Health Quality Partners

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R&D SYSTEMS OF CARE INTEGRATED ADVANCED PREVENTIVE CARE (IAPC) - FOR MORE THAN TWO DECADES HEALTH QUALITY PARTNERS (HQP) HAS INNOVATED AND REFINED A ROBUST AND HIGHLY EFFECTIVE SYSTEM OF CARE DESIGNED TO IMPROVE THE HEALTH OUTCOMES FOR COMMUNITY DWELLING OLDER ADULTS WITH COMPLEX HEALTH AND SOCIAL RISKS - THE ADVANCED PREVENTIVE CARE (APC) MODEL. MORE THAN 2,000 MEDICARE BENEFICIARIES HAVE BEEN CARED FOR BY HQP OVER THE YEARS IN THE APC MODEL. FOR THE LAST THREE YEARS, HQP, IN CONJUNCTION WITH A HIGH- PERFORMING PRIMARY CARE PRACTICE, WITH EXPERIENCE VALUE-BASED CARE PAYMENT MODELS HAS UNDERTAKEN A COLLABORATIVE PRAGMATIC CO-DESIGN INITIATIVE WITH HQP TO APC IN THE PRIMARY CARE PRACTICE SETTING (IAPC). THE INTEGRATION OF THE APC MODEL AIMS TO TARGET AND PROACTIVELY CARE FOR A SUB-POPULATION OF MEDICARE BENEFICIARIES THAT HAVE HIGH AND EMERGING RISKS THAT CAN BE MITIGATED BY INTERVENTIONS DELIVERED BY EXPERIENCED NURSES TRAINED IN HQP'S COMMUNITY-BASED MODEL OF APC. THE IAPC DESIGN HAS DEFINED OPERATIONAL WORKFLOWS AND SPECIFICATIONS FOR IDENTIFYING AND ENGAGING HIGH AND RISING RISK MEDICARE BENEFICIARIES FOR IAPC, DELINEATED PRACTICE CARE MANAGEMENT (PCM) ROLES AND FUNCTIONS, OUTLINED STANDARD WORKFLOWS, AND DEVELOPED STRUCTURED ASSESSMENTS, AND COMMUNICATION AND DOCUMENTATION PROTOCOLS. OVER THE LAST THREE YEARS OF THIS R&D INNOVATION EFFORT, APPROXIMATELY 130 HIGH-RISK OLDER ADULT PATIENTS HAVE BEEN COLLABORATIVELY CARED FOR IN THE IAPC MODEL. TO DATE, THE IAPC MODEL HAS DEMONSTRATED OPERATIONAL FEASIBILITY, ACCEPTANCE BY THE PATIENTS, PHYSICIANS, AND NURSES PARTICIPATING IN THE MODEL, AND THE INITIAL EVALUATION HAS SHOWN A REDUCTION IN INPATIENT COSTS, LOWER HOSPITAL ADMISSIONS, AND FEWER HOSPITAL DAYS IN THE IAPC GROUP IN AN INTENTION TO TREAT POPULATION ANALYSIS. A MIX METHODS ANALYSIS AND PUBLICATION OF RESULTS IS PLANNED FOR 2025.

POPULATION HEALTH CONSULTING & ADVISORY SERVICES MANAGING, AND EVALUATING, SYSTEMS FOR ADVANCED POPULATION HEALTH MANAGEMENT PROVIDES CONSULTATIVE, ADVISORY, ANALYTIC AND RESEARCH & DEVELOPMENT SERVICES TO ORGANIZATIONS RESPONSIBLE FOR POPULATION HEALTH MANAGEMENT IN VALUE-BASED CARE ARRANGEMENTS. IN FULFILLMENT OF THIS WORK, HQP DEVELOPS AND ITERATES METHODS FOR TARGETING AT-RISK SUB POPULATIONS FOR CARE MANAGEMENT AND OTHER INTERVENTIONS TO IMPROVE HEALTH OUTCOMES AND REDUCE UNNECESSARY HEALTH CARE EXPENDITURES. ADVANCED ANALYTICS ARE DEVELOPED BY HQP FOR DESCRIPTIVE, OPERATIONAL, PREDICTIVE AND EVALUATION PURPOSES. CONSULTATIVE SUPPORT IS PROVIDED FOR PROGRAM AND PROCESS IMPROVEMENT, DESIGN/RE-DESIGN, AND INNOVATION.

REPLICATION CONSULTANCY HQP CONTINUES TO SUPPORT ITS HEALTH CARE PARTNERS IN THE ADAPTATION AND REPLICATION OF THE APC MODEL. IN THE FISCAL YEAR 2024, HQP'S REPLICATION SYSTEMS CONSULTANCY PROVIDED SUBJECT MATTER EXPERTISE, COACHING, MENTORSHIP, AND TECHNICAL ASSISTANCE TO TWO PARTNERING ORGANIZATIONS COMMITTED TO IMPLEMENTING APC. SINCE INCEPTION OF THESE PARTNERSHIPS MORE THAN 1,500 AT-RISK OLDER ADULTS HAVE BEEN SERVED THROUGH REPLICATION OF APC. REPLICATION PARTNERS REPORTED HIGH LEVELS OF PARTICIPANT ENGAGEMENT, HIGH SCORES IN PARTICIPANT AND PROVIDER SATISFACTION AND POSITIVE IMPACTS ON HEALTH AND COST OUTCOMES. IN ADDITION, HQP'S COMPREHENSIVE PURPOSE BUILT SPERO SOFTWARE PLATFORM WAS SUBSTANTIALLY UPGRADED AND CONTINUOUSLY DEPLOYED TO SUPPORT REPLICATION PARTNERS IN THEIR IMPLEMENTATION AND MANAGEMENT OF APC.