Icare Program Report Improving Communications and Readmissions: Stories from Fourteen Rural Colorado Communities Presented by Colorado Rural Health Center

Home , East Spanish Peak

iCARE Program Report Improving Communications and Readmissions: Stories from Fourteen Rural Colorado Communities Presented by Colorado Rural Health Center

TABLE OF CONTENTS OPENING LETTER FROM THE CEO 1

ABOUT THE COLORADO RURAL HEALTH CENTER 2

HISTORY OF iCARE 3

CONTEXT: PFACS AND iCARE MEASURES 5

iCARE BY THE NUMBERS: CRITICAL ACCESS HOSPITALS 6

iCARE IN NUMBERS: 2018-2020 8

iCARE PARTICIPATING FACILITIES MAP FOR 2019 10

COMMUNITIES:

MT. SAN RAFAEL HEALTH CENTER 11

SPANISH PEAKS REGIONAL HEALTH CENTER 13

SAN LUIS VALLEY HEALTH 14

RIO GRANDE HOSPITAL AND CLINICS 15

HEART OF THE ROCKIES REGIONAL MEDICAL CENTER 16

SOUTHWEST HEALTH SYSTEM 17

RANGELY DISTRICT HOSPITAL 18

YUMA DISTRICT HOSPITAL AND CLINICS 19

MELISSA MEMORIAL HOSPITAL 21

SEDGWICK COUNTY HEALTH CENTER 22

SOUTHEAST COLORADO HOSPITAL 23

PROWERS MEDICAL CENTER 24

KIT CARSON COUNTY MEMORIAL HOSPITAL 25

KIOWA COUNTY HOSPITAL DISTRICT 26

CONCLUSIONS AND NEXT STEPS 27

OPENING LETTER FROM THE CEO

Numerous reports and publications show the struggles rural communities face with serving a population that is older, sicker and poorer than their urban counterparts. 73% of Colora- do’s landmass is considered rural, with 47 of the 64 counties designated as either rural or frontier, representing 721,500 people. In these areas, the median age is 43, compared to 40 in urban. 22% of adult rural Coloradans are considered obese, 7% of rural adults have diabetes, and 21% of rural kids live in poverty, compared to 11% in urban.

These statistics paint a grim picture of rural life and highlight a detrimental national narrative that needs to change. One step towards shifting these stories is by seeing, demonstrating and showcasing the good work being accomplished in our rural communities. Highlighting the “Power of Rural” is one of the reasons that the iCARE Program was created. When rural communities have the power to come up with solutions that work for their unique environment, innovation takes place and that innovation results in positive change. CRHC is proud of the work that our rural communities and staff have accomplished over the past ten years and know that more positive change will come through our rural community’s collaboration on the Colorado Rural Sustainabil- ity Network.

We hope you enjoy these stories showing how rural is able to demon- strate real change and cost savings through collaborative quality improvement. I like to say that rural can be summed up in one word: community.

Michelle Mills, CRHC CEO

ABOUT THE COLORADO RURAL HEALTH CENTER

The Colorado Rural Health Center (CRHC) was created in 1991 and serves as Colorado’s State Office of Rural Health (SORH) and Rural Health Association. Formed by a group of organizations to identify and address rural health needs in Colorado, CRHC is one of three SORHs in the nation that is structured as a non-profit organization. CRHC provides a variety of services and programs to assist rural hospitals, clinics, and emergency medical service (EMS) agencies, including Colorado’s 32 Critical Access Hospitals and 52 federally certified Rural Health Clinics, CRHC provides a variety of in addressing healthcare issues. services and programs to CRHC’s mission is to enhance assist rural hospitals [32 healthcare services in the state by providing information, education, CAHs], clinics [52 RHCs], and linkages, tools, and energy toward ad- emergency medical service dressing rural health issues. CRHC’s (EMS) agencies across the vision is to improve healthcare ser- State of Colorado. vices available in rural communities to ensure that all rural Coloradans have access to comprehensive, affordable, high quality healthcare.

An innovative leader in addressing rural healthcare issues, CRHC has provided operational, financial and quality improvement assistance to rural hospitals and clinics since its inception. CRHC offers a variety of programs for rural Colorado including:  Critical Access Hospitals (CAHs) and small rural hospitals- quality improvement and operations programs  Rural Health Clinics (RHCs) - compliance, operations and quality improvement programs  Rural health workforce programs  Outreach  Emergency Preparedness  Policy and Advocacy  Health Information Technology (HIT)

HISTORY OF iCARE

CRHC implemented the Improving Communications and Readmissions (iCARE) program in 2010. The program worked with CAHs and rural clinics across Colorado for over ten years to reduce readmissions, improve communications in transitions of care, and improve clinical processes, especially related to chronic disease. The communities engaged in this program had higher populations of patients over the age of sixty, treated patients with multiple chronic conditions, and typically served a higher rate of soci- oeconomically disadvantaged patients.

CAHs and rural clinics provide vital access to care in their rural communities, yet they are often overlooked in national and statewide healthcare initiatives. Additionally, many initiatives are designed for an urban environment. CRHC created iCARE as an opportunity to engage Colorado CAHs and their clinics in a statewide project aligning with national priorities, demonstrating sustainable improvements in reducing hospital readmissions and improving communication in transitions of care. The program highlights the unique characteristics of rural healthcare, the strengths of rural health facilities, and their capacity for innovation to meet the needs of their patients. iCARE began with nine CAHs and expanded two years later, in 2012, to include the RHCs affiliated with the hospitals. The focus and goals for clinics centered on quality improvement (QI) for chronic disease management, specifically diabetes, and addressing the clinic’s role in communications and reducing readmissions in partnership with the hospital. The most recent cohort of the program (February 2018-2020) involved fourteen “communities,” defined as a CAH and their rural health clinic(s).

HISTORY OF iCARE

In its ten years of operation, iCARE evolved with its participants to focus on topics that were relevant and timely. In its most recent iteration, participating CAHs focused on Inappropriate Emergency Department Utilization. Emergency Department (ED) visits are a high-intensity service and a cost burden on the healthcare system, as well as on patients. Some ED events may be attributed to preventable or treatable conditions that could be provided in the clinic. A high rate of ED utilization may indicate poor care management, inadequate access to care or poor patient choices, resulting in ED visits that could be prevented.1,2

For participating RHCs, the program’s focus turned toward patient and family engagement (PFE), and more specifically, establishing Patient and Family Advisory Councils (PFACs). This focus was identified because research over the last ten years has pointed to the important role that patients and families play in not only improving patient satisfaction, but in improving patient outcomes, such as shortening hospital stays, reducing falls, and improving safety of care.3,4 Leaders in healthcare have recognized that the roles of patients and families in healthcare delivery is essential for improving the patient experience and clinical outcomes, and for decreasing costs.3,4 This has been reinforced at the national level with the implementation of government programs designed to encourage healthcare organizations to report on specific quality measures, many of which relate specifically to patient engagement. 5

1 Dowd, B., Karmarker, M., Swenson, T., Parashuram, S., Kane, R., Coulam, R., & Moore Jeffery, M. (2014). Emergency department utilization as a measure of physician performance. American Journal of Medical Quality, 29(2), 135-43. http://ajm.sagepub.com/content/29/2/135.long. 2 Agency for Healthcare Research and Quality. (2015). Measures of care coordination: Preventable emergency department visits. https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/ measure2.html. 3 Bertakis, K.D., & Azari, R. (2011). Patient-centered care is associated with decreased health care utilization. The Journal of the American Board of Family Medicine 24(3), 229-239. https://www.jabfm.org/ content/24/3/229.full. 4 Charmel, P.A., & Frampton, S.B. (2008). Building the business case for patient-centered care. Healthcare Financial Management Association. http://pqcnc-documents.s3.amazonaws.com/fpe/ fperesources/BuildingBusinessCasePCCCharmelFrampton2008.pdf. 5 Kuhn, K.J., Mickelsen, L. J., Morimoto, L. N., Larson, D.B. (2016). The use of patient and family advisory councils to improve patient experience in radiology. American Journal of Roentgenology 5(207), 965-970. 4 https://www.ajronline.org/doi/ref/10.2214/AJR.16.16604.

CONTEXT: PFACS AND iCARE MEASURES

PFACs have been a particularly successful strategy for patient engagement.5 These councils allow communities to gain feedback from patients and their families who frequent the clinic and hospital. PFACs are critical to reducing medical errors, improving healthcare safety and quality, and addressing social determinants of health.5

As part of the last two years of the program, iCARE communities focused on establishing a PFAC if they didn’t already have one, or improving their existing PFAC. iCARE communities also submitted data to help track their QI projects and goals. Participating iCARE clinics reported on the following National Quality Forum, or NQF measures, which serve as a national standard for quality improvement and other healthcare value initiatives:

 NQF #0018 – Controlling high blood pressure

 NQF #0059 – Hemoglobin A1C (HbA1c) Poor Control (>9%)

 NQF #0057 – Diabetic patients with HbA1c test performed

HbA1c is a way to measure diabetes and someone’s chance for developing complications from diabetes. Someone without diabetes should have an HbA1c reading of less than 5.7%.6

These measures are all related to controlling chronic conditions, such as diabetes and hypertension, with the intention of iCARE communities focusing on improving clinic processes and systems for higher risk patients and improving patient outcomes. They are also closely related to hospital readmissions, as patients with a chronic disease, or multiple chronic diseases, are more likely to experience health complications that require hospital (re)admission. In line with this work, participating iCARE hospitals reported on:

 Readmissions within 30 days for same or similar diagnosis

 Inappropriate emergency department (ED) utilization (this is tracked using CPT codes 99281 and 99282, codes that are generally used when a patient presents to the ED with a low complexity issue)

5 Kuhn, K.J., Mickelsen, L. J., Morimoto, L. N., Larson, D.B. (2016). The use of patient and family advisory councils to improve patient experience in radiology. American Journal of Roentgenology 5(207), 965-970. https://www.ajronline.org/doi/ref/10.2214/ AJR.16.16604. 6 5 American Diabetes Association. (n.d.). Understanding A1C. https://www.diabetes.org/a1c. iCARE BY THE NUMBERS: CRITICAL ACCESS HOSPITALS

CRHC began iCARE in 2010 in response to the national scrutiny on hospital readmissions and care transitions and with the desire to provide support, through a rural lens, to Colorado’s CAHs. When the program started, nine of Colorado’s CAHs voluntarily participated in looking at measures, including readmissions, heart failure, and pneumonia. The program has achieved nota- ble results. CAHs have decreased avoidable readmissions rates from 5% to 3%. While this reduction may seem small, CAHs, by nature of their low volumes, have limited readmissions CAHs have decreased and serve populations that, on avoidable readmissions average, have higher rates of chron- rates from 5% to 3%. ic disease and complex care needs than their urban counterparts. Over the course of the program, the number of CAHs involved in iCARE increased to nineteen and readmission rates stayed consistent, averaging 2-3% over the past four years. The 40% decrease in readmissions is attributable to CAHs conducting root cause analyses of avoidable readmissions and improving their processes, such as patient follow-up appointments with their provider-based clinics. The average cost of a readmission for any given cause in 2019 was $13,141.7,8 In 2015, Centers for Medicare & Medicaid Services (CMS) retired heart failure and pneumonia measures. iCARE CAHs’ pneumonia scores averaged 68.3% in 2010 and 100% in 2015. Additionally, iCARE CAHs reported an average rate of 66% in meeting the heart failure measure in 2010, and an average rate of 74% in 2015.

7 Becker’s Clinical Leadership & Infection Control Staff. (2015). 6 stats on the cost of readmission for CMS- tracked conditions. Becker’s Healthcare. https://www.beckershospitalreview.com/quality/6-stats -on-the-cost-of-readmission-for-cms-tracked-conditions.html 8 CoinNews Media Group LLC (Coin News). (n.d.). US inflation calculator. https:// 6 www.usinflationcalculator.com/. iCARE BY THE NUMBERS: CRITICAL ACCESS HOSPITALS

CRHC implemented a short quality improvement focus on examining the low severity levels of Evaluation and Management codes (99281 and 99282) amongst iCARE hospitals. The iCARE hospitals collected baseline data from October 2017 through March 2018 on diagnoses, day and time patient was seen, and payer type. Analysis of the data shows the main diagnoses of those cases are cough, fever, acute upper respiratory infections, and consti- pation. The baseline frequency of low level severity emergency visits for the iCARE network was 29%, compared to 22% frequency by the end the program. The 24% decrease can be attributed to changes that iCARE hospitals are starting to implement, which include extending clinic and pharmacy hours during the week and/or weekend. In the U.S., one of the top three reasons for ER visits in 2012 was upper respiratory infections, which equaled 5.9 million visits.9 For this condition, the median emergency department charge to a patient in 2019 was $800, and the average Colorado insurance reimburses approximately 36%* ($288), leaving the patient to pay the re- maining balance of $512* out of pocket (excluding copay). 8,10,11

*Please Note: Utilizing this data for the provided estimations has limitations: A. Data provided is from 2017 and reflects Medicare Severity Diagnostic Related Group Descriptions that are severe or have complications and does not reflect non-emergent conditions, B. Reimbursed values provided reflect amount a health carrier paid in total and the amount paid by the insured individual (with the assumption this amount corresponds to copay values), C. It is difficult to determine reimbursement values as negotiations occur between insurance carriers and the hospital.

8 CoinNews Media Group LLC (Coin News). (n.d.). US inflation calculator. https:// www.usinflationcalculator.com/. 9 Fay, R. (2019). Emergency rooms vs. urgent care centers. Debt.org. https://www.debt.org/medical/ emergency-room-urgent-care-costs/ 10 Caldwell, N., Srebotnjak, T., Wang, T., & Hsia, R. (2013). “How much will I get charged for this?” Patient charges for top ten diagnoses in the emergency department. PloS one, 8(2), e55491. https:// doi.org/10.1371/journal.pone.0055491 11 Colorado Department of Regulatory Agencies. (n.d.). 2017 CHA hospital price report. http:// doraapps.state.co.us/insurance/drg/Default.aspx. 7 iCARE IN NUMBERS: 2018-2020

During the February 2018-2020 program years, iCARE participants took part in a myriad of activities, including:

 33 site visits  28 project charters

 82 focus team calls  15 sustainability plans

 6 learning sessions  15 informational and network learning webinars  24 newsletters

 30 infographs

Additionally, iCARE participants showed dedication to their practices and patients by focusing on improving their clinical processes and outcomes (see Table 1 below):

Table 1 Measure iCARE Communities’ Averages Feb. ’18: 66% NQF #0018 - Controlling High Blood Pressure Feb. ’20 : 77% Feb. ’18: 44% NQF #0059 - Hemoglobin A1c Poor Control (>9%) Feb ’20: 39% NQF #0057 - Diabetic patients with HbA1c test per- Feb. ’18: 64% formed Feb ’20: 70% Readmission within 30 days for same or similar diag- Feb. ’18: 3.7% nosis Feb ’20: 2.6% Feb. ’18: 29% Inappropriate emergency department utilization Feb ’20: 22%

Program Outcomes:

 From February 2018-2020, iCARE clinics improved their cumulative average rate of controlling their patients’ high blood pressure from 66% to 77%. According to the Centers for Disease Control and Prevention (CDC), less than one in four (24%) American adults with hypertension had their condition under control, based on data from 2013-16. 12

12 Million Hearts. (2019). Hypertension cascade: Estimated hypertension prevalence, treatment and control among U.S. adults. 8 Centers for Disease Control and Prevention (CDC). https://millionhearts.hhs.gov/data-reports/hypertension-prevalence.html

iCARE IN NUMBERS: 2018-2020

Program Outcomes Continued: (refer to Table 1 on previ- For this measure, a lower ous page) percentage is better. It means that more diabetic  In February of 2018, iCARE clinics had a cumulative aver- patients have their HbA1c age rate of 44% of patients with poor control of their levels, markers of the dis- HbA1c levels. By February of 2020, the rate had de- ease, under better control. creased to 39%. Nationally, 41.2% of adults with diabetes who were enrolled in Medicaid Managed Care Plans (HMO) had poor control of their HbA1c levels in 2018.13 The average cost of medical ex-  On average, each iCARE facility saw just over twenty penditures for a person diag- fewer diabetic patients with poorly controlled HbA1c nosed with diabetes is $16,752 levels by the end of the program, saving each per year, of which $9,601.00 is site over $198,500.00 per year. attributed to diabetes. 14  From February 2018-2020, iCARE clinics improved their average HbA1c testing rate among diabetic patients from 64% to 70%. Nationally, adults with diabetes who were enrolled in Medicaid HMO received an HbA1c test 87.8% of the time in 2018.13

 In the same time period, iCARE CAHs had an average readmission rate within 30 days for same or similar diagnosis of 3.2%. In February of 2018, this rate was 3.7% and dropped to 2.6% by February of 2020, a remarkable drop considering low rates are harder to improve upon.

 From February 2018-2020, iCARE CAHs improved their average inappropriate emergency department utilization rate by seven percentage points, low- ering the metric from an average baseline of 29% and ending the program with an average of 22%.

CRHC remains committed to continuing to work with rural healthcare organizations on improvements to their patient outcomes and clinical processes through current and future endeavors.

13 National Committee for Quality Assurance (NCQA).(n.d.). Comprehensive Diabetes Care (CDC). https://www.ncqa.org/hedis/ measures/comprehensive-diabetes-care/ 14 American Diabetes Association. (n.d.). The cost of diabetes. https://www.diabetes.org/resources/statistics/cost-diabetes. 9

iCARE PARTICIPATING FACILITIES MAP FOR 2019

MT. SAN RAFAEL HEALTH CENTER Using the Patient’s Voice for Better Health Outcomes Mt. San Rafael Health Center (MSRHC) is located in Trinidad, CO, a town in southern Colora- do at the foothills of the dramatic Sangre de Cristo Mountains. Trinidad is situated in Las Ani- mas County, which, according to County Health Rankings, has the worst health outcomes of any county in Colorado, based on how long people live and how healthy people feel while they are alive.15 The rate of premature death in the county is more than twice that of Colora- do’s and residents experience “poor or fair health” at a rate approximately 1.4 times that of that state’s.16

Las Animas also experiences a high number of preventable hospital stays, about twice that of the state’s.14 However, this number is trending downward. MSRHC has worked diligently to reduce their hospital readmission rate, which has remained under 5% since November 2018. Creative solutions have been put into place MSRHC has worked diligently by MSRHC staff to help achieve this low rate, such as expanding clinic hours, improving discharge to reduce their hospital phone calls to patients for follow-up care, and im- readmission rate, which has proving medication reconciliation processes, remained under 5% since which helps to avoid medication errors like drug November 2018. interactions and dosing inaccuracies.

MSRHC started their PFAC in 2017 and served as a role model for other participants in iCARE who were themselves establishing PFACs or facilitating ones in their early stages. MSRHC’s PFAC’s first project was revising the patient sign-in process. PFAC members voiced their concern that the sign-in sheet was not discreet enough. Since MSRHC designed their PFAC to include leadership staff, their Chief Nursing Officer was at the meeting to suggest that they implement tear-off sign-in sheets to keep the names of patients hidden. The MSRHC PFAC Team of patients, families, and clinical staff were able to implement this change within a month, before their next PFAC meeting. Meghan Russell, MSRHC’s Marketing Coordinator and PFAC Lead, made it clear that their goal is to be an action committee, and it is clear that MSRHC’s PFAC has been in action. Russell commented,“ Our hope is to be able to say to the things that come up, well, of course, of course we can do something about that.”

14 American Diabetes Association. (n.d.). The cost of diabetes. https://www.diabetes.org/resources/statistics/cost-diabetes. 15 County Health Rankings & Roadmaps. “Colorado 2020: Overview.” https://www.countyhealthrankings.org/app/colorado/2020/ overview. 16 County Health Rankings & Roadmaps. “Colorado 2020: Rankings: Las Animas (LS).” https://www.countyhealthrankings.org/app/ 11 colorado/2020/rankings/las-animas/county/outcomes/overall/snapshot.

MT. SAN RAFAEL HEALTH CENTER Using the Patient’s Voice for Better Health Outcomes Another success that MSRHC’s PFAC had early on was contributing to the facility’s renovations. PFAC members gave input on how rooms should be arranged, where bathroom access should be, and even gave input about the height of the toilet paper hangers. Russell pointed out that this isn’t something staff would think of,“ We take things for granted because we work here every day.” Physical changes to patient rooms, such as the ones MSRHC’s PFAC members made, are essential to reducing negative patient outcomes, such as falls. MSRHC set a goal to become more proac- tive rather than reactive, and Russell said that is one of the biggest values their community members provide them. Of course, Russell mentioned, being open to really listening to your community is essential, “If you’re asking for community input, be ready to receive it and adjust accordingly. You have to be willing to either: A. Have the conversation, or, B. Do something about it.” Russell made it clear that organizing a PFAC is a constant adjust- ment process. She hoped to keep up the PFAC’s momentum and give people a reason to come to their meetings by giving them enough owner- ship, “People will come when they know things “If you’re asking for will happen.” And, as for advice, Russell said, community input, be ready to “Remain open. It is an evolution.” receive it and adjust accordingly.” - Meghan Russell, MSRHC’s Marketing

Coordinator and PFAC Lead

SPANISH PEAKS REGIONAL HEALTH CENTER Harnessing the Power of Two Patient Committees for Clinical Improvements

Sitting on Las Animas County’s northwest shoulder is Huerfano County, the county that Spanish Peak’s Regional Health Center (SPRHC) serves. SPRHC, located in Walsenburg, is named for the pair of statuesque mountains located in the southwestern part of Huerfano County, West and East Spanish Peak. West Spanish Peak is the easternmost mountain over 13,000 feet in the United States.17 SPRHC serves the county’s population of over 6,500 indi- viduals spanning an area of nearly 1,600 square miles.18 SPRHC has worked over several years to establish not only a PFAC in their hospital, but a second Patient Advisory Their PFAC members Board (PAB) in their clinic, both of which have been ac- have also been able to tive in the community. The hospital’s PFAC redesigned help influence hospital- the interior hospital entrance to make it more welcoming wide decisions and to patients, including adding a half-wall and mural to the vision. space. Their PFAC members have also been able to help influence hospital-wide decisions and vision. A PFAC rep- resentative attends board meetings, and SPRHC invited the PFAC to their Leadership Devel- opment Institute to interact with hospital leadership. As part of iCARE, SPRHC’s hospital PFAC and clinic PAB met together at a joint meeting to identify a collaborative project. They decided to help SPRHC with their efforts to increase patient usage of their electronic portal. The two groups worked together to make a plan for increased patient portal uptake in the hospital and clinic through an awareness campaign, engagement activities, and distribution materials and resources. SPRHC’s PFAC and PAB planned to merge into one committee at the conclusion of their project.

From 2016-2018, 8.6% of adults in Huerfano County were diagnosed with diabetes, compared to the state’s average of 6.8%.19 SPRHC has specifically focused on improving patient outcomes for their diabetic population, in fact, they are a nationally recognized site for the Diabetes Prevention Program. Additionally, since February of 2018, SPRHC has had an HbA1c testing rate average of 92.5%. SPRHC was also able to work toward better controlling the blood pressure of patients experiencing high blood pressure. In 2020, the SPRHC clinic was consistently above 80% for controlling high blood pressure, a 10 percentage point improvement from 2018.

17 PeakVisor. (n.d.). Spanish Peaks. https://peakvisor.com/peak/spanish-peaks.html?yaw=0.00&pitch=0.00&hfov=74.60. 18 Census Reporter. (2018). Huerfano County, CO. https://censusreporter.org/profiles/05000US08055-huerfano-county-co/. 18 VISION: Visual Information System for Identifying Opportunities and Needs. Data by county: Diabetes – Adults (%), 2016-2018: 13 Huerfano County. Colorado Department of Public Health & Environment. https://www.colorado.gov/pacific/cdphe/vision-data-tool.

SAN LUIS VALLEY HEALTH Expanding Available Services in Primary Care

San Luis Valley Health (SLVH) faced unique challenges when it came to establishing their PFAC. Located in the San Luis Valley, the geography spans a vast valley with the Sangre de Cristo Mountains and Great Sand Dunes forming the valley’s east boundary, and the San Juan Mountains marking the west boundary. SLVH encompasses two hospitals and four clinics across the valley, making their impact and reach wide, and creating unique considera- tions for programming. SLVH decided to establish PFACs in both their Alamosa and Conejos County hospitals to best represent their unique patient populations in each location. SLVH has had PFACs for several years, but they were able to reinvigorate the committees through iCARE and establish a clinic PFAC that merged with the one at Conejos County Hos- pital. During the final iCARE cohort the Conejos PFAC focused on projects, such as reviewing the clinic’s yearly plan to help improve it, updating the organization’s website, and focusing on quality improvement work, with the PFAC leading member education on the subject. SLVH made significant advances in mental health and care coordination in all of their clinics. Through a 2-year grant, they were able to hire a Behavioral Health Consultant (BHC) and Care Coordinator (CC) to provide needed services in the primary care setting. A nurse practi- tioner at SLVH commented that,“ Behavioral health providers and care coordinators have been the most positive extensions to services that I cannot provide on my own.” SLVH’s BHC highlighted the benefits of behavioral health integration through the story of a patient who struggled with past trauma, resulting in anxiety and depression. The BHC was able to schedule this patient for specialized therapy before the patient left the office that day. She also se- cured a single case agreement with the patient’s insurance provider to cover the services. The CC at SLVH remembered helping a patient set up transportation to access mental health services, “Through care coordination, the patient was able to receive the psychiatry services needed and, as a result, the patient’s physical health improved and the patient was happy . . .” SLVH’s goal for this grant was to serve 1,000 patients per year, which they surpassed. Due to their overwhelming success, along with the identified need by the clinics and community, SLVH has sustained both positions moving forward. Every one of their clinics has experienced the positive impact of integrating behavioral health and care coordination into their workflows. This work, along with other chronic care quality improvement projects at SLVH, contributed to the hospital’s massive improvement in inappropriate ED utilization. From the first quarter of 2018 to the first quarter of 2020, the hospital reduced this measure by 12.6 percentage points, landing them at a rate of less than 1% for inap- SLVH’s BHC, Victoria Romero, LPC-C, counseling a 14 propriate ED utilization. patient

RIO GRANDE HOSPITAL AND CLINICS Targeting Social Determinants of Health with Patient and Family Advisors Rio Grande Hospital and Clinics (RGHC) is comprised of a hospital and four clinics in Rio Grande County, just west of Alamosa and the San Luis Valley. The hospital and one clinic are located in Del Norte, an old mining town that now provides convenient access to the Rio Grande National Forest. The area is known for its hiking trails, camping, fishing, and rock climbing, and the Wolf Creek Ski Area is just a forty minute drive from town. 20 In 2015 and 2017, 46.8% of adults in Rio Grande County had been diagnosed with high blood pressure, some of the highest rates in the state. Colorado’s average in that same time period was 25.8%.21 RGHC made significant strides during the last two years of iCARE. Since June 2019, the clinic has maintained the controlling high blood pressure measure at 85% or higher, despite the high rates of high blood pressure in the county. As part of their work in iCARE, RGHC expanded the hours of all three of their clinics, which may have helped contrib- ute to the hospital’s average inappropriate ED utilization rate of only 5.1%. The hospital also had a follow-up visit completion rate of 96%. The Hospital Transformation Project (HTP) is a re- RGHC decided to involve cent, five-year value-based initiative in Colorado their PFAC . . . in their work that ties some Medicaid supplemental payments to for HTP, specifically through a hospital’s ability to hit performance targets. The program aims to improve health outcomes and re- awareness of social duce costs by attaching quality and value data to the determinants and health Hospital Provider Fee, a source of funding for most Colorado hospitals since 2009.22 RGHC decided to involve their PFAC, established in 2018, in their work for HTP, specifically through awareness of social determinants and health disparities. Their aim was to identify the scope of existing health disparities in their community, possible solutions and interventions, internal system issues, and potential communication failures between RGHC staff and the communities they serve. RGHC has a unique PFAC structure. In addition to their PFAC, they have created an In- ternal Patient and Family Action Committee (I-PFAC) to relay the concerns and work of the PFAC to RGHC staff and to help realize PFAC initiatives. The I-PFAC and PFAC worked together to present data and information in a newsletter distributed twice a year and in an annual report given to the Board of Directors in 2019. Due to the dedicated work of their PFAC and I- PFAC, all of RGHC’s PFAC goals were achieved during the final iCARE cohort.

20 Uncover Colorado. (n.d.). Del Norte, Colorado. https://www.uncovercolorado.com/towns/del-norte/. 21 VISION. Data by county: High blood pressure – Adults (%), 2015 & 2017: Rio Grande County. Colorado Department of Public Health & Environment. https://www.colorado.gov/pacific/cdphe/vision-data-tool. 22 Budd, S. (2019). The Hospital Transformation Program: What we know so far about Colorado’s latest value-based care initiative. Colorado Health Institute. https://www.coloradohealthinstitute.org/research/hospital-transformation-program#:~:text=The% 20Hospital%20Transformation%20Program%20(HTP)%20aims%20to%20improve%20outcomes%20and,most%20Colorado% 15 20hospitals%20since%202009.&text=This%20means%20hospitals%20are%20in%20for%20a%20change.).

HEART OF THE ROCKIES REGIONAL MEDICAL CENTER Improving the Patient Experience in Colorado’s Rockies

With multiple locations around Chaffee County, Heart of the Rockies Regional Medical Cen- ter (HRRMC) is aptly named. Nineteen of the state’s fifty-four fourteeners, or mountains that rise over 14,000 feet above sea level, are located in San Isabel National Forest, just south of the town of Salida. Some of the country’s best whitewater rafting can be found on the Ar- kansas River, which flows through Chaffee County, and the area serves as a mecca for rock climbing, off-road trail driving, boating and gold panning.23 Even in Chaffee County, where many people are outdoor activity enthusiasts, diabetes is still a health concern. About 7.5% of adults had been diagnosed with diabetes in the county from 2016-2018, compared to Colorado’s average of about 6.8%.24 HRRMC did extensive work on their diabetes management and referral protocols, and since February of 2018, they’ve had an average HbA1c testing rate of 96.6%. HRRMC’s Buena Vista clinic has a rate of only 15.85% of diabetic patients with HbA1c levels greater than 9%. The hospital has also maintained a readmission rate of less than 5% since February of 2018. HRRMC staff worked for several years to put the pieces in place to start a PFAC. They faced challenges due to the large size and span of their organization, and concerns about potential conflicts of interest between the PFAC and community members on their Board. During their time in iCARE, HRRMC staff did gain enough momentum and leadership support to start a PFAC, but they had many competing priorities and ultimately decided that it wasn’t the time to start a PFAC. Instead, they focused on the patient experience through their CGCAHPS (Clinician and Group Consumer Assessment of Healthcare Providers and Systems) “top box” survey scores. By choosing to concentrate on this project, HRRMC was able to improve their CGCAHPS top box scores by almost ten percentage points, a remarkable feat.

HRRMC did extensive work on their diabetes management and referral protocols, and since February of 2018, they’ve had an average HbA1c testing rate of 96.6%.

23 Uncover Colorado. (n.d.). Chaffee County, Colorado. https://www.uncovercolorado.com/counties/chaffee/. 24 VISION. Data by county: Diabetes – Adults (%), 2016-2018: Chaffee County. Colorado Department of Public Health & Environment. 16 https://www.colorado.gov/pacific/cdphe/vision-data-tool.

SOUTHWEST HEALTH SYSTEM Quality Improvement in Colorado’s Southwest Corner

Southwest Health System (SHS) is located in the southwestern Colorado town of Cortez in Montezuma County. Montezuma is named for Montezuma II, an esteemed Mexican chief of the Aztec Indians, and the county is rich in Native American archeological sites and struc- tures (including Mesa Verde National Park and Canyons of the Ancients National Monu- ment).25 SHS’s hospital and three clinics all participated in the iCARE program. SHS worked diligently during their time in iCARE to dramatically improve their quality processes around controlling high blood pressure and diabetes management. From February From February 2018 to 2020, 2018 to 2020, the Mancos Valley Clinic im- the Mancos Valley Clinic proved their controlling high blood pressure improved their controlling high measure by 21 percentage points, putting them over 77% for the measure. According to blood pressure measure by 21 data collected in 2015 and 2017, 30.9% of percentage points, putting them adults in Montezuma County had ever been over 77% for the measure. diagnosed with high blood pressure, compared to 25.8% in the state of Colorado.26 In 2016-2018, 12.1% of adults in Montezuma County had ever been diagnosed with diabetes, almost double that of Colorado’s average of 6.8%.27 From February 2018 to 2020, SHS’s Pri- mary Care Clinic improved their HbA1c testing rate by 12.2 percentage points. In the same time period, SHS had an average hospital readmission rate of only 2.67%. SHS started their PFAC in conjunction with the last cohort of iCARE, in 2018. Senior leadership was involved in both the PFAC’s creation and maintenance. Their PFAC focused on projects such as creating a handout to educate hospital and clinic patients on available services to them, and worked to improve patient portal usage.

Southwest Health System Staff

25 Uncover Colorado. (n.d.). Montezuma County, Colorado. https://www.uncovercolorado.com/counties/montezuma/. 26 VISION. Data by county: High blood pressure – Adults (%), 2015 & 2017: Montezuma County. Colorado Department of Public Health & Environment. https://www.colorado.gov/pacific/cdphe/vision-data-tool. 27 VISION. Data by county: Diabetes – Adults (%), 2016-2018: Montezuma County. Colorado Department of Public Health & Environ- 17 ment. https://www.colorado.gov/pacific/cdphe/vision-data-tool.

RANGELY DISTRICT HOSPITAL A Community’s Lifeline Rangely District Hospital (RDH) is located in Rio Blanco County, a county in northwestern Col- orado that borders Utah, and is named for the White River that runs through it. The population of Rio Blanco is about 6,300, with a density of around two people per square mile. Routt National Forest covers 2.9 million acres in the county, providing access to outdoor activities year-round.28 Rio Blanco has some of the highest rates of high blood pressure in the state. In 2015 and 2017, about 46.5% of adults in Rio Blanco County had been diagnosed with high blood pressure, compared to about 25.8% in the state of Colorado.29 RDH’s clinic achieved an average of almost 80% for controlling patients’ high blood pressures during the iCARE program. Addi- tionally, the hospital had an average readmission rate of just 3.33%.

RDH’s clinic achieved an average of almost 80% for controlling patients’ high blood pressures during the iCARE program.

RDH focused on reducing the number of vulnerable patients who repeatedly were seen in the emergency department by working with the care coordinator in the clinic to connect with these patients. They also implemented ‘Senior Life Solutions,’ which is an intensive out- patient group therapy program designed to meet the unique needs of adults, typically ages 65 and older, struggling with symptoms of depression and anxiety that can be age-related. RDH provides needed medical care to the northwestern-most part of Colorado, with the next closest hospital located in Vernal, Utah, more than 52 miles northwest. During the last iCARE cohort, RDH focused on improving their patient engagement, but instead of creating a PFAC, RDH staff brought themselves to their community members. Staff members did community outreach with eight local organizations to help improve the organization’s relationship with the community and gather feedback that they could act upon. Staff members focused on ensuring that the community understood what the hospital and clinic does and provides to the community. They engaged community members to learn more about what they wanted to see from the hospital. These efforts led to invaluable feedback for RDH and improved the relationship the organization has with the community.

Tammy Dunker, Clinic Director at RDH

YUMA DISTRICT HOSPITAL AND CLINICS Celebrating Older Adults through Wellness Between 2003 and 2013, the number of Colorado adults ages 65+ increased by 46.8%, the third highest rate of growth for that population in the nation.28 From 2015-2030, the number is projected to increase by 76.7%. Rural areas of Colorado are, in general, less equipped to support their aging populations than urban areas of the state, and the proportional burden will be higher in south and east rural counties.30 Yuma County is located on the northeastern border of Colorado, touching both Nebraska and Kansas, and supports a population of just over 10,000 in an area that covers over 2,350 square miles.29 18% of Yuma’s overall population is 65+, which is about 1.4 times that of Col- orado’s, at 13%. Additionally, 19% of Yuma’s 65+ population lives in poverty, compared to just 7% in the state of Colorado.31 Yuma District Hospital and Clinics (YDHC) wanted to generate interest in annual wellness visits covered by Medicare, a valuable resource that they were hoping more older adults would take advantage of. YDHC approached their PFAC and asked if they would be willing to pro- mote these visits, and the PFAC took on the challenge. YDHC’s PFAC recognized the hard- ships that many seniors face in their community and decided to hold a Senior Wellness Fair to help older citizens get the support they need, raise awareness about local resources, and celebrate their older population. YDHC and the PFAC got to work putting out a call for fair vendors. They received such a great response that it became necessary to expand the fair outside of the hospital walls and into the parking lot. After months of planning, including advertising the event on Facebook, in the Yuma Newspaper, and through flyers distributed in customers’ shopping bags at the gro- cery store, Yuma’s Senior Wellness Fair took place on June 6, 2019.

Photos from YDHC Senior Wellness Fair

28 Uncover Colorado. (n.d.). Rio Blanco County, Colorado. https://www.uncovercolorado.com/counties/rio-blanco/. 29 VISION. Data by county: High blood pressure – Adults (%), 2015 & 2017: Rio Blanco County. Colorado Department of Public Health & 30 Environment. https://www.colorado.gov/pacific/cdphe/vision-data-tool. Colorado Department of Public Health & Environment. (n.d.). Healthy aging in Colorado: Colorado adults, ages 65 and older. https:// www.cohealthdata.dphe.state.co.us/chd/Age/Healthy-Aging-in-Colorado-Infographic-Older-Adult-Population.pdf. 31 19 Census Reporter. (2018). Yuma County, CO. https://censusreporter.org/profiles/05000US08125-yuma-county-co/.

YUMA DISTRICT HOSPITAL AND CLINICS Celebrating Older Adults through Wellness Nineteen vendors attended the fair, including the local nursing home, assisted living facility, and a local bank. Hospital departments lined the main hospital corridor with displays representing their departments. The lab set up their booth with a large blood cell display, including a microscope equipped with slides for viewing. A vendor was on site to repair mobile medical equipment (wheel chairs, scooters, walkers, etc.). A lot of thought and work went into the vendor booths, with many handing out giveaways, like first aid kits, massages, and coupons for smoothies. All participants were ready to help with the senior population. In addition to raising awareness for Medicare annual visits, two of these visits were performed during the time of the fair, and six veterans were connected with services they had been unsuccessful in getting on their own. YDHC received overwhelmingly positive feedback on the event, with all of the vendors promising to return the following year. The Senior Well- ness Fair has become an annual event at YDHC. In addition to their Senior Wellness Fair, YDHC utilized their time in iCARE to focus on their diabetic population. Chronic disease is an especially prominent concern for Colorado’s 65+ population, with over 90% of this population experiencing at least one chronic condition and over 70% experiencing two or more. 16.8% of Colorado’s 65+ population has diabetes and it is the seventh leading cause of death among this age group.28 From 2016-2018, 6.4% of Yu- ma County’s population had been diagnosed with diabetes, which is similar to Colorado’s rate of 6.8%.32 YDHC has two clinics, one located in Akron, which is in the neighboring county of Washington. From 2016-2018, 11.5% of Washington County’s population had been diagnosed with diabetes, about 1.7 times the state’s rate.33

During the most recent iCARE cohort, Akron clinic made the most improvement in their comprehensive diabetic care out of all of the iCARE participants. Their rate of patients with HbA1c levels >9% dropped from 44.4% to 12.5% from 2018 to 2020. Both of their clinics had an average HbA1c testing rate of over 92%. These remarkable achievements came from tar- geted and in-depth work with YDHC’s diabetic population. They actively focused on improving patient navigation for diabetes management and their processes for diabetic patient eye exams. They also created specific discharge planning folders for patients with diabetes and other chronic conditions to help reduce their readmissions. Their hospital had a readmission rate of nearly 10% in the first quarter of 2018, which dropped to 0% in the last quarter of 2019.

28 Uncover Colorado. (n.d.). Rio Blanco County, Colorado. https://www.uncovercolorado.com/counties/rio-blanco/. 32 VISION. Data by county: Diabetes – Adults (%), 2016-2018: Yuma County. Colorado Department of Public Health & Environment. https://www.colorado.gov/pacific/cdphe/vision-data-tool. 33 VISION. Data by county: Diabetes – Adults (%), 2016-2018: Washington County. Colorado Department of Public Health & Environ- 20 ment. https://www.colorado.gov/pacific/cdphe/vision-data-tool.

MELISSA MEMORIAL HOSPITAL Improving the Patient Experience through Patient Engagement Melissa Memorial Hospital (MMH) and Holyoke Clinic are located in Holyoke, CO, part of Phillips County, which sits on Colorado’s northeastern border with Nebraska. The MMH iCARE team and staff worked diligently to improve their inappropriate ED utilization numbers and keep their readmissions low. Since the first quarter of 2018, MMH has had a 13.3 percentage point improvement in their inappropriate ED use, and a 2.7 percentage point improvement in their same/similar diagnosis readmission rate. Holyoke Clinic achieved a rate of 96.4% of patients with controlled high blood pressure. These achievements all contributed to MMH meeting all of their iCARE goals in the last year of the program. MMH has been transparent with their PFAC from their very first meeting, sharing their HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey scores with PFAC members. The PFAC used these scores to inform their first projects, and chose to focus on quietness at night and medication education. MMH made several PFAC-informed modifications as part of these initiatives, including decreasing TV volumes, implementing quiet hours in the patient care area, purchasing quiet IV poles and quiet kits that include items like eye masks and quiet hour information, and having Senior Leadership participate in patient rounding. MMH staff collect information during weekdays about medication ques- tions and noise levels, so that they can take this information back to their PFAC. The PFAC also focused on providing educational materials for their Hispanic population, which makes up about 38% of Holyoke’s residents and 22% of the county’s residents.34 The PFAC has been a springboard for other quality improvement projects around the hospital, including a time study in the Radiology Department. MMH staff analyzed patient wait times from checking-in at Registration to being greeted by Radiology staff. The study took place over nine days and included 80 patients. Their goal was for patients to wait no more than 10 minutes to be greeted by Radiology staff. The data collected showed that 96% of patients checked in with no problems, and 92% of patients were acknowledged by Radiology staff in ten minutes or less. Even though MMH’s study found that they were close to meeting their goal, a quality improvement project team conducted a root cause analysis and implemented changes to further improve their wait times and help ensure that patients’ needs were being met. These changes included improving signage, installing a doorbell and waiting room camera in the Radiology Department, using notification buttons when a patient is headed from Reg- istration to Radiology, and implementing a system for no- tifying staff which tests a patient needs and when they are receiving them. All of these remarkable initiatives have been patient-focused and patient-led or assisted, and have significantly improved the patient experience at MMH. Jen Cano presenting at August 2020 Learning Session

34 21 Census Reporter. (2018). Phillips County, CO. https://censusreporter.org/profiles/05000US08095-phillips-county-co/.

SEDGWICK COUNTY HEALTH CENTER Keeping Readmissions and Blood Pressures Low through Q.I. Sedgwick County, Colorado is a small county with a population of 2,350 and a total of just 548 square miles.35 It is located in Colorado’s northeastern-most corner, bordered by Ne- braska on two sides. Since February of 2018, Sedgwick County Health Center (SCHC) has maintained an average readmission rate of only 2.9%. They achieved this accomplishment by focusing on their hospital patients’ needs and by creating a detailed discharge information packet. The packet is given to all patients upon discharge from the hospital. The discharge packet provides information on patients follow-up appointments, symptoms to be aware of, medications, labs and x-rays, community resources, and more. Patients receive a copy and are asked to bring it with them to their follow-up appointments, ensuring continuity of care and more engagement in their own care. The packet is also scanned so that the clinic has access to it. In the final year of iCARE, February 2019-2020, SCHC closely monitored their inappropriate emergency department utilization and found that many of their “low-level” visits that could have been seen in the clinic were occurring after hours. Based on this data, SCHC decided to expand their clinic hours, opening earlier in the morning in order to serve more patients in the primary care setting. Diabetes prevalence in Sedgwick County is approximately 11%, about 1.7 times the rate in Colorado as a whole.36 Additionally, in 2013, Sedgwick County was in the third quartile of Colorado counties for adults experiencing high blood pressure, meaning that the prevalence in the county was between 25.5-27.9%. The prevalence of Colorado adults with high blood pressure was 25.8% for the same time period.37 Despite the elevated rate of high blood pressure in the county, SCHC’s clinic has performed exceedingly well in controlling their patients’ high blood pressures. In the most recent iCARE cohort, they maintained their high blood pressure control measure at 72.5% or higher. Sedgwick’s quality improvement team has worked closely with its nurses to keep tickler files that provide reminders for patient testing to ensure that patients receive the appropriate blood pressure screenings and can work with their providers on controlling their high blood pressure.

Sedgwick County Health Center’s iCARE Team

Ann Mick Autumn Martin Danna Wilson Deb Nail Machelle Newth Mary Kantor Sheila Powell

35 Uncover Colorado. (n.d.). Sedgwick County, Colorado. https://www.uncovercolorado.com/counties/sedgwick/. 36 County Health Rankings & Roadmaps. Colorado 2020: Measures, Diabetes prevalence. https://www.countyhealthrankings.org/app/ colorado/2020/measure/outcomes/60/data. 37 Colorado Department of Public Health & Environment. (2014). High blood pressure awareness in Colorado. https:// www.colorado.gov/pacific/sites/default/files/DC_fact-sheet_HTN_Nov-2014_without-Appendix.pdf. 22

SOUTHEAST COLORADO HOSPITAL A Team-Based Approach to Diabetes Management Southeast Colorado Hospital (SCH) in Springfield, CO is located in Baca County, the most south- eastern county in Colorado, bordered by Kansas, Oklahoma, and New Mexico. SCH established a PFAC in 2018 and achieved enormous accomplishments from the committee’s inception, starting with improving the facility’s parking. SCH’s PFAC organized the installation of a con- crete slab in the Physical Therapy Department’s parking lot, where only gravel had been before, to improve the safety of patients coming in and out of the office, who often have limited mobility. Since their first project, the PFAC has also improved the volunteer onboarding process to increase hospital volunteers, and they have revamped their auxiliary committee. SCH’s relationship with their community has markedly improved due to the PFAC, and the PFAC spot- lights SCH employees of the month to show their appreciation for the work that SCH staff do every day for residents. SCH’s PFAC also traveled to Lamar, Colorado to meet with Prowers’s PFAC, another iCARE community, to have a joint meeting to learn and brainstorm with one another to help with the continuous improvement of their PFACs. SCH achieved astounding outcomes on all of their iCARE measures. The hospital maintained an average readmission rate of 2.1% during the final iCARE cohort. The clinic had an average rate of over 75% for controlling patients’ high blood pressures, an average of less than 8% of diabetic patients with HbA1c levels greater than 9%, and an average HbA1c testing rate of over 92%. These numbers were reached through extensive work with SCH’s diabetic population, specifically targeting those with elevated HbA1c results. SCH also realized their goal of having less than twenty patients with uncontrolled HbA1c levels during the last year of iCARE. As a team, the SCH Clinic was able to significantly change the lives of three patients. Their new provider took the opportunity to help some of SCH’s most uncontrolled patients with diabetes. After seeing the patients and reviewing their most recent diabetic labs, they made adjust- ments to their treatment plans. All three of the patients had trouble remembering to check their blood sugars, so the provider started by having them call the nurse and share their blood sugar log numbers each week. If the nurse didn’t hear from them, they would call the patient. By providing accountability to the patients, they were able to get into a routine and remembered to check their blood sugar levels regularly. The provider also had the patients meet with the clinic’s Care Coordinator (CC) Nurse who is training to be a Certified Diabetes Educator. The CC worked with each patient individually to help them set achievable goals, such as replacing a starch with a low carb vegetable three times a week, or adding protein snacks throughout the day to help prevent low blood sugar levels, or learning how to use an insulin sliding scale. Working with one goal at a time gave the patients confidence to make other lifestyle changes. With this team approach, SCH was able to help these patients control their diabetes in just three months. The patients’ HbA1c levels dropped dramatically, with each achieving a reduction between 1.5 and 4.7 percentage points, putting all of them below 9% HbA1c levels. One patient stated,“ I’ve never had an A1c below 9% before!” This patient was finally able to quali- fy for an insulin pump. SCH will continue to target their most uncontrolled diabetic patients using this new workflow. They can already see what a difference they are making. 23

PROWERS MEDICAL CENTER Incorporating Patient and Family Voices at a Systems Level Prowers County, CO sits just north of Baca County on the southeast- ern border of the state, touching Kansas. The county is home to Prowers Medical Center (PMC). PMC’s hospital readmission rate has remained under 5% since November of 2018, meeting one of the facility’s iCARE goals from the last year of the program. Part of this success stems from PMC’s efforts to improve their post-hospital- visit follow-up appointments. PMC achieved a 90% rate of dis- charged hospital patients with a scheduled follow-up appoint- ment, and have a 90%+ attendance rate at those appointments. Lois Schroeder, PFAC Member handing out chemo therapy gift bags PMC’s PFAC has also been a successful endeavor, largely due to the efforts of PMC’s Scheduling Specialist and PFAC Chair. The PFAC has implemented a Com- fort Care Cart for surgery patients and their families to pick out items that will make their stay at the hospital more comfortable, such as prayer shawls and puzzles. Additionally, PMC’s PFAC not only reports to PMC’s Board, they also have a PFAC member on the Board to directly represent the interests of patients and their families. Toward the end of the iCARE program, the PMC PFAC had started to do patient rounding, during which a few PFAC members gather information from patients in the hospital about their experience and what can be done to improve it. This information is then shared with PMC staff members and the PFAC to act on the information gathered. Another successful endeavor of the PMC PFAC has been implementing the No One Dies Alone (NODA) program. The mission behind NODA is a simple, but profound one: just as no one is born alone, in the best of circumstances, no one dies alone. NODA Compassionate Companions provide a dig- nified and respectful death to those who have no family or close friends to be with them at the end of life. Thanks to a passionate PFAC member, PMC now offers NODA at their clinic and hospital in Lamar, CO. So far, the initiative has been received so well that the PFAC member has trained ten community members to be NODA Compassionate Companions. The PFAC is proud to be able to provide respite and flexibility for their community members. Not only does the program provide compassionate companionship for those at the end of life, it also gives grieving family members a break during a stressful time. The PMC NODA Compassion- ate Companions have already been able to assist patients and their families, and have partnered with the local hospice agency for future opportunities to be companions for patients there. Prowers Medical Center’s Comfort Care Cart

KIT CARSON COUNTY MEMORIAL HOSPITAL Improving Emergency Department Transfer Communications through Systems Changes Kit Carson County is located north of Prowers County, on the central eastern border of Colo- rado touching Kansas. The county is named for the fur trapper and Army scout Kit Carson, and contains over 2,000 miles of the Great Plains of eastern Colorado, helping make it one of the most productive agricultural counties in the state.38 Kit Carson County Memorial Hospi- tal (KCCMH) is located in Burlington, the county seat, and was the most recent community to join the iCARE program, coming on in the first quarter of 2019. KCCMH focused on improving their Emergency Department Transfer Communication (EDTC) composite score as part of their iCARE program goals. The EDTC quality measure is relevant to critical access hospitals because they often transfer a higher proportion of emergency department patients than larger urban hospitals do. Improving care transitions can reduce preventable hospital readmissions and adverse events in hospitals.39 KCCMH’s Quality Director took a systematic approach to improve the organization’s EDTC scores. She presented the hospital’s EDTC results at the monthly nurse’s, physician’s, and Board meetings, and gave di- rect feedback to the managers involved with the transfer communication. The staff also used their electronic medical record (EMR) to encourage and remind staff to document the re- quired measures. As a result of the measures taken, KCCMH improved their EDTC composite score from about 20% to 90%, a remarkable accomplishment, especially in such a short amount of time. KCCMH had a strong PFAC coming into the iCARE program. Their membership and attendance has been robust, and they have taken on several projects to improve the hospital and clinic. KCCMH’s PFAC helped implement a more efficient phone system, so that when patients call into the hospital or clinic, they are able to select from an accurate and efficient menu in either Spanish or English. The PFAC also helped improve internal communications at KCCMH through the use of shared calendars among staff members, so that employees are up to date on what is going on in other departments and can more accurately communicate and schedule with each other and patients. The latest focus of the KCCMH PFAC is on in- creasing diversity. The KCCMH PFAC also met their iCARE goal of incorporating quality data within the committee. The KCCMH Quality Director educated the PFAC about quality measures and then had the committee identify which quality measures they wanted to review at their meetings. The Quality Director now prepares a report that the committee can efficiently review at each of their meetings. KCCMH Staff

38 Colorado Encyclopedia. (n.d.). Kit Carson County. https://coloradoencyclopedia.org/article/kit-carson-county. 39 Stratis Health: Rural Quality Improvement Technical Assistance. (2017). Emergency department transfer communication brief. 25 https://www.ruralcenter.org/sites/default/files/EDTC-Brief-February-2017_1.pdf.

KIOWA COUNTY HOSPITAL DISTRICT Sharing Successes of Chronic Care Management Kiowa County, named for the Kiowa Native Americans, is located on Colorado’s eastern border with Kansas and is home to just under 1,500 residents, making it the fifth-least populat- ed county in the state.40 Kiowa County Hospital District (KCHD) serves a 35% Medicare population and has a dispro- portionately high number of patients with multiple chronic diseases. They joined the iCARE program in 2018 and wanted to focus on better management of diabetic patients, improving clinical outcomes, and finding an opportunity to engage more with their community. CRHC recognized that KCHD had a robust Chronic Care Manage- ment (CCM) program, a program specifically designed to help older adults with two or more chronic conditions better manage their diseases. CRHC staff approached KCHD’s CCM program manager and asked them to present information about their program to other iCARE participants at a group learning session. Participants were very engaged with the topic and eager to learn from KCHD and their experience. KCHD quickly became a resource for other communities who were in the process of implementing, or thinking about imple- Kourtney Richards, CCM Program menting, a CCM program. Manager at KCHD KCHD’s clinic achieved a rate of over 96% of their diabetic patients receiving HbA1c testing. The clinic also steadily improved the rates of both their controlling high blood pressure and HbA1c poor control measures. In the final year of iCARE, the KCHD Clinic had an average of just 17% of patients with poor control of their HbA1c levels, and improved their controlling high blood pressure measure by ten percentage points. These statistics are especially impressive given Kiowa County’s geography. The county sits just above Southeast Colorado, which is the region with the highest rate of diabetes in the state and a region with little access to resources, such as classes for diabetes and pre-diabetes management.41 Although KCHD was one of the most recent communities to join iCARE, they did not waste any time getting to work on establishing a PFAC. Within the year KCHD joined iCARE, 2018, they gained full support from their leadership, created a charter and started their PFAC. KCHD’s PFAC has been featured in the local newspaper and on KCHD’s Facebook page. They are hopeful that the committee will continue to improve KCHD’s relationship with the community through more open communication with hospital staff and collaborative improvement work.

40 Colorado Demographics. (2019). Colorado Counties by Population. Cubit. https://www.colorado-demographics.com/ counties_by_population. 41 Colorado Department of Public Health & Environment. (n.d.). Diabetes & cardiovascular disease prevention and management pro- 26 gram sites. http://cdphe.maps.arcgis.com/apps/PublicInformation/index.html?appid=fb2599a11bdc4ea7a38d8d0d35c4a041.

CONCLUSIONS AND NEXT STEPS

The iCARE program has come to a close, but as evidenced by this collection of stories, the work that communities have done continues and serves as a founda- tion for future improvement projects in their facilities. The results that iCARE communities achieved around chronic care, in particular diabetes management initiatives and data collection on HbA1c levels, controlling high blood pressure and hospital readmissions, served as a springboard for the creation of CRHC’s Colorado Rural Sustainability (CORS) Network. The CORS Network aligns the goals and work of CRHC to focus on what makes rural healthcare organizations sustainable, so that they can thrive. The work of the Network will draw on the experiences of Colorado’s rural healthcare facilities and CRHC’s staff to help build up rural healthcare infrastructure. The first cohort of the CORS Network is the Chronic Care Management (CCM) Program. The program aims to help staff and providers improve health outcomes for their patients with two or more chronic conditions, as well as provide billing and cod- ing support for these clinics in order to ensure financial sustainability of the program. CRHC Program staff are currently working with five communities to aid them in implementing CCM programs in their clinics. Kiowa County Hospital Dis- trict’s CCM Program Manager is serving as the Community Mentor for the program, helping guide and support the communities in the midst, or at the begin- ning, of implementing their own CCM programs. For several of the participating communities, the work they did during iCARE assisted in laying the foundational processes on which a successful CCM program can now be built. iCARE communities’ accomplishments in the areas of hospital readmission rates, inappropriate ED utilization, diabetic management, high blood pressure control, and patient family engagement are not only impressive, but are meaningful to the patients that they serve and their larger communities. The work that rural hospitals and clinics do is essential to the health and wellbeing of Coloradans, and impacts communities beyond the four walls of the healthcare facility. It is imperative that we continue to support rural healthcare needs if Colorado is to stay and further grow into a desirable, healthy, and inclusive place to live. CRHC remains dedicated to the mission of improving healthcare outcomes and access in rural Colorado. We continue to support rural communities through our work in building up the rural workforce, providing technical assistance in the areas of quality improvement, compliance, operations, and health information technology, championing rural policy and advocacy, and expanding emergency preparedness efforts.

27 iCARE PROGRAM TEAM

Natalie Vogan Marcy Cameron Katie Schweber Rachel Williams Associate Director of Associate Director of Quality Improvement Program Programs Programs Specialist Coordinator

Colorado Rural Health Center (CRHC) offers services and resources to rural healthcare providers, facilities and communities. For more information on what we do at CRHC and the services and resources we provide, please visit our website at COruralhealth.org.

iCARE Communities at the February 2020 Learning Session.

Thank you to Next Fifty Initiative for funding the iCARE program since 2018.