Aligning Forces for Quality (AF4Q) is the Robert Wood Johnson Foundation’s signature effort to lift the quality of health care in 16 diverse communities, reduce racial and ethnic disparities, and provide models for national reform. AF4Q brings together people who get care, give care, and pay for care to work together toward the shared goal of better health and health care.

 

Today's issue of Spotlight features the work of AF4Q's Humboldt County Alliance.

As patients move from one care setting to another, problems such as lack of follow-up care and miscommunication among clinicians often occur and can put patients at risk for serious complications and hospital readmission. Nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days, at a cost of more than $26 billion every year.

 

Since 2012, the Care Transitions coaching team at St. Joseph Health System in Humboldt County, CA, has been working to improve handoffs by serving as a liaison between the hospital staff and local safety-net primary care practices. Each member of the coaching team is assigned a group of local primary care clinics. The coaches contact the clinics by phone or fax to let them know when one of their patients has been admitted. The staff at the clinics can often assist with issues like medication reconciliation and provide important information about a patient’s clinical or psychosocial history that might not be evident when they’re admitted to the hospital—for instance, they might point out that a patient is in a treatment program for prescription pain medication dependence. 

The Humboldt Alliance’s work to improve public reporting and transparency in health quality metrics was recently featured in the Redwood Times. Aligning Forces Humboldt, in partnership with the Humboldt Del Norte Independent Practice Association, has launched a new webpage to help patients in Humboldt find the best primary care for themselves and their families. The webpage was designed to make it easy to search and compare primary care doctors' offices based on how well doctors provide certain aspects of care, services, tests, and treatments. 

 

"We hope that people will find information on the quality care page useful to find out more about health care in Humboldt County," said Melissa Jones, project director for Aligning Forces Humboldt.

In 2011, the California Health Care Foundation released a report of surgical rates of 13 procedures for selected hospital service areas (HSAs) across the state. The procedures, which are known to be “preference sensitive,” or “elective,” address conditions that could be treated with various interventions depending on the preference of the doctor and patient. The HSAs in Humboldt reported surgical rates more than 150 percent above the state average for six of the procedures. Informed by the data, a coalition in Humboldt County formed the Surgical Rate Project to look at the variation in elective surgical rates. Each surgery represents an expense to the individual and purchaser of care, time off from work, and a length of time devoted to recovery.

 

“A close examination of variation in surgical rates is useful in understanding how care is utilized and how our community may more effectively improve outcomes and lower costs. This project is a perfect example of how we can put the data to work to help transform and evolve our programming to create a healthier community,” said Melissa Jones, project director of AF4Q Humboldt.