A Newsletter for the HHQI Underserved Populations (UP) Network                       July 2014
UP Network Announcements
On August 1, 2014, the HHQI National Campaign will enter a brief static period to prepare for new and exciting enhancements that will launch soon. In the meantime you can continue to enjoy all of the archived tools and resources contained within the HHQI website. Please check back often as we will share details on the campaign's next phase as soon as they are available. No future UP Events are scheduled at this time. 
In the meantime, this is a great opportunity to listen to some of the interesting UP Networking Events you may have missed. The recordings are located in the UP Networking Event Archives.

Some of the topics include:
  • Caregiving
  • Care transitions
  • Collecting and using data
  • Disparities related to health, cultural, literacy, and poverty
  • Disease management (e.g., Alzheimer's, diabetes, compulsive hoarding, nutrition gaps)
  • Dual-eligible and working collaboratively with managed care
  • Hospice and palliative care
  • Mental health
  • Outcomes
  • Proactive measures for QI, surveys, and MAC audits


UP News & Highlights/Tools & Resources


The most vulnerable patients are still falling through the cracks or not the getting needed health care services to improve outcomes and health. Our broken health care systems don't meet the health care needs of all patients. There is no one setting at fault or who can improve the system alone. Unfortunately, we have been working in silos of care on different goals - until recently.

Healthcare reform is an exciting, but challenging time. There are great opportunities to work cross- setting(s) towards the IHI's Triple Aim goals of improving patient outcomes and satisfaction, improving care for all populations, and reducing healthcare costs.





So where do you start with reaching out to other organizations to create collaborative efforts?
Simple Tips for Creating Health Care Collaborations on page 21 of the Underserved Population Best Practice Intervention Package (BPIP) may jumpstart your brainstorming on creating collaborations. Decide on the specific setting and what partners you could you reach out to - think out of the box. The table below can help you get started with some simple ideas and resources.


 Collaboration Opportunities
In-Patient Settings
  • Hospitals
  • Nursing Homes (NH)
  • In-Patient Rehab Units (IRU)
  • Long Term Acute Care Hospitals (LTACH)
  • Possible topic areas
    • Focus on reducing hospitalizations or readmissions
    • Improve care transitions
    • Utilize post-acute care providers effectively



Post-Acute Care Providers
  • Emergent Departments & Urgent Care Centers
  • Primary Care Practices
  • Health Centers (including HRSA centers)
  • Area on Aging Associations (AAA)
  • Possible topic areas
    • Focus on reducing hospitalizations or readmissions
    • Improve communications
    • Utilize post-acute care providers effectively
    • Improve follow-up care
    • Address social/economical needs
  • Reach out to community and chain pharmacies to create a network
  • Request staff education sessions on high-risk or problematic medications, medication management solutions, reconciliation, etc.
  • Develop strategies to address community and patient issues:
    • Access including delivery
    • Adherence
    • Fall Prevention
    • Financial barriers
    • Medication reconciliation
      • Communication with physicians
Mental Health Centers
  • Research all available services
  • Discuss opportunities to bridge patients from one setting to the other
  • Troubleshoot for unmet needs
  • Share education cross both settings
    • Ex: Behavioral health topics, home health benefit, patient engagement strategies, etc.
Community Outreaches
  • Flu clinics
    • Include BP, glucose, or fall screenings
    • Provide other health education
Food Bank
  • Organize a food drive at the agency for donation
  • Offer education or create a list of healthy food donations or for disease specific boxes (e.g., Diabetic, Heart Failure)
  • Provide a list of local food banks with location, times, requirements, etc. to all potentially needy patients
  • Offer screening for food bank participants (e.g., BP, glucose) and offer education
Faith-Based Organizations
  • Establish contact person(s) at organizations
  • Discuss community needs and how the organization could assist
    • Ex: Transportation, clothing, food, housing, etc.
  • Offer screenings or education
    • Ex: Cardiovascular Health, Diabetes, Falls Prevention, Palliative and Hospice Care, etc.

  • Discuss collaborative and pilots with managed care organization
  • Develop relationships with Medical Assistance organizations to improve communication
  • Begin care planning for dual-eligible patients upon Medicare admission for seamless transitions and obtaining needed services
  • Create partnerships or internships to assist with education, research project, data analysis, assist with other collaborations, etc.
  • Find graduate students for home health focused project, thesis, and/or dissertation


For more information or to suggest future UP topics or speakers, please contact us at HHQI@wvmi.org.

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