From January through December 2015, the California Department of Health Care Services, which administers Medi-Cal, the nation's largest Medicaid program, conducted a quality improvement collaborative (QIC) with 9 Medi-Cal managed care plans (MCPs) aimed at improving hypertension control consistent with the Million Hearts initiative. The QIC included quarterly webinars and links to local, state, and national resources that consisted of materials and consultations with subject matter experts. Participating MCPs demonstrated an average increase of 5.0 percentage points in their rates of controlled hypertension. Collaboratives can achieve substantial quality improvement in Medicaid managed care plans

Abbott, Rachel E

Backman, Desiree R

Kizer, Kenneth W

Kohatsu, Neal D

Yu, Zhiwei

eScholarship - University of California

UC DavisUC Davis Previously Published WorksTitleImplementing a Quality Improvement Collaborative to Improve Hypertension Control and Advance Million Hearts Among Low-Income Californians, 2014–2015Permalinkhttps://escholarship.org/uc/item/7v62q4bjJournalPreventing Chronic Disease, 14(7)ISSN1545-1151AuthorsBackman, Desiree RKohatsu, Neal DYu, Zhiweiet al.Publication Date2017DOI10.5888/pcd14.160587 Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaPREVENTING  CHRONIC  DISEASEP U B L I C  H E A L T H  R E S E A R C H ,  P R A C T I C E ,  A N D  P O L I C Y   Volume 14, E61                                                                         JULY 2017   RESEARCH BRIEF  Implementing a Quality ImprovementCollaborative to Improve HypertensionControl and Advance Million HeartsAmong Low-Income Californians,2014–2015 Desiree R. Backman, DrPH, MS, RD1,2; Neal D. Kohatsu, MD, MPH1; Zhiwei Yu, MPH1,2;Rachel E. Abbott1,2; Kenneth W. Kizer, MD, MPH2 Suggested citation for this  article:  Backman DR, Kohatsu ND,Yu Z,  Abbott RE,  Kizer KW.  Implementing  a  QualityImprovement Collaborative to Improve Hypertension Control andAdvance  Million  Hearts  Among  Low-Income  Californians,2014–2015.  Prev  Chronic  Dis  2017;14:160587.  DOI:  https://doi.org/10.5888/pcd14.160587.PEER REVIEWEDAbstractFrom January through December 2015, the California Departmentof Health Care Services, which administers Medi-Cal, the nation’slargest Medicaid program, conducted a quality improvement col-laborative (QIC) with 9 Medi-Cal managed care plans (MCPs)aimed at improving hypertension control consistent with the Mil-lion Hearts initiative. The QIC included quarterly webinars andlinks to local, state, and national resources that consisted of mater-ials and consultations with subject matter experts. ParticipatingMCPs demonstrated an average increase of 5.0 percentage pointsin  their  rates  of  controlled  hypertension.  Collaboratives  canachieve substantial quality improvement in Medicaid managedcare plans.ObjectiveHypertension is a major risk factor for deaths related to coronaryheart disease (CHD) and stroke. Approximately one-third of adultsin the United States have hypertension, but only about half (52%)have their hypertension under control (1). Million Hearts is a na-tional initiative to prevent 1 million heart attacks and strokes by2017 through strategies such as achieving blood pressure controlamong 70% of those who have hypertension (2).The objective of this study was to determine the effect of a qualityimprovement collaborative (QIC) on hypertension control ratesamong  9  managed  care  plans  (MCPs)  whose  performance  atbaseline was below the Million Hearts target.MethodsApproximately 14 million Californians are enrolled in Medi-Cal(3), which is administered by the California Department of HealthCare Services (DHCS). Enrollees eligible for full-scope benefits(nearly 11 million) receive health care provided by a network of23 MCPs (4). Ten MCPs, 9 of which performed below the Mil-lion Hearts target of 70% controlled high blood pressure, volun-teered to participate in the QIC. The plan performing above thetarget was excluded from analysis.In 2015, 407,911 Medi-Cal members enrolled in a MCP had beendiagnosed with hypertension. More than 60% (246,206) of thosewith hypertension were enrolled in 1 of 9 MCPs that participatedin the QIC (5). Of the 23 MCPs, the analysis was limited to QIC-participating and nonparticipating plans with continuous Con-trolling High Blood Pressure (CBP) data since 2009 (n = 19).From January through December 2015, DHCS held quarterly, 1.5-hour webinars with MCPs in which local, state, and national lead-ers presented hypertension control best practices and providedevidence-based tools and resources (6,7). For example, the MCPswere exposed to an effective quality improvement program, theRight Care Initiative (8). Subject matter experts within DHCS alsoThe opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Healthand Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.www.cdc.gov/pcd/issues/2017/16_0587.htm • Centers for Disease Control and Prevention      1were available for consultation. The MCPs shared successes andchallenges in controlling hypertension. MCPs also had access to awebpage providing useful resources. After each webinar, DHCSsent MCPs a survey to garner immediate feedback that was used todesign and tailor subsequent webinars.DHCS measures the effectiveness of its MCPs, in part, through theHealthcare Effectiveness Data and Information Set (HEDIS) (9).An external quality review organization collects and uses adminis-trative and medical record data to calculate HEDIS rates for eachMCP annually (10). The HEDIS CBP measure is defined as thepercentage of members aged 18 to 85 years who had a diagnosisof hypertension and whose blood pressure was adequately con-trolled during the measurement year. The measure’s threshold forhypertension control in adults varies by age and diabetes status,ranging from less than 140/90 mm Hg to less than 150/90 mm Hg(11).SAS version 9.4 (SAS Institute, Inc) was used to conduct an ana-lysis of CBP rates, by MCP. The CBP rates were weighted on thebasis of each plan’s number of enrollees. We used the χ2 test to ex-amine changes in performance (ie, percentage point difference)between calendar year 2014 and 2015. Significance was set at P <.05.ResultsSince 2009, all QIC-participating MCPs had a downward trend inCBP rates. For that reason, managed care staff at DHCS stronglyencouraged low-performing MCPs to participate in the QIC. In2014, the CBP weighted average for all plans was 61.2%, and theaverage CBP rate among the 9 participating MCPs was 56.3%(range, 43.1%–69.3%).During the QIC intervention year (2015), CBP rates improved sig-nificantly in 7 of 9 (78%) participating MCPs. The largest im-provement was 14.6 percentage points, representing a 33.9% im-provement in hypertension control (Table). The mean CBP rateimprovement was 5.0 percentage points.Ten MCPs did not participate in the QIC. CBP rates declined in 6of the 10 nonparticipating MCPs from 2009 to 2014. Four weretrending upward since 2009, although 1 of the 4 plateaued in 2011.In 2014, the average CBP rate among nonparticipating MCPs was64.8%. In 2015, their average rate decreased by 5.7 percentagepoints to 59.1%. In addition, during the study period, CBP ratesdecreased in 9 of the 10 nonparticipating MCPs.  DiscussionParticipation in the QIC was associated with improved hyperten-sion control; 7 of 9 MCPs demonstrated improved control in theintervention period compared with baseline. This improvementwas notable because all plans had a multiyear history of declininghypertension control rates before the intervention. In addition,among nonparticipating plans, 9 of 10 showed decreasing hyper-tension control rates during the study period. These findings showthat there was not a general, secular trend of hypertension controlimprovement among MCPs.Several factors may explain the positive association. First, therewere high participation rates for each of the quarterly 1.5-hour we-binars. Second, there was broad involvement of MCP staff and theactive engagement of DHCS quality consultants. Third, there wasongoing sharing among MCP peers of best practices and barriers.This study has several limitations. The preintervention/postinter-vention design limits attribution of causality. In addition, the 9MCPs that were studied volunteered to participate in the QIC andmay have been motivated because of historical declines in hyper-tension control. Also, the intervention period was only 1 year, solong-term effects could not be assessed.Nevertheless, hypertension control trends among both participat-ing and nonparticipating MCPs were generally downward, sug-gesting that the QIC helped to improve outcomes at a system (ie,MCP) level. The results suggest that learning collaboratives canadvance health care quality metrics with a moderate investment ofresources. The shared learning may have contributed to the im-proved outcomes compared with the preceding period when planswere attempting improvement solely at an individual health-planlevel.DHCS has established mandatory learning collaboratives in thearea of hypertension control, as well as in others. More researchabout such shared learning is needed to examine long-term effects,overcome potential cultural resistance, and develop sustainablebusiness models.AcknowledgmentsThe authors are grateful to staff in the DHCS Managed Care Qual-ity and Monitoring Division and Office of the Medical Directorfor their assistance with the QIP. Gratitude is also extended tostaff at the Centers for Medicare and Medicaid Services for help-ing us advance the Million Hearts initiative in Medi-Cal. Staffmembers who conducted this study were supported by the State ofCalifornia and the Centers for Medicare & Medicaid Services.PREVENTING CHRONIC DISEASE VOLUME 14, E61PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY           JULY 2017The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.2       Centers for Disease Control and Prevention  •  www.cdc.gov/pcd/issues/2017/16_0587.htmAuthor InformationCorresponding Author:  Desiree  R.  Backman,  DrPH,  MS,  RD,California Department of Health Care Services, PO Box 997413,MS 0000,  Sacramento,  CA 95899-7414.  Telephone:  916-440-7628. Email: Desiree.Backman@dhcs.ca.gov.Author  Affiliations:  1California  Department  of  Health  CareServices, Sacramento, California. 2University of California, Davis,Institute for Population Health Improvement, Davis, California.ReferencesHigh blood pressure fact sheet. Atlanta (GA): US Departmentof Health and Human Services, Centers for Disease Controland Prevention. http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm. Accessed October 28, 2016.  1.Million  Hearts  Targets.  Atlanta  (GA):  US  Department  ofHealth and Human Services, Centers for Disease Control andPrevention, Million Hearts. http://millionhearts.hhs.gov/about-million-hearts/targets.html. Accessed October 28, 2016.  2.Medi-Cal  monthly enrollment fast  facts.  Sacramento (CA):Research  and  Analytic  Studies  Division,  CaliforniaDepartment  of  Health  Care  Services;  May  2016.  http://www.dhcs.ca.gov/dataandstats/statistics/Documents/Fast_Facts_May_2016.pdf. Accessed December 7, 2016.  3.Quality strategy. Sacramento (CA): Medi-Cal Managed Care,California Department of  Health Care Services;  November2015. http://www.dhcs.ca.gov/dataandstats/reports/Documents/M M C D _ Q u a l _ R p t s / S t u d i e s _ Q u a l i t y _ S t r a t e g y /MgdCareQualityStrategy2016.pdf.  Accessed  December  7,2016.  4.2016 California DHCS MCP internal rate sheet. Sacramento(CA): California Department of Health Care Services; 2016.  5.Jaffe MG, Lee GA, Young JD, Sidney S, Go AS. Improvedblood  pressure  control  associated  with  a  large-scalehypertension program. JAMA 2013;310(7):699–705.  6.Tools and protocols. Resources to help educate, motivate, andmonitor  your  patients.  Atlanta  (GA);  Centers  for  DiseaseControl and Prevention. https://millionhearts.hhs.gov/tools-protocols/index.html. Accessed February 27, 2017.  7.Right Care Initiative. Berkeley (CA): Right Care Initiative.https://rightcare.berkeley.edu. Accessed October 28, 2016.  8.HEDIS  &  Performance  Measurement.  Washington  (DC):National  Committee  for  Quality  Assurance.  http://www.ncqa.org/HEDISQualityMeasurement.aspx.  AccessedOctober 28, 2016.  9.2015 HEDIS Aggregate Report for Medi-Cal Managed Care.Sacramento  (CA):  Managed  Care  Quality  and  MonitoringDivision,  California  Department  of  Health  Care  Services;January 2016(Revised March 2016). http://www.dhcs.ca.gov/dataandstats/reports/Documents/MMCD_Qual_Rpts/HEDIS_Reports/CA2015_HEDIS.pdf. Accessed December 12, 2016.10.Quality  rating  system  measure  technical  specifications.Baltimore (MD): Centers for Medicare & Medicaid Services,Health Insurance Marketplace; 2015.11.PREVENTING CHRONIC DISEASE VOLUME 14, E61PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY           JULY 2017The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.www.cdc.gov/pcd/issues/2017/16_0587.htm • Centers for Disease Control and Prevention       3TableTable. Controlled High Blood Pressure Rates for Medi-Cal Managed Care Plans, Comparison of Calendar Year 2014 and 2015, HEDISMedi-Cal Managed Care Plan NameCalendar Year 2014 Calendar Year 2015Percentage PointDifferencebPercentageChange%EligiblePopulation CBP Rate,a %EligiblePopulation CBP Rate,a %Alameda Alliance for Health 17,072 43.1 13,963 57.7 14.6 33.9Anthem Blue Cross Partnership Plan 13,956 48.3 29,941 54.6 6.3 13.0CalOptima 22,881 69.3 29,802 72.5 3.2 4.6Care1st Partner Plan 2,913 59.4 3,796 54.0 −5.4 −9.1Health Net Community Solutions, Inc 34,958 61.9 40,917 59.4 −2.5 −4.0Health Plan of San Mateo 7,333 61.8 9,054 68.9 7.1 11.5LA Care Health Plan 53,672 66.8 82,695 68.3 1.5 2.2Molina Healthcare of California 12,147 44.5 17,829 53.3 8.8 19.8Partnership Health Plan of California 16,461 52.1 18,209 63.3 11.2 21.5Abbreviations: CBP, controlled blood pressure; HEDIS, Healthcare Effectiveness Data and Information Set.a The CBP rates were weighted on the basis of the size of each plan’s eligible population.b All significant at P < .05; P values determined by using χ2 test.PREVENTING CHRONIC DISEASE VOLUME 14, E61PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY           JULY 2017The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.4       Centers for Disease Control and Prevention  •  www.cdc.gov/pcd/issues/2017/16_0587.htm

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Implementing a Quality Improvement Collaborative to Improve Hypertension Control and Advance Million Hearts Among Low-Income Californians, 2014–2015

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Implementing a Quality Improvement Collaborative to Improve Hypertension Control and Advance Million Hearts Among Low-Income Californians, 2014-2015.

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