Aligning Forces for Quality (AF4Q) has been the Robert Wood Johnson Foundation’s signature effort to lift the overall quality of health care in targeted communities, reduce racial and ethnic disparities, and provide models for national reform. Minnesota became a focus of AF4Q in 2006; this month, after eight years of funding and milestones, the effort comes to an end.
AF4Q asked the people who get care, give care and pay for care to work together toward common, fundamental objectives to lead to better care. The 16 geographically, demographically and economically diverse communities that have participated in AF4Q cover 12.5 percent of the U.S. population collectively.
Minneapolis was chosen (and later expanded to Minnesota) as one of the four initial pilots in 2006. Minnesota has been a pioneer in the field of quality improvement and performance measurement. Since the early 1990s, we have focused on getting doctors, hospitals, insurers and others to measure the quality of care delivered in the state. With MN Community Measurement as the Minnesota AF4Q Alliance’s lead agency, and guided by a broad stakeholder group, Minnesota has been an ideal partner for AF4Q.
MNCM’s track record of bringing together those who give care, get care and pay for care made us an ideal organization to lead the Minnesota Alliance. Through AF4Q, we have served as a national model for quality measurement. Today, we bringing providers together to measure and assess everything from how doctors treat simple infections to how hospitals, physicians and other health care providers manage costly, chronic conditions such as diabetes and heart disease, as well as how well they communicate with patients.
Laying the foundation to improve the health of our community
AF4Q kicked off during a period of uncertainty, when quality measurement and improvement programs were largely still in their infancy. The community was asking Could we get buy-in? Who would fund measurement and improvement? How could we have meaningful impact that we so deeply sought?.
In this environment, AF4Q offered the structure from which Minnesota prospered. Each organization lent their expertise and leadership, oftentimes collaboratively, to:
- Launch and report on the nation’s first comprehensive statewide patient experience of care survey for clinics;
- Help avoid nearly 8,000 hospital readmissions through Reducing Avoidable Readmissions Effectively (RARE) Campaign;
- Plant and nurture the seed that grew into the national Health Care Home improvement;
- Develop and launch the nation’s first Total Cost of Care measure;
- Support the DIAMOND (Depression Improvement across Minnesota, Offering a New Direction) program, which has become a national model for treating depression through collaborative care; and,
- Release the nation’s first quality results segmented by race, Hispanic ethnicity, preferred language and county of origin.
Many of these initiatives had been trying to get off the ground; however, they required collaboration and alignment across organizations to succeed. Progress is not always straight and linear – it’s often messy. Despite this, the Minnesota AF4Q Alliance accomplished a substantial amount due to our highly-committed community organizations, medical groups and health plans that were all singularly focused on improving outcomes for patients.
“Credit goes to our community. There are some unique things about Minnesota that helped us be successful. Not that it can’t be done elsewhere – but the fact that we have a mix of larger and smaller medical groups that are committed, and the non-profit feel of the health care community, there’s good to be accomplished when we come together and share information,” according to MNCM President Jim Chase.
Working together to get it done
The AF4Q community pulled together quickly to tackle its first two priorities in Cycle One: consumer engagement and ambulatory care quality. With the goal of helping consumers more fully participate in their care by engaging with their health care providers, the Minnesota Consumer Engagement Work Group was formed to analyze best practices, conduct focus groups and publish the results and key learnings. During this time, Minnesota also began to develop new and more robust measures for physician and ambulatory quality reporting, with more than 180 health care professionals attending educational forums focusing on physician involvement in quality reporting. The voluntary patient experience measurement work also began, with nine medical groups, representing 123 clinics, participating in the first patient experience survey.
While, the work begun in Cycle One continued, new activities kicked off in Cycle Two that focused on reducing health disparities, and improving quality and safety. MNCM began collecting race, Hispanic ethnicity, preferred language and country of origin data directly from medical groups. Continuing to advance consumer engagement, new programs, measures and consumer tools were developed for depression, asthma, colorectal cancer screenings and diabetes. The D5 campaign also began to show decisive results as providers used the easy-to-understand concept to help patients recognize the importance of managing all five key health components to keep their diabetes in control.
With strengthened partnerships, new tools and increased trust with providers and consumers, the Minnesota AF4Q Alliance turned its focus to payment reform and the cost of health care in Cycle Three. MNCM developed the methodology specifications to implement a Total Cost of Care (TCOC) measure in 2012 by securing agreement from medical groups, health plans, economists and other stake holders on patient assignment, risk adjustment and methods of calculation. The RARE Campaign to engage hospitals and providers across the continuum of care was also launched by the Institute for Clinical Systems Improvement (ICSI), the Minnesota Hospital Association (MHA) and Stratis Health, with the goal of preventing 4,000 avoidable hospital readmissions statewide. Results of the first state-mandated survey on Patient Experience of Care were also released, with over 700 clinics participating and more than 230,000 patients completing the survey.
Moving into the final cycle, the Minnesota AF4Q Alliance continued to build on the milestones accomplished in previous cycles and completed several critical long-term projects – all with the emphasis on sustaining the momentum after AF4Q’s conclusion. MNCM released the nation’s first-ever report on TCOC in late 2014, which allowed consumers to compare the cost of care at medical groups across the state for the first time. And after years of overcoming challenges and encourage collection by medical groups, MNCM released a landmark Health Equity of Care Report in early 2015 with health outcomes for diabetes, vascular, and asthma care as well as colorectal cancer screening stratified by race, Hispanic ethnicity, preferred language and county of origin.
Several important multi-year projects that focused on developing new methods to improve the quality of care and to engage consumers concluded during Cycle Four:
- Bonnie Westra, a professor at the University of Minnesota, led a two-year project to develop content, tools and provide training on how to help consumers find and use quality health information online.
- ICSI wrapped up work on three initiatives: TCOC community building, RARE Campaign and improving patient experience in ambulatory settings.
- MHA concluded a sizeable project on hospital care transitions.
- Stratis Health developed guidance and trainings to disseminate the results and learnings of care transitions and readmissions initiatives across the state.
During the final cycle, AF4Q also provided additional funding as mini-grants to support five Minnesota AF4Q Alliance partner initiatives that further developed sustainable networks, supported consumer engagement and facilitated strategic alignment. Those projects were:
- Collective Action Planning – Included a community scan and report that detailed how community partners aligned mental health measures and activities.
- Community Health Worker Integration in Asthma and Mental Health Care – Increased awareness and adoption of team-based strategies among pediatric asthma care and mental health providers.
- Evaluation of Benefits and Burdens of Medical Group Performance Reporting – Strived to uncover the causes of data collection burden and document the benefits to providers who participate in health care measurement and reporting programs.
- Measures Lab Testing – Developed as an online platform to efficiently test newly-developed quality measures before they’re submitted for endorsement; proposed for inclusion in federal programs; or implemented to support quality improvement efforts.
- Multi-lingual Advanced Care Planning Resources – Created and translated patient education videos on completing and sharing advanced care planning into Somali, Hmong and Spanish.
Beyond Aligning Forces for Quality
Over the last eight years, AF4Q communities have built transformative partnerships, often where none existed before. Minnesota has been a key player in shaping AF4Q both through its work locally, as well as through its willingness to share learnings with other communities nationwide.
With the support of AF4Q, Minnesota has been able to springboard off our collective expertise and passion to make significant and meaningful change in our community. We are confident that Minnesota will continue to be a national leader in health, and health care measurement and improvement. Our partner organizations have a strong collaborative spirit and history of working together, as well as with other varied stakeholders, to achieve our collective goals. We will continue seeking impactful and collaborative ways to improve the health of all Minnesotans, both by guiding initiatives begun during AF4Q to their next breakthrough and by identifying new challenges faced by our community.
For more information on our AF4Q partners, milestones, and projects, read A State of Innovation: The Minnesota AF4Q Alliance’s Report to the Community.