December 2017
The Quarterly Newsletter of the HHQI Underserved Populations (UP) Network


Quarterly UP Network Webinar | January 18, 2018 | 2-3pm ET
Actions to Improve Health Literacy
Health literacy is a silent but significant barrier for adults, especially the elderly. Nearly nine out of 10 adults in the U.S. have some health literacy issues that reach across all socioeconomic, cultural/race, and education levels. Healthcare providers need to understand barriers and have strategies to address various health literacy areas.

This educational webinar presented by the Home Health Quality Improvement National Campaign (HHQI) will explore several key areas including: measurement, navigation, verbal/written communication, and evaluation. Register now .

Approved for 1.5 hours of Nursing CEs by the Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Learn more.

Expert Presenters:
Misty Kevech , RN, MS, HHQI RN Project Coordinator
Cindy Sun, RN, MSN, HHQI RN Project Coordinator
Quality Insights
Now Available: October 2017 UP Network Webinar Recording

Check out the Creating Dementia-Capable Systems of Healthcare UP webinar recording where Debra Cherry, BA, MA, PhD, Executive Vice President of Alzheimer's Greater Los Angeles, shared components from a Dementia Cal MediConnect Project that her organization found to be successful. She shared ideas about indicators, barriers, and strategies to improve the dementia care in the home health setting. Free nursing and social worker continuing education credits are still available with the recording in HHQI University.

Save the Dates: 2018 UP Network Webinars

January 18
April 19
July 19
October 18

All webinars will be held from 2-3pm ET.  As details are available, they will be published on the HHQI UP Page and emailed directly to those who are subscribed to our  UPDate and Educational & Networking Opportunities mailing lists . 


In today's healthcare environment, organizations are aligning with the Triple Aim concept created by the Institute of Healthcare Improvement's (IHI).  The diagram shows the Centers for Medicare & Medicaid Services' (CMS) adaptation. 

One of the goals of the Affordable Care Act (ACA) is to improve health by expanding healthcare access and improve the delivery of health care systems. It is already apparent that in order to have a greater impact with population health and health equity,  organizations will need to address social, economic, and environmental factors that influence the health of patients (Heiman & Artiga, 2015). Bridging healthcare and community health has been the focus over the last 20 years. The Chronic Care Model,  developed by the MacColl Institute, continues to influence healthcare reform, especially with Medicaid delivery and payment initiatives.
The Henry J. Kaiser Family Foundation identified social determinants in the "Beyond Health Care:  The Role of Social Determinants in Promoting Health and Health Equity" Issue Brief (11/04/15). The brief describes the disparity of the amount of money in the U.S. spent on healthcare vs. social services that provides critical assistance to some populations.
The following table from the Kaiser Issue Brief identifies six key categories as well as the various health outcomes affected.

The issue describes several key population health strategies including the initiative in Camden, New Jersey focusing on high hospital utilizers using zip codes to identify understand the social variances.

Home Health Lens

Since home health agencies (HHAs) provide care in the home the clinicians have the opportunity to identify many of the social determinants and day-to-day barriers.
Quality Assurance & Performance Improvement (QAPI) requirements are a critical component of the new Home Health Condition of Participation (CoP). HHAs are required to create a QAPI Performance Improvement Project (PIP) around problem areas identified from agency data.  The PIP should focus on high risk, high volume, or problem prone areas. The draft Home Health CoP Interpretive Guidelines also included the following statement:  "High risk areas may include global concerns such as a type of service such as pediatrics, geographic concerns such as the safety of a neighborhood served or specific patient care services such as administration of intravenous medications or tracheostomy care. All factors would be associated with significant risk to the health or safety of patients." This statement validates developing a PIP based upon a social determinant issue identified from data assessment.

OASIS data does not include many elements related to social determinants data but there are some items that may be beneficial. Examples can include:  M0065 (Medicaid # - can possibly identify dual eligible populations if accurately completed), M0140 (Race/Ethnicity); M0150 (Current Payment Source), M1033 (Risk for Hospitalization), M1034 (Overall Status), M1036 (Risk Factors), M1100 (Patient Living Situation), M1870 (Feeding or Eating), M1880 (Ability to Plan and Prepare Light Meals), M1890 (Ability to Use the Telephone), M2102 (Types and Sources of Assistance), etc.

Additional data sources may include the agency's comprehensive assessment, chart reviews, and other logs. The following list data sources for consideration:  
  • HHQI Data Reports
  • Acute Care Hospitalization, Oral Medication Management, and Immunization Reports 
  • Includes reports related to race groups, and payment source  
  • Home Health Cardiovascular Data Registry (additional abstraction required)  
  •  Dual Eligibility Status for abstracted cardiovascular patients




The following tools and resources are available to support your organization's quality improvement of the various social determinants identified in the previous table.

2016 National Healthcare Quality and Disparities Report (AHRQ, 2017)

CMS Equity Plan for Medicare

HHQI's Underserved Population Best Practice Intervention Package (BPIP) - foundational information on various topics including many of the social determinants identified.     

For more information or to suggest future UP topics or speakers,  please contact us at Visit our website t learn more about  HHQI .

This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality 

Improvement Organization supporting the Home Health Quality Improvement National Campaign, 

under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. 

Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. 

Publication number 11SOW-WV-HH-ADL-121517