Remarks to the American Health Quality Association

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by HRSA Administrator Mary K. Wakefield

July 16, 2009
Washington, D.C.

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Thanks for the invitation to be here with you today.

I've been on the job at HRSA since March, and the weeks have passed in a blur. When President Obama offered me the job as HRSA Administrator, it was a challenge I knew I had to accept. I felt that the path of my life's work – in nursing, in rural health care and in public policy -- had trained and prepared me for it.

Where else but as HRSA Administrator would I have an opportunity to try to elevate and address the problems I've spent my career working on? HRSA's programs touch on all of them: access to care, quality of care, bolstering the health care workforce. It's all in HRSA:

• Our health centers provide first-class primary care to some of the neediest populations in America;
• Our Ryan White grantees provide some of the best care for people living with HIV/AIDS that can be found anywhere -- a model, really, for HIV/AIDS care worldwide;
• Our Maternal and Child Health experts lead the Federal government's efforts to fight infant mortality and improve the health of mothers and their children;
• Our health professions staff helps train and place health care professionals where they're needed most;
• Our rural health policy office provides financial and technical support to keep struggling rural hospitals open and work with them to strengthen the quality of care they provide; and
• Our transplantation staff helps save or improve thousands of lives each year by directing the country's organ donation, distribution and transplantation system.

And that's just a quick summary. Our annual budget is $7.2 billion. And President Obama and the Congress assigned us another two-year infusion of $2.5 billion through the Recovery Act. Of that total, $2 billion is targeted to health centers to expand services and operating hours, pay for capital improvements, and buy new equipment – including health information technology. Already we've awarded about three-quarters of the Recovery money to our health center grantees.

The remaining $500 million in Recovery Act funds will be invested in workforce development, because the President understands that we need more health care professionals if we're going to provide more health care:

• $300 million will go to the National Health Service Corps to put thousands more doctors, dentists, advanced-practice nurses and other professionals into our neediest communities in exchange for paying down their student debts.
• The other $200 million will be invested in health professions programs, with much of the funds flowing to colleges and universities to build institutional capacity and support qualified students.

If you knew HRSA's work in the past, you probably heard us called the “Access Agency,” and, certainly, getting medically underserved people into care is what we do. But that's only part of it. We want to make sure our patients have access to high-quality primary health care, care that is equal to any available.

HRSA has for many years been involved on a number of fronts to improve the quality of care we support through our thousands of community-based grantees, and we'll be intensifying those efforts while I'm administrator.

I see QIOs as natural partners in our quality improvement work. And I hope at the conclusion of my remarks you'll consider working with us more closely, because I believe that your agenda is also our agenda.

Our health centers have for decades been involved in activities to improve the quality of care they deliver to patients. In recent years, 90 percent of health centers have participated in Health Disparities Collaboratives, which bring together teams of health center staff – doctors, dentists, nurses, and social workers – to transform their systems of care by learning and then implementing better ways to work together, better ways to treat their patients.

The Collaboratives focus on improving care for patients suffering from a variety of chronic diseases: asthma, cancer, cardiovascular disease, diabetes and more.

Data collection and analysis of patient outcomes is at the core of the Collaboratives' work. Health centers track outcomes to test the value of the changes they implemented and made improvements as needed to boost results.

The kind of data collection and analysis that is at the core of the Collaboratives is standard operating procedure at health centers. Each year all of our grantees input information to the Uniform Data System (UDS) on patient demographics, services provided, staffing, clinical indicators, utilization rates, costs, and revenues.

Staff at our Bureau of Primary Health Care then reviews the data not only to ensure compliance with legislative and regulatory requirements, but to improve health center performance and operations. UDS data help to identify trends over time, and gives HRSA management vital information that we use to establish or expand targeted programs and identify effective services and interventions.

We have a subgroup of health center grantees that you may find especially interesting: our Health Center Controlled Networks.

These Networks are groups of health centers, partially funded by HRSA, that create a collaborative business relationship capable of implementing Health Information Technology among all their members. Members of the Networks work as a unit, using the technology to improve operational effectiveness and clinical quality by sharing management, financial, technology, and clinical support services.

They are natural partners in your work in that:

• They have extensive knowledge and expertise in analyzing the HIT needs of safety-net providers and in improving quality in the health center setting; and
• Many have centralized databases to make reporting and quality improvement easier.

The Collaborative model worked so well in improving the quality of care in health centers that we've expanded it to other realms.

Right now, we're concluding the first year of our Patient Safety and Clinical Pharmacy Services Collaborative, and we're about ready to expand its reach. This aim of this Collaborative, headed by our Center for Quality and our Office of Pharmacy Affairs, is to improve patient safety and health outcomes by integrating clinical pharmacy services into the care of patients with multiple chronic diseases like diabetes, obesity, and hypertension.

As with health centers, this Collaborative works by organizing community-based health providers into teams that learn ways to improve patient safety and health outcomes. Then they return home to implement those practices. To date, teams from 68 communities representing 210 health care organizations are involved in the Collaborative.

Already, in only a year, we've had remarkable, inspiring successes. A statewide team in Arizona led by the El Rio Community Health Center in Tucson recently won a Pinnacle Award from the American Pharmacists Association Foundation for their work in improving diabetes patients' blood pressure, blood glucose and cholesterol levels.

And in New Mexico, the QIO there, the New Mexico Medical Review Association, is an integral part of a Collaborative team working to improve communication between community pharmacists and primary care providers in an effort to improve patients' medication adherence. The target population is 600 high-risk patients with multiple chronic diseases such as diabetes, hypertension, and congestive heart failure.

We feel the Collaborative is a great initiative, with the potential to dramatically improve health care. We welcome and invite all QIOs to join us before the July 31 deadline for the second wave of the Collaborative. For more information, you can visit the PSPC website or call the PSPC co-directors Jimmy Mitchell, Office of Pharmacy Affairs, or Denise Geolot, Center for Quality.

In our Maternal and Child Health programs, we're about to extend the proven value of the Collaborative model to our Healthy Start grantees. Healthy Start projects combat disturbingly high infant mortality rates in 100 struggling communities across the country.

Again, we're going to form grantee teams to learn from each other in sessions designed to promote peer-to-peer learning and inter-team exchange. An Expert Work Group has been formed to improve the systems grantees currently use by implementing evidence-based practices and innovative, community-driven interventions.

We're calling this Collaborative the “Interconception Care Learning Community,” because its aim will be to impact pregnancies of high-risk women during their interconception period, commonly defined as 18 to 24 months between pregnancies. It's a critical time to modify risks such as disease, harmful health behaviors, and environmental hazards that can cause adverse outcomes for women and their infants.

We plan to kick off the Learning Community, which will run for three years, in early August.

Over the past five years, our Division of Services for Children with Special Healthcare Needs has also used the learning collaborative model to improve access to care for children and youth with special health care needs, youngsters who require care or services beyond the level of need for most children.

The learning collaborative model has been implemented in three Division programs: newborn hearing screening, epilepsy and medical home.

Twenty-five states have participated in the newborn hearing screening collaborative, and have reduced the number of infants with hearing loss due to lack of follow-up or lost documentation. This example of enhanced vigilance in quality efforts makes a dramatic case for ensuring health care and, thereby, quality of life for our children.

Improvement teams from ten states have worked on improving access to primary and specialty care for children with epilepsy, especially those living in medically underserved areas. These teams have focused on several key areas at the core of quality concerns: increasing the number of children referred to a pediatric neurologist in a timely manner; reducing the backlog of appointments for specialty providers; and increasing the percentage of parents who feel they are a valued and integral part of the care team.

And in MCH's medical home collaborative, primary care practices from 18 states worked on improving community-based services delivered through the medical-home model of care.

Quality also is an important part of Ryan White HIV/AIDS Program legislation, which actually mandates quality management programs in our HIV/AIDS Bureau. In direct technical assistance, the Bureau invests $1.5 million annually in the National Quality Center, which provides TA for HIV/AIDS grantees, and $1 million in HIVQual, a quality improvement program run by the New York State AIDS Initiative, which offers grantee TA and support on software that tracks quality performance.

In addition, over the past few years, HAB has worked extensively to develop quality measures for its grantees. This includes both clinical measures and measures for case management, oral health care, the ADAP drug assistance program, and systems-level measures for Part A and B grantees. Although grantees are not required to use these measures in their quality programs, they are certainly encouraged to do so.

The first five clinical measures are embedded in Client-Level Data, which are being collected for the first time this month. And we're working to embed the clinical measures within HIVQual, which I just mentioned, and in our CAREWare software.

HAB has also worked with the National Center for Quality Assurance to bring together national stakeholders to assure alignment of measures as other organizations, like CMS, adopt measures for HIV.

In addition, we've made quality improvement a key part of our rural health programs.

Over the past year we've made a concerted effort to create links between AHQA, the QIOs and our State Flex programs, which work with the 1,300 Critical Access Hospitals across this country.

Thanks to your efforts, we've had 63 percent of Critical Access Hospitals reporting at least one measure for “Hospital Compare” in 2006. That is all the more remarkable when you consider that CAHs get no financial benefit from reporting, unlike other hospitals under Medicare that do.

We hope that we can find additional ways for QIOs to work with Critical Access Hospitals in coming years by linking up with the 45 State Flex programs, which get on average about $500,000 a year to work with CAHs on a variety of quality improvement and performance improvement activities.

HRSA also funds the Small Health Care Provider Quality Improvement Grants. This program had been on the books for several years when the Institute of Medicine, in its 2003 Report, "Quality Through Collaboration," recommended that HRSA find funds to support it. We began with a pilot of 15 grantees, and it went so well that we've expanded it. Now we have 55 grantees focusing on improving outcomes for patients with diabetes or heart disease. The program provides support for projects to develop a disease registry and receive special training on disease management over a two-year project period.

On policy regarding the implementation and use of Health Information Technology, I feel confident that HRSA shares many goals with the QIO community:

• We want to see full adoption of Electronic Health Records among safety-net providers;
• We don't want to see adoption for adoption's sake – we want truly “meaningful use” of technology that advances health care quality, value, and eliminates disparities;
• We want to and are already working hard to provide technical assistance to safety-net providers. These efforts, led by our Office of HIT, disseminate advances in HIT and support policy that encourages use of HIT for tasks such as e-prescribing, information exchange, and reporting of measures.

HRSA grantees increasingly are adopting health IT to improve outcomes and reduce disparities. Besides the grantees I mentioned earlier, our Office for the Advancement of Telehealth has tremendous experience using long-distance electronic technology to diagnose and treat patients and spread best practices and other valuable medical information to distant sites.

In creating the Regional HIT Extension Centers funded under the Recovery Act, the expertise of HRSA grantees would be, I think, very helpful.

I'll conclude by restating what I said at the beginning: I think HRSA and QIOs are natural partners.

That may not have been the case to date, but we admire your work and want to explore more ways to collaborate in the future.

I hope my presence here today has helped persuade you that many opportunities do exist to build fruitful, working partnerships among QIOs, HRSA and our grantees. I hope also that you share our willingness to pursue those opportunities.

Thank you.