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Since the passage of the Affordable Care Act, health care payers, purchasers, providers, and consumers have shown an increased commitment to health and health care quality.
The initial National Quality Strategy, published in March 2011, established three aims and six priorities for quality improvement (see Figure 1). The National Quality Strategy encourages efforts to identify and adopt unified measures that meet the reporting requirements of multiple programs and initiatives across the Federal Government, the private sector, States, and even individual health systems and providers.
This report includes updates to the national tracking measures that align to each of the National Quality Strategy's six priorities and demonstrate national health and health care quality trends. The 2012 National Quality Strategy progress report identified three strategic opportunities for accelerating system-wide improvement across all of the aims and priorities; this report provides information on progress made against each.
Develop a national strategy for data collection, measurement, and reporting that supports performance measurement and improvement efforts of public- and private-sector stakeholders at the national and community level.
Public- and private-sector efforts to align measures are contributing to the development of a national strategy for collecting data, measuring improvement, and public reporting. There is also evidence of a growing community-level infrastructure to support quality improvement across the Nation. Finally, private and public payers are embracing a new perspective on health care payment and delivery—one that emphasizes value over volume and rewards providers that deliver high-quality care. The National Quality Strategy serves as a guiding force in the multitude of quality improvement efforts across the Nation, fostering alignment across national, Federal, State, and private sector stakeholders to improve health and health care quality for all Americans.
The National Strategy for Quality Improvement in Health Care (National Quality Strategy) continues to inspire and guide a nationwide effort to coordinate public and private efforts to improve the quality of health and health care for all Americans. The National Quality Strategy encourages alignment of health and health care quality programs and performance measures across the country.
This report provides an update on the Nation's progress improving quality across six priority areas, while also highlighting local examples of excellence that show what is possible. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models. The 2012 Annual Progress Report to Congress on the National Quality Strategy elaborated on these six priorities, and established long-term goals (see Figure 3) and national tracking measures to monitor quality improvement progress.
A broad and robust stakeholder engagement process informed the choice of these priorities, long-term goals, and measures. Last year's progress report to Congress on the National Quality Strategy offered an in-depth look at the implementation activities taking place across the Federal Government. A spotlight on unprecedented collaboration between public and private payers, leading to the establishment and adoption of a consensus set of core measures. New progress on reducing the burden of data collection for providers engaged in quality improvement.
Private sector champions achieving excellence and sharing best practices in each of the six priority areas.
A spotlight on the three strategic opportunities, reflecting the breadth of activity to improve quality infrastructure across the country. Though this progress report only touches upon some of the robust quality improvement activities taking place across the Federal Government and the Nation, it is an encouraging survey of progress and engagement. Performance measures allow us to gauge the quality of care provided, identify best practices for achieving desired outcomes, and identify opportunities for improvement.
New Consensus Among Public and Private Payers on Quality Measurement The Affordable Care Act required that multi-stakeholder groups provide input on the best performance measures for public reporting and performance-based payment programs.
The Measures Application Partnership is helping HHS identify and prioritize the best performance measures. The involved parties, including Service Employees International Union (SEIU), American Federation of Labor—Congress of Industrial Organizations (AFL-CIO), IBM, Xerox, Aetna, Cigna, WellPoint, United Healthcare, and the national Blue Cross Blue Shield Association agreed to work together to implement this core set of measures in their programs as soon as possible. As more public and private payers tie payment to health care quality, programs requiring data collection have proliferated. Many CMS programs, such as the Physician Quality Reporting System (PQRS), Physician Value-based Payment Modifier, the Shared Savings Program for Accountable Care Organizations (ACOs), and the Electronic Health Record (EHR) Incentive Programs require reporting of quality measures by physicians and other eligible professionals. Other Federal agencies have taken similar steps to align measures and reduce the burden of reporting.
Central to the National Quality Strategy are six priorities that focus national quality improvement efforts. Across the country, health care providers, payers, and communities have accepted the invitation of the National Quality Strategy to align care delivery, payment incentives, and local infrastructure to drive improvement—and they are achieving significant results.
Finally, this section includes aspirational targets for improvement for each of the national tracking measures.
Everyone agrees that no patients should be harmed by the health care they receive and all clinicians should be empowered with the best tools and information to deliver safe, effective, quality care.
1 Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control and Prevention (CDC), and Centers for Medicare & Medicaid Services (CMS), 2010. 3 The target date for the Priority 1 measures was adjusted from 2013 to 2014, because the 3-year Hospital Engagement Network program, a key driver for improvement in these measures, did not begin until December 2011.
Nationwide data from 2011 indicates the HAC rate is declining, and although the all-payer 30-day readmission rate isn't declining yet, recent data from the Medicare program is promising. High-quality care is not only safe; it is also timely, accessible, and consistent with individual and family preferences and values. 6 AHRQ, Center for Financing, Access, and Cost Trends, Medical Expenditure Panel Survey, 2010. 7 AHRQ, Center for Financing, Access, and Cost Trends, Medical Expenditure Panel Survey, 2010.
Though updated nationwide data is not yet available on these two measures, local communities, private payers, and individual practices are improving the person and family experience of care in significant and innovative ways. In January 2011, Kaiser Permanente in Southern California implemented a shared decision-making pilot in three of its medical centers.
Conscious, patient-centered coordination of care not only improves the patient's experience, it also leads to better long-term health outcomes, as demonstrated by fewer unnecessary trips to the hospital, fewer repeated tests, fewer conflicting prescriptions, and clearer advice about the best course of treatment. 8 Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau; CDC, National Center for Health Statistics, National Survey of Children's Health, 2007. The Southcentral Foundation in Anchorage, Alaska, provides primary outpatient care to approximately 55,000 Alaska natives and American Indians using a team-based approach, recognized by the National Committee for Quality Assurance as a Level 3 Patient-Centered Medical Home™, the highest level achievable. 13 CDC, National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 2007–2008.
While there are slight declines in the rates for cholesterol management and smoking cessation in the table above, these changes are not statistically significant.
21 Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies, National Survey on Drug Use and Health, 2010.
The national tracking measure for depression appears to be declining, but the change between the baseline rate and most recent rate is not statistically significant.
23 Available at Robert Wood Johnson Foundation Health Policy Snapshot: Childhood Obesity Issue Brief, September 2012.
24 Agency for Healthcare Research and Quality, Center for Financing, Access, and Cost Trends, Medical Expenditure Panel Survey, 2010. 25 See the HHS Budget in Brief for a discussion of investments and proposals to reduce health care spending.
28 See the HHS Budget in Brief for a discussion of investments and proposals to reduce health care spending.
Recent trends in national indicators of cost growth and individual affordability are very encouraging. Innovative new models of paying for health care are spreading rapidly nationwide and are beginning to yield results that will further drive down future costs. 30 Available at The Kaiser Family Foundation and Health Research and Educational Trust, Employer Health Benefits: 2012 Annual Survey, September 2012.
The 2012 National Quality Strategy progress report illuminated three specific approaches for accelerating system-wide improvement across all of the aims and priorities of the National Quality Strategy.
Develop an infrastructure at the community level that assumes responsibility for improvement efforts, resources for communities to benchmark and compare performance, and mechanisms to identify, share, and evaluate progress. To successfully drive quality improvement, these strategic opportunities will require engagement by both public- and private-sector partners, adoption of common goals across stakeholders, and the engenderment of shared accountability throughout the health care system. All payers, public and private, benefit from consensus on a national strategy for data collection, measurement, and reporting while ensuring the privacy and security of personally identifiable information. The ultimate goal is to allow providers to make health care decisions based on real-time data analysis using patient data reports and clinical decision support tools, such as computerized alerts and reminders.
Empowered by new authority granted through the Affordable Care Act, CMS is providing unprecedented access to timely health care data in an effort to support performance measurement, quality improvement, and patient and family engagement. Additionally, CMS has created an ACO data sharing program in which participating Medicare ACOs receive monthly beneficiary-level claim feeds, currently helping approximately 250 ACOs better coordinate care for more than 4 million Medicare beneficiaries.
Many health care organizations view the adoption of an EHR system with evidence-based clinical decision support capabilities as the first step to transforming their practices to provide consistently high-quality care across their communities. The Affordable Care Act directed HHS to support the transformation of health care financing and delivery away from reimbursement for volume of services and toward payment for the value of care delivered to beneficiaries.
Most importantly, commercial and State-based programs that also support health care transformation are complementing these Federal payment and delivery system reforms. 33 Oregon Health Care Quality Corporation, Health Improvement Collaborative of Greater Cincinnati, Kansas City Quality Improvement Consortium, Maine Health Management Coalition Foundation, HealthInsight, California Healthcare Performance Information System.
35 Available at Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost and Quality Results, Patient-Centered Primary Care Collaborative, 2012. The National Quality Strategy is an adaptable and evolving resource to improve health, improve quality of care, and lower costs for all Americans. There are many indicators of national progress on quality improvement, with each measure offering a different lens through which to view and understand progress.
The effort to focus on measures that are the most relevant to clinicians, payers, and consumers can reduce the administrative burden of data collection and reporting.
In the 3 years since the passage of the Affordable Care Act, the Nation has seen increasing interest and activity in health care quality improvement and delivery system reform. 1 See the HHS Budget in Brief for a discussion of investments and proposals to reduce health care spending. From award-winning vlogger and entrepreneur Connor Franta comes this collectible hardcover editioncomplete with a brand-new bonus chapterof his New York Times bestselling memoir, A Work in Progress, which was selected by Forbes as a Top 5 Breakthrough Book of 2015 and won the Goodreads Choice Award for Best Memoir.In this intimate memoir of life beyond the camera, YouTube star Connor Franta shares the lessons he has learned on his journey from small-town boy to Internet sensationso far. This work has been selected by scholars as being culturally important, and is part of the knowledge base of civilization as we know it. James Elmes (1782-1862), the son of a builder, trained at the Royal Academy Schools as an architectural designer, but his career encompassed publishing and writing on architecture as well. The 18th century was a wealth of knowledge, exploration and rapidly growing technology and expanding record-keeping made possible by advances in the printing press.
The National Strategy for Quality Improvement in Health Care (National Quality Strategy) establishes a framework for coordinating and focusing the significant efforts of these diverse stakeholders to improve the quality of health and health care for all Americans. The National Quality Strategy's first annual progress report to Congress, published in April 2012, elaborated on these six priorities and established long-term goals and national tracking measures to monitor quality improvement progress. Measure alignment allows stakeholders to gauge performance outcomes, while also creating continuity and consistency for providers and consumers. Furthermore, the Federal Government is taking unprecedented steps forward in sharing appropriate data with clinicians who are undertaking quality improvement efforts and with consumers making care decisions. Communities continue to recognize the role of health and non-health care stakeholders alike in promoting better health and health care quality, and use a variety of tools, such as health information technology, to support better health and health care for their community members. In the few years since the passage of the Affordable Care Act, a growing number of stakeholders are increasing their emphasis on health and health care quality improvement, yielding promising returns and evidence of a health system transformation underway.
The National Quality Strategy serves as a resource for identifying and prioritizing quality improvement efforts, sharing lessons learned, and measuring the collective success of Federal, State, and private-sector health care stakeholders across the country. The past year has seen significant advancements in patient safety research and improvement, adoption of new care delivery models rewarding quality improvement, public-private alignment of data collection and measurement, and a decrease in cost growth across the American health care system.
The 2012 progress report also highlighted three strategic opportunities for improvement, which cut across all six priority areas to support ongoing innovation and improvement.
This year's progress report focuses on overall quality improvement, while also offering new granularity and focus in some of the priority areas. Since the passage of the Affordable Care Act, performance measurement has become increasingly important. HHS contracted with the National Quality Forum to convene the Measures Application Partnership, a consensus-based entity composed of over 60 public- and private-sector organizations representing consumers, businesses and purchasers, labor, clinicians, hospitals, and Federal partners. In October 2012, the group began meeting with Federal agencies, including the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ), to discuss an approach for developing common performance measures for value purchasing among public and private payers, and leveraging work by the Measures Application Partnership. In 2013, Buying Value seeks increased adoption of the core measure set by local and regional purchasing coalitions, and the increased use of electronic measures, including those that have been selected for the EHR Incentive Programs.
While these initiatives appropriately focus the attention of health care providers on quality outcomes and improvement, they also require effort and infrastructure to provide clinically relevant evidence-based guidelines at the point of care, standardized multipurpose data collection, and interoperable data transmission.
Established in various statutes at different times, these programs often have different quality reporting requirements. The same measures that hospitals report for the Hospital Inpatient Quality Reporting (IQR) program are posted on Hospital Compare, and the Hospital Value-Based Purchasing program uses a subset of these IQR measures. In 2012, the Health Resources and Services Administration (HRSA) established the Measures Management Review Board to harmonize and align measures across HRSA to promote the use of nationally recognized measures, such as those endorsed by the National Quality Forum and used in the CMS EHR Incentive Programs and PQRS.
In 2012, HHS established a Measurement Policy Council (MPC) to ensure ongoing harmonization of measures across agencies and programs. Established in 2011 after significant stakeholder input, the six priorities now guide public and private investments in quality improvement.
This section highlights select communities and health systems that have shown dramatic improvement in each priority area and, in some cases, insights from those leaders about how to replicate their success. Aspirational targets for patient safety (priority area #1) and cardiovascular health (priority area #4) were established last year to align with the goals of the Partnership for Patients and the Million Hearts® Initiative. Eliminating infections, falls, and other harms in health care settings is fundamental to improving quality.


Among Medicare patients, who represent approximately 58 percent of all hospital readmissions, the hospital readmission rate decreased in 2012. The Irving, Texas-based VHA cooperative of nonprofit hospitals reduced all-payer, all-cause readmissions by 17.6 percent in just 12 months across 192 hospitals. Individuals stay healthier when they and their families are actively engaged in their care, understand their options, and make choices that work for their lifestyles. Patients diagnosed with osteoarthritis of the hip or knee were offered video-based decision aids to help them identify their treatment goals and navigate the various care options based on their values and preferences. Quality language assistance services and the adoption of electronic health records make it easier for clinicians to effectively communicate with patients across settings, and new models of care delivery and payment, such as patient-centered medical homes and ACOs, are giving providers shared incentives to work together to keep patients healthy.
The Foundation's small, integrated, primary care teams include a physician, one or two medical assistants, a full-time nurse focused on care coordination, an administrative assistant to provide case management support, and often a behaviorist. The successful efforts of the Million Hearts Initiative, as well as numerous other public- and private-sector efforts, suggest that the rates will show improvement over time. Access to healthy food, preventive services, and physical exercise are all vital to maintaining overall health and preventing painful and costly medical complications. Due to the increased coverage of mental health services under the essential health benefits provisions of the Affordable Care Act, we expect this measure to show improvement over time. Moreover, quality improvement often goes hand in hand with cost savings for both payers and consumers. Private payers are increasingly implementing payment models similar to the Medicare ACOs, which hold providers accountable for improving quality and lowering the rate of growth in expenditures for an assigned patient population. These three strategic opportunities are based on input provided by the National Priorities Partnership, a group of national health care stakeholders.
Though this level of coordination and collaboration is rare in health care, remarkable progress to date on these three strategic opportunities are cause for hope and further inspiration. The ongoing work and significant progress in that effort is described in Section 2 of this report.
To that end, the HHS Office of National Coordinator for Health IT will release a health IT-focused quality improvement strategy that aims to coordinate evidence-based guidelines, clinical decision support tools, and electronic clinical quality measures.
Qualifying entities that participate in the Medicare Data Sharing for Performance Measurement program are now eligible to receive previously restricted Medicare data to measure provider performance.
However, providers across the Nation face similar hurdles to successfully implementing EHRs. To that end, HHS offers more than three dozen opportunities for providers across the care spectrum to participate in pilot programs to improve quality and reduce the cost of care.34 Examples of these programs include Bundled Payments for Care Improvement, Strong Start for Mothers and Newborns, and Health Care Innovation Awards. For example, Horizon Blue Cross Blue Shield of New Jersey has shown improved quality and reduced costs through its patient-centered medical home initiatives.
A Collaborative Accountable Care Model In Three Practices Showed Promising Early Results On Costs And Quality Of Care. The national tracking measures for each of the six National Quality Strategy priority areas were chosen to give the broadest possible view of national quality improvement. HHS will continue to pare down and consolidate the measures that providers are required to collect and report. There is a growing body of evidence on how to keep patients safer, how to best coordinate care to improve outcomes, and how to lower costs through improvement. Department of Health and Human Services (HHS) Measures Inventory throughout 2012 and reached a consensus on the following measures in the areas of hospital-acquired conditions (HAC), hypertension control, care coordination, patient experience, smoking cessation, and depression screening. This book may have occasional imperfections such as missing or blurred pages, poor pictures, errant marks, etc.
This book may have occasional imperfections such as missing or blurred pages, poor pictures, errant marks, etc.
A friend of Benjamin Robert Haydon and his circle, he was the first publisher (in his Annals of Fine Arts) of Keats' most famous odes. This work was reproduced from the original artifact, and remains as true to the original work as possible. In its determination to preserve the century of revolution, Gale initiated a revolution of its own: digitization of epic proportions to preserve these invaluable works in the largest archive of its kind. Implementation of the National Quality Strategy involves identifying and prioritizing quality improvement efforts, sharing lessons learned, and measuring the collective success of Federal, State, and private sector health care stakeholders across the country. The 2012 report also identified three strategic opportunities for improvement, which cut across all six priority areas.
These alignment efforts include the work of the Measures Application Partnership, composed of over 60 public- and private-sector organizations, and the Buying Value initiative, a group of 19 private health care purchasers and purchasers' representatives. This report highlights communities, health systems, and organizations that have shown dramatic improvement in each priority area. Provider payments are increasingly contingent upon demonstrating progress in meeting established performance thresholds.
This work immediately inspired action from public and private payers across the health care sector.
As of February 2013, the Buying Value purchasers reached agreement with leading health plans on an initial core set of ambulatory care measures for use by health plans and private purchasers. Alignment of private- and public-sector quality measures is critical to lowering the burden of reporting on providers and measuring progress toward achieving better health outcomes, quality care, and lower costs. CMS is pursuing opportunities to align reporting requirements in 2013 for eligible professionals practicing in groups.
As a result, hospital IQR measure data can also be used to determine if the hospital has met its Hospital Value-Based Purchasing measure data reporting requirements.
The goal is to reduce the reporting burden for HRSA grantees, including community health centers and health services organizations, by developing a common reporting platform to more easily report quality measures data.
Guided by the six priority areas of the National Quality Strategy, the Measurement Policy Council began by reaching consensus on measures for hypertension control, smoking cessation, hospital-acquired conditions (HAC), care coordination, patient experience of care, and depression screening and remission (see Appendix B). The 2012 progress report on the National Quality Strategy added national tracking measures in each of the six priority areas to provide a national, all-payer lens through which to understand our national progress. These examples of rapid improvement and achievement of excellence present a preview of the future. The additional targets, appearing for the first time this year, were developed through a consensus process with public- and private-sector content experts using predictive modeling based on past performance of major data sources.
High-quality care means appropriate care transitions, so that patients who leave the hospital do not have to be readmitted.
VHA's success is built upon its collaboration with hospitals, which view VHA as a trusted advisor, and upon championing the use of qualitative tools and approaches to help hospitals improve safety and quality. Improving health care quality includes improving the experience of care, from ease of getting appointments to clear communication about care plan options. Over 80 percent of patients who used the tools thought they were very helpful, and the tools also had a significant impact on care choices, including a 50 percent reduction in the number of elective hip replacement surgeries over the 9-month pilot compared with a matched case control group from a previous year. While the rate for patient-centered medical homes (below) fell slightly, we believe that with the burgeoning number of public- and private-sector-sponsored patient-centered medical homes across the Nation, the measure will show improvement over time as the data reflects current reality.
The Prevention and Public Health Fund, created by the Affordable Care Act, helps States and communities expand and sustain the necessary infrastructure to prevent disease, detect it early, and manage conditions before they become severe. Additionally, local communities are proving that progress is possible through concerted effort, even on seemingly intractable problems.
Hospital-acquired infections, avoidable readmissions, and uncoordinated, duplicative care endanger patient safety and increase health care costs.
Examples of the breadth and depth of activity within each of the strategic opportunities are highlighted below. The strategy will define specific actions for payers, providers, and vendors, to improve quality using health IT.
The first seven organizations from across the country have already been selected, and they include primarily regional nonprofit organizations interested in working with their local health care community to improve quality.33 Participating entities are required to combine these Medicare data with claims data from other sources to produce reports on provider performance that will be available to the general public. Department of Veterans Affairs in collaboration with CMS, the Department of Defense, and the Markle Foundation's Consumer Engagement Workgroup—helps inform and empower patients and their families in their health care decisionmaking.
The Federal Government intends to take a leadership role in developing best practices for monitoring and evaluation, which will be examined in subsequent iterations of this report. The Department's enthusiastic engagement with private payers, through the Measures Application Partnership and the Buying Value initiative, will continue to drive this work. These measures have been selected in concert with the Measures Application Partnership, and the majority will be used in relevant programs across HHS agencies.
I am here to work with you where you are on your journey order to create the fitness program benefits you! By means of therapeutic music, we can assist these children to come to maturity in many ways. His words will resonate with anyone coming of age in the digital era, but at the core is a timeless message for people of all ages: dont be afraid to be yourself and to go after what you truly want. Exploring his past with insight and humor, his present with humility, and his future with hope, Connor reveals his private struggles while providing heartfelt words of wisdom for young adults. This work - the first biography of Wren - was published in 1823, and is dedicated to the President and Fellows of the Royal Society, of which Wren was a founder member in 1660. Therefore, you will see the original copyright references, library stamps (as most of these works have been housed in our most important libraries around the world), and other notations in the work.This work is in the public domain in the United States of America, and possibly other nations. Now for the first time these high-quality digital copies of original 18th century manuscripts are available in print, making them highly accessible to libraries, undergraduate students, and independent scholars.The Age of Enlightenment profoundly enriched religious and philosophical understanding and continues to influence present-day thinking.
This second annual report provides updates on public and private payers' collaborative efforts to align quality measures, progress against national tracking measures (where possible) and establishment of aspirational targets (as needed), private-sector successes in each of the six priority areas, and progress on each of the three strategic opportunities. These organizations are working together and making progress toward developing common performance measures for value purchasing among public and private payers.
Their success demonstrates the potential impact of implementation of the National Quality Strategy.
The Buying Value Common Measures list now includes 35 measures; 20 of these measures are part of Stage 2 Meaningful Use in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs.
The ongoing, iterative alignment between HHS and initiatives such as Buying Value are important steps forward in achieving consensus among private and public payers on quality measurement.
In 2012, CMS launched the process for using electronic health records to directly report the quality data required by other hospital programs, and allow hospitals using certified EHR technology to use the same data (and often in the same format) to report on quality measurement and deliver clinical care.
The council, composed of 11 HHS operating divisions, also agreed on processes for adoption of consensus measures across programs. These targets were established with the recognition of the slow rate in which progress can be shown across nationally representative data in combination with the need for the targets to have face validity with the general public. To improve this experience for patients and their caregivers, Mount Sinai opened a geriatric Emergency Department (ED) that is quieter, has more space, and allows family members and caregivers to be with patients.
Based on these and similar favorable results from other pilots, Kaiser Permanente is expanding the use of these decision aids to all of its medical centers in Southern California, Colorado, and the Northwest. The team members are physically co-located to encourage communication and, when patients call, nurses decide whether to schedule a same-day appointment with a physician or health care provider or offer counseling by phone. Improving the quality of American health care demands an intense focus on preventing and treating cardiovascular disease.
The National Quality Strategy focuses attention on keeping care affordable as efforts to innovate and improve health and health care delivery continue. Medicare spending per beneficiary grew just 0.4 percent per capita in fiscal year 2012, continuing the pattern of very low growth in 2010 and 2011. It serves about one-third of all 3.4 million CareFirst members in Maryland, Washington, DC, and northern Virginia. The Blue Button capability allows Veterans to securely download their personal health information from their My HealtheVet account, and self-enter their personal health indicators, emergency contact information, test results, and family health history.
More than half of eligible providers have qualified for and received incentive payments for demonstrating meaningful use of EHRs, and nearly 80 percent of eligible hospitals have done so. Future iterations of this report will describe these ongoing efforts and will also reflect the breadth of participation in quality reporting and improvement efforts.
This body of wisdom will grow as we evaluate the new models of care being tested across the Nation. This full-color collection includes photography and childhood clippings provided by Connor and is a must-have for anyone inspired by his journey. His words will resonate with anyone coming of age in the digital era, but at the core this is a timeless message for people of all ages: dont be afraid to be yourself and to go after what you truly want.
We believe this work is culturally important, and despite the imperfections, have elected to bring it back into print as part of our continuing commitment to the preservation of printed works worldwide.
We believe this work is culturally important, and despite the imperfections, have elected to bring it back into print as part of our continuing commitment to the preservation of printed works worldwide. Elmes based his work on the so-called 'Parentalia', or notes on the Wren family compiled by his son (also Christopher), and privately printed by his grandson Stephen in 1750. Within the United States, you may freely copy and distribute this work, as no entity (individual or corporate) has a copyright on the body of the work.As a reproduction of a historical artifact, this work may contain missing or blurred pages, poor pictures, errant marks, etc. Works collected here include masterpieces by David Hume, Immanuel Kant, and Jean-Jacques Rousseau, as well as religious sermons and moral debates on the issues of the day, such as the slave trade.
Additionally, multiple Federal agencies are making significant strides in reducing the reporting burden for providers by aligning performance measures across programs and reducing the number of measures where possible.
The National Quality Strategy helps foster alignment of performance measures across the Federal Government, the private sector, States, and even individual health systems and providers.
Furthermore, many hospital programs are aligning to focus on smaller sets of measures that maximize improvement and better outcomes for patients.
The section below includes updates to these baselines where new national data are available. Over time, we do expect to see progress in National Quality Strategy implementation reflected in improved results in these tracking measures.
VHA then works with hospitals over a 10- to 14-week period to redesign and test new clinical practices that more closely align with the leading institutions. Understanding the importance of a simple person-to-person conversation, trained volunteers armed with reading glasses, hearing aids, crossword puzzles, and magazines sit with seniors to help them get their bearings and feel comfortable. Now thousands of patients will be supported in making the decisions that are consistent with their lifestyles and values.


As a result of its team-based care coordination, the Foundation has seen a decrease in emergency room visits by 5 percent, hospital admissions by 53 percent, specialty care visits by 65 percent, and visits to primary care doctors by 20 percent.11 The Foundation also uses its EHR system to facilitate care coordination and keep medical records safe and private, ensure prescription safety, and provide alerts and reminders about health screenings and immunizations. The Million Hearts Initiative is a public-private partnership between HHS and 65 partners, led by the Centers for Disease Control and Prevention, with the goal of preventing 1 million heart attacks and strokes over the next 5 years. The Affordable Care Act also makes it easier for patients with private insurance or Medicare to afford necessary preventive services, like mammograms and wellness exams, by prohibiting insurers from charging co-pays for these important services.
The strategy provides a national call to align clinical best practices and outcomes with financial incentives through new health care delivery models, such as ACOs, patient-centered medical homes, and bundled payment arrangements.
The medical home program links insurance payments to primary care providers to the quality of care they deliver. Medicare beneficiaries can use Blue Button to download copies of their personal health information from their MyMedicare.gov account. RECs have been successful at getting medical practices to change the way they use health IT to improve quality. This full-color collection includes photography and exclusive childhood clippings and is a must-have for anyone inspired by his journey.
We appreciate your understanding of the imperfections in the preservation process, and hope you enjoy this valuable book. Elmes puts Wren's life and works into the context of the intellectual ferment of Restoration England, and combines the narrative of Wren's life with an architectural commentary on his most important works. Scholars believe, and we concur, that this work is important enough to be preserved, reproduced, and made generally available to the public.
The Age of Reason saw conflict between Protestantism and Catholicism transformed into one between faith and logic -- a debate that continues in the twenty-first century.++++The below data was compiled from various identification fields in the bibliographic record of this title. When all payers use the same measures, stakeholders have consistent information to gauge performance and outcomes, and providers have a lower reporting burden.
While this work resides within HHS, the MPC used criteria established by the Measures Application Partnership, a public-private partnership convened by the National Quality Forum. The data sources for the key measures provide nationally representative snapshots, but there is a lag between when the data snapshot is taken and when the information is available to report; accordingly, the data collection and reporting is slow to show progress. Since 2011, Dignity Health has dramatically reduced rates of hospital-acquired infections across its 36 hospitals in 3 states, achieving a 70 percent decline in central-line associated bloodstream infections (CLABSI), a 53 percent decline in ventilator-associated pneumonia (VAP), a 52 percent decline in surgical site infections (SSI), and a 24 percent reduction in catheter-associated urinary tract infections (CAUTI). The initiative is focusing on aspirin use, blood pressure and cholesterol screenings, clinical decision and caregiver support, and smoking cessation to achieve this goal. But even as these changes go into effect nationally, local communities remain leaders in public health promotion and achievement. In June 2013, CareFirst reported that the program reduced costs and improved the quality of care even more in its second year than in its first, citing cost savings of $98 million for the medical home program in 2012, compared with $38 million the year before.
In addition to Federal agencies, private-sector partners like UnitedHealth Group, Aetna, and Kaiser Permanente are adopting Blue Button. They are helping providers meet challenges to achieve meaningful use and are leveraging those accomplishments to support quality improvement and other health care transformation goals. It has been used with persons, of all ages from preschool to late adulthood and with many types of disabilities whether congenital or adventitious.
We appreciate your support of the preservation process, and thank you for being an important part of keeping this knowledge alive and relevant.
We expect to show progress on the national quantitative data over time, but for this report, we're highlighting select programs across the Nation that demonstrate progress in each of the priority areas.
Together these four harms represent over 80 percent of all health care-associated infections nationwide. Most of the savings came from reduced hospital admissions, less use of emergency rooms, and lower spending on drugs.
Through engagement with the Partnership for Patients, these systems and other high performers now share their best practices, such as the use of clinical decision support and quality measure alignment, with 3,700 hospitals nationwide. A Email Kristin or fill out the Contact Form with your questions on how she can help you reach your fitness goals.Looking for heart-healthy recipes?
Because music is reinforcing, it can be used to motivate movements or structure exercises which are prescribed in physical rehabilitation.
A Music therapy sessions Music therapy sessions incorporate the use of different musical media to achieve individualized treatment goals. Through movement to music and dance routines, movements may become more controlled, fluid and purposeful.
Live music offers increased flexibility and adaptability to match and guide physical movements elicited by the client. Musical instruments may be used to work on range of motion, handgrasp strength, and non-verbal self-expression. These instruments are often adapted to fit the specific physical capabilities of each client. The use of computer-aided and electronic musical equipment also allows severely physically disabled clients to reach their fullest creative potential. The act of singing may assist in the maintenance and improvement of oral motor skills and pulmonary functioning. Singing provides opportunities to improve breath-control, rate of speech,A articulation and pronunciation skills. Discussion of lyrics and songwriting may provide opportunities to discuss and share personal thoughts and experiences. Music therapy can increase an individual's level of independence, and enhance feelings of self-confidence, self-worth and self-esteem. Facilitate relaxationRelaxation is an important component in achieving increased range of motion and flexibility.
Music experiences that can promote relaxation include listening to carefully chosen music, instrumental improvisation and music-assisted relaxation exercises. Although most people may find sedative music effective in achieving a relaxed state, this may not be true in all cases. The music therapist is able to recognize and monitor the effects of the presented music on the individual.
Increase motor coordinationMotor coordination can be improved through many musical experiences. The use of selected instruments can improve range of motion as well as fine and gross motor skills through strategically, placing instruments around the individual or using instruments that require the use of specific muscle groups or, body parts.
Eye hand coordination can also be improved through the use of instruments that require increased precision in physical motion. The use of rhythmic auditory stimuli has been shown to increase independent, even control of ambulation in individuals with uneven or arrhythmic gait patterns and to facilate temporal and quantitative muscular control in children with gross motor dysfunction.3. Reinforce and provide motivation for physical exerciseThe use of music in therapy provides a positive and enjoyable atmosphere for persons with physical disabilities to experience success.
Through providing live background music, adaptability and flexibility is maintained so that the music therapist can more easily match the individual's motions in tempo, style and rhythm.
Music can help provide distraction and diversion from exercises that may be difficult for the individual, provide motivation to maintain participation and make a regular exercise routine seem less tedious.4. Foster independence, self-confidence- and self-esteemAs physical abilities improve, and persons have increased opportunities to practice and acquire new skills and abilities, independence can be fostered and self-confidence and self-esteem enhanced.
A positive self-image and self-concept can be developed through music therapy interventions and music therapy activities can be adapted according to the individual's needs and capabilities.
Develop functional speech and communication abilitiesSinging and speech have many commonalities. The use of vocal exercises used in singing can enhance oral motor skills such as articulation, breath control, and vocal intensity. Through manipulating tempo and rhythm, clarity of speech can be enhanced and the rate of speech can be modified to provide increased communication abilities for the individual. Melodic intonation therapy involves the sung intonation of propositional sentences in such a way that the intoned pattern is similar to the natural prosodic pattern of a sentence when it is spoken.
This technique has been shown to be effective in improving word-morpheme performance levels, sentence lengths, articulation skills and intelligibility for language delayed apraxic children and has been an effective treatment for some persons with severe aphasia . Music has also been effective as a stimulus to promote spontaneous speech with physically challenged children and to promote non-verbal communication through bliss symbols or sign language.6. Motivate interaction with othersPersons with physical disabilities may encounter decreased opportunities and motivation for social interaction. Music therapy can provide opportunities to interact with peers through a shared experience. Group ensembles provide opportunities to develop peer relationships, develop social interaction skills and provide opportunities for cooperation and working together as a group toward a common goal.
Group music therapy sessions can also provide opportunities to share personal experiences with others and provide a means and an outlet for appropriate self-expression.A Music therapy and children with autism Music Therapy is particularly useful with autistic children owing in part to the nonverbal, non threatening nature of the medium. Parallel music activities are designed to support the objectives of the child as observed by the therapist or as indicated by a parent, teacher or other professional. A music therapist might observe, for instance, the child's need to socially interact with others.
Musical games like passing a ball back and forth to music or playing sticks and cymbals with another person might be used to foster this interaction.
Eye contact might be encouraged with imitative clapping games near the eyes or with activities which focus attention on an instrument played near the face. Preferred music may be used contingently for a wide variety of cooperative social behaviors like sitting in a chair or staying with a group of other children in a circle.A Music Therapy is particularly effective in the development and remediation of speech.
The severe deficit in communication observed among autistic children includes expressive speech which may be nonexistent or impersonal.
Speech can range from complete mutism to grunts, cries, explosive shrieks, guttural sounds, and humming. There may be musically intoned vocalizations with some consonant-vowel combinations, a sophisticated babbling interspersed with vaguely recognizable word-like sounds, or a seemingly foreign sounding jargon.
Higher level autistic speech may involve echolalia, delayed echolalia or pronominal reversal, while some children may progress to appropriate phrases, sentences, and longer sentences with non expressive or monotonic speech. Since autistic children are often mainstreamed into music classes in the public schools, a music teacher may experience the rewards of having an autistic child involved in music activities while assisting with language.It has been often noted that autistic children evidence unusual sensitivities to music. Some have perfect pitch, while many have been noted to play instruments with exceptional musicality.
Music therapists traditionally work with autistic children because of this unusual responsiveness which is adaptable to non-music goals Some children have unusual sensitivities only to certain sounds.
One boy, after playing a xylophone bar, would spontaneously sing up the harmonic series from the fundamental pitch.
Through careful structuring, syllable sounds were paired with his singing of the harmonics and the boy began incorporating consonant-vowel sounds into his vocal play.
Soon simple 2-3 note tunes were played on the xylophone by the therapist who modeled more complex verbalizations, and the child gradually began imitating them.Since autistic children sometimes sing when they may not speak, music therapists and music educators can work systematically on speech through vocal music activities.
In the music classroom, songs with simple words, repetitive phrases, and even repetitive nonsense syllables can assist the autistic child's language.
Meaningful word phrases and songs presented with visual and tactile cues can facilitate this process even further.
Parents and teachers alike can assist the child in remembering these prosodic features of speech by prompting the child with the song.While composing specialized songs is time consuming for the teacher with a classroom full of other children, it should be remembered that the repertoire of elementary songs are generally repetitive in nature.
Even in higher level elementary vocal method books, repetition of simple phrases is common. While the words in such books may not seem critical for the autistic child's survival at the moment, simply increasing the capacity to put words together is a vitally important beginning for these children.For those teachers whose time is limited to large groups, almost all singing experiences are invaluable to the autistic child when songs are presented slowly, clearly, and with careful focusing of the child's attention to the ongoing activity.
To hear an autistic child leave a class quietly singing a song with all the words is a pleasant occurrence.
To hear the same child attempt to use these words in conversation outside of the music class is to have made a very special contribution to the language potential of this child.
Music is effective because it is a nonverbal form of communication, it is a natural reinforcer, it is immediate in time, provides motivation for practicing nonmusical skills, and is successful because almost everyone responds positively to at least some kind of music.A Music therapists work in a variety of settings, including medicine, rehabilitation, psychiatric care, special education, correctional facilities, state schools, community-based health care, and private practice. For example, the therapist and client might compose songs for the purpose of expression of feelings; one client might learn to play the piano for the purpose of improving fine motor skills, while another client might use instruments to improvise unspoken emotions. Following coursework, students complete a six-month full time clinical internship and a written board certification exam.
Music therapy can increase an individual's level of independence, and enhance feelings of self-confidence, self-worth and self-esteem.
Through providing live background music, adaptability and flexibility is maintained so that the music therapist can more easily match the individual's motions in tempo, style and rhythm. A positive self-image and self-concept can be developed through music therapy interventions and music therapy activities can be adapted according to the individual's needs and capabilities. A music therapist might observe, for instance, the child's need to socially interact with others. In the music classroom, songs with simple words, repetitive phrases, and even repetitive nonsense syllables can assist the autistic child's language.
Music therapy with young children is the functional use of musical interactions to enhance and develop socialisation, communication, self-expression, and sensory-motor skills.Who is a registered music therapist (RMT)?Registered Music Therapists (RMTs) are skilled and qualified musicians and therapists who assess, design and implement programs to meet the needs of young children.
When applied therapeutically by a RMT, music becomes a pleasurable therapeutic medium that facilitates advancement toward articulated and often multi-purpose goals and objectives. Music therapy can address several needs simultaneously and is highly transferable to the home environment. Furthermore, as young children with delay in development are not necessarily delayed in their music skills, music therapy allows them to experience a sense of success and fun whilepursuing other non-musical goals. The Music Therapy Process Specific music therapy goals are determined by the RMT through initial music therapy assessment and ongoing review of the child.



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