Spotlight on Western New York
Monday, January 26, 2015
Western New York
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 Western New York Alliance.
A Community Helps its Most Vulnerable Citizens Battle Chronic Disease
The P2 Collaborative of Western New York’s Safety Net Care Coordination Initiative provides funding and support to eight Buffalo-area practices to help them use care coordination, in the form of one-on-one coaching with patients, to improve outcomes for diabetic patients. The program focuses on helping safety net practices improve the care received by Medicaid patients with diabetes, says Glenda Meeks, the P2 Collaborative’s manager for quality improvement system development. The Alliance chose to focus on diabetes care because the disease is a concern across Buffalo's safety net practices. 
A diabetes care coordinator meets one-on-one with patients and uses a motivational approach to encourage lifestyle changes. The care coordinators track appointments, medications, and blood sugar levels for patients in a practice’s registry. By working closely with diverse patient groups, frontline clinicians are helping patients with diabetes modify their diets, develop lasting exercise regimens, and change the way they manage their health. As part of the initiative, the Alliance collects monthly data reports from the safety net practices' electronic medical records, analyzes them, shares the results with the practices, and helps them identify additional opportunities for improvement.
Improving Primary Care with a PEA

The Western New York Alliance, led by the P2 Collaborative, has trained 850 health care providers within the last four years to improve quality and change the way health care is delivered in Western New York, transforming practices into patient-centered medical homes (PCMH). According to NCQA, “medical homes can lead to higher quality and lower costs, and can improve patients’ and providers’ experience of care.” The Alliance’s Practice Enhancement Associates (PEAs) have worked with providers to make process improvements within primary care practices to manage their patient populations struggling with chronic conditions, such as diabetes, and use electronic medical records to ensure evidence-based care is being delivered. The goal of the PEA program is to help primary care practices attain PCMH status through improvements in practice administration, information technology, and data collection. PEAs work on-site with primary care clinics to implement best practice principles in a way that works for them, providing new ideas and technical advice.

Creating Regional Partnerships to Improve Care Transitions Case Study: Western New York
Care Transitions of Western New York, under the leadership of  P² Collaborative of Western New York, united 10 regional hospitals and 8 community-based organizations located in 7 counties across Western New York. The goal was to improve the health of Medicare fee-for-service patients in Western New York who were transitioning from hospital to home. Through this program, the Alliance anticipated that participating hospitals would experience a reduction in the number and severity of avoidable readmissions. 
More than 50 trained coaches worked throughout Western New York on this initiative. During the first twelve months of the program, more than 280 patients received coaching services from local community-based organizations, out of approximately 1,200 eligible patients. Care transitions coaches collected readmissions data for patients in the program, and those who were not in the program but who were eligible to participate. P² Collaborative shared data during monthly phone calls with hospital leaders. By conducting case reviews with the partner hospitals, the Alliance learned what could be done differently to prevent readmissions and improve the quality of care.
Aligning Forces for Quality (AF4Q) is the Robert Wood Johnson Foundation’s (RWJF) signature effort to lift the overall quality of health care in targeted communities, reduce racial and ethnic disparities in health care and provide models for national reform. Alliance teams represent the people who get care, give care, and pay for care.
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