A Newsletter for the HHQI Underserved Populations (UP) Network     |   March 2016

Welcome to the Underserved Populations (UP) Network e-newsletter, the UPDate. This quarterly newsletter provides several summaries of news and/or research that affects underserved populations which may include: Health disparities, underserved regions, dual-eligible, or small home health agencies.
Underserved Population (UP) Network Announcements

Save the Date
Underserved Populations (UP)
Quarterly Networking Event

"Long-Term Negative Effects of Trauma"
Thursday, April 21, 2016  |  2-3pm (ET)

Guest Speaker: 
Prestera Center
This activity is pending approval for Nursing (ANCC) and Social Worker (NASW) continuing education credits, which will be free for learners.

Did you miss January's UP Networking Webinar?

The 1-hr webinar provided insights and education related to how an enhanced discharge and rural transitions model can improve patient outcomes. Strategies need to incorporate patient's perspective and to build on community strengths to support a patient's transition back home and back into the natural systems of support.

Guest Speakers: 
Dr. Joseph Knapp, MD, International Heart Institute of Montana; Craig Ravesloot, PhD, Rural Institute, University of Montana; and Heidi Boehm, RN, BSN, St. Patrick Hospital, Montana 

UP Network Webinar Schedule:
All webinars will be held from 2-3pm ET. Unless specified below, topics for UP Network webinars on the following dates are to-be-determined. Check this page periodically for additional information as it becomes available, or subscribe to the UPDate to receive details and registration links as soon as they are available.

April 21*
Long-Term Negative Effects of Trauma
January 19
July 21*
April 20
October 20*
July 20

October 19

UP News & Highlights

April is National Minority Health Month 2016. The Office of Minority Health (OMH) is kicking off the theme "Accelerating Health Equity for the Nation." This issue of the UPDate takes a look at hospitalizations and certain factors affecting the underserved populations. 

Centers for Medicare & Medicaid Services (CMS) continues to focus on
reducing avoidable hospitalizations across all settings including home health. Not all admissions/readmissions are preventable but many can be avoided if we can address barriers patients encounter before, during, and after the hospitalization. 
Studies show certain factors such as "race, ethnicity, language proficiency, age, socioeconomic status, place of residence, and disability, among others-when tied to particular costly and complicated medical conditions such as heart failure, pneumonia, and acute myocardial infarction, to name a few-may be predictors of readmission risk and readmissions" (CMS, 2015). Additionally, CMS (2015) indicates that "minority and other vulnerable populations are more likely to be readmitted within 30 days of discharge for chronic conditions, such as congestive heart failure, than their white counterparts.

"Minority CHF patients often face a myriad of barriers to care that include those related to poor social support, living in low-resource or socioeconomically disadvantaged communities, lack of a usual source of care, limited English proficiency, health literacy, numeracy and general literacy, as well as issues of mistrust, and discomfort with self-engagement, to name a few" (CMS, 2015).

Key areas to assess and identify issues that are critical to reducing hospitalizations with your populations include:

Tools & Resources
HHQI Tools & Resources Related to the Identified Critical Issues (free)

  • HHQI Underserved Population BPIP - pp. 34-37
  • HHQI - many patient tools are available in other languages (Spanish, Chinese, Russian, & Vietnamese) - use the search button for the specific language to find what is available
Social Determinants:
Linkage to Primary Care/Usual Source of Care:
CMS's Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries (2015) provides hospitals (but relevant information for all healthcare settings) on what data to collect and to create an action plan on addressing the barriers that face your at-risk populations.  
Chartbook on Health Care for Blacks  provides a summary of trends across measures and health care for people who are African American.  
Medicare Learning Network Suite of Products for Rural Health Providers brochure provides various links for rural health communities.

Does your organization have any of these issues that are affecting your hospitalization rates? Consider developing a QAPI Plan around the issue.

Free tools to Develop a QAPI Performance Improvement Project (PIP) around Racially andt Ethnically Diverse Issues 
Also check out the Morbidity and Mortality Weekly Report (MMWR) Supplements: Volume 65 - Strategies for Reducing Health Disparities - Selected CDC-Sponsored Interventions, United States, 2016.
For more information or to suggest future UP topics or speakers,
please contact us at HHQI@wvmi.org.
Click here for more information about the HHQI National Campaign.
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This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-ADL-030216