information Systems (MMIS).

• Groundbreaking initiatives

to support accelerated

implementation of the

patient-centered medical

home (PCMH) model of

primary care, particularly

in clinics that serve as a

safety net.

• Application of cutting-edge,

evidence-based strategies

to improve quality, enhance

patient experience and

control costs for millions

of Americans through our

contracts with public- and

private-sector clients across

the nation.

As organizations rethink how

they deliver care, our work

over the last two years is giving

our clients a head start in areas

that are crucial to success

in America’s changing

healthcare environment.

Recognized for excellence

While our primary objective is

to provide value to our clients

from their own perspectives,

I am particularly proud that the

efforts of our superb staff have

resulted in considerable external

recognition for our work since

our last report. We value

this independent confirmation

that we are serving our

communities in partnership

with clients, providers, patients

and other key stakeholders.

The next chapter

No one can predict with certainty

how the transformation of

American healthcare will proceed

as reform takes hold, but there

will doubtless be significant

challenges as well as enormous

opportunity. At Qualis Health,

we continue to look forward with

our partners in order to overcome

the challenges and transform

opportunities into success.

With gratitude to everyone we

have served and with whom we

have collaborated, we are proud

to share some of our recent

accomplishments in this report.

We could not have achieved

them alone.

Sincerely,

Jonathan Sugarman, MD, MPH

President and CEO

Qualis Health

Mission

To generate, apply and

disseminate knowledge to

improve the quality of healthcare

delivery and health outcomes.

VisionTo be recognized for leadership,

innovation and excellence in

improving the health of

individuals and populations.

Core ValuesIntegrity and Professionalism

Collaboration

Stewardship

Qualis Health Services

Care Management

We provide a suite of care management services

(also known as “medical management”) to support

cost-effective, patient-centered, high quality care.

Utilization Management: We help our clients to be

responsible stewards of healthcare resources by

avoiding overuse, misuse and underuse of health

services. Utilization management assures that

patients receive the right care, in the right setting,

at the right time.

Case Management: Our case managers guide

injured and ill patients as they navigate through

a complex healthcare system to obtain care.

Case management is a systematic approach that

includes careful assessment of an ill or injured

person’s unique healthcare needs, individualized

care planning, removal of barriers to the receipt

of appropriate medical and social services and

continuous monitoring to assure the best

possible outcomes.

Healthcare Quality, Safety and Efficiency Consulting Our consultants and multidisciplinary teams

assist healthcare providers, institutions and policy

makers to make positive, transformational changes

to more efficient, effective healthcare delivery

systems and models. Our approaches emphasize

the design of lean, reliable workflow and

patient-centered processes.

Health Information Technology (HIT) Consulting We provide consulting services to assist

providers, healthcare facilities, government

agencies and others to leverage health information

technology in order to improve care delivery,

to support effective business operations and to

comply with regulatory requirements. We help

clients plan and implement technology solutions

ranging from electronic health records in

physician offices to statewide Medicaid

Management Information Systems.

Recognized for Delivering ResultsWe are proud of the awards and accolades that Qualis Health has recently received for the work we do to

advance healthcare quality and value on behalf of our clients and their patients—and we share this recognition

with our partners across the healthcare community.

• Washington State Quality Award: Leadership Level

• Case In Point Platinum Award: Medicaid Case Management Program

• Case In Point Platinum Award: Utilization Case Management Program

• MarCom Award: Platinum and Gold Winner

• Seattle Business Magazine: 100 Best Companies to Work For

CASE IN POINT

Transforming Safety Net Clinics into Patient-Centered Medical Homes Bringing to life a new model of comprehensive primary care

The New Model for Primary Care

The patient-centered medical home (PCMH) model

represents the country’s shared vision for the future

of primary care. It reflects the goals of national

healthcare reform: greater access, higher efficiency

and quality care, improved patient experience and

provider satisfaction and better health outcomes.

Continuous and Team-Based Healing Relationships

Team-based care is foundational to the PCMH model.

In order to support a team-based approach, PCMHs:

• Establish and support care delivery teams.

• Link the patient to a provider and a care team

so that they recognize each other as partners

in care.

• Assure that patients are able to see their own

provider or care team whenever possible.

• Define roles and distribute tasks among care

team members to reflect their skills, abilities

and credentials.

• Cross-train care team members to maximize

flexibility and ensure patients’ needs are met.

Policymakers and providers are directing extraordinary attention to a new model

of care: the patient-centered medical home (PCMH). It’s a team approach to

providing comprehensive, coordinated primary care with a focus on the whole

person. In partnership with the MacColl Institute for Healthcare Innovation,

Qualis Health is leading the Safety Net Medical Home Initiative (SNMHI)—a

five-year initiative sponsored by The Commonwealth Fund, to accelerate

the transformation to the PCMH model in 65 practices serving vulnerable

populations in five states.

What happens when physicians,

nurses, medical assistants and

receptionists work collaboratively

in a well-aligned, cooperative

team? At Idaho’s Health West

clinics, higher patient satisfaction,

higher staff morale and lower

turnover are all a result of their

transformation to the team-based

PCMH model.

“There’s a traditional hierarchy

in the medical world,” said Mark

Horrocks, MD. “The doctor is ‘the

king’ at the top, with the nurse

below and the receptionist at

the bottom. When a patient

comes into this kind of setting,

all responsibility for care is

put on the doctor because

everyone else is afraid or feels

unempowered to participate.

When Qualis Health showed

what the PCMH team model

could mean for us, it was the

green light we needed to change.”

Within four months, the staff at

Health West’s Pocatello clinic

restructured its approach to

patient care—together. With

coaching from Teri Barker,

Medical Home Facilitator for the

Idaho Primary Care Association

(IPCA),* all staff members are

now working at the top of their

licensure—as a collaborative

care team that unites around the

patient. The IPCA is one of five

regional coordinating centers

selected by Qualis Health to

provide support to a network

of local clinics.

“If you want to offer the type of

preventive care that’s part of

the PCMH model, you need the

whole clinic to support it,” Barker

said. “Health West’s leadership

provided the environment for

everyone to feel comfortable

as equal partners.”

Health West has taken its

transformation beyond

its three clinics participating in

the SNMHI to include all six of

its locations in Southeastern

Idaho. Health West is a Federally

Qualified Health Center dedicated

to meeting the healthcare needs

of its community regardless

of ability to pay.

*The Idaho Primary Care Association also received support from the Idaho Blue Cross Foundation for Health.

Everyone can see the dramatic impact of

leading-edge technology in clinical settings such

as operating rooms and emergency rooms. But

information technology advances are just as vital to

making healthcare more effective and efficient on

the administrative side.

For state Medicaid agencies, HIT is crucial to

improving quality, increasing access and

controlling costs. To that end, Qualis Health is

helping these agencies in Alaska and Vermont to

design and implement their new Medicaid

Management Information Systems (MMIS), with

the goal of receiving federal certification.

Our information technology consulting division,

Outlook Associates, is helping both states usher

in the new generation of MMIS. In the past, MMIS

were primarily financial and accounting systems

for paying provider claims. Today’s MMIS provide

a more integrated, interoperable solution to

more broadly support the Medicaid program in

implementing healthcare reform initiatives.

In Alaska, we provide comprehensive technical

assistance to oversee MMIS implementation

and certification. We also work closely with

stakeholders to conduct user testing and ensure

change management, which is vital to successful

adoption of this new technology.

In Vermont, we support the planning and

procurement of the new MMIS. We provide a

variety of initiatives—from defining system

requirements to leading vision sessions that bring

together stakeholders to discuss how the new

MMIS can support the Medicaid program as it

implements healthcare reform.

Ultimately, the value of MMIS are larger than

any single state. They will enable the level of

data exchange required to support the Medicaid

Information Technology Architecture (MITA)—a

nationwide initiative to foster an integrated business

and IT transformation across the Medicaid enterprise.

Qualis Health will work with Medicaid agencies as

they migrate to MITA, making MMIS the central

information repository in supporting Medicaid with

standards that improve healthcare outcomes and

administrative procedures for Medicaid beneficiaries.

Qualis Health helps our clients leverage the value of health information

technology (HIT) to improve quality, control costs and increase access to care.

We bring a unique approach that combines technical expertise in HIT with a

track record of results in operational improvement and health system planning.

Adopting new HIT is a process that includes selecting, implementing and

optimizing technology to meet the business and clinical goals of the organization.

We focus on adding value every step of the way.

Leveraging Health Information Technology to Improve CareHelping states implement new Medicaid Management Information Systems

Helping Small Primary

Care Practices Master

Electronic Health Records

Electronic health records (EHRs)

are so integral to improving care

and costs that the federal

government provides Medicare

and Medicaid incentive payments

when eligible providers adopt

EHRs and achieve specific goals

of meaningful use. The transition

to EHRs can be daunting.

With funding from the U.S.

Department of Health and Human

Services, Qualis Health is leading

the Washington & Idaho Regional

Extension Center (WIREC)—one

of 62 centers around the country

helping providers to achieve

meaningful use of EHRs. We

bring a combination of national

insight and local expertise in

technical assistance and best

practices to advance rapid EHR

adoption and meaningful use.

Family/Patient Self-Management

Hospital Discharge

Physician and Community Continuity

Patient

Reducing Hospital Readmissions Through Better Care CoordinationLeading a patient-centered approach to care transitions

Improving care transitions as Medicare beneficiaries leave the hospital is vital

to better healthcare and cost control. With one in five Medicare patients back in

the hospital within 30 days, unplanned re-hospitalizations cost Medicare over

$17 billion annually. Through Stepping Stones: The Care Transitions Project of

Whatcom County, Washington, Qualis Health is working with community

partners to implement methods that enable safer, more effective transitions.

Care transitions coaching is just one of the proven methods that we provide.

Stepping Stones provides living proof that

when care transitions are supported with strong

coordination and communication, they are safer

and more effective for the patient. As part of this

federally funded initiative, a Qualis Health care

transitions coach recently helped a Medicare- and

Medicaid-enrolled patient with multiple chronic

illnesses who had been hospitalized nine times

in just 13 months.

Our coach began by working with a concerned

relative of the patient, who went from tears of

helplessness at the first meeting to feeling

empowered and able to support her loved one in

better managing her care. Over the course of a

month, our coach helped the patient and her

caregiver to master the four pillars of care

transition:* medication self-management, timely

follow-up care, recognizing the warning signs of a

worsening condition and using a personal health

record. Our coach also linked the caregiver to

community services for additional training

and support.

For seven months, the patient remained in her own

home and successfully avoided any return trips to

the hospital. In addition to improving her health and

quality of life, the care transition coaching resulted

in significant Medicare and Medicaid savings.

Nine typical re-admissions cost Medicare

approximately $84,000.

Reducing hospital readmissions is not just a

hospital problem, nor is the solution solely

a hospital responsibility. By engaging a community

of care that focuses on the patient, Stepping

Stones is at the forefront of care transition

management. The project, which runs through

2011, is an initiative of The Centers for Medicare

& Medicaid Services, which contracted with

Qualis Health. Local co-sponsors and partners

are PeaceHealth St. Joseph Medical Center, the

Northwest Regional Council and the Critical

Junctures Institute.

*Developed by Eric Coleman, MD from The Care Transitions Program.

Better Care Transitions by Design

Improved care transitions depend on solutions that

implement change in three domains: family/patient

self-management, hospital discharge and physician

and community continuity. All are centered on the

needs of the patient. The project structure of Stepping

Stones embodies this focus, which unites the family

and patient, physician and community and the

hospital to enable safe, effective care transitions.

This material was prepared by Qualis Health, the Medicare Quality Improvement Organization for Idaho and Washington, in part under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

Coordinating Care for Those at Highest RiskHelping patients make connections as they navigate through a complex system

Healthcare reform promises to improve access to insurance for people with

preexisting conditions. While insurance may improve access to care, patients

with complex medical needs will continue to require assistance with care

coordination as they navigate through the health system. Since 2007, we have

provided catastrophic and complex chronic condition case management, as well

as utilization review services, to meet the unique needs of the Washington State

Health Insurance Pool (WSHIP). Our goal: to improve outcomes and add value.

In Washington State, our

patient-centered approach to

case management can change

lives. Sometimes it even helps

save them.

In late 2008, one of our

case managers—a licensed

independent clinical social

worker with thousands of hours

of clinical practice—began

working with a patient who was

on a liver transplant waiting

list due to liver failure from

alcohol abuse. The patient also

suffered from diabetes, chronic

pain and depression.

Working closely with the patient,

our case manager developed a

supportive, trusting relationship

with her. She helped the patient

begin a multi-faceted treatment

plan established by her primary

care physician, which drew on

our partnerships with a wide

community of care providers

and case managers. Our case

manager conducted intricate

and frequent case coordination

contacts. By closely adhering

to the care plan, which included

psychiatric treatment, chemical

dependency outpatient treatment

services and a women’s

Alcoholics Anonymous (AA)

group, the patient’s liver lab

results began to improve.

Few recoveries occur in a

straight line. Our case manager

helped the patient deal with

a series of medical setbacks

and complicated surgeries,

supporting the patient’s

fundamental goal: to stay

alive. The patient returned to

AA and completed her chemical

dependency program. She

gradually recuperated, regained

her strength and sense of

humor and no longer

experienced depression.

This patient’s long-term medical

outcome has been excellent. Less

than two years after starting case

management, her liver lab results

were so dramatically improved

that she no longer requires an

organ transplant. She continues

to improve her general health

and maintain her sobriety.

Improving Outcomes,

Controlling Costs

In addition to improving

healthcare outcomes, Qualis

Health case management

helps the Washington State

Health Insurance Pool (WSHIP)

control costs. During the

2009–2010 fiscal years, our

services resulted in average net

savings of $9.4 million, with an

average return on investment

of $7.50 for every dollar spent

by WSHIP.

Serving the Public Good with Our Medicaid PartnersHelping Alaska’s kids and communities move forward

Our Medicaid experience in many states makes Qualis Health a valued partner

and collaborator in serving the interests of Medicaid enrollees and the public

good. As Medicaid introduces new eligibility requirements, categories of

coverage and delivery models, we are helping states ensure that significant

change leads to significant improvement in healthcare quality, value and access.

In our 2007–2008 report we

highlighted a bold initiative of the

Alaska Department of Health and

Social Services to “Bring the Kids

Home.” Through our Medicaid

Mental Health contract with the

state of Alaska, we help bring

home—and keep home—the

hundreds of children being

treated in out-of-state psychiatric

institutions. In the process,

we identify treatment options

and resources statewide and

control the state’s cost for

behavioral healthcare.

In partnership with Alaska’s

Division of Behavioral Health,

our care coordination program

has facilitated the development

and implementation of more

effective discharge plans. This

supports patients and their

families in making successful

transitions back to their homes

in Alaska.

In collaboration with out-of-state

treatment facilities, we reduced

the undesirable trend of sending

Alaskan children for psychiatric

care outside of their home state.

Since contract inception, the

number of children in out-of-state

psychiatric residential treatment

facilities has been reduced

by 62%.

The program’s success is a

testament to respecting the

importance of place. Qualis

Health has care coordinators

who live and work in Alaska. They

provide the geographic presence,

knowledge of local services and

cultural understanding essential

to successful discharge planning

and equitable care. They serve as

an important bridge back home,

helping to ensure that, when

children do come home, they are

more likely to receive care that

fully meets their needs—in their

own communities.

Keeping More Kids at Home

Since Qualis Health joined

the initiative in January 2008,

improved discharge planning

has advanced the trend that

everyone wants to see: fewer

children leaving their families

and communities for treatment.

FY 04 FY 05 FY 06 FY 07 FY 08 FY 09

0

200

400

600

800

Out-of-State Admittances

752

110

Dropped 85.4%

Locations

Anchorage, Alaska

Irvine, California

Boise, Idaho

Lincoln, Nebraska

Seattle, Washington

Qualis Health At A Glance

Senior Management Group

Jonathan Sugarman, MD, MPH

President and CEO

Marci Weis, RN, MPH, CCM

Chief Operating Officer

Jennifer Freeman, CPA

Chief Financial Officer

Mary Sellers, CCP, CPHIMS

Chief Information Officer

Foster C. “Bud” Beall Jr., MA

Vice President

Consulting Services

Outlook Associates

Michael B. Garrett, MS, CCM

Vice President

Business Development

Debra Naubert

Vice President

Human Resources

Joyce Shaw

Vice President

Corporate Communications

Board of Directors

Timothy Frazier, MS

(Chair)

Hugh Straley, MD

(Vice Chair)

Karl B. Kurtz

(Secretary/Treasurer)

Steven Burgon, JD

Andrew D. D. Craigie

Mabel Ezeonwu, PhD, RN

Hilke Faber, RN, MN

Ernest H. Kimball IV, MPH

Clara (Billie) Lewis, RN

Margaret Stanley, MHA

Lori Whittaker

PhD, MD, MPH, FAAFP

2009–2010 Revenue by Business Product

Care Management

Patient Safety & Quality Consulting

Health Information Technology

2009–2010 Revenue by Market Segment

Medicaid

Public Payers

Foundations/Nonprofits

Medicare

Commercial

Consolidated Revenue(in millions)

Partial Client List

• Alaska Department of Health and Social Services

• Centers for Medicare & Medicaid Services

• The Commonwealth Fund

• County of San Diego, Health & Human Services Agency

• Idaho Department of

Health & Welfare

• L.A. Care Health Plan

• Los Angeles County Department of Mental Health

• Motion Picture & Television Fund

• Nebraska Department of Health and Human Services

• Office of the National Coordinator for Health Information Technology

• Providence Health & Services Alaska

• REACH Healthcare Foundation

• Seattle-King County Department of Public Health

• Vermont Agency of Human Services

• Washington State Department of Labor & Industries

• Washington State Department of Social and Health Services

• Washington State Health Insurance Pool

• Washington Teamsters Welfare Trust

Financials

64%25%

11%

40%

25%

20%

9%

6%

2010

$33

2009

$30

2008

$29

2007

$24

2006

$23

Qualis Health

Corporate Headquarters

PO Box 33400

Seattle, Washington 98133-0400

(206) 364-9700 or (800) 949-7536

Fax (206) 368-2419

info@qualishealth.org

www.qualishealth.org