Like so many others, I was horrified at the brutal and senseless killing of George Floyd only to be brought back to that same, dark place just days later by the equally tragic death of Rayshard Brooks. It is hard not to engage in genuine soul searching in the wake of tragedies that have inflicted searing pain on the families and friends of these two men while bringing countless numbers of people into the streets of this country and around the world seeking - no, demanding - an end to the systemic scourge of racism.
My reflections have been both personal and organizational and I have found a measure of inspiration in the role that the Wisconsin Collaborative for Healthcare Quality can play in supporting this goal. Indeed, we are almost called to it by virtue of the organizational values that were established when WCHQ was created in 2003. Words such as "trust," "inclusiveness," "shared responsibility," "acknowledgement," and "transparency" take on a completely different connotation when placed in the context of the obligation we all must accept if we are to overcome what is often referred to as this country's "original sin."
Yet, we must do more than recite platitudes or hide behind abstract slogans; we must act. And act we have, as WCHQ made a bold and affirmative statement last September with the issuance of Wisconsin's first report on the extent of health care disparities - by race, ethnicity, and insurance - in ambulatory care. As we acknowledged at the time, the report by itself will not remove barriers to care; however, it is impossible to find one's way out of a dark place without a light to guide the path forward. We know that light opened more than a few eyes and we plan to shine it ever more brightly again soon.
Years ago, a colleague sent me off on a new career opportunity with the obligatory “best wishes” card in which she inscribed a quote from Johann Wolfgang von Goethe – “Knowing is not enough; we must apply. Willing is not enough, we must do.” We know what we must do. The staff at WCHQ stand prepared to join with our members, partners and other valued stakeholders in answering the call to eliminate disparities in pursuit of better health for all.”
- Chris Queram
Several changes will be made to the Fall 2020 measure specifications, most are related to blood pressure readings and types of visits. The Measurement Advisory Committee (MAC) has approved these new specifications after much deliberation and in consultation with the Blood Pressure Workgroup.
According to Matt Gigot, WCHQ's Director of Performance Measurement and Analysis, the measures being affected will now align with current national standards and Wisconsin's updated care delivery environment."
In summary, the changes made are numbered below:
- Controlled blood pressure threshold will now be <140/90 for all patients with essential hypertension, including patients aged 60 and over. This change will affect Controlling High Blood Pressure, Diabetes Care, and Ischemic Vascular Disease (IVD) Care measures.
- Home blood pressures and weights from patients will now be eligible readings. They can be provided digitally, in writing or verbally, and they need to be stored in the electronic medical record. The allowance for home blood pressure results will affect the Controlling High Blood Pressure, Diabetes Care and IVD Care measures. The allowance for home weight results will affect the Adult Body Mass Index (BMI) Control measure.
- Telehealth, telephone visits, and online visits/e-visits will now count as denominator eligible visits. This change will affect the Controlling High Blood Pressure, Diabetes Care and IVD Care measures. This change may be extended to additional measures pending recommendation from the Measurement Advisory Committee.
- The CPT visit code 99211 will now count as a denominator eligible visit. This change will affect all WCHQ ambulatory measures.
WCHQ members will now have more measures aligned with NCQA’s HEDIS measures and matching national guidelines, such as adding CPT code 99211 to measure denominators. In addition, blood pressure threshold of <140/90 for all adults with a diagnosis of essential hypertension follow American College of Cardiology and U.S. Preventive Services Task Force recommendations.
Home blood pressure readings are being encouraged by professional organizations, such as the American Heart Association and the Centers for Disease Control and Prevention. Capturing blood pressures at home can more accurately reflect a patient’s blood pressure and guide providers in appropriate medication prescribing. Thus, controlling blood pressure becomes more attainable. WCHQ acknowledges the role of the provider and health systems in managing their own policies on how and when home blood pressure readings are used and documented. Language was added within the measure specifications stating, “Accepting these BP results is at the discretion of the provider.”
The Blood Pressure Workgroup emphasized the importance of health systems to educate patients on using appropriate blood pressure monitors and validating the monitors in the clinic at least annually. Currently, stating whether the blood pressure reading was taken at home in a discrete field is not required. However, in the future, the MAC would like the ability to distinguish blood pressures between in-clinic and home readings. WCHQ staff will begin to work with members to ensure they have the technical capabilities to document if a blood pressure reading was taken at home.
The MAC was previously reviewing whether to include telemedicine visits in chronic disease measures before the current pandemic. However, COVID-19 certainly highlighted the need to more quickly adapt measures to the transitioned health care environment. In allowing telehealth, telephone visits, and online visits/e-visits, member quality reports will see less of a dip than might normally be seen under the pandemic circumstances.
Early Testing for COVID-19 Credited with Reducing Cases
Sixteenth Street Community Health Centers has an impressive reputation for providing high quality, accessible care to underserved populations. At no time has their relationship with the community been more critical than during the COVID-19 outbreak.
Sixteenth Street has always had a deep and trusting bond with the primarily Hispanic community on Milwaukee's south side, which is one of the most concentrated areas of poverty in Milwaukee. In the communities they serve, more than 65 percent of the residents are Hispanic, nearly a third live in poverty and about 16 percent are uninsured.
The work of Sixteenth Street to collect specimens and test people in their community was credited with slowing the spread of COVID-19 on the south side by Milwaukee Mayor Tom Barrett and Health Commissioner Jeanette Kowalik at an April 17 press briefing.
"My hat is off in a huge way to them (Sixteenth Street)," Barrett said referencing the clinic's testing efforts. "Their ties to that community are so strong and so deep that they've been able to focus."
President and CEO Julie Schuller, MD, said her organization stepped in early to provide onsite testing to those living on the south side of Milwaukee, a move she credits with reducing the number of cases. Testing and care is offered at the clinic to existing and new patients. The clinic asks those who think they need a test to call before coming in to be tested.
As of June 19, Sixteenth Street had collected 5,764 tests with 1,997 (35%) positive cases.
The Sixteenth Street staff have adapted their services to virtual platforms, which includes telehealth services for medical and behavioral health patients and bilingual Facebook live sessions in Spanish. They have also increased grass roots efforts to connect with residents. This includes going door to door to hand out educational materials, passing out masks in high trafficked areas and to local businesses and placing bi-lingual signage in the community that advises on safe practices to prevent spreading the disease.
“This pandemic has created substantial challenges for our community. Our ability to adapt quickly to the changing environment and focus on testing and education has been critical to keeping people safe,” Dr. Schuller said. “How care looks in the future may change. But our commitment to meeting the needs of our residents no matter the circumstance will remain unwavering.”
For more information about Sixteenth Street, go to: sschc.org
NOTE: If you are a data submitter to WCHQ and you would like zip code level COVID-19 Risk Reports, contact Mary Kay Fahey.
Adolescent and Child Health
WCHQ is supporting its members as they begin to reopen pediatric clinics and catch up on routine care of children and adolescents. WCHQ members met twice in June to discuss strategies, best-practices, and potential roadblocks when reopening pediatric clinics during the COVID-19 pandemic. Members reported that the continued use of telehealth has been a challenge as physical clinics reopen, requiring changes in both culture and workflow in order to continue the use of telehealth where appropriate. The steering team plans to hold additional discussions in July to share strategies and brainstorm best practices for encouraging the use of virtual visits.
The WCHQ Adolescent and Child Health steering team regularly monitors improvement on publicly reported measures as well as steering team-only measures. At the June steering team meeting, the team reviewed the Spring 2020 publicly reported data and improvement on the pediatric suite of measures, including well-child visits and immunizations for adolescents and children. The team also began brainstorming relevant education topics that will assist members in identifying improvement strategies.
For more information on WCHQ’s adolescent and child health work, please contact Abbey Harburn.
WCHQ is building a member-wide registry of health systems that have integrated behavioral health. The registry will describe the type of model or spectrum of integrated care at each health system and the tool used if tracking patient outcomes. With this information, members will better understand the behavioral health landscape in Wisconsin. Members can then ask questions or reach out to specific health systems that have implemented similar models of integrated care that they would like to implement. Adoption and expansion of integrated behavioral health might increase as members can more easily find peers for support and best practice sharing.
We continue to support members in their recovery through the COVID-19 pandemic. At the June 8 Behavioral Health Steering Team meeting, members shared details on plans for hosting in-person group therapy sessions while complying with using social distancing guidelines and actions to safely bring patients with severe mental illness or medication needs into the clinic.
WCHQ members are focused on supporting the mental health of their employees and care teams.
Froedtert and the Medical College of Wisconsin: Thomas Heinrich, MD, Professor of Psychiatry and Family Medicine and Behavioral Health Physician Champion Adviser, states they are supporting healthcare workers, including students, residents, and pharmacists, through virtual support groups and virtual one-on-one visits. Behavioral health staff are rotating hours where healthcare workers can call-in as needed for mental health support and to join group sessions. The behavioral health staff have also rolled out a primary prevention resiliency program for health care workers.
ProHealth Care: Jon Marschall, PsyD, Clinical Psychology in Behavioral Health Services, states they are putting together a task force for secondary stress to try identifying and reducing any preventable outcomes of COVID-19. This includes working towards resiliency building. Behavioral health staff are providing hour timeslots and support group sessions for mental health support for health care workers. Coping strategies include mindfulness and processing exercises.
Access Community Health Center: Beth Zeidler Schreiter, PsyD, Chief Behavioral Health Officer, states they are addressing the health and wellness of health care workers through various avenues and strategies. Behavioral health staff hold twice a week 15-minute lunchtime virtual sessions on mindfulness and meditation for all staff. The team created a gratitude tree for all staff to view and add their own written messages of gratitude on the tree leaves. Weekly Caring for Clinicians sessions are led by behavioral health staff with medical providers to provide support, debriefing, and collegiality. Wellness and resiliency are added to the agendas of all staff meetings, and wellness resources and links are updated routinely on their main organizational webpage for staff. For more information, contact Sarah Wright.
Chronic Disease: In-person Visits on the Rise as Telehealth Declines
WCHQ member health systems are diligently working to re-open clinics to provided needed care to patients who have been overdue for physicals and routine screenings, while making provisions to provide the safest possible care.
WCHQ members have implemented new processes, that include a requirement that staff wear masks at all times, patients are screened in advance of appointments and they have eliminated the use of waiting rooms. These changes are occurring rapidly and while providers increase face-to-face visits and continue to offer telehealth visits. While telehealth visits are declining, WCHQ members have recognized that they have played an important role in the patient care that will endure beyond this pandemic.
WCHQ member organizations are reporting a significant backlog of patients who are overdue for important tests and screenings. Clinics are prioritizing patients with chronic diseases and proactively reaching out to patients to schedule appointments yet these delays in care may impact quality of care measures. WCHQ recently published performance results for 2019 and noted that across WCHQ’s membership, diabetes Blood Sugar (A1c) Control measure showed a significant improvement from the six months prior, with more than 183,000 patients in control. This represents an increase of over 8,000 patients from the previous reporting period. Hypertension control rates remained stable; a significant feat given that WCHQ’s members perform consistently better than the national average . Going forward, WCHQ and its members are focused on ensuring patients receive the care they need to ensure continued positive outcomes.
WCHQ facilitates a regular meeting of members, the WCHQ Chronic Disease Learning Collaborative, which guides and supports improvement on diabetes and hypertension control. Future meetings will cover topics ranging from team-based care, self-measured blood pressure monitoring, addressing health disparities, as well as other topics. WCHQ members are welcome to join meetings at any time throughout the year. Contact Cara Winsand to learn more about the Chronic Disease team.
Oral Health Collaborative
The Oral Health Collaborative team is focused on COVID-19 issues related to teledentistry, emergency dental care and reopening offices. Procuring PPE is a major challenge in the dental community. All health care professionals, including dentists, will find this guidance document valuable on the proper procedures associated with decontaminating PPE. The Wisconsin Department of Health shared the guidance document with WCHQ in advance of it being sent directly to all licensed health care professionals.
The dental collaborative members have reviewed their unblinded, quality-of-care data reports and are planning a quality improvement project. The group expects to publicly report new oral health measures later this year.
If you are interested in learning more about the Oral Health Collaborative, contact Jen Koberstein.
For the past few months, WCHQ has been transitioning to a new product for Fall 2020 reporting. The old system - RBS - will be retired and in its place will be Data Voyager, a new product developed by a local Madison company, Symphony Care. The transition is underway and going well. WCHQ staff are currently reviewing the first drafts of Fall 2020 measures. A handful of members who have been piloting the new system have received their first data quality reports, which provide helpful insight into the completeness and cleanliness of submitted data.
The new platform offers several member benefits; including, multiple stages of data quality review, detailed patient level reports, and a highly configurable platform.
For more information contact: Jared Nishida
What's Next? July 9 - Telehealth with Dr. Dirk Steinert
Telehealth visits skyrocketed when the pandemic closed clinics. However, not all providers and patients had used telehealth and comfort levels with it vary.
On July 9, 12-12:30 PM Dr. Dirk Steinert, medical director of quality at Ascension Wisconsin will present "One Physician's Experience in Building Trust in a Telehealth Environment." Dr. Steinert will share best practices that evolved as he made "house calls" to his primary care patients. Read more about Dr. Steinert's experience here. Registration is open, direct questions to Mary Kay Fahey.
Two COVID-19 Focused Webinars: Epidemiology and Behavioral Health
The pandemic disrupted in-person education programming, but WCHQ quickly pivoted to respond to members' need for information related to COVID-19, telehealth and responding to the increased need for behavioral health services.
Dr. Nasia Safdar, medical director of infection control at UW Hospitals and Clinics and an internationally known infectious disease expert, presented WCHQ's June 8 webinar. Dr. Safdar COVID-19 and explained how various interventions can be useful in preventing the spread. She cautioned that this fall we could see COVID-19 converge with season flu, which will create an even greater need to test. Here is the link to this recorded webinar.
Neftali Serrano, PsyD, a widely respected behavioral health professional and health care leader, noted at a WCHQ June 22 webinar that behavioral health professionals had fewer challenges adapting their visits to the telehealth format than their medical colleagues. He said the telephone - without video - is more acceptable to some patients and more readily available, especially in remote areas or with patients who do not have smartphones. The recording of this webinar is here.
A huge proponent of integrating behavioral health into primary care, Dr. Serrano said it improves health system responses to increased mental health needs not just for patients but also for health system staff during times of crisis, such as COVID. Telehealth can be adapted to increase team efficiency and provider satisfaction, and integrated behavioral health should be the standard of care.
August 6 Live Webinar: "Addressing Intimate Partner Violence During the COVID-19 Pandemic"
The coronavirus has created isolation, job losses and increased stress levels. All these factors increase the risk of domestic violence, which has risen due to the coronavirus. Home, for some, can be a dangerous place.
Registration is open for “Addressing Intimate Partner Violence During the Pandemic,” a live WCHQ webinar August 6 at 1:00-2:00 PM with Dr. Stacy Ogbeide, a Board-certified clinical health psychologist. This learning session will focus on identifying, screening and referring to treatment for intimate partner violence, which will help clinicians address IPV in their practices during the COVID-19 pandemic.
Dr. Ogbeide is the director of behavioral health education and an associate professor with the family medicine residency at UT Health San Antonio. She is a proponent of integrating behavioral health into primary care settings and is highly regarded for her contributions to the profession, having received the Integrated Care Champion Award of the Missouri Psychological Association and an Early Career Psychologist Contributions Award from the Association for Psychologists in Academic Health Centers. For information contact Mary Kay Fahey.