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 Kansas City Alliance.

Almost 10 percent of American children have been diagnosed with asthma, and its prevalence is particularly high in minority populations. Kansas City health leaders are working together to tackle high pediatric asthma rates by building solutions to better identify and treat the condition. By working closely with children and their families, physicians, nurses, and community partners have been able to reduce the severity of asthma for children in a unique pilot program.

 

These efforts are led by the Kansas City Quality Improvement Consortium, one of RWJF’s Aligning Forces for Quality (AF4Q) communities, which has brought together providers, researchers, and patients to improve the way care is delivered in the region.

When an elderly patient or a patient with a serious or complex illness is discharged from the hospital, that person is particularly vulnerable. 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. Some patients have additional problems such as depression, social isolation, or a lack of housing or transportation that may increase their risk of 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.

 

Trent DeVreugd, director of Transitions of Care for the Kansas City Quality Improvement Consortium, meets with all partner hospitals in the transitions of care program about once a month to share data and discuss trends. They review monthly data on the percentage of Medicare fee-for-service patients who were eligible for the program based on diagnosis, how many accepted and declined enrollment, and which coaches have the most success enrolling patients. By collecting and analyzing data, care transitions programs can gauge whether they are achieving their program goal of reducing hospital readmissions for Medicare fee-for-service patients.