Quality Management

CCHN is involved in a number of initiatives that promote the delivery of consistent, high quality services across the continuum of care and uses the Wagner Chronic Care Model (CCM) as an evidenced-based guide for quality improvement. The CCM is a multi-dimensional framework for improving care and synthesizes basic elements of health care including the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Using a blend of evidence-based programs and tools associated with each element, can foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise.

In partnership with IDS and AMP providers, CCHN has positioned itself to facilitate pilot projects using evidence-based models, and those that demonstrate effectiveness and result in improved health outcomes can be adopted and endorsed by the larger provider network. Individually and collectively these efforts result in integrated systems, improved care quality and communication, higher provider reimbursements, reduced health care costs and a healthier community. 

Patient Centered Medical Home

CCHN endorses and supports the Patient-Centered Medical Home (PCMH) approach to providing comprehensive primary care. 

In 2008, the National Committee for Quality Assurance’s (NCQA) began the PCMH Recognition Program by developing a set of standards for practices to organize care around patients, working in teams and coordinating and tracking care over time. PCMH enhances the quality of patient care through the Chronic Care Model and facilitates partnerships between individual patients and their personal physicians who are trained to provide first contact, continuous and comprehensive care.  Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services).

CCHN has assisted 7 local practices in reaching Level 3 of PCMH 2008, the highest  recognition that could be achieved for that specific set of standards. Practices that have achieved NCQA’s PCMH Recognition can take advantage of financial incentives that health plans, employers, federal and state-sponsored pilot programs offer. 

Moving forward CCHN will assist practices in achieving the new PCMH 2011, which builds on the success of the earlier standards and make the program even more responsive to patients’ needs.   Although the standards have always pointed practices toward using systems—including electronic health records—to support tracking care, PCMH 2011 aligns closely with many elements of another CCHN-endorsed program, Meaningful Use, which rewards clinicians for using health information technology to improve quality.

Guided Care Nurses

Developed by the Roger C. Lipitz Center for Integrated Health Care at the John Hopkins Bloomberg School of Public Health, Guided Care has been tested in numerous clinical trials and studies.  It has been shown to improve both the quality of patient care and patient satisfaction with care.  Studies further show a reduction in the use of expensive services, especially in integrated care delivery systems. 

CCHN has assisted several PCHM practices by training an RN within the practice as a Guided Care Nurses (GCN). GCNs will lead care delivery teams to improve case management for patients with multiple chronic conditions by maintaining care plans and managing transitions of care. GCNs will demonstrate and facilitate the use of evidence-based tools and programs resulting in improved care coordination and patient health outcomes.

Diabetes Recognition Program

To address one of the most chronically ill patient populations, NCQA  has developed the Diabetes Recognition Program (DRP) to help clinicians use evidence-based measures and provide excellent care to patients with diabetes. Physicians who achieve recognition are identified as high-quality clinicians who have demonstrated that they are on the leading edge of quality care delivery to diabetic patients..

Facilitated by CCHN staff, 36 local primary care physicians have received recognition for NCQA through the DRP by submitting data that demonstrates performance that meets the program’s key diabetes care measures.  These measures include eye exams, blood pressure tests, nutrition therapy and patient satisfaction.  When people with diabetes receive quality care as outlined in these measures, they are less likely to suffer complications such as heart attacks, stroke, blindness, kidney disease and amputation.


To support quality improvement initiatives, CCHN promotes the use of assessment instruments used for screening, diagnosing, and monitoring a number of chronic conditions from depression to diabetes.

Depression  Screening (PHQ9)

This questionnaire incorporates DSM-IV depression diagnostic criteria with other leading major depressive symptoms into a brief self-report tool which is completed by the patient and scored by the clinician.  Based on the scoring, provisional diagnosis are identified and a number of treatment recommendations are outlined.

Steadi Toolkit

Falls, especially for older adults, can lead to a number of serious complications.  The Steadi Toolkit was developed by the CDC’s Injury Center for health care providers who see older adults in their practice who are at risk of falling or who may have fallen in the past. The STEADI Tool Kit gives health care providers the information and tools they need to assess and address their older patients’ fall risk.

RAND 36 Health Survey

CCHN staff have begun training with local medical practices using an additional screening tool, the RAND 36. 

RAND 36 is self-report survey that provides a generic measure of health status in the following 8 areas: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to emotional problems, emotions well being, social functioning, energy/fatigue, and general health perceptions.

Health Information Technology

Meaningful Use

To improve healthcare in the US, the Meaningful Use (MU) incentive program was established to increase the use of Electronic Health Record Systems in three distinct stages. In 2010, the standards for MU Stage 1 was developed by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs and allows eligible providers and hospitals to earn incentive payments if they attest to meeting the specific criteria by 2014. If providers do not meet the requirements by 2015, they may be penalized. Providers can begin attesting to MU stage 2 in 2014, which will include a more advanced set of standards. 

CCHN assists providers with Electronic Medical Records (EMR) implementation and is currently assisting 93 providers inclusive of physicians and extender staff to achieve MU Stage 1.  Many of the requirements for MU Stage 1 and PCMH 2011 overlap, allowing CCHN to leverage staff support to our providers. 

Chronic Disease Registries

With an overall objective to become clinically integrated, CCHN staff in partnership with the IDS has been building an IT infrastructure inclusive of a web-based electronic patient registries using Covisint Healthcare®. The patient registries allow CCHN staff to gather and analyze nationally-accepted, QI performance measures and provide feedback to physicians in a quarterly progress report that can be used to improve patient care and outcomes. A total of 10 area practices and 81 providers are participating in the registry project for Diabetes and Cardiovascular disease.

Chautauqua Health Connects

CCHN is currently working on the development if a secure messaging system, Chautauqua Health Connects (CHC), through an Office of Rural Health Policy Outreach grant. The CHC project involves linking Chautauqua County health care organizations through a HIPPA compliant web-based health information exchange using Covisint Healthcare®. The exchange network will enable the electronic transfer of secure messages such as discharge summaries or referrals to Meals on Wheels between hospitals, physicians, skilled nursing, home care, hospice, and the Community Resource Center (CRC). The system will improve information flow and strengthen communications among health care providers and community based services.

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